Riverview Estates

F-F600 began 03/19/25 and was completed 03/20/25 at 12:30 PM. Nursing staff were not allowed to work until they were educated on the policy and clinical protocols for assessing residents and notification to the physician upon changes in condition. On 03/20/25, an onsite verified the completion of the corrective actions to remove the immediacy. After the immediacy was removed the deficient practice remained at a scope and severity of G to represent the actual harm to Resident R26.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or 26768 potential for actual harm

The facility had a census of 23 residents. Based on observation, interview, and record review, the facility Residents Affected - Some failed to perform background checks as required for four employees. The employees were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the 23 residents of the facility at risk for potential abuse, neglect, or exploitation.

Findings included:

- On 03/18/25 a review of staffing for background checks for facility staff was completed. Upon request and

review the facility was unable to provide evidence a criminal background check had been completed before four employees began working around and with residents.

The facility records revealed the following staff started employment at the facility before the background checks returned:

Certified Nurse Aide (CNA) N started on 07/09/22 and the background check was not verified until 02/04/24.

CNA O started on 01/24/24 and the background check was not verified until 02/12/24.

Housekeeping Staff U started on 11/05/21 and the background check was not verified until 12/03/24.

Maintenance Staff V started on 02/20/24 and the background check was not verified until 02/22/24.

On 03/18/25 at 01:39 PM, Administrative Staff A verified the facility had not received the background checks for four staff prior to those staff working in the facility.

The facility's Monitoring Background Checks policy, dated 09/06/2021, stated following each background check on each newly hired employee, human resource personnel would routinely check the state website for

the results of the checks. The date of the background check, the result, and the date the result was recorded would be tracked.

The facility failed to perform background checks as required for four employees who were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26768

Residents Affected - Few The facility had a census of 23 residents. The sample included 12 residents with one reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on

observation, interview, and record review, the facility failed to provide Resident (R) 11 a device to secure the catheter tubing to keep it from pulling and causing discomfort. This deficient practice placed Resident R11 at risk for pain or injury related to the catheter use and Resident R11 developed two open sores related to the catheter rubbing.

Findings included:

- Resident R11's Electronic Medical Record (EMR) documented diagnoses of an open wound of the penis (male organ with urethra tube which carries urine to outside the body), pain, and Urinary Tract Infection (UTI - an infection

in any part of the urinary system).

The Quarterly Minimum Data Set (MDS), dated [DATE REDACTED], documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented Resident R11 required maximum staff assistance for toileting, had a urinary catheter, and occasional moderate pain. The MDS documented Resident R11 had no skin issues.

Resident R11's Care Plan for urinary catheter, dated 01/03/25, directed staff to provide a 16Fr. (French) 30 cubic centimeters (cc) catheter, and change the catheter per physician's order. The staff were directed to not allow tubing or any part of the drainage system to touch the floor and provide catheter care daily and as needed.

The staff were to change the catheter bag weekly, assess the drainage, and record the amount, type, color, and odor. The staff were to observe for leakage and irrigate the catheter only if an obstruction was suspected. The staff were to keep the catheter system a closed system as much as possible, manipulate tubing as little as possible during care, and measure and record the urine output. The staff was to position

the catheter collection bag below the level of the bladder and store the collection bag inside a protective dignity pouch. The staff was to use a catheter strap as needed and ensure enough slack was left in the catheter tubing between the meatus (opening on the penis which leads into the body) and the strap.

The Physician Order, dated 10/17/24, directed staff to ensure a 16Fr.30 cc catheter was in place.

The Progress Note, dated 03/12/2025 at 09:06 AM documented Resident R11's catheter change was completed. When changing the catheter, Resident R11's penis was found to have two sores. The sores were approximately 0.5 centimeters (cm) in diameter. Resident R11's catheter rubbed against the sores. The physician was faxed and the family was notified regarding the issue.

The Progress Note, dated 03/17/2025 at 11:43 AM documented Resident R11 denied abuse or neglect and nursing staff reported that catheter tubing was rubbing against the penis area. The note stated licensed nurses were to apply protective barrier cream to the area until healed and after healed to prevent skin impairments. The care plan was reviewed and updated to ensure the catheter tubing was not pressing or rubbing against his perineal area or penis which could cause skin impairments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 On 03/19/25 at 12:00 PM, Licensed Nurse (LN) H donned personal protective equipment (PPE) and took gauze, Calmoseptine, and wound cleanser into Resident R11's room. Resident R11 was in bed and LN H performed wound Level of Harm - Minimal harm or care to the two penis wounds as ordered. Resident R11 had no catheter secure device or strap-on. potential for actual harm

On 03/19/25 at 12:00 PM, LN H stated that Resident R11 did not leave the device on due to the adhesive. LN H Residents Affected - Few thought he had signed a risk agreement to not wear the securing device.

On 03/19/25 at 12:10 PM, Administrative Nurse D verified staff should have placed a secure device for the resident's catheter tubing to prevent pulling on it as care planned and he had no risk agreement to not wear

a secure device or strap.

The facility's Urinary Catheter Care policy, dated August 2022, directed staff to ensure the catheter remained secured with a securement device to reduce friction and movement at the insertion site. The policy stated staff should record any problems noted at the insertion site such as redness, bleeding, irritation, or pain.

The facility failed to provide R 11 a device to secure the catheter tubing to keep it from pulling and causing discomfort. This deficient practice placed Resident R11 at risk for pain or injury related to the catheter use and Resident R11 developed two open sores related to the catheter rubbing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 26768

Residents Affected - Many The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to properly date opened bags of food with the open date and

the expiration date. This practice placed the 23 residents at risk for foodborne illness and poor-quality food.

Findings included:

- On 03/13/25 at 08:20 AM, an inspection of the facility kitchen cold storage revealed the #4 upright freezer had seven opened, undated bags of frozen vegetables and potato items. The #5 freezer contained an opened box of hamburger patties with the plastic bag open to the air and undated.

On 03/13/25 at 08:20 AM, Dietary Staff BB verified the bags were undated or the date was not readable. She stated the marker staff used for frozen foods was not appropriate as the ink rubbed off.

The facility's Food Receiving and Storage policy, dated October 2017, stated foods would be received and stored in a manner that complied with safe food handling practices. The policy stated all foods stored in the refrigerator or freezer would be covered, labeled, and dated with a use-by date. The freezer must keep frozen foods solid, and wrappers of frozen food must stay intact until thawing, opened containers must be dated and sealed or covered during storage.

The facility failed to properly date opened bags of food with the open date and the expiration date. This deficient practice placed the 23 residents at risk for foodborne illness and poor-quality food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27168

Residents Affected - Few The facility had a census of 23 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview,

the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 13. This placed the residents at risk for inadequate end-of-life care.

Findings included:

- Resident R13's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbance, arteriosclerotic heart disease (ASHD - is a condition where the arteries that supply blood to the heart become narrowed and hardened due to buildup of plaque, a sticky substance), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear).

Resident R13's Significant Change Minimum Data Set (MDS), dated [DATE REDACTED], recorded Resident R13 had severe cognitive impairment. The MDS recorded she required extensive staff assistance with transfers and activities of daily living (ADLs). The MDS documented the resident received hospice services.

Resident R13's facility Care Plan, dated 03/04/25, recorded Resident R13 required extensive staff assistance with most ADL care. Resident R13's Care Plan documented the resident had a diagnosis of dementia and required hospice services.

The care plan directed the staff to provide comfort and encourage family and friends' support system. The care plan directed staff to observe closely for signs of pain and administer medications as ordered. The facility care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and

the hospice contact information.

Review of Resident R13's clinical record revealed the resident was admitted to hospice care on 03/04/25. The facility had a plan of care provided by hospice in the electronic health record.

On 03/13/25 at 12:45 PM, Resident R13 was dressed in street clothes in a recliner in her room. Resident R13 was talking about house insulation coming down and the house was very cold, continued to talk but had word salad.

On 03/19/25 at 10:30 AM, Administrative Nurse D verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 The facility's Hospice Program policy, dated July 2021, documented hospice services are available to residents at the end of life. The facility has an agreement in place with at least one Medicare-certified Level of Harm - Minimal harm or hospice to ensure that residents who wish to participate in a hospice program may do so. When a resident potential for actual harm has been diagnosed as terminally ill, the Director of Nursing Services would contact the hospice agency and request that a visit/interview with the resident/family be conducted to determine the resident's wishes relative Residents Affected - Few to participate in the hospice program. It is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including:

Determining the appropriate hospice plan of care.

Change the level of services provided when it is deemed appropriate.

Provide medical direction, nursing, and clinical management of the terminal illness.

Provide spiritual, bereavement, and/or psychosocial counseling and social services as needed; and

Providing medical supplies, durable medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms.

In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with hospice representatives and ensure the level of care provided is appropriately based on the individual resident's needs. Coordinated care plans for the resident's hospice services would include the most recent hospice plan of care as well as the care and services provided by the facility including the responsible provided and discipline assigned to specific tasks, in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.

The coordinated care plan would reflect the resident's goals and wishes, as stated in his/her advanced directive and during ongoing communications with the resident's representative, including:

a. Palliative goals and objectives.

b. Palliative interventions.

c. medical treatment and diagnostic tests.

The coordinated care plan would be revised and updated as necessary to reflect the resident's current status.

The facility failed to coordinate care between the facility and the hospice provider for Resident R13, who received hospice services. This deficient practice placed her at risk for inadequate end-of-life care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 27168 potential for actual harm

The facility had a census of 23 residents. The sample size included 12 residents. Based on observation, Residents Affected - Many record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R) 13 who had Influenza A (a contagious viral infection of the nose, throat and lungs that is spread from person to person through respiratory droplets). This placed the residents at increased risk for infection.

Findings included:

- On 03/13/25 at 09:30 AM, observation revealed License Nurse (LN) I entered the room of Resident R13, who was on Droplet Precautions EBP. Observation revealed a sign posted on the resident's door of the resident's room giving instruction on personal protection equipment (PPE - gown and gloves). The PPE equipment and supplies were located in an over-the-door hanging container in the resident's room. Continued observation revealed LN I entered the resident's room and donned only gloves. LN I sat down beside the resident while

she was in bed and began to talk to her about how she was feeling and conversing back and forth. LN I was

in the room for approximately eight minutes when LN J observed LN I in the resident room and explained to LN I the resident required staff and visitors to don a gown due to Resident R13 being on contact and droplet precautions. LN I stood up and went to the PPE that was stored on the resident's door and donned a gown then sat down next to the resident in her bed and started talking to her again.

On 03/19/25 at 09:45 AM, Administrative Nurse D verified Resident R13's room door had a Contact Isolation sign posted on the door and instructions for wearing appropriate PPE. Administrative Nurse D verified the resident's door had a sign that stated, Contact Precautions and anyone entering the room should wash their hands, don gloves, and a mask. The sign did not indicate to wear a gown. Administrative Nurse D stated she would discuss the Isolation precautions with Administrative Nurse E, the Infection Preventionist, and verify

the Isolation Precautions the resident should be on due to the resident had been diagnosed with Influenza A. Administrative Nurse D stated she would wear a gown if the resident had droplet precautions.

On 03/19/25 at 01:00 PM, Administrative Nurse E verified after reviewing the infection control protocol Droplet Precautions and Contact Precautions that the staff should wear PPE when providing care for Resident R13 which would include washing hands, donned gloves, mask, and gown. Administrative Nurse E stated she obtained the signs and the guidelines from the CDC website. Administrative Nurse E said the facility would do some education with the staff regarding EBP and wearing PPE for resident care.

The facility's Enhanced Barrier Precautions policy, dated March 2024, documented EBP's are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP was used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and gloves used in addition to standard precautions

during high-contact resident care activities when contact precautions do not otherwise apply.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Gloves and gown are applied prior to performing the high-contact resident care activities (as opposed to

before entering the room) Level of Harm - Minimal harm or potential for actual harm PPE is changed before caring for another resident.

Residents Affected - Many Face protection may be used if there is also a risk of splash or spray.

Examples of high-contact residents are activities requiring the use of gowns and gloves for EBP's including:

Dressing

Bathing/showering

Transferring

Providing hygiene

Changing linens

Changing briefs or assisting with toileting

Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator.); and

Wound care (any skin opening requiring a dressing).

The facility's Isolation-Categories of Transmission-Based Precautions, policy, dated September 2020, documented that Transmission-Based Precautions were initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory-confirmed infection, and is at risk of transmitting the infection to other residents.

Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status.

Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet, and airborne.

The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission, and recommended precautions.

When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for any type of precautions.

a. The signage informs the staff of the type of CDC precautions, instructions for the use of PPE, and/or instructions to see a nurse before entering the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 b. Signs and notifications comply with the resident's right to confidentiality or privacy.

Level of Harm - Minimal harm or When transmission-based precautions are in effect, non-critical resident-care equipment items such as a potential for actual harm stethoscope, and digital thermometer would be dedicated to a single resident when possible.

Residents Affected - Many If re-use of items is necessary, then the items would be cleaned and disinfected according to current guidelines before use with another resident.

Droplet Precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large particles that can be generated by the individual coughing, sneezing, talking, or by performance of procedures such as suctioning).

Residents on droplet precautions are placed in private room if possible.

Mask are worn when entering the room.

Gloves, gown, and goggles are worn if there is a risk of spraying respiratory secretions.

The facility failed to ensure staff applied the appropriate PPE required for EBP for Resident R13. This placed the resident at increased risk for infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27168 potential for actual harm

The facility had a census of 23 residents. The sample includes 12 residents, with seven residents reviewed Residents Affected - Some for immunizations, Resident (R) 5, Resident R10, Resident R11, Resident R13, Resident R16, Resident R21, and Resident R22, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.

Findings included:

- Review of Resident R10, Resident R11, Resident R13, Resident R16, and Resident R21 clinical medical records lacked evidence the facility or the resident representative received or signed a consent to receive or informed declination for the pneumococcal vaccine PCV20.

Review of Resident R5's electronic health record revealed the resident was admitted to the facility on [DATE REDACTED]. Resident R5 had not been offered or received a pneumococcal vaccine since admission.

Review of Resident R22's electronic health record revealed the resident was admitted to the facility on [DATE REDACTED]. Resident R22 had not been offered or received a pneumococcal vaccine since admission.

On 03/19/25 at 02:00 PM, Administrative Nurse E stated residents are offered the pneumonia vaccines on admission and as indicated. Administrative Nurse E said the facility would sign a consent or deny receiving

the vaccine. Administrative Nurse E verified that every resident in the building had not been reviewed to determine if they were eligible to receive the PVC20 vaccine or not. Administrative Nurse E verified they did not have a definitive system in place to determine who was eligible, if they were eligible if they had been offered or declined the vaccinations, and it was something they had recently been working on.

On 02/13/25 at 2:35 PM, Administrative Nurse D verified the facility lacked a system in place to identify which residents were eligible for which pneumococcal vaccination. Administrative Nurse D stated they did not have

a system in place to identify which pneumococcal vaccine the residents were eligible for or if they were eligible and if so for which one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 175497 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175497 B. Wing 03/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Riverview Estates 202 S Washington Street Marquette, KS 67464

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 The facility's Pneumococcal Vaccine policy dated; October 2019 documented all residents were offered pneumococcal vaccines to aid in the prevention of pneumonia/pneumococcal infections. Prior to or upon Level of Harm - Minimal harm or admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when potential for actual harm indicated, are offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Assessment of Residents Affected - Some pneumococcal vaccination status was conducted within five working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative receives information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education is documented in the resident's medical record. Pneumococcal vaccines are administered to residents per the facilities physician approved pneumococcal vaccination protocol. Residents/representatives have the right to refuse vaccinations. If refused, appropriate information is documented in the resident's medical record indicating the date of refusal of the pneumococcal vaccine. Administration of the pneumococcal vaccines was made in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

The facility failed to offer the PCV20 pneumococcal vaccination for Resident R5, Resident R10, Resident R11, Resident R13, Resident R16, Resident R21 and Resident R22.

This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumonia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 175497