Health inspection·August 11, 2024

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident out of 14 residents reviewed (Resident CR1). Findings include: According to the national library of medicine, irreversible death is classified as a person having the following: rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (pooling of blood to dependent areas resulting in a red/purple coloration), decapitation (total separation of the head from the body), transection (cut in half), and decomposition (the state or process of rotting) A review of Resident CR1's clinical record revealed admission to the facility on [DATE], with multiple diagnoses including cancer of the right lung, type 2 diabetes, heart disease, and anxiety. A review of Resident CR1's clinical record revealed a physician order dated [DATE], identifying the resident was to receive CPR (cardio pulmonary resuscitation-emergency lifesaving procedure performed when the heart stops beating or if the resident stops breathing. Immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac or pulmonary arrest. A nurse's note dated [DATE], at 11:15 AM, completed by Employee 3 (LPN), indicated that Resident CR1 was declining while in wheelchair, transferred to bed. Physician Assistant (PA) notified and at bed side. Resident expired. Resident pronounced by Physician assistant. A review of the PA's progress note dated [DATE], it revealed she was called to the room to see Resident CR1. The resident had been in the dayroom asking to go back to his room. He was wheeled back to his room and according to the PA's documentation he took his last breath while being placed back in bed. The progress note indicated the resident was found lying in bed, and unresponsive to verbal or noxious (painful) stimuli. The resident's pupils were fixed and dilated (when the pupil, round black part of the eye does not respond to light or fixed, indicating the brain is not responding to send a signal back to the eye to constrict, the pupil- fixed and dilated pupils are a sign if brain death) and his heart sounds could not be heard. The resident was without a pulse or respirations. Although the resident's physician's orders indicated that if the resident were to suffer a cardiac or respiratory event the facility was to perform CPR in order to attempt to save the resident during a cardiac arrest, the facility failed to implement CPR as ordered. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 395691 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverstreet Manor 440 North River Street Wilkes-Barre, PA 18702 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)