Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
treated residents in a manner to maintain their dignity when they did not pull privacy
curtains and left residents exposed to their roommates or families and staff walking by
the resident’s room, which affected three of 13 sampled residents (Resident #11, #33, and
#41). The facility census was 41.
Review of the facility’s undated resident rights policy showed:
– Each resident shall be treated with consideration, respect a full recognition of his/her
dignity and individuality, including privacy in treatment and care of his/her personal
needs.
1. Review of Resident #41’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/28/18, showed:
– Severe cognitive impairment;
– Always incontinent of bowel and bladder;
– Required extensive assistance of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/13/18, showed:
– Total dependence with ADLs due to decreased cognitive ability: Ensure the resident is
clean, dry, and appropriately dressed at all times;
– Skin breakdown related to bowel and bladder incontinence and mobility issues: Staff will
provide perineal care as needed.
Observation on 7/9/18, at 4:10 P.M., showed Certified Nurse Aide (CNA) A and Nurse
Assistant (NA) A did the following:
– Entered the resident’s room to perform perineal care;
– Shut the room door, did not pull the privacy curtain between the residents, and pulled
back the resident’s bedding while the resident’s roommate lay in the bed beside him/her;
– Pulled down the resident’s trousers and opened up the resident’s brief;
– Exposed the resident’s perineal area to check for wetness;
– Staff discussed if the resident was wet enough to provide perineal care and then
redressed the resident.
2. Review of Resident #33’s admission MDS, dated [DATE], showed:
– Severe cognitive impairment;
– Always incontinent of bladder;
– An [MEDICAL CONDITION] (loop of small intestine connected to the abdominal wall to
create a stoma, to pass stool out of the body);
– Total dependence of staff for all ADLs.
Review of the resident’s care plan, updated on 6/26/18, showed:
– Problem: Urinary incontinence;
– Approach: provide good peri-care after each incontinent episode and staff to change
[MEDICAL CONDITION] as needed to prevent breakdown.
Observation on 7/9/18, at 4:25 P.M., showed CNA A and NA A did the following:
– Entered the resident’s room to perform perineal care and pulled back the resident’s
bedding:
– Staff exposed the resident’s abdomen, opened a soiled brief, and started perineal care;
– During perineal care staff ran out of gloves, NA A left the resident’s room and left the
door wide open;
– The resident lay on his/her back with his/her genitals and [MEDICAL CONDITION] bag
exposed to residents and staff walking by the resident’s room;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
– After several minutes passed, CNA A realized the resident lie exposed with the door open
and covered the resident with a sheet;
– Facility staff and residents walked by the room before CNA A covered the resident.
During an interview on 7/9/18, at 5:00 P.M., NA A said he/she should have shut the door
when he/she left the room to provide privacy for the resident and also should pull the
privacy curtain.
During an interview on 7/9/18, at 5:10 P.M., CNA A said:
– He/she should pull the privacy curtain and shut the door when leaving the room;
– They should have covered the resident with a sheet before the NA A left the room.
3. Review of Resident #11’s quarterly MDS, dated [DATE], showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– The resident has a feeding tube;
– Indwelling catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the Resident #11’s care plan revised on 6/18/18, showed:
– Total dependence on staff for care due to decreased cognitive ability and a [DIAGNOSES
REDACTED].
– Staff assistance with perineal care due to urinary incontinence;
– Change incontinent pads as soon as possible after the resident voids or defecates.
Observation on 7/9/18, at 2:35 P.M., Certified Nurse Aide (CNA) A and Nurse Aide (NA) A
did the following:
– Assisted the resident to bed with a mechanical lift to provide incontinent care;
– Staff did not pull the privacy curtain;
– CNA A provided incontinent care as the resident lay completely unclothed, staff then
rolled the resident over and exposing the resident’s buttock and rectal area;
– The privacy curtain between Resident #11 and his/her roommate was not pulled;
– The resident lay in his/her bed near the window completely uncovered and exposed with
the privacy curtain not pulled;
– The other resident in the room continued to lay in his/her bed as staff dressed Resident
#11;
– Staff did not close the privacy curtain or cover the resident’s unclothed body at any
time during care.
During an interview on 7/9/18, at 2:50 P.M. CNA A and NA A said:
– Staff should provide privacy for every resident and they should have pulled the privacy
curtain during cares;
– Staff should cover a resident as much as possible during care.
4. During an interview on 7/12/18, at 2:30 P.M., the Director of Nurses (DON) said:
– She expected staff to pull the privacy curtain between residents during care.
– Staff should shut the door and pull curtains to maintain dignity for the residents.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to ensure they provided
residents or residents’ with a Skilled Nursing Facility (SNF) Beneficiary Protection

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
Notification as required under 42 CFR (Code of Federal Regulations) Part 405.1200-1240
when they discharged three of three sampled residents (Residents #30, #37 and #40) for
review of the those residents discharged from Medicare benefits. Residents must be
notified of the date Medicare services will be discontinued, their right to appeal and how
to appeal, and that they may continue on Medicare services if they do not agree, pending
the appeal. The facility census was 41.
The facility did not have a policy to address SNF Beneficiary Protection Notifications.
Review of 42 CFR Part 405.1200, Notifying beneficiaries of provider service terminations
showed (b) Advance written notice of service terminations. Before any termination of
services, the provider of the service must deliver valid written notice to the beneficiary
of the provider’s decision to terminate services. The provider must use a standardized
notice, as specified by Centers for Medicare and Medicaid Services (CMS), in accordance
with the following procedures:
– (1) Timing of notice. A provider must notify the beneficiary of the decision to
terminate covered services no later than 2 days before the proposed end of the services.
If the beneficiary’s services are expected to be fewer than 2 days in duration, the
provider must notify the beneficiary at the time of admission to the provider. If, in a
non-residential setting, the span of time between services exceeds 2 days, the notice must
be given no later than the next to last time services are furnished.
1. Review of Resident #41’s beneficiary notice showed his/her services would end on
2/5/18. The resident’s guardian signed the form on 2/6/18.
During an interview on 7/12/18 at 11:00 A.M., the resident’s guardian said the facility
faxed the notice to her office on 2/6/18.
2. Review of Resident #30’s beneficiary notice showed his/her services would end on
2/12/18. The resident’s guardian signed the form on 2/14/18.
During an interview on 7/12/18, at 11:15 A.M., the resident’s guardian said the facility
faxed the notice to her office on 2/13/18, at 9:15 A.M.
3. Review of Resident #37’s beneficiary notice showed his/her services would end on
3/26/18. The resident’s guardian signed the form on 3/27/18.
During an interview on 7/12/18, at 11:30 A.M., the resident’s public administrator said
he/she could not find the actual notice to confirm when it was sent to their office.
4. During an interview on 7/12/18, at 12:30 P.M., the social service manager said she got
the notices from therapy and she had 24 hours to send them out to the resident’s
representative. She would send them by fax or email to guardians/public administrators.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interview, the facility failed to maintain a safe and clean
environment for the residents. The bathroom floors and thresholds in resident rooms # 102,
#104, #105, and #106 were stained black and sticky. This affected eight residents. The
facility sidewalk had a crumbling area the width of the walk. This could affect any
resident or staff using the sidewalk. The facility census was 41.
Observation on the entrance to the survey on 7/9/18 showed the sidewalk on the west side
of the facility had an area one foot long and across the width of the sidewalk that was
crumbling.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Observation during survey tour on 7/9/18, showed the bathroom between resident rooms #102
and #104 had large black stains all over the floor. The floor was sticky and the bathroom
smelled of urine. The bathroom thresholds in resident rooms #105 and #106 were missing and
black sticky substance was in the floor.
Observation on 7/11/18, at 12:00 P.M., showed housekeeping staff cleaned the bathroom
floor and half of the black stains remained. During an interview at that time, Housekeeper
A said they cleaned the floors every day plus when needed. They sweep, spray, clean, then
mop the floor. She tried to scrub cracks and corners with a toothbrush, but could not get
all the stains off.
During an interview on 7/11/18, at 2:10 P.M., the maintenance manager said housekeeping
staff did not clean the floors with the cleaner he suggested. Some bathroom floors were
replaced before he started and he did not know why they did not install the thresholds.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to assure they
provided care and treatment in accordance with professional standards of practice when
staff failed to follow physicians’ orders for two residents (Resident #11 and #13) of 13
sampled residents. The facility census was 41.
Review of the facility’s policy for Physician Orders, (MONTH) (YEAR), showed:
-All medication and treatment regimes will be ordered by a licensed physician authorized
to practice medicine in this state and must be seen by the physician at least every sixty
days;
-Treatment orders specify what is to be done, location and frequency,and duration of the
treatment.
1. Review of Resident #11’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/4/18, showed:
– Severe cognitive impairment resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– The resident has a feeding tube;
– Indwelling catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/18/18, showed:
– Total dependence on staff for care due to decreased cognitive ability and a [DIAGNOSES
REDACTED].
– Impaired skin integrity related to a feeding tube with stated goal that resident will
not have further advancement of current gastric burn;
– Wound care and dressing changes per physicians’ orders;
– Change incontinent pads as soon as possible after the resident voids or defecates.
Review of the resident’s physician’s orders [REDACTED].
– An order date 7/2/18 for triple antibiotic ointment to gastric burn under left breast,
cleanse area with warm water until healed.
– A new order dated 7/5/18, to cleanse gastric burn under left breast with warm water,
apply thin layer of hydrogel (a gel that assists in protecting the body from wound
infection and promotes efficient healing), and cover with ABD (abdominal gauze pads) pad

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
twice daily until healed.
Observation on 7/10/18, at 6:18 A.M., showed:
– The resident laying in his/her bed with fibersource (nutritionally complete tube feeding
formula) infusing via percutaneous endoscopic gastrostomy (PEG, an endoscopic medical
procedure in which a tube PEG tube is passed into a patient’s stomach through the
abdominal wall);
– No dressing to the gastric burn under the resident’s left breast.
Review of Resident #11’s treatment administration record (TAR) on 7/10/18, at 6:35 A.M.,
showed:
– An order to cleanse gastric burn under left breast with warm water and apply a thin
layer of hydrogel and cover with ABD, pad twice daily 6:00 A.M. to 6:00 P.M. and 6:00 P.M.
to 6:00 A.M., until healed.
– LPN A’s initials on the TAR on 7/9/18, from 6:00 P.M., to 6:00 A.M., which indicated
that he/she provided the dressing change as ordered.
Review of Resident # 11’s TAR on 7/10/18, at 3:00 P.M., showed:
– A line marked through LPN A’s initials on the TAR on 7/9/18, from 6:00 P.M., to 6:00
A.M.
During an interview on 7/10/18, at 6:20 A.M., Licensed Practical Nurse (LPN) A said:
– He/she works twelve hour shifts 6:00 P.M. to 6:00 A.M.;
– Last evening (7/9/18), Resident #11’s feeding tube disconnected from and fibersource
leaked onto the dressings to the gastric burn and they were saturated. He/she removed them
and left the burn uncovered;
– On 7/9/18, LPN B instructed him/her to not put a dressing on the gastric burn as
ordered, he/she said it should be open to air;
– The current dressing order was not effective because the tape was causing skin
irritation;
– He/she did not notify the resident’s physician because he/she thought LPN B had notified
the resident’s physician;
– There is no documentation that the resident’s physician was notified or made aware that
additional orders were needed for wound care.
– He/she did not follow the physician’s orders [REDACTED].
During an interview on 7/11/18, at 10:18 A.M., LPN B said:
– He/she did not inform LPN A on 7/9/18, to not put a dressing on the resident’s gastric
burn;
– He/she did the resident’s dressing change earlier today and the area should be covered
at all times;
– On 7/5/18, the physician saw the resident and changed the treatment to the current
treatment order;
– The gastric burn is improving and responding to the current treatment order;
– The open area should be covered at all times to prevent infection in the area as the
resident is incontinent of bowel and bladder.
During an interview on 7/11/18, at 3:13 P.M., CNA A said:
– Resident # 11’s burn is usually covered and if the dressing comes off he/she she would
inform the charge nurse.
2. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/11/18, showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– The resident has a feeding tube;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– Always incontinent of bladder and bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/8/18, showed:
– The resident is dependent on staff for care due to a [DIAGNOSES REDACTED].
– The resident is receiving restorative nursing services related to joint contractures and
decreased range of motion in the resident’s upper and lower extremities;
– Staff are directed to apply the braces to hands as directed.
Review of the resident’s (MONTH) (YEAR) POS, showed:
– Hand splint to both hands on for two hours, three times daily.
Observations of Resident #13 on 7/9/18, 7/10/18, 7/11/18, and 7/12/18, showed:
– Multiple observations through out the four days at various times no braces applied to
the resident’s contracted hands.
– On 7/9/18, at 2:20 P.M., staff provided care; no splints on the resident;
– On 7/9/18, at 3:16 P.M., resident lying in the bed with no splints on;
– On 7/10/18, at 6:20 A.M., resident lay in bed with no splints on;
– On 7/11/18, at 2:00 P.M., resident sitting in the day area with no splints on;
– On 7/11/18, at 3:20 P.M., resident in bed with staff providing care no splints on;
– On 7/12/18, at 8:30 A.M., the resident lay in bed with no splints on.
During an interview on 7/11/18, at 3:02 P.M., Certified Nurse Aide (CNA) C said:
– He/she is familiar with Resident #13 and frequently is assigned to provided care for
him/her;
– The resident did have splints but they are missing and he/she had seen them on the
resident twice in the last six months.
During an interview on 7/11/18, at 3:13 P.M., CNA A said:
– He/she frequently provided care for Resident #13.
– The resident does not have any splints for his/her hands.
– He/she had not talked to anyone about where the resident’s splints were.
During an interview on 7/12/18, at 8:45 A.M., CNA E said:
-He/she is familiar with Resident #13 and frequently is assigned to provided care for
him/her;
-When the facility had a restorative aide, Resident # 13’s braces were put on daily but
the braces are no longer used.
3. During an interview on 7/12/18, at 2:30 P.M., the Director of Nursing (DON) said:
– It was unclear why LPN A’s initials were marked out on Resident #11’s TAR on 7/9/18,
from 6:00 P.M., to 6:00 A.M.;
– If a treatment was not done, staff should circle their initials to indicate it was not
done, and then write an explanation on the back of the TAR;
– After reviewing of the back of the Resident #11’s TAR she said there was no explanation;

– When a dressing change order is needed, staff should notify the physician and obtain the
new order; this should be documented;
– Nursing staff does not have the authority to change a dressing order.
– The nurse on the 6:00 P.M. to 6:00 A.M. shift should have completed the treatment to the
resident’s gastric burn as it was ordered by the physician to be done twice daily.
– If the dressing needed to be changed, she expected nursing staff to apply a dressing
and the area should be covered at all times;
-The facility no longer utilizes a restorative aide and if the physician ordered hands
splints then she expects staff to follow physicians orders.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
performed proper, complete perineal care (cleansing of the perineal and rectal areas) to
three incontinent, dependent residents of 13 sampled residents (Resident #11, #13 and
#33). The facility census was 41.
Review of the facility’s policy on perineal care, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Purpose: To cleanse the perineum and to prevent infection and odor;
– Guidelines: Separate the legs and flex the knees, use one gloved hand to stabilize and
open the perineal folds, with the other hand, wash from front to back;
– Roll the resident away from you, use a new washcloth and wash around the rectal area,
rinse and dry, remove gloves, and wash hands.
1. Review of Resident #33’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/30/18, showed:
– Severe cognitive impairment, always incontinent of bladder, and [MEDICAL CONDITION]
(loop of small intestine connected to the abdominal wall to create a stoma, to pass stool
out of the body);
– Total dependence of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/26/18, showed:
– Problem: urinary incontinence;
– Approach: provide good peri-care after each incontinent episode and staff to change
[MEDICAL CONDITION] as needed to prevent breakdown.
Observation on 7/9/18, at 4:25 P.M., showed:
– Certified Nurse Aide (CNA) A and Nurse Assistant (NA) A entered the resident’s room to
perform perineal care, washed and gloved their hands, and pulled back the resident’s
bedding.
– CNA A removed the resident’s [MEDICAL CONDITION] bag, emptied it and placed it back on
the resident;
– Opened the resident’s brief, wet with urine, and CNA A rolled the resident on his/her
right side;
– NA A wiped the resident’s left buttock, did not wipe the right buttock, thighs, or all
areas wet with urine;
– Rolled the resident onto his/her back, and CNA A wiped down and back up the inner
perineal fold twice, wiped each groin area once, and did not wash all frontal areas wet
with urine.
During an interview on 7/9/18, at 5:00 P.M., NA A said he/she should have cleaned the
sides of the legs, inner perineal areas, and all areas wet with urine during perineal
care.
During an interview on 7/9/18, at 5:10 P.M., CNA A said:
– He/she should not wipe down the inner perineal folds and back up again;
– During perineal care, all areas soiled should be cleaned.
2. Review of Resident #11’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/4/18, showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
– The resident has a feeding tube;
– Indwelling catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/18/18, showed:
– Total dependence on staff for care due to decreased cognitive ability and a [DIAGNOSES
REDACTED].
– Staff assistance with perineal care due to urinary incontinence;
– Change incontinent pads as soon as possible after the resident voids or defecates.
Observation on 7/9/18, at 2:35 P.M., showed CNA A and NA A provided incontinent care as
the resident lay in bed and did the following:
– Both staff entered the room and did not wash their hands before they put on clean
gloves;
– CNA A removed the resident’s pants and opened the wet brief;
– CNA A used a disposable wipe, made one downward wipe then folded the disposable wipe and
made one downward wipe;
– CNA A did not cleanse all the resident’s frontal perineal skin folds;
– Both staff rolled the resident onto his/her side, and NA A pulled the wet brief from
under the resident;
– CNA A used one disposable wipe and wiped the resident’s rectal area, removing fecal
material and he/she reported the resident was having a bowel movement;
– CNA A did not cleanse the resident’s right or left buttock that came in contact with
urine;
– CNA A removed his/her gloves and did not wash his/her hands;
– After dressing the resident and situating him/her in bed, both staff washed their hands
and exited the resident’s room.
During an interview on 7/9/18, at 2:50 P.M. CNA A and NA A said:
– Staff should cleanse all skin folds including the right and left buttock when providing
incontinent care;
– Staff should use more than one wipe to cleanse the frontal perineal skin folds.
3. Review of Resident #13 ‘s quarterly MDS, dated [DATE], showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– The resident has a feeding tube;
– Always incontinent of bladder and bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/8/18, showed:
– The resident is dependent on staff for care due to a [DIAGNOSES REDACTED].
– Incontinence care after each incontinent episode;
– At risk for skin breakdown staff are directed to keep the resident clean and dry.
Observation on 7/11/18, at 3:05 P.M., showed CNA A and CNA C provided incontinent care as
the resident lay in bed and did the following:
– Both staff washed their hands and put on clean gloves before starting incontinent care;
– The resident did not have a brief on;
– CNA C used one disposable wipe and he/she made one downward wipe on the resident’s
fontal perineal skin fold;
– CNA C did not make any more attempts to cleanse the rest of the resident’s perineal area
which had come in contact with urine.
– Staff did not roll the resident onto his/her side and did not cleanse the resident’s
right or left buttock that came in contact with urine
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
During an interview on 7/11/18, at 3:11 P.M., CNA A and CNA C said:
– When providing incontinent care, all areas should be cleansed to remove urine and fecal
material.
4. During an interview on 7/12/18, at 2:30 P.M., the Director of Nurses (DON) said:
– All areas soiled or wet should be cleaned during perineal care;
– One wipe, one swipe, and throw the wipe away;
– Staff should not wiped down the inner perineal folds and back up again.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to assure staff
used proper techniques and follow facility policy to reduce the possibility of accidents
and injuries during mechanical lift transfers. This affected two of 13 sampled residents
(Resident #11 and #33). The facility census was 41.
Review of the facility’s policy on Hydraulic Lifts, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Open the lift legs to the widest point, at the closest location to the resident (bed or
chair);
– Position the sling under the resident and move the lift with the base under the bed;
– Attach the S hooks to the overhead bar and raise the resident, when the resident has
been lifted clear of the bed, grasp the bar, and move to the chair;
– Position the wheelchair and lock the wheelchair brakes.
Review of the manufacturer’s instructions on the battery operated mechanical lift, dated
2011, showed:
– Transferring the resident: Wheelchair wheel locks MUST be in a locked position before
lowering the resident into the wheelchair for transport.
1. Review of Resident #33’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/30/18, showed:
– [DIAGNOSES REDACTED].
– Severe cognitive impairment and did not ambulate;
– Total dependence of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/26/18, showed:
– [DIAGNOSES REDACTED].
– ADL function: Resident is unable to transfer self-related to cognitive decline and left
femur fracture: Resident will transfer with assist with use of mechanical lift, instruct
staff in use of mechanical lift for transfers and proper transfer techniques, and provide
two assistance for transferring.
– Total dependence of staff for all ADLs.
Observation on 7/9/18, at 4:25 P.M., showed:
– Certified Nurse Aide (CNA) A and Nurse Assistant (NA) A completed perineal care and
prepared to transfer the resident to his/her wheelchair;
– Staff rolled the resident, placed a lift sling under the resident, and attached the
sling loops to the lift bar;
– NA A raised the resident off the bed, pulled the lift away from the bed, and moved the
lift toward the resident’s wheelchair;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
– CNA A stood behind the resident’s wheelchair, did not lock the wheelchair, and grabbed
onto the resident;
– The wheelchair moved back and forth while CNA A tried to hold the wheelchair in place
with his/her body when lowering the resident into the wheelchair.
During an interview on 7/9/18, at 5:00 P.M., NA A said the wheelchair should be locked
when staff lowered the resident into it.
During an interview on 7/9/18, at 5:10 P.M., CNA A said the wheelchair should have been
locked and not move while he/she tried to transfer the resident.
During an interview on 7/12/18, at 2:30 P.M., the Director of Nurses (DON) said she
expected staff to lock the resident’s wheelchair during mechanical lift transfers.
2. Review of Resident #11’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/4/18, showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan revised on 6/18/18, showed:
– Total dependence on staff for care due to decreased cognitive ability and a [DIAGNOSES
REDACTED].
– Assistance of two staff for transfers with a mechanical lift.
Observation on 7/9/18, at 2:35 P.M., showed CNA A and NA A assisted the resident from
his/her wheelchair to the bed as follows:
– Both staff entered the room and attached the lift seat straps to the lift bar of the
mechanical lift;
– The brakes on the wheelchair remained unlocked;
– CNA A used the control and raised the resident from the wheelchair and the wheelchair
moved backwards about two inches;
– NA A stood next to the side of the resident’s wheelchair and supported the resident’s
legs;
– CNA A pushed the lift over the resident’s bed and then lowered the resident into his/her
bed as NA A moved the wheelchair out of the way;
– Staff then provided care and and exited the resident’s room.
During an interview on 7/9/18, at 2:50 P.M., CNA A and NA A said:
– The brakes on the wheelchair should be locked during a transfer.

F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the
director of nurses on a full time basis.

Based on interview and record review, the facility failed to use the services of a
registered nurse (RN) for at least eight consecutive hours a day, seven days a week, for
resident care. The facility census was 41.
The facility did not provide a policy for staffing.
Review of the staff schedule for (MONTH) (YEAR), showed no RN coverage scheduled for the
weekends.
During an interview on 7/12/18, at 12:00 P.M., the Administrator said:
– He knew that it is a federal requirement to have RN coverage daily;
– The Director of Nursing (DON) acts as the RN coverage Monday thru Friday;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 10)
– Frequently there is no RN coverage on weekends.
During an interview on 7/12/18, at 12:15 P.M., the DON said:
– There is no RN coverage on the weekend due to no applicants;
– The facility accepts skilled residents and is aware of the federal regulation requiring
RN coverage.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
administered medications with a medication error rate of less than 5%. Facility staff made
four medication errors out of 28 opportunities for error, resulting in a medication error
rate of 14%. This affected two of 13 sampled residents (Residents #21 and #29). The
facility census was 41.
Review of the facility’s policy on Medication Administration Guidelines dated (MONTH)
(YEAR), showed it is the purpose of this facility that residents receive their medications
on a timely basis and in accordance with established policies;
– To benefit a resident’s health as ordered by the physician;
– Staff are directed to read the label three times before administering the medication;
– Guidelines: The person administering the drugs must chart medications immediately
following the administration; to include the date, time administered, dosage, etc.; must
be entered in the medical record; and signed by the person entering the data;
– A current Physician’s Desk Reference (PDR) or drug reference is available at each
nurses’ station.
Review of the online undated Physician Digital Reference showed:
– Potassium (for the treatment of [REDACTED].
1. Review of Resident #29’s (MONTH) physician’s orders [REDACTED].
– [MEDICATION NAME] 15 milligrams (mg), take one tablet orally once daily for pain;
– [MEDICATION NAME] 25 mg, take one tablet orally every morning;
– Potassium chloride (CL) ER (extended release), 10 milliequivalents (meq), take one
tablet orally once daily for supplement.
Observation on 7/12/18, at 8:40 A.M., showed:
– Certified Medication Technician (CMT) A prepared the resident’s morning medications in
the hall outside the resident’s room;
– Obtained the resident’s card of [MEDICATION NAME] 15 mg and popped the medication into
the medication cup, (the card read to take with food);
– Obtained the resident’s card of spiralactone 25 mg and popped the medication into the
medication cup, (the card read to take with food);
– Obtained the resident’s card of potassium 10 meq and popped the medication into the
medication cup, (the card read to take with food);
– Entered the resident’s room and administered the cup of medications to the resident;
– CMT A left the resident’s room and did not provide a snack for the resident.
During an interview on 7/12/18, at 8:45 A.M. the resident said:
-He/she had an upset stomach today and did not eat breakfast today;
-He/she frequently does not eat breakfast.
2. Review of Resident # 21’s (MONTH) POS showed the following:
-[MEDICATION NAME] 15 mg, take one tablet orally once daily for pain.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
Observation on 7/12/18, at 9:15 A.M., showed- CMT A prepared the resident’s morning
medications in the hall outside the resident’s room;
– Obtained the resident’s card of [MEDICATION NAME] 15 mg and popped the medication into
the medication cup, (the card read to take with food);
– Entered the resident’s room and administered the cup of medication to the resident;
– CMT A left the resident’s room and did not provide a snack for the resident.
During an interview on 7/12/18, at 9:20 A.M. the resident said:
-He/she did not eat breakfast this morning and frequently does not eat breakfast.
During an interview on 7/12/18, at 1:00 P.M. CMT A said:
– Residents #21 and #29 do not usually eat breakfast;
– Staff should read the label two times before administering medications to ensure the
physicians orders are followed;
– He/she did not know that Resident #29’s cards of [MEDICATION NAME] 15 mg, spiralactone
25 mg, and potassium 10 meq read to administer the medications with food;
– He/she did not know that Resident # 21’s cards of [MEDICATION NAME] 15 mg, read to
administer the medications with food;
– He/she should have administered the residents’ medications with meals.
3. During an interview on 7/12/18, at 2:30 P.M., the Director of Nursing (DON) said:
– Staff must always follow physician’s orders [REDACTED].
– Staff are directed to read the label three times before administering medications;
– Staff should use the five rights for medication administration the right patient, the
right drug, the right dose, the right route, and the right time.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
dated a multi-dose bottle when opened, failed to ensure several residents’ insulin pens
and other medications remained in a refrigerator when facility staff defrosted the
refrigerator located in the medication room for two of 13 sampled residents (Resident #20
and #33) and failed to ensure staff did not store their food with residents’ medications.
The facility census was 41.
Review of the facility policy, dated (MONTH) (YEAR), titled Storage of Medications,
showed:
– Biologicals or medications requiring refrigeration must be kept in a separate, securely
fastened refrigerator at or near the nurses’ station or in a refrigerator within a locked
medication room;
– Drugs must be stored at appropriate temperature levels; drugs requiring refrigeration
must be stored between 36 and 46 degrees Fahrenheit (F);
– No discontinued outdated or deteriorated drugs or biologicals may be retained for use.
– All controlled substances must be stored under double lock and key;
-When drugs are stored in the same refrigerator as foods, the drugs must be kept in a
closed container clearly labeled DRUGS.
Review of the facility undated policy titled Food Safety Requirements showed:
– Food items not fully consumed or food items intended for later resident consumption,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
shall be stored in an appropriate container, with adequate label and date, and stored in
designated refrigerator container, with adequate label and date, and stored in a
designated refrigerator as determined by the facility, or in the resident’s personal
refrigerator.
Review of the undated Physician online Reference for [MEDICATION NAME] used to treat
anxiety and often during end of life, showed this directed staff to discard 90 days after
opening the bottle.
Review of the online undated Physician Digital Reference for [MEDICATION NAME][MEDICATION
NAME](an injection for maintenance therapy of [MEDICAL CONDITION], a chronic and severe
mental disorder that affects how a person thinks, feels and behaves), showed the
medication should be refrigerated (between 36 and 46 degrees F).
1. Review of Resident #33’s (MONTH) (YEAR) physicians’ order sheet (POS) showed:
– [MEDICATION NAME] 2 mg/ml (milligrams/milliliters), give 0.25 ml to 1.0 ml sublingual
(under the tongue) every hour as needed for anxiety.
Observation on [DATE], at 4:02 P.M., of the facility’s medication refrigerator in the
medication storage room showed:
– The refrigerator partially left open and the thermometer inside the refrigerator read 42
degrees F;
– Ice approximately 1 ,[DATE] inch thick completely covered the freezer.
– The lock box contained Resident #33’s opened bottle of liquid [MEDICATION NAME];
– The bottle did not contain a date showing when staff opened the bottle;
– A plastic container that contained three slices of pizza, the container, not labeled and
did not contain a date.
During an interview on [DATE], at 4:15 P.M., Licensed Practical Nurse (LPN) B said:
-Residents #33’s liquid [MEDICATION NAME] should have a date written on the bottle when
staff opened the bottle to ensure the medication is not expired;
-He/she planned to discard the staff’s pizza and staff’s food should not be stored with
the resident’s medications.
2. Review of Resident #20’s (MONTH) (YEAR) physicians’ order sheet (POS) showed:
– [MEDICATION NAME][MEDICATION NAME] mg inject one syringe intramuscular (IM) every 2
weeks in the morning for a [DIAGNOSES REDACTED].
Observation on [DATE], at 6:30 A.M., of the facility’s medication refrigerator in the
medication storage room showed:
– The medication refrigerator door completely open and all the medications from the
refrigerator sitting on the counter in the medication room;
– A plastic container that contained more than seven insulin pens sat on the counter;
– Two boxes of Resident #20’s [MEDICATION NAME][MEDICATION NAME] on the counter;
– The lock box that contained Resident #33’s liquid [MEDICATION NAME] sat on the counter;
– The refrigerator thermometer was next to the medications and the temperature was 70 F.
During an interview on [DATE], at 6:45 A.M., LPN A said:
– He/she started to defrost the refrigerator in the medication room at about 4:00 A.M.;
– He/she placed all the medications from the refrigerator on the counter a few hours ago;
– He/she should have placed all the contents into another refrigerator;
– The lock box contained Resident #33’s [MEDICATION NAME] and this too should be
refrigerated;
– The plastic container on the counter contains several residents’ insulin pens and the
instructions on the pens reads to refrigerate prior to use.
During an interview on [DATE], at 2:30 P.M., the Director of Nursing (DON) said:
– Medications should be dated when opened, because the expiration date of medications can
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
change once opened;
– Medications that require refrigeration should be refrigerated at all times and when the
refrigerator in the medication room is being defrosted, she expects staff to utilize one
of the facility’s other refrigerators;
– Resident #20’s [MEDICATION NAME][MEDICATION NAME] very expensive medication;
– Food should not be stored in the medication room refrigerator.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation, interview and record review, the facility failed to ensure dietary
staff served food at an appetizing temperature. This had the potential to affect all
residents. The facility census was 41.
Observation on 7/10/18, at 7:25 A.M., showed Cook A began serving the residents. He/she
took the lids off the steam table. At 7:48 A.M., staff served the last tray as a test
tray. The pancakes were 96.6 degrees Fahrenheit (F). The sausage was 111.4 degrees F. The
scrambled eggs were 114.6 degree F. The milk’s temperature was 44.4 degrees F.
During an interview on 7/12/18, at 9:05 A.M., Cook A said the food needs to be 145 degrees
F when served.
During an interview on 7/12/18, at 9:15 A.M., the dietary manager said hot food should be
served at 135 degrees F and cold food should be served at 42 degrees F.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed infection control protocols to prevent the spread of infection when staff did not
wash their hands when entering resident rooms or before giving care, when going from a
soiled area to a clean area during perineal care, before touching clean items and
medications, which affected three of 13 sampled residents (Resident #11, #13 and #33).
Additionally, staff poured medication from a med cup back into the medication bottle,
which affected one additional resident (Resident #21). The facility census was 41.
Review of the facility’s policy on Gloves, Nursing Guidelines Manual, (MONTH) (YEAR),
showed:
– Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, urine, fecal
material, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with
these substances) and/or persons with a rash.
– Gloves must be changed between residents and between contact with different body sites
of the same resident.
– Remember: Gloves are not a cure-all. They should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects.

– Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
a glove easier than to the skin of your hands.
– Handling medical equipment and devices with contaminated gloves is not acceptable.
– The following general guidelines are recommended:
– Change gloves between contacts (as defined above) with different residents or with
different body sites of the same resident.
– The infection control policies did not address hand sanitizers.
Review of the facility’s Medication Administration policy dated (MONTH) (YEAR), showed:
– Staff are directed to use a syringe and or a calibrated medication cup to obtain the
accurate number of milliliters (ml) when administering liquid medications.
– The policy did not indicate to not pour contents back into a multi-dose medication
bottle.
1. Review of Resident #33’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/30/18, showed:
– Severe cognitive impairment, always incontinent of bladder, and [MEDICAL CONDITION]
(loop of small intestine connected to the abdominal wall to create a stoma, to pass stool
out of the body);
– Total dependence of staff for all activities of daily living (ADLs).
Review of the resident’s care plan, updated on 6/26/18, showed:
– Problem: urinary incontinence;
– Approach: provide good peri-care after each incontinent episode and staff to change
[MEDICAL CONDITION] as needed to prevent breakdown.
Observation on 7/9/18, at 4:25 P.M., showed:
– Certified Nurse Aide (CNA) A and Nurse Assistant (NA) A entered the resident’s room to
perform perineal care, washed and gloved their hands.
– Staff exposed the resident’s abdomen revealing an [MEDICAL CONDITION] bag full of fecal
material, which CNA A removed;
– The resident grabbed the bag and stoma site, and sprayed fecal material over the
resident’s sheets, his/her shirt, arm, and hands;
– NA A grabbed the resident’s hands, but the resident’s arm rubbed on the stoma site;
– CNA A emptied the resident’s [MEDICAL CONDITION] bag into the toilet, placed it back on
the resident, and removed his/her gloves, but did not wash his/her hands and touched the
resident before he/she applied alcohol hand sanitizer to his/her hands;
– NA A removed the resident’s soiled sheet and wiped the resident’s hands soiled with
fecal material. NA A looked at the resident’s arm to find green fecal material, washed the
resident’s arm, removed his/her gloves, used alcohol hand sanitizer on his/her hands and
regloved.
– Staff opened the resident’s brief, wet with urine, and CNA A rolled the resident on to
his/her right side for NA A to clean the resident’s buttocks;
– Rolled the resident onto his/her back, the resident pulled of his/her [MEDICAL
CONDITION] bag, and CNA A replaced it on the resident again.
– CNA A removed the soiled gloves, did not wash his/her hands, grabbed clean gloves with
soiled hands and regloved.
– CNA A performed perineal care on the frontal inner perineal folds with soiled gloves,
walked to the other side of the bed, bent over to pick the trash on the floor, while
his/her lanyard went into the trash can wear it touched wipes soiled with fecal material.
– CNA A removed soiled gloves, applied alcohol hand sanitizer to his/her hands, did not
clean his/her soiled lanyard, then assisted NA A to dress the resident.
During an interview on 7/9/18, at 5:00 P.M., NA A said staff should wash their hands after
they removed soiled gloves and not touch anything with soiled gloves.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
During an interview on 7/9/18, at 5:10 P.M., CNA A said he/she should wash hands after
she/she removed soiled gloves;
– Should not touch the resident or anything clean with soiled gloves;
– His/her lanyard should not go into the trash can, touch soiled wipes, and he/she should
have stopped and cleaned it.
2. Review of Resident #13’s quarterly MDS, dated [DATE], showed:
– [DIAGNOSES REDACTED].
– Feeding tube.
Review of the resident’s (MONTH) (YEAR) physician order [REDACTED].
– [DIAGNOSES REDACTED].
– [MEDICATION NAME] (medication to control [MEDICAL CONDITION]) 300 milligrams (mg)
capsule, take one capsule per tube three times daily for [MEDICAL CONDITION];
– [MEDICATION NAME]/[MEDICATION NAME] (APAP) 5/325 mg, take one tablet per tube every 6
hours for pain, not to exceed three grams of APAP in all meds in 24 hours.
Observation on 7/11/18, at 3:10 P.M., showed:
– Licensed Practical Nurse (LPN) B in the facility medication room, preparing the
resident’s medications for peg tube administration, opening drawers and going through
medication cards to find correct medication card;
– LPN B did not wash his/her hands and glove;
– LPN B grabbed the resident’s [MEDICATION NAME] capsule with bare hands and poured the
contents into a medication cup;
– Crushed the [MEDICATION NAME] tablet and poured into a medication cup;
– LPN B entered the resident’s room for peg tube medication administration, washed and
gloved his/her hands, and administered the medications.
During an interview on 7/11/18, at 3:30 P.M., LPN B said he/she should put gloves on to
touch a resident’s medication.
3. Review of Resident #11’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by the facility, dated 5/4/18, showed:
– Severe cognitive impairment; resident is rarely/never understood;
– Extensive assist of two staff for bed mobility, transfers, dressing and hygiene needs;
– The resident has a feeding tube;
– Indwelling catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/18/18, showed:
– Total dependence on staff for care due to decreased cognitive ability and a [DIAGNOSES
REDACTED].
– Staff assistance with perineal care due to urinary incontinence;
– Change incontinent pads as soon as possible after the resident voids or defecates.
During an observation on 7/9/18, at 2:35 P.M., – CNA A and NA A assisted the resident to
bed with a mechanical lift to provide incontinent care;
-Both staff entered the room, and did not wash their hands before they both put on clean
gloves;
-Staff transferred the resident from his/her wheelchair to the bed with the mechanical
lift;
-Both staff rolled the resident to remove the lift seat from under the resident;
-CNA A provided incontinent care including removing fecal material from the resident’s
rectal area then he/she removed his/her gloves and did not wash his/her hands;
-With dirty hands, CNA A touched clean linen, put a clean gown on the resident, assisted
NA A to pull the resident up in bed, adjusted the pillow under the resident’s head,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265480

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/12/2018

NAME OF PROVIDER OF SUPPLIER

GRAND RIVER HEALTH CARE

STREET ADDRESS, CITY, STATE, ZIP

118 TRENTON ROAD
CHILLICOTHE, MO 64601

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
touched the call light, and lowered the bed, with dirty hands;
-NA A removed his/her gloves did not wash his/her hands before touching clean items with
dirty hands;
-Both staff washed their hands and exited the resident’s room.
During an interview on 7/9/18, at 2:50 P.M. CNA A and NA A said:
-Staff should wash their hands when entering a resident’s room before providing care.
-Staff should wash their hands and change gloves between dirty and clean tasks.
-Staff should not touch clean items with dirty hands.
-Staff should always wash their hands after glove removal.
4. Review of Resident #21’s admission MDS, dated [DATE], showed:
– No cognitive impairment;
– Independent with bed mobility, dressing, and limited staff assistance with transfers and
toileting needs;
– [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) POS showed the following:
– [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) mg /milliliters (ml) liquid,
take 17.5 ml orally twice daily.
Observation on 7/12/18, at 9:15 A.M., showed:
– Certified Medication Technician (CMT) A prepared the resident’s morning medications in
the hall outside the resident’s room;
– Poured [MEDICATION NAME] into two 30 ml medication cups which sat on top of the
medication cart;
– One cup contained 15 ml and the other cup contained 10 ml;
– Used a syringe to withdraw 2.5 ml from the medication cup that contained 10 ml;
– Squirted the contents from the syringe which was 2.5 ml into the medication cup that
contained 15 ml for a total of 17.5 ml;
– Did not discard the 7.5 ml of [MEDICATION NAME] from the medication cup and he/she
poured the contents back into the bottle of [MEDICATION NAME].
During an interview on 7/12/18, at 1:00 P.M., CMT A said:
– Staff should never pour medications back into the bottle;
– He/she should have discarded Resident #21’s [MEDICATION NAME].
5. During an interview on 7/12/18, at 2:30 P.M., the Director of Nurses (DON) said:
– She expected staff to remove soiled gloves and wash their hands before any clean care
given;
– Staff should wash their hands when entering or exiting a resident’s room;
– Staff should have clean hands and gloves when they handle a resident’s medications;
– A lanyard should not go down into a trash can and staff should clean their lanyard if it
goes into the trash can;
– She expected staff to have all soiled areas cleaned after a resident touched the
[MEDICAL CONDITION] area.
– Liquid medicine must never be poured back into the original bottle.