Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0576

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on interview and record review the facility failed to ensure mail delivered to the
facility on Saturdays was consistently distributed to residents on the day of delivery.
This has the potential to affect all the residents residing at the facility. The facility
census was 65 residents.
Record review of the facility’s Mail Distribution Policy and Procedure showed:
-Mail would be delivered unopened to residents on the same day of mail delivery by the
Activities Department and
-All resident outgoing mail would be mailed within 24 hours of receipt.
1. During interview on 9/24/18 at 9:45 A.M. the Activity Director said:
-He/she worked Monday through Friday and
-He/she was currently the only Activity staff at the facility.
During an interview on 9/25/18 at 10:00 A.M. with 10 residents who normally attend the
Resident Council Meetings, the group members said:
-During the week from Monday through Friday the Activity Director delivered the mail to
the residents;
-On Saturdays nobody from the Nursing staff or any other department distributed the mail
to the residents on Saturdays and
-If residents got mail on a Saturday it was delivered to them the following Monday by the
Activity Director.
During an interview on 10/2/18 at 3:15 P.M. the Director of Nursing (DON) said:
-The postal delivery person places mail in the facility’s mail box Monday through Saturday
and occasionally on Sundays;
-The Registered Nurse (RN) supervisor on the Saturday Day Shift should sort the mail and
deliver the mail to the residents on Saturday and
-Agency nurses may not know they are to deliver the mail to the residents on Saturdays.

F 0577

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on interview and record review, the facility failed to ensure residents were made
aware of the location of the State Agency Survey results. This had the potential to affect
all the residents. The facility census was 65 residents.
1. During an interview on 9/25/18 at 10:00 A.M., ten residents who normally attend the
Resident Council meetings met for discussion, and the residents said:
-They had never discussed in the Resident Council meetings or had been told by any
facility staff the location of the results from the State Inspection for the residents
and/or their families to read and
-None of the residents who attended the group interview knew where the results would be
located.
Observation on 9/25/18 at 11:10 A.M. showed survey results were located in a closed
notebook which was sitting on a table near the front entrance outside the Administrator’s
office.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0577

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
Record review of the Resident Council Meeting Minutes for June, (MONTH) and August, (YEAR)
showed there was no discussion during these months related to how to access the state
survey results.
During an interview on 10/2/18 at 3:15 P.M. the Director of Nursing (DON) said:
-The results of the last survey were sitting on a table in a notebook near the front
entrance and
-Did not know if the residents had ever been told or knew where to look for the survey
results.

F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Immediately tell the resident, the resident’s doctor, and a family member of situations
(injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident’s
physician and/or the resident’s family were notified of the resident’s wounds for two
sampled residents (Resident #25 and #35) out of 32 sampled residents. The facility census
was 65 residents.
Record review of the facility’s wound care policy revised on 6/1/15, showed the following:
-Any significant abnormal findings are reported to the resident’s physician and to the
resident’s contact person and
-The staff is to document the of the primary care provider notification, orders received,
family notification and resident response to any treatment.
1. Record review of Resident #35’s Face Sheet showed he/she was admitted to the facility
on [DATE] and with the following Diagnoses: [REDACTED].
-Muscle Weakness;
-[MEDICAL CONDITIONS] disease of the arteries and veins of the extremities) and
-Cognitive communication deficits.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated tool required to be completed by staff for care planning) dated 7/7/18 showed
he/she:
-Was severely cognitively impaired and
-Was at risk for the development of pressure ulcers.
Record review of the resident’s pressure ulcer Care Plan dated 7/10/18 showed the resident
had the potential for pressure ulcer development related to immobility, incontinence, and
his/her Braden score risk (a tool completed by staff to show if the resident was at risk
of developing pressure ulcers).
Record review of the resident’s Weekly Skin assessment dated [DATE] completed by Licensed
Practical Nurse (LPN) A showed:
-The resident’s skin condition was dry and the resident had blisters;
-The areas affected were the hip area and ankle area and
-The right hip area was circled on the body site area.
Record review of the resident’s Nurse’s Notes dated 9/22/18 completed by LPN D showed:
-The resident had a blister on the back of the right heel that has lost fluid, the skin
was loose and intact;
-The nurse would continue to monitor and
-The staff did not document the resident’s physician or family were notified of the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
resident’s right heel blister.
Record review of the resident’s Nurses Notes dated 9/23/18 showed:
-The resident had a raised area to his/her right heel;
-The resident’s right heel was cleaned and gauze was applied;
-There were no physician’s order for treatment of [REDACTED].
-The staff did not document the resident’s physician or family were notified of the
resident’s raised area to his/her right heel.
During an interview on 9/27/18 at 1:17 P.M., LPN B said:
-He/she had only worked on this unit two times and
-He/she did not notify the family of the resident’ right heel blister but should have.
During an interview on 9/27/18 at 2:44 P.M., LPN D said:
-He/she was aware of the residents right heel wound and
-He/she should have notified the resident’s family and physician when he/she discovered
the wound on 9/22/18.
During an interview on 9/27/18 at 4:21 P.M., LPN A said:
-When he/she completed the resident’s skin assessment on 9/22/18, the resident had a red
hip area and right heel blister and
-He/she did not notify the resident’s physician and family member of the resident’s right
heel blister and hip area but should have.
2. Record review of Resident #25’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-High blood pressure;
-Heart failure;
-Dysphagia (inability or difficulty swallowing)
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation);
-Cognitive communication deficit and
-[MEDICAL CONDITION].
Record review of the resident’s Pressure Ulcer care plan dated 1/3/18 showed:
-The staff were to avoid shearing during positioning, transferring, and turning;
-The staff were to conduct a weekly skin assessment by a licensed nurse and daily with
cares by the nursing staff;
-Consult with the outside wound company as needed;
-Complete treatment orders to the wound area and
–Staff documented on the care plan discontinued-healed with no date.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she:
-Was severely cognitively impaired with inattention and disorganized thinking and
-Was at risk of pressure ulcers.
Record review of the resident’s Nurses Notes dated 9/8/18 at 10:28 A.M. showed:
-The resident had two fluid filled blisters;
-One blister was 1 ¾ inch long on his/her right upper/outer thigh and one blister ¼ inch
on the back of his/her left thigh and
-The staff did not document the resident’s physician or family were notified of the
resident’s thigh blisters.
Record review of the resident’s Nurses Notes dated 9/10/18 showed:
-The resident continued to have the noted areas and
-The staff did not document the resident’s physician or family were notified of the
resident’s thigh blisters.
3. During an interview on 9/27/18 at 1:33 P.M., Registered Nurse (RN) Supervisor A and LPN
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
C said:
-If a resident has skin break down and
-The nurse should notify the resident’s family and physician.
During an interview on 9/27/18 at 4:29 P.M., the Director of Nursing (DON) said:
-When a wound was identified, he/she expected the charge nurse to contact the resident’s
physician and family and
-He/she expected the nurse to call the physician for treatment orders before doing a
treatment.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to fully complete the Skilled
Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS- ) or the Notice of
Medicare Provider Non-Coverage (NOMNC, form CMS- ) for two sampled residents (Resident #17
and #64) out of three sampled residents who were discharged from Medicare part A services
and remained in the facility. The facility census was 65 residents.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification
memo (S&C-09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS- ) is issued when all
covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident’s stay
that Medicare will not pay for skilled nursing or specialized rehabilitative services and
the provider believes that an otherwise covered item or service may be denied as not
reasonable or necessary, the facility must inform the resident or his/her legal
representative in writing why these specific services may not be covered and the
beneficiary’s potential liability for payment for the non-covered services. The SNF’s
responsibility to provide notice to the resident can be fulfilled by the use of either the
SNFABN (form CMS- ) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to
pay for them him/herself or through other insurance they may have; and
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits, the provider has met is
obligation to inform the beneficiary of his/her potential liability for payment and
related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys
notice to the beneficiary of his/her right to an expedited review of a service
termination.
1. Record review of Resident #17’s SNF Beneficiary Protection Notice Review showed:
-The resident was discharged from Medicare Part A service and remained in the facility on
7/13/18.
-The facility staff member made a note on the form stating the SNFABN and the NOMNC were
not issued by the Social Worker.
Record review of Resident #64’s SNF Beneficiary Protection Notice Review showed:
-The resident was discharged from Medicare Part A service and remained in the facility on
7/22/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 – Few

(continued… from page 4)
-The facility staff member made a note on the form stating the SNFABN and the NOMNC were
not issued by the Social Worker.
During an interview on 9/26/18 at 8:51 A.M., the Business Office Manager (BOM) said:
-He/she had pulled the files and could not locate SNFABNs or NOMNCs for the residents.
-The Social Worker was out under emergency conditions in the hospital.
-He/she had looked through the Social Workers office and none were found.
During an interview on 9/26/18 at 08:56 A.M., the Administrator said:
-The Social Worker was responsible for completing the NOMNC and SNFABNs.
-The Social Worker was in the hospital at this time.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to notify the resident and the
resident’s representative in writing of transfer to a hospital, including the reason for
the transfer (a resident advocate who provides support and assistance with problems and/or
complaints regarding the facility) a copy of the notification for four sampled residents
(Resident #56, #64, #66, and #315) out of 32 sampled residents. The facility census was 65
residents.
Review of the facility Transfer and Discharge, Emergency policy statement dated 12/2016
showed:
-Emergency transfers and discharges may be necessary to protect the health and/or
well-being of the residents.
-Should it become necessary to make an emergency transfer or discharge to a hospital or
other related institution, our facility will implement the following procedures:
-Prepare the resident for transfer;
-Notify the resident representative (sponsor) or other family member; and other
appropriate or as necessary (the policy did not instruct staff to provide written
notification to the resident and the resident’s representative within 12 hours of the
resident’s transfer or discharge); and
-The name, address and telephone number of the Office of the State Long-Term Care
Ombudsman; and a copy of the notice will be sent to the State Long-Term Care Ombudsman.
1. Record review of Resident #56’s Face Sheet showed:
-He/she was admitted to the facility on [DATE];
-He/she had a [DIAGNOSES REDACTED].
-He/she had a responsible contact person.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated tool
required to be completed by facility staff for care planning) dated 7/31/18 showed he/she
was mildly cognitively impaired.
Record review of the resident’s Nurse’s Notes dated 8/24/18 at 3:15 P.M. showed:
-His/her physician was at the facility and saw the resident;
-His/her physician ordered the resident be admitted to a local hospital for possible
[MEDICAL CONDITION] a condition in which the airways in the lungs become inflamed and
cause coughing, often with mucus, or wheezing) or pneumonia
-The resident’s contact person was contacted;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-He/she left the facility via ambulance to go the hospital for admission; and
-No mention of a transfer letter being given to the resident or the residents contact
person.
Record review of the resident’s Physician’s Telephone Orders sheets showed:
-A physician’s orders [REDACTED].
-A physician’s orders [REDACTED].
Record review of the resident’s Nurse’s Notes dated 8/27/18 at 4:30 P.M. showed the
resident was readmitted to the facility.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a discharge letter was given to the resident, the resident’s
responsible party or if the ombudsman was notified of the resident’s transfer on 8/21/18.
2. Record review of Resident #66’s Nurse’s Notes dated 6/26/18, showed the resident had
hit his/her head and was transferred to a hospital due to a brain bleed out and the
medical doctor wanted to take all precautions for the resident’s health and safety.
Record review of the resident’s Discharge Summary, dated 6/27/18 showed the following:
-The reason for the resident’s discharge was due to a fall at the facility and the
resident was sent to the local hospital emergency room for medical treatment and
additional safety precautions according to physician’s orders [REDACTED].
-Medical defined conditions and prior medical history-was left blank;
-Medical status measurement-was left blank;
-Physical and Mental Functional Status-Ambulated with cane with unsteady gait;
-Sensory and physical impairments/vision and hearing -glasses vision adequate with minimum
difficulty hearing;
-Nutritional status and requirements-heart healthy, mechanical soft diet, nectar thick
liquids;
-Special treatments and procedures-none;
-Mental and psychosocial status- family involved with cares;
-Dental condition-had jagged teeth with some missing and gum tissues pink and moist;
-Activities potential-poor;
-Rehabilitation potential-poor;
-Cognitive status-alert with confusion with severe dementia;
-Activity discharge summary-due to the resident’s health condition the resident was unable
to participate in activities during his/her stay;
-Social Services discharge summary-resident was here for Long-Term Care but program
services discontinued due to emergency hospital visit; and
-Rehabilitation Therapy was left blank
Record review of the resident’s discharge summary did not include the
resident/responsibility party’s signature, resident’s appeal rights, including name,
address (mailing and email), and telephone number of the entity which receives such
requests, and information on how to obtain an appeal form, assistance in completing the
form, and submitting appeal hearing request. The name, address (mailing or email) and
telephone number of the Office of the State Long-Term Care Ombudsman was not included in
the discharge information.
-Moderate cognitive impairment; had Brief Mental Interview Status (BIMS) score of 10 which
means the resident was moderately alert and cognitively impaired;
-Totally dependent on staff for needed total maximum assistance in all Activities of Daily
Living (ADL;s) such transfers, bed mobility, toilet use, personal hygiene and dressings;
and
-Poor balance and gait challenges.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
Record review of the resident’s medical record on 9/27/18, showed there was no
documentation that showed a discharge letter was given to the resident’s responsible party
or if the ombudsman was notified of the transfers on 6/29/18.
3. Record review of Resident #64’s Face Sheet showed the resident was admitted to the
facility on [DATE] and had a family member as his/her responsible party.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to the completed by the facility staff for care
planning) dated 6/16/18 showed the resident was severely cognitively impaired.
Record review of the resident’s Nurses Notes dated 6/1/18 showed:
-The resident was up for lunch and was very weak and could not feed himself/herself; and
-The resident’s physician was notified and the resident was sent to the hospital.
Record review of the resident’s Nurses Notes dated 6/4/18 showed the resident returned
from the hospital at 4:30 P.M.
Record review of the resident’s Nurses Notes dated 6/5/18 showed:
-The resident complained of pain and his/her abdomen was enlarged; and
-The resident’s physician was notified and the resident was sent to the hospital.
Record review of the resident’s Nurses Notes dated 6/9/18 showed the resident returned
from the hospital at 7:00 P.M.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a discharge letter was given to the resident’s responsible party
or if the ombudsman was notified of the transfers on 6/1/18 or 6/5/18.
4. Record review of Resident #315’s Face Sheet showed the resident was admitted to the
facility on [DATE] and had a family member as his/her responsible party.
Record review of the resident’s quarterly MDS dated [DATE] showed the resident was
cognitively intact.
Record review of the resident’s Nurses Notes dated 9/14/18 showed:
-The resident had several episodes of emesis (vomiting) and the physician was called; and
-The resident was sent to the hospital per the physician.
Record review of the resident’s Nurses Admission assessment dated [DATE] showed the
resident returned from the hospital at 8:45 A.M.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a discharge letter was given to the resident’s responsible party
or if the ombudsman was notified of the transfer on 9/14/18.
5. During an interview on 9/25/18 at 3:19 P.M., the Corporate Administrator said:
-The facility was not notifying residents and/or responsible parties of the transfer to
the hospital; and
-The facility was not contacting the ombudsman of the resident’s transfer to the hospital.
During an interview on 9/27/18 at 9:00 A.M.,, the Certified Medication Technician (CMT) A
said the facility did not provide a discharge/transfer notice prior to the resident
leaving for the emergency room and did not provide written notice of discharge/transfer to
Long Term-Care Provider prior to the resident leaving to go to the emergency room .
During an interview on 10/1/18 at 9:45 A.M., the Licensed Practical Nurse (LPN) E said the
facility did not provide a discharge/transfer notice to the Long-Term Care Ombudsman
Officer prior to the resident leaving to go to the hospital emergency room .
During an interview on 10/03/18 at 10:30 A.M., the Director of Nursing (DON) said:
-The resident was not given any paperwork when going to the hospital;
-The nurse would verbally tell the resident where they were going;
-The nurses do not give any notice to the resident up transfer;
-The ombudsman was not notified of the transfers; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-He/she was unaware this needed to be done.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a bed hold policy was
given to the resident or the resident’s responsible party at the time of transfer for four
sampled residents (Resident #56, #64, #66, and #315) out of 32 sampled residents. The
facility census was 65 residents.
Review of the facility Transfer and Discharge, Emergency policy statement dated 12/2016
showed:
-Emergency transfers and discharges may be necessary to protect the health and/or
well-being of the residents.
-Should it become necessary to make an emergency transfer or discharge to a hospital or
other related institution, our facility will implement the following procedures:
-Prepare the resident for transfer;
-Notify the resident representative (spouse) or other family member; and other appropriate
or as necessary; and
-The resident and/or the resident’s responsible party would be provided a bed hold policy.

1. Record review of Resident #56’s Face Sheet showed:
-He/she was admitted to the facility on [DATE];
-He/she had a [DIAGNOSES REDACTED].
-He/she had a responsible person contact.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool required to the completed by the facility staff for care planning dated
7/31/18 showed he/she was mildly cognitively impaired.
Record review of the resident’s Nurse’s Notes dated 8/24/18 at 3:15 P.M. showed:
-His/her physician was at the facility and saw the resident;
-His/her physician ordered the resident be admitted to a local hospital for possible
[MEDICAL CONDITION] a condition in which the airways in the lungs become inflamed and
cause coughing, often with mucus, or wheezing) or pneumonia
-The resident’s contact person was contacted;
-He/she left the facility via ambulance to go the hospital for admission and
-No mention of a bed hold notice being given to the resident or the residents contact
person.
Record review of the resident’s Physician’s Telephone Orders sheets showed:
-An order dated 8/21/18 for him/her to be sent to the local hospital for admission and
-An order dated 8/27/18 for the resident to be readmitted to the facility.
Record review of the resident’s Nurse’s Notes dated 8/27/18 at 4:30 P.M. showed the
resident was readmitted to the facility.
2. Record review of Resident #66 Nurses’ Notes dated 6/26/18, showed he/she had hit
his/her head and transferred to a hospital due due to a brain bleed out and the medical
doctor wanted to take all precautions for the resident’s health and safety and provided

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
physician’s orders [REDACTED].
Record review of the resident’s Discharge Summary,dated 6/27/18, showed the following:
-The reason for the resident’s discharge was due to a fall and the resident was sent to
the local hospital emergency room for medical treatment and additional safety precautions;
-Medical defined conditions and prior medical history-was left blank;
-Medical status measurement-was left blank;
-Physical and Mental Functional Status – Ambulated with cane with unsteady gait;
-Sensory and physical impairment/vision and hearing-glasses vision adequate with minimum
difficulty hearing;
-Nutritional status and requirements-heart healthy, mechanical soft diet, nectar thick
liquids;
-Special treatment and procedures-none;
-Mental and psychosocial status-family involved with care;
-Dental condition-had jagged teeth with some missing and gum tissues pink and moist;
-Activities potential-poor;
-Rehabilitation potential-poor;
-Cognitive status- alert with confusion with server Dementia;
-Activity discharge summary-resident was here for Long-Term Care but program services were
discontinued due to emergency hospital visit;
-Social Services discharge summary-resident was here for Long-Term Care but program
services discontinued due to emergency hospital visit and
-Rehabilitation Therapy- as left blank;
Record review of the resident’s Discharge Summary dated 6/27/18 showed the discharge
summary did not include the bed-hold policy was given to the resident and or the
resident’s representative.
-Record review of the resident’s Brief Interview Mental Status (BIMS) showed a score of 10
which means the resident was moderately alert and cognitively impaired;
-He/she was totally dependent on staff and needed total maximum assistance in all
Activities of Daily Living such as transfers, bed mobility, toilet use, personal hygiene
and dressings and
-He/she had poor balance and gait challenges.
3. Record review of Resident #64’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a family member as his/her responsible party.
Record review of the resident’s significant change MDS dated [DATE] showed the resident
was severely cognitively impaired.
Record review of the resident’s Nurses Notes dated 6/1/18 showed:
-The resident was up for lunch and was very weak and could not feed himself/herself and
-The resident’s physician was notified and the resident was sent to the hospital.
Record review of the resident’s Nurses Notes dated 6/5/18 showed:
-The resident complained of pain and his/her abdomen was enlarged and
-The resident’s physician was notified and the resident was sent to the hospital.
Record review of the resident’s Nurses Notes dated 6/9/18 showed the resident returned
from the hospital at 7:00 P.M.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a bed hold policy was given to the resident’s responsible party
on 6/1/18 or 6/5/18.
4. Record review of Resident #315’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had a family member as his/her responsible party.
Record review of the resident’s quarterly MDS dated [DATE] showed he/she was cognitively
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
intact.
Record review of the resident’s Nurses Notes dated 9/14/18 showed:
-The resident had several episodes of emesis (vomiting) and the physician was called and
-The resident was sent to the hospital per the physician.
Record review of the resident’s Nurses Admission assessment dated [DATE] showed the
resident returned from the hospital at 8:45 A.M.
Record review of the resident’s medical record on 9/27/18 showed there was no
documentation that showed a bed hold policy was given to the resident or the resident’s
responsible party for the transfer on 9/14/18.
5. During an interview on 9/25/18 at 3:19 P.M., the Corporate Administrator said the
facility was not sending the bed hold policy with the residents.
During an interview on 9/27/18 at 9:30 A.M., the Certified Medication Technician (CMT) A
said the facility did not provide a written notice of the bed-hold policy to the resident
leaving for the emergency room and did not provide appropriate written notice to the Long
Term Care Ombudsman in a timely manner.
During an interview on 10/1/18 at 9:45 A.M., Licensed Practical Nurse (LPN) E said the
facility did not provide written notice of the bed-hold policy to the resident prior to
him/her leaving the facility to go to the emergency room .
During an interview on 10/03/18 at 10:30 A.M., the Director of Nursing (DON) said:
-The resident was not given any paperwork when going to the hospital and
-The nurses do not give any notice to the resident upon transfer.

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 interview the facility failed to ensure the
resident’s Physician order [REDACTED]. on how to administer and the time to give the
[MEDICAL CONDITION] medication were written on the POS and it matched the residents
Medication Administration Record [REDACTED]. The facility census was 65 residents.
Record review of the manufacturer recommendations for [MEDICATION NAME] ( a medication
used to treat arthritis pain), showed the following:
-Precautions were increased risk for severe stomach bleeding, gastrointestinal upset
and/or bleeding, and
-Take [MEDICATION NAME] during or immediately after food with a full glass of water or
milk.
Record review of the manufacturer recommendations for [MEDICAL CONDITION] medications
showed the following:
-Take [MEDICAL CONDITION] medications first thing in the morning with water on an empty
stomach and wait an hour before eating or drinking coffee, and
-Wait at least three to four hours before taking any other medications.
1. Record review of Resident #18’s (MONTH) (YEAR) POS, showed physician’s orders
[REDACTED].>-Resided on the secured unit due to Dementia (a group of thinking and
social symptoms that interfere with daily functioning like memory loss),
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] 50 micrograms (mcg) take one tablet by mouth daily at 6:00 A.M. (it

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 10)
does not instruct staff to give on an empty stomach and not to give with other
medications) used to treat [MEDICAL CONDITION], and
-[MEDICATION NAME] ([MEDICATION NAME]) 220 milligrams (mg) give two tablets by mouth twice
daily at 8:00 A.M. and 8:00 P.M. used to treat pain. (there was no instructions from
pharmacy when to give the [MEDICATION NAME] with food).
Record review of the resident’s (MONTH) (YEAR) MAR indicated [REDACTED]
-[MEDICATION NAME] 220 mg give two tablets by mouth twice daily. It was originally written
to be given at 8:00 A.M. and 8:00 P.M., the staff crossed out those times and wrote 6:00
A.M. and 6:00 P.M. and (there were no instructions from pharmacy on when to give
[MEDICATION NAME] with food),
-The staff initialed the box that they gave [MEDICATION NAME] at 6:00 A.M. from (MONTH) 1,
(YEAR)-September 27, (YEAR); and
-[MEDICATION NAME] 50 mcg one tablet by mouth daily and it was to be given at 6:00 A.M.
(there was no instructions from pharmacy to give [MEDICATION NAME] on an empty stomach and
not to give with other medications).
Observation and interview on 9/26/18 at 6:00 A.M. showed Registered Nurse (RN) B during
the medication pass:
-RN B punched out the [MEDICATION NAME] into the medication cup. RN B said [MEDICATION
NAME] was supposed to be given with [MEDICATION NAME] and it has always been given with
the [MEDICATION NAME].
-RN B said the pharmacy did not write instructions on the MAR indicated [REDACTED].M. with
the [MEDICATION NAME].
-RN B held the [MEDICATION NAME] and said the day shift will give it with the resident’s
breakfast.
-RN B said he/she was going to speak with the Director of Nursing (DON) about the times of
the [MEDICATION NAME] and the [MEDICATION NAME] should be given and the instructions that
should be on the MAR indicated [REDACTED].
During an interview on 10/2/18 at 12:58 P.M., the DON said:
-The resident’s [MEDICAL CONDITION] medication should be given on an empty stomach and not
with any other medications.
-The charge nurses do the monthly change over to make sure the POS matches the MAR.
-Does not know who are why the staff crossed out the time at 8:00 A.M., and 8:00 P.M. and
put the 6:00 A.M. and 6:00 P.M. for the resident’s [MEDICATION NAME].
-The resident’s POS and MAR indicated [REDACTED].
-The resident’s POS and MAR indicated [REDACTED].M.
-The resident’s POS showed the [MEDICATION NAME] to be given twice at 8:00 A.M. and 8:00
P.M.
-The resident’s MAR indicated [REDACTED].M. and 8:00 P.M. to 6:00 A.M. and 6:00 P.M. and
the resident’s [MEDICATION NAME] should be given with food and not with the [MEDICATION
NAME].
-Expected the staff to follow physician’s orders [REDACTED].

F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Plan the resident’s discharge to meet the resident’s goals and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to assist one sampled resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
(Resident #31) out of 32 sampled residents, who wanted to be discharged to another
facility. The facility census was 65 residents.
Record review of the facility’s Resident Rights policy revised (MONTH) (YEAR) showed the
resident has the right to be supported by the facility in exercising is/her rights.
1. Record review of the resident’s Face Sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Unspecified displaced [MEDICAL CONDITION] and fifth cervical vertebra (spinal cord
injury); and
-Was [AGE] years old.
Record review of the resident’s discharge Care Plan edited 3/23/18 showed the resident:
-Had a potential for discharge; and
-Would discharge without difficulty when the time was appropriate.
Record review of the resident’s quarterly Minimum Data (MDS-a federally mandated tool
required to be completed by facility staff for care planning) dated 6/19/18 showed the
resident:
-Was cognitively intact;
-Was totally dependent on staff for bed mobility, dressing, transfers and bathing;
-Did not want to discharge to the community; and
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s Social Services Progress Notes dated 6/20/18 showed:
-The resident requested medical records to be sent to a facility in North Dakota;
-The medical records were sent to the facility in North Dakota; and
-There was no further documentation about the referral.
Record review of the resident’s Care Plan Conference Sheet dated 9/19/18 showed:
-The resident’s family had requested to have a referral sent to a nursing home in Liberty;
and
-There was no further documentation related to this referral or any other referrals made
by the facility related to transfering to another facility.
During an interview on 9/24/18 at 11:29 A.M., the resident said:
-He/she had been trying to move closer to Kansas City to be near family;
-No one would help him/her to move to another facility;
-He/she had talked to the Social Services Director (SSD) and the Administrator;
-His/her parents arranged for a possible transfer to a nursing home;
-He/she was accepted at another nursing home in Liberty; and
-Then the transfer to the nursing home in Liberty had been canceled but he/she had not
been told why.
During an interview on 9/25/18 at 8:20 A.M., the Assistant Director of Nursing (ADON)
said:
-The resident was working on transferring to another facility with Social Services
Director;
-The SSD was in the hospital at this time;
-Many times information was sent to facilities and was denied; and
-The Administrator had been working on the resident’s transfer to another facility also.
During an interview on 10/01/18 at 11:27 A.M., the Administrator said:
-Two referrals were sent out of state to facilities but the payer source was Missouri
Medicaid;
-These facilities would not accept him/her due to his/her payer source;
-The SSD had sent paperwork to a nursing home in Liberty and the facility did come out to
evaluate the resident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-This referral was more family driven;
-He/she had told the resident about the facilities not accepting him/her;
-The SSD had talked to the resident about the referral rejection;
-He/she would have to look for additional information and additional social services
notes; and
–No additional documentation was received from the facility.
During an interview on 10/02/18 at 12:45 P.M., the resident said:
-He/she had been asking for help for discharge planning to go to another facility;
-The facility staff had not provided him/her with assistance with transferring to another
skilled nursing home or provided him/her a list of skilled nursing homes; and
-The facility staff had not helped him/her try to find a facility closer to his/her
family.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide
activities to meet the needs of three sampled resident’s (Resident #5, #15, and #50) with
severe cognitive deficits (impairment in an individual’s mental processes including memory
and thinking skills) and communication difficulty out of 32 sampled resident’s. The
facility census was 65 residents.
1. Record review of Resident #5’s Face Sheet showed he/she was admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (damage to the brain caused by
an injury to the head);
-Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, impulsiveness, disorientation stupor deterioration of
intellectual capacity and function, and impairment of memory, and judgment);
-Anxiety disorder (A chronic condition characterized by an excessive and persistent sense
of apprehension);
-[MEDICAL CONDITION] (a brain disorder that leads to shaking, stiffness, and difficulty
with walking, balance and coordination); and
-Muscle weakness.
Record review of the resident’s Activity Progress Notes dated 3/9/18 showed:
-He/she was brought to the large living room area for a music listening activity;
-He/she seemed to interact with music as he/she in the past had played many instruments
and understood music; and
-He/she occasionally smiled.
Record review of the facility activities records showed he/she was present at only one two
34 activities provided from 6/1/18 through 9/24/18.
Record review of the resident’s Activity Progress Notes dated 6/14/18 showed:
-He/she responded to live music and had eye expressions; and
-He/she was always encouraged and taken to most activities by staff.
Record review of the resident’s Minimum Data Set (MDS-a federally mandated tool required
to be completed by facility staff for care planning) dated 6/26/18 showed he/she:
-Did not speak;
-Was rarely/never understood by others and rarely/never understood by other;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-Was severely cognitively impaired;
-Received extensive staff assistance for bed mobility and eating;
-Was totally dependent on staff for transfer, locomotion, dressing, and personal hygiene;
and
-Received hospice (end of life) services.
Record review of the resident’s care plan dated 6/29/18 showed:
-Goals including that he/she would have enhanced quality of life with continued
participation in activities appropriate for him/her and he/she would have his/her needs
and wants anticipated and provided by staff;
-He/she had a TV in his/her room and enjoyed watching it;
-His/her activities would have to be changed to his/her declining condition;
-He/she was now nonverbal and on hospice care; and
-He/she needed a variety of activities that were appropriate for him/her.
Record review of the resident’s Activity Progress Notes dated 8/1/18 showed:
-He/she was on hospice care;
-He/she responded to music and verbal contact; and
-His/her eyes reacted to verbal stimuli and sometimes he/she smiled.
Record review to the resident’s Record of One-To-One Activities notes dated 8/30/18
showed:
-He/she was fed by the activity director;
-The activity director talked with him/her about various subjects; and
-He/she would react to subjects with his/her eyes and did smile at one subject.
Record review of his/her physician’s orders [REDACTED].
-Hospice care; and
-He/she may participate in planned activities as tolerated.
Record review of the resident’s Activity Progress Notes dated 9/4/18 showed:
-He/she was on hospice services;
-He/she responded to live music and verbal conversation with his/her eyes; and
-His/her condition did not warrant too much activity, he/she was always included.
Observation on 9/24/18 at 10:26 A.M. showed:
-He/she was alert and up in his/her Broda chair (a padded wheeled chair capable of being
reclined) in the common living area by the TV but was not attentive to the TV; and
-He/she did not respond when spoken to.
Observation on 9/24/18 at 10:51 A.M. showed:
-He/she was alert and up in his/her Broda chair (a padded wheeled chair capable of being
reclined) and
-He/she did not respond when spoken to; and
-His/her room door was quiet with no TV or radio on.
Observation on 9/28/18 at 2:08 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her room was quiet with no radio or TV on; and
-He/she did not respond to being spoken to except to look toward the person speaking.
2. Record review of Resident #15’s Face Sheet showed he/she admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (paralysis partial or total loss
of use of all their limbs and the torso);
-[MEDICAL CONDITION] (disease or damage that affects the function or structure of the
brain); and
-[MEDICAL CONDITION] (loss of the ability to understand or express speech caused by brain
damage).
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
Record review of the resident’s Activity Progress Notes dated 4/3/18 showed:
-He/she seemed to enjoy the music and TV in his/her room; and
-He/she was unable to participate in most daily activities.
Record review of the facility activities records showed he/she was present at only three
of 34 activities provided from 6/1/18 through 9/24/18.
Record review of the resident’s care plan date 7/6/18 showed:
-He/she had little or no activity involvement related to immobility, physical limitations,
cognitive status, and impaired hearing and vision – he/she was unable to communicate but
did follow voices and light;
-A goal that he/she would have enhanced quality of life with his/her participation in
activities appropriate for him/her;
-Have volunteer read to him/her as needed;
-Play music on TV or radio for social stimulation;
-Provide him/her with one-to-one activities two to three times a week;
-Turn on the TV in his/her room for him/her to listen to daily for social stimulation; and
-Take him/her to appropriate activities for him/her.
Record review of the resident’s Activity Progress Notes dated 8/1/18 showed:
-He/she seemed to respond to music and being read to;
-His/her condition severely limits his/her ability to be active; and
-The facility provided no Record of One-To-One Activities for the resident.
Observation on 9/25/18 at 7:52 A.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 9/25/18/18 at 1:51 P.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 9/27/18/18 at 12:35 P.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 9/27/18/18 at 1:08 P.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 9/28/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 9/28/18/18 at 1:47 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her privacy curtain was partially pulled; and
-His/her roommates TV was playing.
Observation on 9/28/18/18 at 1:51 P.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 10/2/18 at 2:52 P.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
Observation on 10/3/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed; and
-His/her room was quiet with no music or TV playing.
3. Record review of Resident #50’s Face Sheet showed he/she admitted to the facility
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
originally on 12/23/16 with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (partial or full
paralysis on one side of the body) and [MEDICAL CONDITION] (loss of or decrease in
sensation on one side of the body) affecting his/her right dominant side;
-Muscle weakness; and
-Cognitive communication deficit (difficulty communicating because of injury to the brain
that controls the ability to think).
Record review of the resident’s Activity Progress Notes dated 1/2/18 showed:
-He/she participated in Bingo, family visits, ministries, entertainment, socials and
watched TV; and
-He/she would be encouraged to participate in activities of his/her choice and maintain
his/her current activity level.
Record review of the facility activities records showed he/she was present at only ten of
34 activities provided from 6/1/18 through 9/24/18.
Record review of the resident’s care plan dated 6/14/18 with revisions dated 9/17/18
showed:
-He/she had limited physical mobility, cognitive deficits, a communication problem,
weakness, and was on hospice care;
-He/she had little or no activity involvement related to immobility, physical limitations,
and he/she preferred to participate in activities only when his/her spouse was present and
declined other invitations;
-A goal that he/she would have enhanced quality of life with active participation in
activities of his/her choice one to two times per week;
-His/her preferred activity was Bingo or food related activities but he/she would watch TV
in the common area at times or in his/her room;
-Staff interventions included-
–Explain to him/he the importance of social interaction, leisure activity and leisure
time;
–Encourage him/her to participation by offering to assist him/her with Bingo cards when
his/her spouse was not present;
–Provide him/her with a variety of activities and locations to maintain his/her interest;
–Provide him/her with assistance to and from activities; and
–Staff would monitor his/her participation levels and adjust his/her activity plan to
meet his/her needs
Record review of the resident’s POS dated 9/1/18 through 9/30/18 showed his/her physician
ordered:
-May participate in planned activities as tolerated; and
-Up ad lib (may be out of bed as much as he/she wished).
Observation on 9/24/18 at 11:11 A.M. showed:
-His/her room was quiet with no radio or TV on; and
-When spoken to, he/she did not respond.
Observation on 9/25/18 at 1:49 P.M. showed:
-His/her room was quiet with no radio or TV on; and
-When spoken to, he/she did not respond.
Record review of the resident’s One-To-One Activities notes dated 9/25/18 showed:
-His/her condition limits his/her ability to be too active;
-With the help of his/her wife he/she did play bingo and did enjoy the live music
performances; and
-The Activity Director did do one-on-one feeding and visiting with him/her about the past
and farming.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
Observation on 9/26/18 at 8:38 A.M. showed:
-He/she was laying on his/he bed;
-He/she was alert and did not speak or respond to staff when spoken to;
-He/she did not assist staff when he/she was rolled from side to side and positioned in
bed; and
-His/her room was quiet with no radio or TV sound.
-Observation on 9/28/18 at 1:43 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her curtain was partially pulled; and
-His/her roommates TV was on and turned toward him/her.
-Observation on 10/3/18 at 8:38 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her room was quiet with no radio or TV on; and
-When spoken to, he/she did not respond.
-Observation on 10/3/18 at 9:03 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her room was quiet with no radio or TV on; and
-When spoken to, he/she did not respond.
4. During an interview on 10/3/18 Cook A said:
-He/she was filling in with providing activities to residents because the facility was
without an Activity Director at this time;
-Resident #50 could minimally participate in Bingo with his/her spouse present; and
-Residents #5, #15 and #50 needed an individualized one-to-one activity program to meet
their needs.
During an interview on 10/3/18 the Director of Nursing (DON) said:
-Resident #5, Resident # 15 and Resident #50 had limitations in their abilities to
communicate and participate in activities; and
-Each needed individualized one-to-one activities.

F 0686

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
preventative measures were in place for development of pressure ulcers resulting in an
avoidable unstageable pressure ulcer on the right heel for one sampled resident (Resident
#35); failed to ensure preventative measures were in place, failed to assess, monitor,
track and stage the resident’s pressure ulcers, failed to obtain physician’s treatment
orders for treatment of [REDACTED].#25) who had avoidable pressure ulcers including a
right thigh blister, a blister on the back of his/her left leg, a right planter foot
unstageable pressure ulcer, and an unstageable pressure ulcer on his/her left great toe;
failed to correctly assess and document the stage for one resident’s (Resident #50)
unstageable pressure ulcer on his/her left gluteal fold (crease between the lower buttocks
and upper thigh); and failed to assess for support surface needs (mattress) and prevention
needed for one sampled resident (Resident #19) who was at risk for pressure ulcers out of
32 sampled residents. The facility census was 65 residents.
Record review of the facility’s Wound Care Policies and Procedures Reference revised

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 17)
6/1/15 showed:
-Stage2 pressure ulcers: (partial thickness loss of dermis presenting as a shallow open
ulcer with a red or pink wound bed, without slough (dead tissue). It may also present as
an intact or open/ruptured blister);
–Goals: Prevention of progress through relief of pressure, absorption of drainage; moist
wound healing; protection from injury;
–If a resident was on a standard mattress, replace with a pressure redistributing
mattress;
–If friction was the suspected injury as to the feet and heels, wear loose white cotton
socks while in bed;
–Apply a [MEDICATION NAME] dressing (an adhesive dressing which had combined absorbent
materials with an adhesive substance to manage and contain light to moderate drainage)
extending beyond the wound bed by 1 ½ to two inches;
-Stage 3 pressure ulcers: (a full thickness tissue loss. Subcutaneous fat may be visible
but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the
depth of tissue loss. (MONTH) include undermining (is caused by erosion under the wound
edges resulting in a large wound with a small opening) in or tunneling (is a channel or
tunnels that extend into the subcutaneous tissue under the skin).
–Goals: Prevention of progress through relief of pressure, absorption of drainage; moist
wound healing; protection from injury; insulation of wound bed;
–Relieve pressure to the area though a turning schedule or elevate the area.
–If the resident was on a standard mattress, replace with either a pressure
redistributing mattress or a specialty surface;
–If friction was the suspected injury as to the feet and heels, wear loose white cotton
socks while in bed;
–Clean with normal saline and evaluate the wound bed; apply a skin sealant around the
wound bed and pack with gel impregnated gauze (packing dressing for wounds with depth);
-Stage 4 pressure ulcers: (Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar (tan, brown or black dead tissue)may be present on some parts of the
wound bed. Often includes undermining and tunnelling);
–Moderate amount of drainage and less than 50% slough in the wound bed;
–Goals: Prevention of progress through relief of pressure, absorption of drainage; moist
wound healing; protection from injury; insulation of wound bed;
–Relieve pressure to the area though a turning schedule or elevate the area.
–If the resident was on a standard mattress, replace with either a pressure
redistributing mattress or a specialty surface;
–Clean with normal saline and evaluate the wound bed; apply a skin sealant around the
wound bed and pack with gel impregnated gauze;
-Unstageable pressure ulcers: (Full thickness tissue loss in which the base of the ulcer
is covered by slough and/or eschar);
–Relieve pressure to the area though a turning schedule or elevate the area.
–If the resident was on a standard mattress, replace with either a pressure
redistributing mattress or a specialty surface;
–If friction was the suspected injury as to the feet and heels, wear loose white cotton
socks while in bed; and
–Clean with normal saline and evaluate the wound bed.
1. Record review of Resident #35’s Face Sheet showed the resident was admitted to the
facility on [DATE] and with the following Diagnoses: [REDACTED].
-Muscle Weakness;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 18)
-[MEDICAL CONDITIONS] disease of the arteries and veins of the extremities); and
-Cognitive communication deficits.
Record review of the resident’s significant change Minimum Data Set (a federally mandated
assessment tool required to be completed by facility staff for care planning) dated 7/7/18
showed:
-The resident was severely cognitively impaired;
-Did not reject cares;
-Needed extensive assistance with bed mobility, transfers, and dressing;
-Was incontinent of bladder and occasionally incontinent of bowels;
-Used a wheelchair;
-Was at risk for the development of pressure ulcers; and
-Did not have prevention in place to prevent pressure ulcers including no turning or
repositioning schedule or a pressure reducing mattress.
Record review of the resident’s pressure ulcer Care Plan dated 7/10/18 showed:
-The resident had the potential for pressure ulcer development related to immobility,
incontinence, and his/her Braden score risk (a tool completed by staff to show if the
resident was at risk of developing pressure ulcers).
Record review of the resident’s Braden Scale for Predicting Pressure Sore Risk dated
7/22/18 showed the resident was at moderate risk for developing pressure ulcers.
Record review of the resident’s Pressure Ulcer Risk Evaluation Prevention Intervention
Protocol dated 7/22/18 showed the resident was at moderate risk for developing pressure
ulcers.
Record review of the resident’s Weekly Skin assessment dated [DATE] showed:
-The resident’s skin condition was dry and had redness; and
-The buttock area was circled on the body site area.
Record review of the resident’s Weekly Skin assessment dated [DATE] by Licensed Practical
Nurse (LPN) D showed:
-The resident’s skin condition was dry and had redness; and
-The back of the legs were circled on the body site area.
Record review of the resident’s Weekly Skin assessment dated [DATE] completed by LPN A
showed:
-The resident’s skin condition was dry and the resident had blisters;
-The areas affected were the hip area and ankle area; and
-The right hip area was circled on the body site area.
Record review of the resident’s Nurse’s Notes dated 9/22/18 at 3:45 A.M., completed by
Licensed LPN D showed:
-The resident had a blister on the back of the right heel that has lost fluid, the skin
was loose and intact;
-The nurse would continue to monitor; and
-There were no physician’s order for treatment of [REDACTED].
Record review of the resident’s Nurses Notes dated 9/23/18 at 2:00 A.M. showed:
-The resident had a raised area to his/her right heel;
-The resident’s right heel was cleaned and gauze was applied; and
-There were no physician’s order for treatment of [REDACTED].
Observation on 9/24/18 at 12:21 P.M., showed:
-The resident was in his/her wheelchair in the dining room;
-Had on pink low ankle socks and his/her feet were resting on the foot pedals of his/her
wheelchair; and
-His/her ankles and legs appeared severely swollen.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 19)
Record review of the resident’s Nurses Notes dated 9/24/18 completed by LPN D showed new
physician’s orders were received for Skin Prep (a topical barrier for use between skin and
adhesives) to the back of the right heel daily until healed for open area.
Record review of the resident’s Physician’s Orders Sheet (POS) showed:
-On 9/24/18: Skin Prep to the back of the right heel daily until healed; and
–This physician’s order was received two days after the right heel pressure ulcer was
identified by the staff.
Observation on 9/26/18 at 10:00 A.M., showed the resident:
-Was sitting in his/her wheelchair at the dining room table with her head resting on the
table;
-Was wearing white anklets socks and his/her feet were resting on the dining room floor;
-The residents feet and ankles were swollen;
-LPN B wheeled the resident to his/her room;
-LPN B removed the resident’s right sock and the sock was wet;
-The resident had a blister to his/her right lateral (outside) heel that had popped; the
skin from the blister was laying over the wound bed and you could not assess the wound
bed;
-The wound was the size of a golf ball and the popped blister was draining clear drainage;
-LPN B washed his/her hands and put on gloves and applied skin prep to the resident’s
popped blister;
-LPN B and Certified Medication Technician (CMT) A transferred the resident to his/her bed
and laid the resident on his/her left side facing the wall; and
-The resident’s mattress was a regular foam mattress, the staff did not float the
resident’s heels with a pillow or apply bunny boots or another pressure reducing boot to
prevent further skin breakdown to his/her heels.
Record review of the resident’s Nurses Notes dated 9/26/18 showed:
-The resident’s right heel blister had erupted;
-The resident’s physician was notified and gave new orders to apply Triple Antibiotic
Ointment (TAO) and cover with a border dressing (a self-adherent, bordered foam dressing)
daily and as needed; and
-The staff were to contact the outside wound company to evaluate and treat the resident’s
blister.
Observation on 9/25/18 at 12:30 P.M. showed:
-The resident was in his/her wheelchair in the dining room;
-Had on pink low ankle socks and his/her feet were resting on the foot pedals of his/her
wheelchair;
-The ankle socks appeared very tight around his/her ankles; and
-His/her ankles and legs appeared severely swollen.
Record review of the resident’s (MONTH) (YEAR) Physician’s Orders Sheet (POS) showed:
-On 9/26/18: The skin prep order to the back of the right heel was discontinued; and
-On 9/26/18: Clean the right heel with normal saline the apply TAO and cover with a border
dressing; contact the outside wound company to evaluate and treat.
Observation on 9/27/18 at 8:37 A.M. showed:
-The resident was lying in bed on his/her right side;
-The resident’s heels were lying flat on a regular mattress; and
-There were no pillows floating the resident’s heels or in between the resident’s knees.
During an interview on 9/27/18 at 8:40 A.M., CMT A said:
-He/she would turn the resident side to side but the resident was combative;
-The resident would sometimes let him/her turn him/her in the bed but not often;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 20)
-The resident had a spot on his/her heel;
-The resident has heelbo (Heel/Elbow Protectors protect the elbow or heel from abrasion
and promotes healing of pressure ulcers) socks at night;
–Observation showed the heelbo cushion sock in the resident’s night stand drawer and not
on the resident;
-The resident wore non-skid socks during the day;
-The resident did not wear bunny boots (soft padded boots) or (Pressure Relief Ankle Foot
Orthosis-Prafo, a device that is worn on the calf and foot similar to a boot and is often
used for patients that spend the majority of their time in bed to prevent pressure ulcers
from developing on the back of the heel or for patients who are ambulatory ) boots;
-The nurse would assess the residents’ wounds; and
-CMTs were not to assess the residents’ wounds.
During an interview on 9/27/18 at 8:51 A.M.; CMT B said:
-In bed, the resident rubbed his/her leg a little bit and got a wound on his/her heel;
-He/she was not sure who found the resident’s wound;
-He/she saw a little redness on his/her heel a couple weeks ago and he/she reported it to
LPN A;
-He/she thought skin prep was being applied to the heel;
-He/she had completed the skin prep treatment to the heel when it was red;
-He/she did not treat pressure ulcers but could put skin prep on a red area;
-He/she would also treat open wounds like skin tears;
-He/she used pillows to float the resident’s heels because he/she could not find the
resident’s bunny boots;
-He/she would put pillows in between the resident’s knees;
-He/she would put a pillow between his/her feet so the heel did not touch the bed when
he/she put him/her to sleep; and
-The resident would occasionally be combative.
Observation and interview on 9/27/18 9:02 A.M., the Assistant Director of Nursing (ADON)
showed/said:
-He/she had looked at the resident’s heel and the wound was not draining at that time so
the physician’s orders for treatment might not be appropriate;
-The Resident was in bed and the resident’s right heel was lying flat on a regular
mattress with no pressure prevention;
-Since there was no drainage today he/she needed to call and get a more appropriate
treatment;
-The resident’s left foot had a discolored area to the right ankle which was small and
dry;
-The ADON had a wound measuring device;
-He/she had not been told of the resident’s ankle blisters;
-The area was non-blanchable (Intact skin with non-blanchable redness of a localized area
usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its
color may differ from the surrounding area. Further description: The area may be painful,
firm, soft, warmer or cooler as compared to adjacent tissue);
-He/she could not see the wound bed on the dark area which could be unstageable;
-He/she was responsible for completing all the wound measurements when a resident
developed a wound at the facility and would also would assess the wounds;
-The resident had a blister that was being skin prepped and the blister broke was a
possibility;
-No one reported the blister to him/her;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 21)
-The resident should have heel protectors on his/her feet;
-The resident was not combative during treatment;
-The resident’s right heel blister had 60% epithial tissue (line the outer surfaces of
organs and blood vessels throughout the body), 40%-red/purple which would make the wound
an unstageable pressure ulcer;
-The pressure ulcer to the resident’s right heel measured 6.0 centimeters (cm) in length
by 5 cm in width;
-The darkened area was by 4.2 cm in length and 3.7 cm in width for the unstageable part of
the pressure ulcers pressure ulcer;
-There was redness to the right lateral ankle that was blanchable that needed to be
watched closely;
-The resident’s pressure ulcer on his/her heel was caused by pressure;
-The blister was fluid filled and then it opened;
-The resident needed an alternating low air loss pressure mattress and heel protectors;
-The staff should not be placing socks and shoes on the resident during the day;
-The ADON cleaned the heel with wound cleanser;
-The ADON put TAO on the right heel and with covered the heel with border gauze;
-This was the physician’s order but he/she would call the physician for a more appropriate
treatment order; and
-The resident was on a solid foam mattress.
During an interview on 9/27/18 at 9:40 A.M., LPN A said:
-For pressure ulcer prevention, the resident had moisture barrier cream to his/her
buttocks;
-The resident’s right heel area was getting skin prep to it when LPN A returned to work on
9/24/18;
-The area had been wrapped with kerlix (woven gauze that is non-adhesive used to wrap
wounds and burns);
-When the kerlix was taken off it tore the resident’s right heel pressure ulcer open;
-He/she was not sure if the ADON was informed;
-The right heel was breaking down;
-He/she was the charge nurse for the unit but was in the office this week completing MDSs
so he/she has not been on the unit;
-He/she had worked on the unit over the weekend and had gone to assess the resident’s
right heel pressure ulcer this past weekend;
-He/she wrote it down on the Weekly Skin Assessment sheet (dated 9/22/18);
-The resident had a blister with skin prep being applied;
-He/she did not assess or measure the resident’s right heel;
-He/she did not document much about the resident’s right heel;
-Usually the ADON looked at skin assessment sheets and they would go look at the wound
together;
-The resident liked to lay on his/her right side but did not want to re-position;
-He/she did not put preventative measures in place at the time;
-The staff should not put socks and shoes on the resident;
-He/she would not have been able to get a low air-loss mattress on the weekend;
-The staff knew of the pressure ulcer and the staff should be floating the resident’s
heels;
-The resident’s right heel should not be touching the floor or any surface; and
-The resident should be positioned by pillows to float the heel.
Observation on 9/27/18 at 10:00 A.M. showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 22)
-The resident was lying in bed on a regular mattress with yellow ankle socks on; and
-The resident’s heels were resting on a pillow and were not floated.
During an interview on 9/27/18 at 1:17 P.M., LPN B said:
-He/she had only worked on this unit two times;
-This was the first he/she has saw the resident’s blister (on 9/26/18);
-He/she did not get any information in report from the nurse that the resident had a heel
blister;
-The resident did not have any prevention in place for the prevention or treatment of
[REDACTED].>-The resident was only on a foam mattress;
-He/she had not seen any prafo boots or prevention on his/her feet;
-The resident should have his/her heels floated and a low air loss mattress; and
-The resident should have had prafo boots and not have tight socks or shoes on.
Observation on 9/27/18 at 1:24 P.M., showed the resident:
-Was in his/her wheelchair in the dining room; and
-Had bunny boots on and his/her right heel pressure ulcer was resting directly on the foot
pedal of the wheelchair.
During an interview on 9/27/18 at 1:33 P.M., Registered Nurse (RN) Supervisor A and LPN C
said:
-If a resident has skin break down;
-The nurse needed to reinforce education with staff including repositioning;
-The nurse should notify the resident’s family and physician;
-If a resident had a heel wound, the resident should be reposition every two hour;
-The resident should have heel protectors on and the staff should be floating the
resident’s heels;
-The staff should have a prafo boot versus a bunny boot if resident has an unstageable
wound to the heel so the heel would be floated;
-The staff may put a low air loss pressure mattress in place;
-The staff should put interventions in to meet the individualized needs of the resident;
and
-The ADON would be the first one to assess a resident’s wound and determine what services
were needed.
During an interview on 9/27/18 at 2:44 P.M., LPN D said:
-At night the resident was up on 9/22/18;
-A Certified Nursing Assistant (CNA) had changed the resident and noticed the resident had
a blister on his/her heel;
-The CNA report it to him/her;
-He/she assessed the resident’s blister and it looked like the blister had lost the fluid;
-The blister was a flesh color at that time;
-He/she looked at it and did not see any drainage;
-He/she had cleaned it and put his/her socks back on him/her;
-The blister was not open;
-He/she did not call and get orders from the resident’s physician or notify the resident’s
family in the morning;
-He/she had covered the resident’s right heel blister with gauze for drainage and
cushioned it;
-He/she did not put a low air loss mattress in place or prafo boots;
-He/she had propped his/her foot back up in the wheelchair because the resident wanted to
be up;
-On 9/24/18 the resident’s right heel blister was still a skin color and he/she called the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 23)
resident’s physician to get an order for [REDACTED].>-The wound was not open at that
time;
-He/she passed the blister information on in report to the on-coming nurse;
-He/she did not notify the ADON, DON or call the family;
-He/she would normally pass the information of a new wound to the ADON; and
-The ADON would assess for whatever actions and interventions were needed for the wound.
During an interview on 9/27/18 at 4:21 P.M., LPN A said:
-When he/she completed the resident’s skin assessment on 9/22/18, the resident had a red
hip area and a right heel blister;
-He/she had documented ankle area instead of heel area on the skin assessment;
-He/she did not notify the resident’s physician or the resident’s family member;
-He/she did not write a nurses note about the blister;
-He/she was told about it and did not add any prevention or interventions; and
-He/she should have called the resident’s physician at that time.
During an interview on 9/27/18 at 4:29 P.M., the Director of Nursing (DON) said:
-Whoever identified the pressure ulcer and the charge nurse would need to contact the
resident’s physician and family;
-He/she expected the nurse to call the resident’s physician for treatment orders before
doing a treatment;
-The pressure ulcer needed to be reported to the on-coming nurse, the ADON and to
himself/herself;
-He/she had not been notified of the resident’s right heel blister;
-If need be the outside wound company would be called to assess the wound;
-He/she expected the nurse to put interventions in place at the time the wound was found;
-The Braden and the pressure ulcer prevention guide was used so a care plan could be
developed;
-The resident, according to the assessments, should have a pressure relieving mattress;
-At this time, he/she ordered a low air loss mattress for the resident due to active
pressure ulcer;
-On 9/22/18, physician’s orders and prevention/treatment should have been put in place
immediately by the charge nurse;
-The physician and family should have been notified;
-He/she expected better documentation about the resident’s pressure ulcer and where it was
located;
-The resident’s physician order was for TAO but he/she thought skin prep was needed to
toughen the area of the heel;
-The resident’s heels should be floated at all times and not resting on the floor or hard
surface; and
-The ADON would generally assess the pressure ulcer along with the nurses to make
determinations.
Observation on 9/27/18 at 5:01 P.M., showed:
-The resident was in his/her wheelchair eating dinner; and
-The resident had bunny boots on both feet which were resting directly on the foot rest of
the wheelchair.
2. Record review of Resident #25’s Face Sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-High blood pressure;
-Heart failure;
-Dysphagia (inability or difficulty swallowing)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 24)
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation);
-Cognitive communication deficit; and
-[MEDICAL CONDITION].
Record review of the resident’s Pressure Ulcer care plan dated 1/3/18 showed:
-The resident had a left heel wound;
-The staff were to administer the resident’s medications as ordered;
-The staff were to avoid shearing during positioning, transferring, and turning;
-The staff were to conduct a weekly skin assessment by a licensed nurse and daily with
cares by the nursing staff;
-Consult with the outside wound company as needed;
-Complete treatment orders to the wound area; and
–Staff documented on the care plan discontinued-healed with no date.
Record review of the resident’s POS showed:
-On 1/3/18, a physician’s order (for a left heel wound) to cleanse the left heel with
normal saline and apply skin prep to the left heel daily.
Record review of the resident’s Treatment Administration Record (TAR) dated (MONTH) (YEAR)
showed:
-A physician’s order on 1/3/18 to cleanse the left heel with normal saline and apply skin
prep to the left heel daily; and
-The treatments were completed by CMTs and licensed nursing staff.
Record review of the resident’s Braden Scale for Predicting Pressure Sore Risk dated
7/25/18 showed:
-The resident was at risk for the development of pressure ulcers;
-Friction and shearing:
–The resident required moderate to maximum assistance with moving; and
—Complete lifting without sliding against sheets was possible.
Record review of the resident’s quarterly MDS dated [DATE] showed the resident:
-Was severely cognitively impaired with inattention and disorganized thinking;
-Needed supervision and the assistance of one staff member for bed mobility;
-Needed the limited assistance of one staff member for transfers;
-Needed the extensive assistance with mobility in his/her wheelchair and personal hygiene;
-Did not have contractures (an abnormal usually permanent condition of a joint,
characterized by flexion and fixation);
-Was at risk of pressure ulcers;
-Did not have pressure ulcers;
-Needed a pressure relieving device in his/her wheelchair; and
-Did not need a pressure relieving mattress or a turning and repositioning program.
Record review of the resident’s TAR dated (MONTH) (YEAR) showed:
-A physician’s order on 1/3/18 to cleanse the left heel with normal saline and apply skin
prep to the resident’s left heel daily; and
-The treatments were documented as completed by CMTs and licensed nursing staff.
Record review of the resident’s Weekly Skin Integrity Review dated 8/24/18 completed by
showed:
-The resident’s skin was dry and intact;
-The resident had an old, healed area; and
-The resident’s left elbow area was circled on the body site area.
Record review of the resident’s Nurse Notes dated 8/28/18 showed:
-The resident had a large reddened area on the right bottom of his/her foot with a small
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 25)
blister;
-The hospice nurse was here and notified the family and new physician’s orders were
obtained; and
–There was no documentation that showed pressure ulcer prevention or healing
interventions were put in place.
Record Review of the POS [REDACTED].
Record review of the resident’s TAR 8/28/18 through 8/31/18 showed:
-A physician’s order to apply skin prep to the resident’s reddened areas and blister on
the resident’s right foot each shift and PRN; and
-This was documented as being administered by CMTs and licensed nursing staff.
Record review of the resident’s Weekly Skin Integrity Review dated 9/7/18 showed the
resident’s skin was dry and intact.
Record review of the resident’s Nurses Notes dated 9/8/18 at 10:28 A.M. showed:
-The resident had two fluid filled blisters;
-One blister was 1 ¾ inch long on his/her right upper/outer thigh and one blister ¼ inch
on the left back of his/her thigh; and
–There were no physician’s treatment orders or wound tracking completed for this wound.
Record review of the resident’s Nurses Notes dated 9/10/18 showed the resident continued
to have the noted areas.
Record review of the resident’s Nurses Notes dated 9/11/18 showed:
-The resident had a black area to the end of his/her left great toe; and
-The resident’s physician was notified and treatment orders were obtained for the left
great toe.
Record review of the resident’s POS dated (MONTH) (YEAR) showed the following physicians:
-Not dated: Skin Prep to the left great toe every shift and as needed until healed; and
-There were no physician’s orders for the resident’s blisters to his/her right upper/outer
thigh area or the resident’s left back of the thigh until 9/14/18.
Record review of the Resident’s TAR dated (MONTH) (YEAR) showed:
-On 1/2/18: Cleanse left heel area with normal saline and apply Skin Prep once daily;
–This was completed by nursing staff and CMTs.
-On 9/11/18: Skin Prep to the left great toe every shift and as needed until healed;
–This was completed 43 times out of 49 times and signed as completed by nursing staff and
CMTs; and
-There was no documentation that showed the resident’s blisters to his/her right
upper/outer thigh area or the resident’s left back of the thigh were treated in this
month.
Record review of the resident’s Nurses Notes dated 9/14/18 at 9:00 A.M. showed:
-The resident’s physician was here to see the resident;
-The physician assessed the area of the resident’s toe and the left thigh area;
-The physician stated the left thigh area was due to shearing during movement and gave
orders;
-The physician ordered TAO and cover the areas; and
–These physician’s orders were not on the (MONTH) (YEAR) POS or TAR.
Record review of the resident’s Weekly Skin Integrity Review dated 9/21/18 showed:
-The resident’s skin was intact with bruises; and
-The coccyx area was circled on the body site area.
Record review of the resident’s Medical Record on 9/27/18 showed:
-The POS dated (MONTH) (YEAR) had no treatment orders for the right thigh blister or left
thigh blister.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 26)
Record review of the resident’s TAR dated (MONTH) (YEAR) showed:
-On 9/27/18, a new physician’s order to apply skin prep to the resident’s left heel each
shift and as needed.
Record review of the resident’s Weekly Skin Integrity Review dated 9/27/18 by LPN B
showed:
-The resident’s skin was dry;
-The resident had a left heel dark area;
-The resident’s left thigh was scabbed; and
-The buttocks area, the back of the right leg, and the left heel were circled on the body
site area.
Record review of the resident’s Nurses Notes dated 9/27/18 at 2:00 P.M., showed:
-The resident had a dark discolored area to the left heel;
-Skin Prep was applied per the resident’s physician; and
-Hospice (end of life care) would provide heel protectors and a low air loss mattress.
Observation on 9/27/18 at 5:04 P.M. showed:
-The resident was in the dining room in a geri-chair (a reclining chair used for
positioning and comfort);
-Both hands were contracted and closed;
-The resident had white socks pulled tightly on his/her feet and toes; and
-His/her feet were hanging over the cushioned foot rest.
Observation on 9/27/18 at 5:12 P.M. showed:
-A regular foam mattress was on the resident’s bed.
Observation on 9/28/18 at 8:46 A.M. showed:
-The resident was in a geri-chair in the common area;
-Both hands were contracted and closed;
-The resident had white socks on that fitted tightly and his/her heels were floated off
the end of the foot rest; and
-The resident had a hoyer sling (Hoyer lifts are used for transfers when a person requires
90-100% assistance to get into and out of bed. A sling fits under the person’s body in the
bed and connects with chains to the hoyer lift frame. A hydraulic pump is used to lift the
person off the bed surface) underneath him/her.
Observation on 9/28/18 at 9:34 A.M. showed:
-The resident’s white socks were fitted closely to both feet;
-The resident had a hoyer sling underneath him/her; and
-Both of the resident’s arms were fitted closely to the inner area of his/her geri-chair.
Observation on 9/28/18 at 10:08 A.M. showed:
-The resident was alert, seated in his/her geri chair and had a heel protector on his/her
right foot;
-The Chief Operating Officer (COO)/RN and LPN B transferred the resident to his/her bed
with a hoyer lift then roll

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
restorative services to two sampled residents (Resident #20 and #15) out of 32 sampled

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
residents. The facility census was 65 residents.
Record review of the facility’s Restorative Nursing Policies and Procedures revised
6/29/17 showed:
-Certified Nurses Aides (CNAs) were responsible for providing range of motion during
cares;
-Licensed staff were responsible for overseeing the program on their units; and
-The Administrator and Director of Nursing (DON) were accountable for providing adequate
staff these goals and to provide resources, supplies, and equipment for restorative
services.
1. Record review of Resident #20’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Stroke.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated
assessment tool required to be completed by the facility staff for care planning) dated
7/24/18 showed the resident:
-Was cognitively intact;
-Was totally dependent on staff for transfers, bed mobility, and dressing; and
-Had limitations of Range of Motion (ROM-full movement potential of a joint, usually its
range of flexion and extension) of his/her upper and lower extremities (arms and legs).
Record review of the resident’s Care Plan revised on 7/25/18 showed the resident:
-Had self-care performance deficits related to [MEDICAL CONDITION]; and
-Needed to have restorative services per the physician’s orders [REDACTED].
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s Nursing Rehab/Restorative Plan of Care dated (MONTH)
(YEAR) showed there were no restorative services completed.
Observation on 9/24/18 at 11:48 A.M. showed the resident had a flaccid left arm/hand and a
flaccid left leg/foot.
During an interview on 9/24/18 11:48 A.M., the resident said he/she could not move his/her
left hand/arm or left leg/foot.
Observation on 9/25/18 at 8:59 A.M., showed:
-The resident was in his/her electric wheelchair;
-The resident could use his/her right hand; and
-The resident had a flaccid left arm/hand and a flaccid left leg/foot.
During an interview on 9/26/18 12:14 P.M., the Assistant Director of Nursing (ADON) said:
-The staff member who was responsible for restorative therapy was no longer here;
-The resident had not received therapy; and
-No other staff members had been assigned to complete restorative services for the
residents.
During an interview on 10/01/18 at 10:14 A.M., Licensed Practical Nurse (LPN) F said:
-The restorative aide was no longer here and he/she was unsure if he/she had been
replaced; and
-The residents should be receiving restorative services per the physicians orders.
During an interview on 10/03/18 at 10:30 A.M., the DON said:
-Resident #20 has limited ROM and would benefit from restorative services;
-The restorative aide quit and had only given a four day notice;
-He/she had not asked the CNAs to completed ROM with the residents; and
-The resident should have received restorative services per the physicians orders.
2. Record review of Resident #15’s Face Sheet showed he/she admitted to the facility on
[DATE] and had the following Diagnoses: [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
-[MEDICAL CONDITION] (disease or damage that affects the function or structure of the
brain).
Record review of the resident’s MDS dated [DATE] showed he/she:
-Had limitations in range of motion (ROM) of his/her upper extremities (shoulder, elbow,
wrist, hand); and
-Had limitations in ROM of his/her lower extremities (leg, knee, ankle, foot).
Record review of the resident’s care plan date 7/6/18 showed:
-An intervention for staff to place rolled wash clothes in his her hands daily; and
-Place inside hand for contracture daily.
Record review of the resident’s POS dated 9/1/18 showed his/her physician ordered:
-Rolled wash cloth to both his/her hands; and
-Place inside his/her hands daily for contracture (shortening and hardening of muscles,
tendons or other tissue, often leading to the deformity and rigidity of joints) daily.
Observation on 9/25/18 at 7:52 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed (bent) at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had no wash cloth rolls in his/her hands.
Observation on 9/25/18/18 at 1:51 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had no wash cloth rolls in his/her hands.
Observation on 9/26/18 at 5:44 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed (bent) at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had no wash cloth rolls in his/her hands.
Observation on 9/27/18/18 at 12:35 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
During an interview on 9/27/18 at 12:40 P.M. Certified Nursing Assistant (CNA) A said:
-As far as he/she knew it was the Restorative Aide (RA) who was responsible for putting
the wash cloth rolls in the resident’s hands or the licensed nurse;
-When the facility had an RA, the RA put the rolled wash cloths in the resident’s hands;
-He/she did notice that the resident did not have a wash cloth in his/her left hand; and
-He/she would get a wash cloth and put it in the resident’s left hand.
Observation on 9/27/18/18 at 1:08 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had wash cloths in his/her right and left hands.
Observation on 9/28/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 9/28/18/18 at 1:47 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 9/28/18/18 at 1:51 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 10/2/18 at 2:52 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 10/3/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had a rolled wash cloths in his/her right and left hands.
During an interview on 10/3/18 at 9:10 A.M. Licensed Practical Nurse (LPN) C said:
-The CNAs put the rolled wash cloths in the resident’s hands; and
-He/she checked that the rolled washed cloths were in the resident’s hands once each
shift.
During an interview on 10/3/18 the DON said:
-The resident had limited ROM;
-He/she could benefit from a RA program;
-Rolled wash clothes should have been placed in both the resident’s hands;
-CNAs were responsible for placing the rolled wash cloths in the resident’s hands;
-Licensed nurses were responsible for checking to make sure the CNAs had placed the rolled
wash cloths in the resident’s hands;
-Range of motion to the resident’s arms and legs was not being provided; and
-He/she had not talked to the CNAs about doing range of motion to the resident’s arms and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
legs when completing the resident’s cares.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide only
distilled water and ensure C-Pap was cleaned in accordance to the manufacturer’s
recommendations for one sampled resident (Resident #6) out of 32 sampled residents. The
facility census was 65 residents.
Record review of the facility’s Continuous Positive Airway Pressure ([MEDICAL CONDITION] –
a device with a pump that forces air into the nasal passages during sleep at pressures
high enough to overcome airway obstructions to stimulate normal breathing)/Bilevel
Positive Airway Pressure ([MEDICAL CONDITION] – a device which functions similar to a
[MEDICAL CONDITION] except that during the wearer’s exhalation there is less pressure from
the machine against the exhalations), Support Policy/Procedure, dated 2001 and revised
March, (YEAR), showed:
-Clean, distilled water should be used in [MEDICAL CONDITION] humidifier chambers; and
-Masks and tubing should be cleaned daily by placing in warm, soapy water and soaking and
agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and
allow to air dry between uses.
Record review of the facility’s Use of Oxygen Policy, dated 2001 and revised July, (YEAR),
showed:
-If a reusable humidifier is used it should be emptied, rinsed, dried and refilled with
sterile water daily,
-Reusable humidifiers should not be stored with water in them since microorganisms may
grow in the water; and
-Routine equipment inspection and maintenance should be performed based on the
manufacturer’s recommendations.
Record review of the manufacturer’s instructions for [MEDICAL CONDITION] care, use and
cleaning showed:
-The air-inlet filter should be checked every 10 days and cleaned as needed with warm
water and dishwashing solution and allowed to dry completely before reuse,
-The air supply tubing should be removed from the [MEDICAL CONDITION] device and cleaned
daily with mild detergent and water, rinsed and allowed to air dry; and
-Cleaning for the mask should be according to the mask manufacturer’s recommendations.
Record review of [MEDICAL CONDITION]/[MEDICAL CONDITION] Machine Cleaning and Maintenance
Suggestions by the American Sleep Apnea Association, August, 2011, recommended the
following cleaning protocol:
-Daily cleaning should consist of placing the [MEDICAL CONDITION]/[MEDICAL CONDITION]
tubing, mask or pillows and headgear into a sink with warm soapy water (a small amount of
mild dish detergent is recommended). Agitate the supplies in the water for approximately
five minutes and rinse well with warm water. Allow enough time for the supplies to dry
completely,
-Weekly cleaning consisted of rinsing the filter under running water, squeezing the filter
and blotting with a clean towel to remove most of the moisture. (The resident’s [MEDICAL
CONDITION] manufacturer’s recommendation was to clean every 10 days.) A disposable filter

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
should not be washed and should be replaced monthly or sooner if it becomes dirty. To
disinfect the humidifier chamber after washing with warm soapy water, place in a solution
of one part vinegar to three to five parts water and soak for 30 minutes. Rinse
thoroughly; and
-Annual maintenance consisted of servicing the machine yearly by a durable medical
equipment company to ensure the pressure is set correctly and the machine is working
properly.
Record review of Care and Replacement of [MEDICAL CONDITION] Equipment, (YEAR), by the
American Sleep Apnea Association showed:
-Recommended daily cleaning of the [MEDICAL CONDITION] mask cushion with mild pure soap
and water and air dry. The headgear (straps used to hold the mask in place) should be
cleaned weekly,
-Recommended use of distilled water when filling the humidifier chamber daily. Empty water
each morning. Clean the water chamber with a 10 minute soak in mild pure soap. Rinse well
and air dry after each use,
-To cut residue and disinfect the clean mask and tubing, use one part vinegar to three
parts water; and
-Annually replace the filter.
1. Record review of Resident #6’s Face Sheet showed he/she was admitted to the facility on
[DATE] with:
-Sleep Apnea (a condition that occurs when the airway becomes narrow as the muscles relax
during sleep which reduces oxygen in the blood and causes arousal from sleep) and
-[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation).
Record review of the resident’s Ineffective Breathing Pattern during Sleep Care Plan,
dated 1/26/16 showed:
-The resident had difficulty breathing during sleep and resting periods due to [DIAGNOSES
REDACTED].
-Interventions included:
–Check the resident’s oxygen levels every shift and record,
–Provide prompt treatment of [REDACTED].
–Clean C-PAP machine and mask as needed,
–Clean mask with soap and water in the morning as needed,
–Change C-PAP tubing every 90 days and as needed for malfunction,
–Rinse filter weekly and as needed and
–On 2/19/16 an intervention was added for setting the C-PAP to 14 centimeters (cm) of
water pressure at night and during naps.
Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning purposes), dated
6/26/18 showed:
-The resident was cognitively intact; and
-The resident performed most Activities of Daily Living (ADL – dressing, grooming,
bathing, eating, and toileting) with no assistance or with set-up support only from staff,
and one-person assistance for personal hygiene.
Record review of the Physician order [REDACTED].
-Orders beginning 8/16/18 for the following:
–Weekly Cleanse [MEDICAL CONDITION] machine tubing with soap and water, rinse and place
in bag; close loosely to air dry; and
–Change C-PAP bag weekly.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
Record review of the resident’s Medication Administration Record [REDACTED].
Observation on 7/24/18 showed the resident had a [MEDICAL CONDITION] machine with water in
the reservoir and no distilled water in the room.
During interview on 10/1/18 at 9:08 A.M. the resident said:
-As far as he/she knew every time the [MEDICAL CONDITION] machine was filled it is filled
by him/her with tap water,
-A Certified Nurse Aide told him/her it was fine to use tap water in the [MEDICAL
CONDITION] machine; and
-Staff do not clean any part of the [MEDICAL CONDITION] mask or the tubing on a daily
basis.
During interview on 10/1/18 at 1:31 P.M. Licensed Practical Nurse (LPN) E said:
-The distilled water for the [MEDICAL CONDITION] machine was kept in the medication
storage room and nurses let Central Supply know when they need more;
-He/she had been instructed to use distilled water when filling the [MEDICAL CONDITION]
machine;
-He/she checked each shift to make sure the resident had water in the [MEDICAL CONDITION]
reservoir. If the machine was empty he/she filled it with distilled water;
-He/she was unaware the resident was putting tap water into the machine;
-The [MEDICAL CONDITION] mask and tubing was cleaned each week with soapy water and left
to air dry and
-He/she hadn’t seen any information from the [MEDICAL CONDITION] machine manufacturer or
mask manufacturer on how to properly clean the [MEDICAL CONDITION] supplies.
During an interview on 10/2/18 at 3:15 P.M. the Director of Nursing (DON) said:
-The [MEDICAL CONDITION] tubing and mask should be cleaned daily if that was the
manufacturer’s recommendation,
-Tap water should not be used in the [MEDICAL CONDITION] machine; and
-The water in the [MEDICAL CONDITION] reservoir should be emptied daily and filled with
fresh distilled water.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to assess all the
resident’s risks for entrapment and/or other accidents to determine if the benefits of bed
rails outweighed the risks and to explore methods of treatment other than bedrails prior
to installing bedrails for five sampled residents(Residents #54, #64, #5, #15 and #50);
failed to complete quarterly side rail assessment for one sampled resident (resident #64;
and failed to update one resident’s side rail consent form to reflect the current type of
side rail and to ensure the resident’s side rail consent showed the resident’s legally
responsible party did or did not consent to side rail use for one sampled resident
(Resident #15) out of 32 residents. The facility census was 65 residents.
Record review of the facility’s Bed Rails/Side Rails (Use and Implementation) Policy and
Procedure showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
-The facility will attempt to use alternates prior to installing a side or bed rail,
-The resident’s risk of entrapment will be evaluated prior to bed rail installation,
-The risks and benefits of bed rails/side rails will be reviewed with the resident and/or
responsible party and consent obtained prior to installation and
-Qualified staff will assess the resident for continued use of bed rails/side rails at
minimum quarterly, annually and with significant change.
1. Record review of Resident #54’s Face Sheet showed the resident was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].>-[DIAGNOSES REDACTED] (MG – an [DIAGNOSES
REDACTED] neuromuscular disease that leads to muscle weakness which can result in double
vision, drooping eyelids, difficulty speaking and trouble walking),
-[MEDICAL CONDITION] (difficulty falling or staying asleep),
-Generalized muscle weakness,
-Difficulty walking,
-A history of [MEDICAL CONDITION] (TIA – a brief episode of neurological dysfunction
causing a loss of blood flow in the brain, spinal cord or retina without tissue death. A
TIA can cause the same symptoms associated with stroke such as paralysis, weakness or
numbness on one side of the body) and
-History of Falling.
Record review of the resident’s Side Rail Assessment, dated 12/28/16 showed:
-The side rail was requested for safety and security and because of the resident’s medical
symptoms,
-The resident had physical weakness,
-The rails were to assist the resident in repositioning, sitting up, transferring (moving
from one surface such as the bed to another surface such as a wheelchair) and to prevent
the resident from rolling out of bed,
-There was no documentation that alternate methods of treatment had been attempted or
considered prior to determining bed rails would be used,
-There was no documentation that sleep patterns were being considered prior to the use of
the side rails and
-At the time of the Side Rail Assessment the resident did not have a decline in cognitive
status and the side rails did not impede the resident’s freedom.
Record review of the resident’s Consent for Use of Side Rails, dated 8/8/17 showed:
-A one-half side rail was recommended for the right and left sides of the bed at all times
when the resident was in bed for positioning and mobility related to weakness due to
[MEDICAL CONDITION] symptoms ([MEDICAL CONDITION] is a neurological disorder with symptoms
of a slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait),
-Negative outcomes of side rail use unique to the resident were not identified,
-There was no documentation of alternative methods of treatment for [REDACTED].
-The resident’s legal representative signed the consent and
-Documentation at the bottom of the form showed the resident had a physician order
[REDACTED].>Record review of the resident’s Quarterly Minimum Data Set (MDS – a
federally mandated assessment instrument completed by facility staff for care planning
purposes), dated 6/19/18 showed:
-The resident was cognitively intact,
-The resident had fluctuating inattention (difficulty focusing attention) and was not
disorganized (showed no signs of illogical flow of ideas),
-The resident required oversight for bed mobility, transfers (moving from one surface to
another), walking, eating, toileting, and personal hygiene with no physical help required
to set-up only support to perform these tasks, and required one-person physical assistance
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
with dressing. The resident was unsteady, but able to stabilize for transfers without
assistance,
-The resident used a walker,
-The resident was not on a mechanically altered diet (foods were of regular texture and
consistency),
-The resident was occasionally incontinent of bladder and always continent of bowel and
-The resident had [DIAGNOSES REDACTED].
Record review of Nursing Notes dated 8/7/18 through 8/23/18 showed:
-The morning of 8/7/18 the resident was found unresponsive with oxygen saturation levels
at 70 percent (%) (94% and above is considered normal, and supplemental oxygen is usually
given when oxygen levels fall below 90%),
-Emergency Medical Services (EMS) was contacted and the resident left the facility with
EMS at 7:00 A.M.,
– Notes from the admitting hospital showed [DIAGNOSES REDACTED].
-The resident returned to the facility on [DATE],
-On 8/12/18 the resident was noted to have slow thought processes,
-On 8/13/18 the resident was found on the floor at 11:15 A.M. with slurred speech,
-The physician, guardian and EMS were contacted and EMS arrived at 11:37 A.M. by which
time the resident had become unconscious,
-The admitting local medical hospital called the facility at 2:20 P.M. saying the resident
was intubated (a tube was inserted into the resident’s trachea (windpipe – a
cartilage-reinforced membranous tube extending from the top portion of the throat to the
top portion of the lungs to maintain an open airway), and the resident would be
transferred to another local hospital once stabilized,
-The resident returned to the facility on [DATE],
Record review of the resident’s Significant Change MDS, dated [DATE] showed:
-The resident was moderately cognitively impaired,
-The resident had fluctuating inattention (difficulty focusing attention) and fluctuating
disorganized thinking (illogical flow of ideas),
-The resident required one-person limited physical assistance with bed mobility,
transfers, locomotion, toileting, hygiene and dressing. The resident was unable to
stabilize for transfers without assistance,
-The resident used a wheelchair,
-The resident was on a mechanically altered diet (a diet used with people who have
difficulty chewing and/or swallowing) and
-The resident was occasionally incontinent of both bladder and bowel.
Record review of the resident’s Activities of Daily Living (ADL – eating, dressing,
transferring, bathing, toileting and personal hygiene) Care Plan, dated 8/31/18 showed:
-The resident had self-care deficits related to weakness, cognitive decline and impaired
balance,
-The resident required one-person assistance with bed mobility, transfers, dressing,
hygiene and toilet use and
-On 9/4/18 an intervention for one-half side rails times two to assist with bed
positioning and mobility was added to the plan.
Record review of the resident’s Physician order [REDACTED].
-The resident was on a pureed diet (all food is ground, pressed and/or strained to a soft,
smooth consistency similar to pudding),
-The resident used a wheelchair as tolerated,
-The resident had orders beginning on 9/21/18 for Occupational Therapy (OT) intervention
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
five to seven days per week times four weeks for therapeutic exercise and activity,
self-care management, wheelchair management and neuro re-education (instruction in
exercises designed to improve balance, coordination, posture, and functional activities),
-The resident had PO for Speech Therapy (ST) beginning 9/26/18 three to four days per week
times four weeks to increase swallow safety, cognitive language skills and cognition and
-The resident had one-half side rails times two while in bed to aid in positioning and
mobility.
Record review of the resident’s Quarterly Minimum Data Set, dated dated [DATE] showed
assistance needed for dressing increased to extensive assistance.
Record review of the resident’s record showed there were no Annual Side Rail/Bed Rail
Assessments completed since 12/28/16.
Record review of Quarterly Side Rail Assessments after 12/28/16 showed there was no
documentation following the resident’s significant change of how the resident’s decline in
overall functioning affected the his/her risks related to side rail use.
During an interview on 9/25/18 at 2:15 P.M. the Assistant Director of Nursing (ADON) said:
-The resident had confusion following his/her hospitalization s and attempted to elope
once three weeks prior, requiring the resident to be placed on 15 minute checks for three
weeks,
-The resident was closer to his/her pre-hospitalization baseline and was back on regular
two-hour checks and
-The resident remained quieter than before the hospitalization s.
During an interview on 9/26/18 at 6:58 A.M. Licensed Practical Nurse (LPN) E said the
resident was not mentally functioning where he/she was prior to 8/7/18, although he/she
had improved over the past few weeks and was continuing to slowly stabilize.
During an interview on 9/26/18 at 7:35 A.M. LPN A said:
-A significant change MDS was completed following the resident’s hospitalization because
the resident was more confused and required increased assistance with ADLs,
-The resident was weaker and had poorer balance following his/her hospitalization s and
-The resident’s strength and cognition was gradually improving with therapy.
During an interview on 10/2/18 at 3:15 P.M. the Director of Nursing (DON) said:
-All risks unique to the resident should be assessed prior to determining if benefits of
bed rails outweighed the risks and
-Treatment methods other than bedrails, and risks related to bed rail use specific to the
resident should be discussed with the resident’s legal representative and documented prior
to the legal representative signing a consent for bed rail use.
2. Record review of Resident #64’s Face Sheet showed the resident was admitted to the
facility on [DATE] and had the following Diagnoses: [REDACTED].
-Muscle weakness;
-Lack of coordination;
-Reduced mobility;
-Agitation and anxiety.
Record review of the resident’s Consent For Use of Side Rails dated 10/2/17 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
-The resident’s responsible party:
–Gave consent for 2 side half side rails on the upper part of the resident’s bed.
Record review of the resident’s Evaluation for the use of side rails dated 10/17/17
showed:
-The side rails were being used for medical symptoms including weakness, orthostatic
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
hypertension (a sudden and abrupt increase in blood pressure when a person stands up);
-The side rails would assist the resident with bed mobility of turning side to side,
moving up and down in bed, holding themselves to the side, pulling themselves from a
laying position to a sitting position;
-The side rails would assist the resident with balance, supporting self, exiting and
entering the bed more safely, and transferring more safely;
-The side rails would prevent the resident from rolling out of bed and provide a sense of
security;
-There was no documentation that showed the alternatives to the side rails were tried
prior to the use of the side rails.
-The side rails were re-evaluated on 1/5/18, 1/30/18, 5/11/18, 6/4/18, 6/10/18, and 9/6/18
for continued use of two half side rails on the resident’s bed.
Record review of the resident’s significant change MDS dated [DATE] showed the resident:
-Was severely cognitively impaired;
-Needed extensive assistance of staff for transfers;
-Needed limited assistance of staff for bed mobility.
Record review of the resident’s fall care plan revised 6/19/18 showed the resident had
half side rails up to assist in positioning and bed mobility.
Record review of the resident’s POS dated (MONTH) (YEAR) showed a physician’s orders
[REDACTED].
Observation on 9/24/18 at 1:54 P.M. showed the resident:
-Was in bed watching television;
-Had a low air loss mattress (tiny laser made air holes in the mattress top surface
continually blow out air causing the patient to float) with two half side rails up on both
sides of his/her upper bed.
Observation on 9/25/18 at 7:57 A.M. showed the resident:
-Was in bed asleep;
-Had a low air loss mattress with two half side rails up on both sides of his/her upper
bed.
Observation on 9/26/18 at 5:49 A.M. showed:
-The resident was asleep in his/her bed on a low air loss mattress with two half side
rails up on both sides of his/her upper bed;
-There was a four inch gap between the mattress and the side rail on the left side of the
bed and a two inch gap between the mattress and the side rail on the right side of the
bed.
3. Record review of Resident #5’s Face Sheet showed:
-He/she was admitted to the facility on [DATE] and
-He/she had [DIAGNOSES REDACTED].>–[MEDICAL CONDITION] (damage to the brain caused by
an injury to the head);
–Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, impulsiveness, disorientation stupor deterioration of
intellectual capacity and function, and impairment of memory, and judgment);
–[MEDICAL CONDITION] (a brain disorder that leads to shaking, stiffness, and difficulty
with walking, balance and coordination; and
–Muscle weakness.
Record review of the resident’s Consent for Use of Side Rails dated 11/8/14 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
-The resident’s responsible party gave consent for 2 full side rails on the upper part of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
the resident’s bed for indications of uncontrolled movements secondary to his/her brain
damage and [MEDICAL CONDITION] disorder;
-The side rails were to be released every two hours for 15 minutes and could also be
released during activities and supervised visits;
-The area to check boxes that the person signing the form did or did not give consent to
the use of side rails was blank; and
-The form was signed by the resident’s legally responsible person on 4/20/18 and had not
been updated or a new form signed to reflect that he/she had one-half or one quarter side
rails.
Record review of the resident’s annual Minimum Data Set (MDS-a federally mandated tool
required to be completed by facility staff for care planning) dated 6/26/18 showed he/she:
-Was severely cognitively impaired;
-Received extensive staff assistance for bed mobility;
-Was totally dependent on staff for transfer, locomotion, dressing, and personal hygiene;
-Did not walk; and
-Had limitations in range of motion of his/her upper and lower extremities.
Record review of the resident’s care plan dated 6/29/18 showed:
-He/she had limited physical mobility and all his/her cares were completed by staff;
-He/she would be free of complications including fall related injuries;
-Interventions included-
–One quarter side rails up on both sides of his/her bed to aide in positioning and
mobility related to his/her weakness; and
–Keep his/her bed in the lowest position.
Observation on 9/28/18 at 2:08 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her on quarter side rails fit next to his/her mattress without obvious gap; and
-He/she did not respond to being spoken to except to look toward the person speaking.
Record review of the resident’s medical record on 10/2/18 showed no Evaluation for Use of
Side Rails.
On 10/2/18 the facility administrator provided requested Evaluation for Use of Side Rail
forms for the resident but no Evaluation for the Use of Side Rails for the resident.
4. Record review of Resident #15’s Face Sheet showed:
-He/she was admitted to the facility on [DATE] and
-He/she had [DIAGNOSES REDACTED].>–[MEDICAL CONDITION] (paralysis partial or total
loss of use of all their limbs and the torso);
–[MEDICAL CONDITION] (disease or damage that affects the function or structure of the
brain); and
-Unspecified [MEDICAL CONDITION].
Record review of the resident’s Consent for Use of Side Rails dated 4/20/12 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
-The resident’s responsible party gave consent for 2 full side rails on the upper part of
the resident’s bed for indications of uncontrolled movements secondary to his/her brain
damage and [MEDICAL CONDITION] disorder;
-The side rails were to be released every two hours for 15 minutes and could also be
released during activities and supervised visits;
-The area to check boxes that the person signing the form did or did not give consent to
the use of side rails was blank; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
-The form was signed by the resident’s legally responsible person on 4/20/18 and had not
been updated or a new form signed to reflect that her/she had one-half or one quarter side
rails.
Record review of the resident’s Evaluation for use of Side Rails dated 6/308/17 showed:
-The side rails were being considered for safety;
-Medical symptom that contributed to the resident’s need for side rails was that he/she
was unable to support his/her turn in an upright position;
-The side rails would assist the resident to avoid rolling out of bed;
-Two full side rails were recommended at that time;
-Side rail precautions and alternatives had been discussed with the resident and the
resident’s family/representative was not checked as completed;
-No documentation that showed alternatives to the side rails were tried prior to the use
of the side rails; and
-The comments section showed that the resident had one-half side rails and a bolster
mattress pads (a parameter mattress cover) on 6/30/17 and no changes on 2/12/19, 1/3/18,
4/19/18, and 5/24/18 and 6/30/1.
Record review of the resident’s MDS dated [DATE] showed he/she:
-Was totally dependent on staff for all his/her care needs including bed mobility,
transfer and dressing and
-Did not walk;
-Had limitations in range of motion (ROM) of his/her upper extremities (shoulder, elbow,
wrist, hand); and
-Had limitations in ROM of his/her lower extremities (leg, knee, ankle, foot).
Record review of the resident’s care plan date 7/6/18 showed:
-Place rolled wash clothes in his her hands daily for contractures daily;
-He/she needed to be evaluated for an supplied with a High-Low bed (a bed frame capable of
being lowered close to the floor and raised for performing care) one quarter side rails, a
perimeter mattress (also known as bolster cover – a mattress cover with long rounded
cushions that surround and define the edge of the mattress to promote a safe bed
environment without the need for side rails);
-Side rails may be removed (lowered) for cares;
-He/she needed to be turned and repositioned by staff; and
-He/she had a [MEDICAL CONDITION] disorder and staff was to keep his/her bed in the lowest
position with the bakes locked.
Record review of the resident’s POS dated 9/1/18 showed his/her physician ordered:
-One-half side rails on both sides of his/her bed to aide in positioning due to immobility
and [MEDICAL CONDITION];
-Rolled wash cloth to both his/her hands; and
-Place inside his/her hands daily for contracture (shortening and hardening of muscles,
tendons or other tissue, often leading to the deformity and rigidity of joints) daily.
Observation on 9/25/18 at 7:52 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed (bent) at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had no wash cloth rolls in his/her hands.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 39)
Observation on 9/25/18/18 at 1:51 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had no wash cloth rolls in his/her hands.
Observation on 9/26/18 at 5:44 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed (bent) at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had no wash cloth rolls in his/her hands.
Observation on 9/27/18/18 at 12:35 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
During an interview on 9/27/18 at 12:40 P.M. Certified Nursing Assistant (CNA) A said:
-As far as he/she knew it was the Restorative Aide (RA) who was responsible for putting
the wash cloth rolls in the resident’s hands or the licensed nurse
-When the facility had an RA, the RA put the rolled wash cloths in the resident’s hands;
-He/she did notice that the resident did not have a wash cloth in his/her left hand; and
-He/she would get a wash cloth and put it in the resident’s left hand.
Observation on 9/27/18/18 at 1:08 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had wash cloths in his/her right and left hands.
Observation on 9/28/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 9/28/18/18 at 1:47 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
–His/her mattress had a perimeter cover;
-His/her one quarter side rails were up;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 9/28/18/18 at 1:51 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 10/2/18 at 2:52 P.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a wash cloth which was not rolled in his/her right hand; and
-He/she had no wash cloth roll in his/her left hand.
Observation on 10/3/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers; and
-He/she had a rolled wash cloths in his/her right and left hands.
During an interview on 10/3/18 at 9:10 A.M. LPN C said:
-The CNAs put the rolled wash cloths in the resident’s hands; and
-He/she checked that the rolled washed cloths were in the resident’s hands once each
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
shift.
During an interview on 10/3/18 the DON said:
-The resident had [MEDICAL CONDITION];
-He/she had not had a [MEDICAL CONDITION] in a long time;
-Side rails have risks and the facility could look at eliminating his/her side rails; and
-There was no longer an indication for his/her to have side rails on his/her bed.
5. Record review of Resident #50’s Face Sheet showed:
-He/she was originally admitted to the facility on [DATE];
-He/she had [DIAGNOSES REDACTED].>–[MEDICAL CONDITION] (partial or full paralysis on
one side of the body) and [MEDICAL CONDITION] (loss of or decrease in sensation on one
side of the body) affecting his/her right dominant side;
–Contracture of his/he right and left hands; and
– History of [MEDICAL CONDITION] (TIA – a neurological event caused by a temporary lack of
adequate blood and oxygen to the brain, with the signs and symptoms of a stroke, but which
go away within a short period of time; also called a mini-stroke).
Record review of the resident’s Evaluation for use of Side Rails dated 2/8/17 showed:
-The side rails were being considered for safety;
-Medical symptoms that contributed to the resident’s need for side rails were weakness and
balance deficit;
-The side rails would assist the resident in turning side to side, moving up and down in
bed, holding himself/herself to one side, pulling himself/herself from laying to sitting
position, avoiding falling out of bed and providing a sense of security;
-One-Half right and left upper side rails were recommended at all times when the resident
was in bed due to his/her request and his/her medical symptoms;
-Side rail precautions and alternatives had been discussed with the resident and the
resident’s family/representative;
-No documentation that showed alternatives to the side rails were tried prior to the use
of the side rails; and
-The comments section showed continue to use side rails and/or no changes at this time
dated quarterly on 5/19/17, 11/10/18, 2/12/18, 4/19/18 and 7/5/18.
Record review of the resident’s Consent for Use of Side Rails dated 2/14/17 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
and
-The resident’s responsible party gave consent for 2 side half side rails on the upper
part of the resident’s bed at all times when he/she was in bed related to weakness and a
history of stroke.
Record review of the resident’s care plan dated 6/14/18 with revisions dated 9/17/18
showed:
-He/she had limited physical mobility, a risk for falls, cognitive deficits, a
communication problem, weakness an hand contractures; and
-He/she needed one-half side rails up to assist him her with bed mobility and positioning,
an air mattress (a specialized mattress with an air pump to provide a pressure
re-distribution surface) and his/her bed in the lowest position.
Record review of the resident’s POS dated 9/1/18 showed his/her physician ordered:
-One-half side rails up on both sides of his/her bed while in bed to aid in positioning
due to mobility due to weakness; and
-An air mattress.
Observation on 9/24/18 at 11:11 A.M. showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed; and
-His/her bed was in a low position.
Observation on 9/25/18 at 1:49 P.M. showed:
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed; and
-His/her bed was in a low position.
Observation on 9/26/18 at 8:38 A.M. showed:
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed;
-His/her bed was in a low position;
-LPN C and the DON completed cares for the resident, including turning him/her from side
to side in his/her bed;
-When turned, he/she did not move his/her arms or hands when prompted by the DON, did not
use his/her side rails to assist staff in repositioning him/her; and
-He/she was held in position on his/her left, then right side during care.
Observation on 9/28/18 at 1:43 P.M. showed:
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed; and
-His/her bed was in a low position.
Observation on 10/3/18 at 9:03 A.M. showed:
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed; and
-His/her bed was in a low position.
Observation on 10/3/18 at 9:03 A.M. showed:
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed; and
-His/her bed was in a

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that nurses and nurse aides have the appropriate competencies to care for every
resident in a way that maximizes each resident’s well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish and maintain
competencies and skill sets of facility licensed nursing staff, Certified Medication
Technicians (CMTs) and Certified Nurses Assistants (CNAs) for pressure ulcer prevention,
early detection, identification, and treatment of [REDACTED]. This has the potential to
effect all residents who were more dependent on staff for activities of daily living (ADL
– dressing, grooming, bathing, eating, and toileting). The facility census was 65
residents.
1. Record review of the facilities Course Completion History showed:
-On 9/17/17, 33 staff members completed training for Nutrition in the Healing of Pressure
Injuries (ulcers) and Slow Healing Wounds; and
-There was no other training completed in the past year related to prevention, early
detection, identification, and treatment of [REDACTED].
During an interview on 9/27/18 at 1:59 P.M. the Chief Operating Officer (COO)/Registered
Nurse (RN) said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 43)
-He/she was going to start education on pressure ulcers and pressure ulcer prevention; and
-He/she had received educational information today from the wound company.
During an interview on 9/27/18 at 4:29 P.M., the Director of Nursing (DON) said:
-There was no more documented training related to pressure ulcers;
-The only documentation was from 9/17/17;
-He/she expected the staff to have more training related to pressure ulcers; and
-The Staff Educator was no longer at the facility.
During an interview on 10/1/18 at 10:02 P.M., CMT B said he/she had not received training
on pressure ulcer prevention in the past year at the facility.
During an interview on 10/1/18 at 2:37 P.M., Licensed Practical Nurse (LPN) A said:
-The staff educator left this month; and
-The pressure ulcer prevention training that was scheduled did not happen because the
educator was no longer employed at the facility.

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
medications were administered with an error rate of less than five percent (%). Two
medication errors were detected out of 30 observed medication opportunities resulting in
an error rate of 6.67%. The facility census was 65 residents.
Record review of the manufacturer recommendations for Megastrol showed:
-To take at the same time everyday,
-This mediacation is absorped through the skin and lungs women who are pregnant or may
become pregnant should not handle this medication or breathe the dust from the tablets due
to it may harm the unborn child.
Record review of the manufacturer recommendations for [MEDICAL CONDITION] medications
showed the following:
-Take [MEDICAL CONDITION] medications first thing in the morning with water on an empty
stomach and wait an hour before eating or drinking coffee,
-Wait at least three to four hours before taking any other medications.
1. Record review of Resident #35’s (MONTH) (YEAR) physician’s orders
[REDACTED].>-[DIAGNOSES REDACTED].
-[MEDICATION NAME] 125 micrograms (mcg) one tablet by mout daily at 6:00 A.M. with
instructions from the pharmacy to give on an empty stomach and with no other medications.
-This medication is used to treat [MEDICAL CONDITION].
-Megastrol 40 milligrams per milliliter (mg/ml) and to give 5 mls to equal 200 mg by mouth
daily at 6:00 A.M. for an appetite stimulant. Tthe staff crossed out 6:00 A.M. and wrote
to give at 6:30 A.M. There was no instructions from pharmacy on how to give this
medication.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]
-Megastrol 40 mg/ml to give 5 mls to equal 200 mg by mouth daily at 6:00 A.M. for an
appetite stimulant,
-[MEDICATION NAME] 125 mcg give one tablet by mouth daily at 6:00 A.M. with instructions
by the pharmacy to give on an empty stomach and with no other medications.
-The staff initialed the box showing they gave [MEDICATION NAME] and Megastrol together

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 44)
everyday at 6:00 A.M. from (MONTH) 1, (YEAR) through (MONTH) 30 except for (MONTH) 17 it
was left blank with no reason why it was not given ont that day.
Observation and interview on 9/26/18 at 6:00 A.M, during the medication pass showed
Registered Nurse (RN) B:
-Popped the [MEDICATION NAME] pill from the bubble pack into the medication cup,
-Measured 5 ml of Megastrol into the medication cup.
-Went into the dining room where the resident was sitting at the dining room table and
gave the resident both medications.
-RN B was not aware that you can not give other medications with [MEDICATION NAME] and
he/she did not read the instructions on the resident’s MAR.
During and interview on 10/2/18 at 12:58 P.M. the Dirctor of Nursing (DON) said:
-The resident’s [MEDICATION NAME] should be given on an empty stomach and not with any
other medications.
-The staff should follow the physician’s orders [REDACTED].

F 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide routine and 24-hour emergency dental care for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
dental/oral care services were provided for one sampled resident (Resident #59) with
severe tooth decay, who had recommendations for immediate dental treatment, out of 32
sampled residents. The facility census was 65 residents.
Record review of the facility’s Transportation Policy/Procedure, dated December, 2008,
showed:
-The facility would help arrange transportation for residents as needed; and
-Residents inquiring about transportation services would be referred to Social Services.
1. Record review of Resident #59’s Face Sheet showed he/she was admitted to the facility
on [DATE] and had Medicare coverage. The resident was diagnosed with
[REDACTED].>-[MEDICAL CONDITION] (TBI – damage to the brain resulting from external
mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or
penetration by a projectile),
-[MEDICAL CONDITION] (A pattern of drinking that interferes with day to day activities),
-Stimulant (legal and illegal drugs that heighten energy and alertness) Abuse (A stimulant
use disorder that leads to compulsive drug-seeking behaviors, emotional distress and/or
negative physiological symptoms severe enough to affect day to day activities); and
-Nicotine Dependence, cigarettes (An addiction to tobacco products which makes it
difficult to stop smoking).
Record review of the resident’s Activities of Daily Living (ADL – dressing, grooming,
bathing, eating, and toileting) Care Plan, dated 3/22/16 showed:
-The resident performed most ADLs with supervision,
-The following interventions were added to the plan on 3/15/17:
–The resident was to see the physician for any tooth problems,
–The resident had his/her own teeth and staff should assist the resident with oral care
as needed; and
–[MEDICATION NAME] was to be applied to the affected tooth and gums pro re nata (PRN – as
needed).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 45)
Record review of the resident’s Annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning purposes), dated
3/13/18 showed:
-The resident was cognitively intact,
-The resident could perform ADLs with oversight supervision and either no staff assistance
or set-up assistance only; and
-There was no documentation that there were problems with the resident’s teeth, gums, or
with oral discomfort.
Record review of the resident’s Physician order [REDACTED].
Record review of the resident’s Dental Report, dated 4/9/18 showed:
-The resident had a dental evaluation on 4/9/18;
-The resident had severe periodontal disease and generalized severe decay; and
-Recommendations were for treatment for [REDACTED].
Record review of the resident’s Physician’s Progress Note, dated 8/3/18 showed:
-The resident’s teeth, numbers seven through 10, were in a very poor state;
-an order for [REDACTED].>-A referral to the treating doctor.
Record review of the resident’s Nursing notes and Social Services notes, dated 8/3/18
through 9/9/18, showed no documentation that transportation services had been arranged by
the facility staff for a dental surgery appointment or that the resident was planning on
making the transportation arrangements.
Record review of the resident’s Nursing Note, dated 9/10/18 showed:
-The resident had a dental consult appointment at a local facility;
-The appointment was rescheduled for 10/30/18 at 1:00 P.M.; and
-The reason for not following up with the dental appointment on 9/10/18 was not
documented.
Observation on 9/25/18 between 10:00 A.M. and 10:50 A.M. showed when the resident was
speaking during the Residents’ Group Meeting multiple teeth were visibly missing or
damaged.
During an interview on 9/27/18 beginning at 4:11 P.M. the resident said:
-He/she had complained about his/her teeth since he/she had arrived at the facility;
-Since his/her admission three teeth had been extracted;
-It was recommended in April, (YEAR) that all teeth be removed while under general
anesthesia (Drugs administered intravenously (into the veins) and/or inhaled to render a
patient unconscious so the patient does not feel pain during a medical procedure);
-He/she had been on antibiotics within the past couple of months due to a tooth and/or gum
infection;
-An appointment had been set up the first part of September, (YEAR) to have all his/her
teeth removed;
-He/she was told by facility staff that transportation would be set up for the full-mouth
dental extractions, but when the time came to be picked up no transportation service
arrived. The facility called the transportation company and was told he/she was not on
their pick-up list, so the appointment was canceled and had to be rescheduled towards the
end of October, (YEAR);
-His/her gums hurt and his/her teeth were cracking and falling out;
-Within the past month parts of three teeth had come out. (At this point the resident
pointed to a few teeth to show which ones had recently broken off); and
-Gum disease was causing his/her teeth to fall out.
During an interview on 9/28/18 at 9:01 A.M. Certified Nurse Assistant (CNA) A said:
-The resident has had multiple dental appointments canceled within the past year;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 46)
-He/she was told by other staff and the resident that approximately two weeks ago the
resident had an appointment to get his/her teeth extracted and the facility failed to make
transportation arrangements; therefore, another appointment had to be made;
-At the time of the appointment the resident was upset that the procedure was canceled
because transportation hadn’t been arranged; and
-The resident spoke with the Director of Nursing (DON) about his/her frustrations
regarding the extraction surgery cancellation.
During an interview on 9/28/18 at 9:57 A.M. the DON said:
-The resident had a dental appointment set up a couple of months prior and he/she couldn’t
remember why the resident didn’t go then;
-The Social Services Designee had the responsibility of setting up transportation services
for resident appointments, but that responsibility recently fell temporarily on the
facility Administrator;
-The resident’s dental extraction appointment was set up to take place two to three weeks
ago;
-On the day of the appointment facility staff realized transportation had not been
arranged;
-The transport services company was contacted, but transportation could not be arranged at
the last minute; and
-The extraction procedure was rescheduled for (MONTH) 30, (YEAR).
During an interview on 10/1/18 at 2:35 P.M. LPN A said:
-Dental services are set up frequently by the facility; and
-If a resident had a recommendation for immediate dental services the facility should be
able to arrange such services within a three-month time period at the very longest.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review the facility failed to ensure menus
accommodated the residents’ choices and preferences as requested during Resident Council
Meetings. The practice had the potential to affect all residents living at the facility.
The facility census was 65 residents.
Record review of the facility’s Nutrition Policy and Procedure, Menus section showed:
-Menus would be planned to meet the nutritional needs and preferences of residents and be
in accordance with dietary allowances of the Food and Nutrition Board of the National
Research Council; and
-Two, four-week menu cycles per year were utilized and they should fit the needs and
preferences of the residents.
1. Observation on 9/24/18 at 12:24 P.M. of the lunch meal showed:
-The main meal was barbeque chicken (chicken salad was the alternate entree), potato
salad, corn on the cob (or creamed corn depending on resident diets) and canned apricots;
-Residents had water and one or two other beverages such as milk and/or fruit flavored
drinks; and
-None of the residents had fresh fruit or peanut butter.
Record review of the Resident Council Meeting Minutes, dated 6/2/18 showed the residents

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
would love to have tacos and fried chicken.
Record review of the Resident Council Meeting Minutes dated 7/10/18 showed fried chicken
and chef salad as a requested resident choice meal.
Record review of the Resident Council Meeting Minutes dated 8/3/18 showed the residents
had requested pizza or chef salad for a resident choice meal.
During an interview on 9/25/18 at 10:00 A.M., ten residents who normally attended the
monthly Resident Council meetings were asked about the food that was served at the
facility. The residents said:
-The facility followed the menus made out by the Dietitian;
-Some weeks there was a lot of repetition in the foods offered;
-They had gotten bananas before, but no other fresh fruit. Almost all the fruit they
received came out of a can. They would like to have fresh fruit like watermelon and
oranges;
-Nobody ever got peanut butter no matter what diet they were on. The facility had jelly,
but they couldn’t have peanut butter and jelly sandwiches;
-Meals and snacks seemed to be a lot of starch and carbohydrates. Bedtime snacks were
usually cookies and crackers. They would like the option to have fresh fruit for snacks;
and
-The food preferences had been discussed repeatedly in the Resident Council meetings. They
had input into specially planned resident choice meals. They didn’t have input on the day
to day menus.
Record review of the facility’s four-week Spring/Summer Menu Cycle showed:
-There was some repetition of foods offered in Week One, where whipped potatoes and gravy
were on the menu for Sunday, Tuesday and Thursday for the lunch meal and pasta salad was
on the menu for Monday and Thursday for the supper meal;
-Bedtime snacks consisted of cookies. On all four weeks graham crackers were on the menu
for Sundays and Thursdays; vanilla wafers were on the menu for Tuesdays and Saturdays;
sugar cookies were listed for Mondays; chocolate chip cookies for Wednesdays; and oatmeal
cookies for Thursdays;
-Some entree items that residents mentioned liking were not reflected on the four-week
rotating menu. These included tacos, pizza and chef salad;
-Peanut butter was not on the menu cycle and the menu did not mention alternates that were
available; and
-Weekly menus showed no days in which fresh fruit was on the menu for breakfast. Week One
showed chilled watermelon for lunch on Monday and fresh fruit for supper on Saturday. Week
Two showed chilled fresh fruit for Saturday. Week Three showed chilled melon for supper on
Friday. Week Four showed chilled watermelon for lunch on Tuesday and a grape, melon and
strawberry mix for lunch on Thursday. All other lunches and suppers in which fruit was
served offered only canned or frozen fruit options. Bananas and fresh oranges were not
mentioned on the menu.
During an interview on 10/1/18 at 2:04 P.M. the Dietary Manager said:
-The Dietician made up the menus and the facility stuck close to the menus;
-The Spring/Summer menu started the first weekend in (MONTH) and was a 28 day cycle. The
Fall/Winter menu started the first weekend of (MONTH) and was also a four-week, 28-day
menu cycle;
-In the winter all tropical fruits were canned. Strawberries reflected on the menu were
frozen. Most fruit came in a can or jar or was frozen. He/she had ordered 144 bananas at a
time before for the residents;
-Food was ordered monthly according to the menu; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 48)
-Bedtime snacks consisted of graham crackers, oatmeal rounds, sandwich cookies and Lorna
Dunes. Residents on a pureed diet usually had applesauce, pudding or ice cream. The 10:00
A.M. snack was similar to the bedtime snack in the type of snack offered. He/she mixed a
variety of cookies, puddings and applesauce at snack time and had offered bananas as a
snack in the past.
During an interview on 10/2/18 at 3:15 P.M. the Director of Nursing (DON) said:
-Residents’ choices should be reflected on the rotating menus;
-Fresh fruit would be a good way to provide variety to residents; and
-He/she was unaware that peanut butter was not available to residents when appropriate for
their diet.

F 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Conduct and document a facility-wide assessment to determine what resources are
necessary to care for residents competently during both day-to-day operations and
emergencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a facility-wide
assessment to determine what resources were necessary to care for residents competently
during both day-to-day operations and emergencies as required by 11/28/17. This had the
potential to affect all of the residents. The sample was 32 residents. The facility census
was 65 residents.
Record review of the facility’s Facility Assessment policy, dated 2001 and revised on
July, (YEAR) showed:
-The facility-wide assessment would be conducted annually by a designated team to update
the facility’s capacity to meet the needs of the resident and ensure resources were
available to meet resident needs. The team would consist of the Administrator, a governing
body representative, the Medical Director, the Director of Nursing and a designee from the
following departments:
–Environmental Services, Physical Operations, Dietary Services, Social Services,
Activities and Rehabilitation;
-A detailed review of the resident population would be conducted that included data from
the past 12 months;
-A detailed review of available resources would be made to determine requirements related
to buildings; vehicles, budgets, equipment and supplies, services, personnel, staff
education and training, health records and resources needed by personne;,
-Evaluation of gaps in services and lack of appropriate resources;
-Requirements to meet resident needs during various types of emergencies;
-Ability to provide various types of specialized care;
-Evaluation of significant changes in the resident census or characteristics; and
-The facility assessment would be reviewed quarterly to determine if a facility-wide
re-assessment was warranted.
1. Record review of the facility’s Facility Assessment Tool (the Date of Assessment space
was left blank) showed:
-The facility’s top [DIAGNOSES REDACTED].
–[MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease process that decreases the ability
of the lungs to perform ventilation);

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 49)
-Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that
is primarily a result of a deficiency or complete lack of insulin secretion in the
pancreas or resistance to insulin);
-[MEDICAL CONDITION] reflux disease (GERD – heartburn/back-up of stomach acid into the
tube connecting the mouth to the stomach);
-Depression (a mental disorder characterized by a feeling of mild to profound sadness and
frequently accompanied by a loss of interest in things that were once pleasurable);
-Muscle Weakness;
-The tool did not indicate how many residents were diagnosed with [REDACTED].
-Were bedfast;
-Had pressure ulcers (sores caused by pressure on a body area);
-Had contractures (an abnormal, usually permanent condition of a joint, characterized by
an inability to fully move the affected area);
-Were diagnosed with [REDACTED].>-Had Dementia (a progressive organic mental disorder
characterized by chronic personality disintegration; confusion, disorientation, stupor,
deterioration of intellectual capacity and function, and impairment of control of memory,
judgment, and impulses);
-Had wandering or other behaviors;
-Had a catheter (a tube passed through the urethra into the bladder to drain urine);
-Were receiving Hospice services (end of life care);
-Needed Intravenous (IV) therapy, IV nutrition, and/or blood transfusion;
-Received nutrition through tube feedings or required a mechanically altered diet
(referring to food texture);
-Had an unplanned significant weight loss/gain;
-Used a wheelchair, walker or were ambulatory most of the time;
-Were incontinent of bowel or bladder;
-Were receiving specialized treatments such as [MEDICAL CONDITION];
-Required [MEDICAL TREATMENT] (process of cleansing the blood by passing it through a
special machine – necessary when the kidneys are not able to filter the blood);
-Received respiratory treatments;
-Received [MEDICAL CONDITION] care (surgical opening into the wind pipe into which a tube
is inserted to allow passage of air and removal of secretions) or ostomy care (artificial
or surgical opening);
-Received Physical, Occupational or Speech Therapies;
-Were on psychotherapeutic medication, [MEDICAL CONDITION] or antibiotic therapy; and
-Utilized assistance devices during meals and/or at other times.
The Facility Assessment failed to show:
-The numbers and types of staff needed on any shift or living area to meet the residents’
needs. Specifically, the Facility Assessment did not show numbers of facility and/or
contracted staff needed in several areas including, but not limited to Maintenance,
Dietary, Housekeeping, Therapy Services, Physician Services, Laundry Services and the type
of staff and hours needed in each of these departments. It did not show the numbers and
positions of nursing staff required to meet the residents’ needs and the living areas they
were needed on for any of the facility’s three daily nursing shifts;
-Assessment of resource (financial, physical, equipment, staffing, Pharmacy, medical and
informational) requirements needed to meet the residents’ needs;
-Documentation for staff education related basic wound care in the Staff Competency and
Education Needs section;
-Gaps in services and lack of facility resources; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 50)
-The facility’s capacity to provide basic and specialized services in all care and
treatment areas.
During an interview on 9/25/18 at 11:18 A.M. the Corporate Administrator said the facility
assessment had not been completed by the facility Administrator.
During an interview on 9/26/18 at 8:59 A.M. the Administrator said:
-He/she talked about the Facility Assessment during Quality Assurance meetings;
-The facility assessment was a complicated process and had never been completed; and
-He/she didn’t think there was a policy on the Facility Assessment.
During an interview on 9/28/18 at 8:23 A.M. the Director of Nursing (DON) said:
-The facility’s Staff Trainer was responsible for wound care trainings. The trainer
recently left the facility and he/she could not find documentation of wound care trainings
for the past year. There were residents in the facility who had wounds;
-During the Day Shift there were three to four Charge Nurses employed at the facility.
There were four living areas and sometimes one nurse worked on two separate halls. When
there were three Charge Nurses a Certified Medication Technician (CMT) worked on the
locked, secure unit. One Certified Nurse Assistant (CNAs) worked on each hall and
sometimes there were two on the secured unit;
-On the Evening Shift there were at least two nurses in the building and usually three,
with a CMT on the secured unit. On the Evening Shift there was usually one CNA on each of
the four halls; and
-On the Night Shift there were two nurses, one on each side of the building, and three to
four CNAs.
During an interview on 10/2/18 at 3:15 P.M. the DON said:
-The Administrator was working on the Facility Assessment; and
-The Facility Assessment should be completed each year and be comprehensive.

F 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Have the Quality Assessment and Assurance group have the required members and meet at
least quarterly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to identify quality issues in
need of quality assessment (an evaluation of a process and/or outcomes to determine if a
defined standard of quality is being achieved) and assurance (the implementation of
principles of continuous quality improvement) (QAA) activities, determine the cause of the
issues, and develop and implement plans of action to correct identified problems regarding
pressure ulcers (localized damage to the skin and/or underlying soft tissue that occurs as
a result of intense and/or prolonged pressure) affecting three residents (Resident #35,
Resident #25, and Resident #50) with pressure ulcers and one resident (Resident #19) at
risk for development of pressure ulcers and failed to address that restorative services
were not provide for two sampled residents (Resident #20 and Resident #15) with
limitations of Range of Motion (ROM-full movement potential of a joint, usually its range
of flexion and extension) out of 32 sampled residents. The facility census was 65
residents.
1. The QAA Committee did not identify that preventative measures were not in place to
prevent the development of pressure ulcers resulting in an avoidable unstageable pressure
ulcer on the right heel for one sampled resident (Resident #35).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 51)
2. The QAA Committee did not identify that preventative measures were not in place and
that the facility did not assess, monitor, track and stage the resident’s pressure ulcers,
and failed to obtain physician’s treatment orders for treatment of [REDACTED].#25) who had
avoidable pressure ulcers including a right thigh blister, a blister on the back of
his/her left leg, a right planter foot unstageable pressure ulcer, and an unstageable
pressure ulcer on his/her left great toe.
3. The QAA Committee did not identify that the facility failed to correctly assess and
document the stage for one resident’s (Resident #50) unstageable pressure ulcer on his/her
left gluteal fold (crease between the lower buttocks and upper thigh).
4. The QAA Committee did not identify that the facility failed to assess for support
surface needs (mattress) and prevention needed for one sampled resident (Resident #19) who
was at risk for pressure ulcers.
5. The QAA Committee did not identify that the facility failed to provide restorative
services to address Resident #20’s limitations in range of motion.
6. The QAA Committee did not identify that the facility provide restorative services to
address Resident #15’s limitations in range of motion.
7. During the QAA interview on10/3/18 at 9:16 A.M. the Administrator said:
-The QAA committee meets monthly and quarterly, was attended by all department heads, the
Medical Director and contracted staff as needed;
-Each month the committee discussed resident fall rates, safety meeting information, what
in-service training was provided during the month and any other training conducted with
staff;
-In the past nine months, the QAA committee had looked at medication issues such as times
of administration;
-The QAA Committee had not addressed resident pressure ulcers – pressure ulcers were not
on the committee’s monthly QAA meeting agenda, it was rare for the QAA Committee to have
anything to address regarding pressure ulcers in QAA meetings, and one resident’s pressure
ulcer was discussed during the most recent QAA meeting;
-The Restorative Aide had left employment since the last QAA meeting -the facility was
trying to fill that position internally, no current employee wanted to be considered;
-Nursing staff was walking with one resident who had concerns regarding not receiving RA
services;
-Restorative nursing services had not been addressed in QAA meetings;
-A list of prior facility cited regulatory deficiencies was discussed at a Quality of Care
(C[NAME] – a meeting to evaluating care needs of specific residents) or QAA, he/she did
not remember which, to look at what documentation was in place related to the prior cited
deficiencies; and
-He/she had been the administrator at the facility for one year and he/she would have to
clarify if it was an expectation to use the Centers for Medicaid and Medicare Services
(CMS) Quality Indicator Report (data compiled from submitted resident Minimum Data Sets –
MDS, a federally mandated assessment tool required to be completed by the facility staff
for care planning) to assist the QAA Committee to identify quality issues.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 – Few

(continued… from page 52)
Based on observation, interview and record review the facility failed to ensure personal
protective equipment of gowns were readily available related to infection control
isolation for extended-spectrum beta-lactamase (ESBL – enzymes produced by many species of
bacteria which destroy one or more antibiotics; it is one of the ways in which bacteria
develop resistance to antibiotics), failed to maintain the resident’s Foley catheter bag
and tubing below the level of his/her bladder and his/her catheter tubing off the floor
during care, and failed to maintain hand hygiene during treatment of [REDACTED].#50) out
of 32 sampled residents. The facility census was65 residents.
Record review of the facility Isolation Categories of Transmission-Based Precautions
policy date (MONTH) 2012 showed:
-Standard Precautions shall be used when caring for residents at all times regardless of
their suspected or confirmed infection status;
-Transmission-Based Precautions shall be used when caring for residents who are documented
or suspected to have communicable diseases or infections that can be transmitted to
others;
-The facility shall make every effort to use the least restrictive approach to managing
individuals with potentially communicable infections;
-Transmission-Base precautions shall only be used when transmission cannot be reasonably
prevented by less restrictive means;
-Transmission-Based precautions will be used whenever measures more stringent than
Standard Precautions are needed to prevent or control the spread of infection; and
-Based on Centers for Disease Control and Prevention (CDC) definitions three types of
Transmission-Based Precautions have been established.
Record review of the Antibiotic Resistant Organism: Extended Spectrum Beta Lactamase
Organisms (ESBL) dated (MONTH) (YEAR) showed:
-ESBLs are resistant to specific antibiotics;
-Appropriate precautions will be instituted when caring for residents with known ESBL
infections (presence of signs and symptoms of illness caused by bacteria, virus or
parasite) or colonization (presence of an organism without symptoms of illness);
-ESBLs reduce the effectiveness of antibiotics;
-ESBLs are commonly found in infectious material including fluids particularly from the
site of infection/colonization and devices, supplies, or other environmental surfaces
contaminated with body fluids; and
-Universal/Standard Precautions are applied whenever handling blood or body fluids
regardless of presence of specific organisms.
Record review of the CDC Transmission-Based Precautions showed:
-Transmission-Based Precautions are the second tier of basic infection control and are to
be used in addition to Standard Precautions for patients who may be infected or colonized
with certain infectious agents for which additional precautions are needed to prevent
infection transmission;
-Use Contact Precautions for patients with known or suspected infections that represent an
increased risk for contact transmission;
-Use PPE appropriately, including gloves and gown;
-Wear a gown and gloves for all interactions that may involve contact with the resident or
with the resident’s environment; and
-Donning PPE upon room entry and properly discarding before exiting the resident room is
done to contain pathogens.
Record review of the facility Hand Hygiene/Handwashing policy dated (YEAR) showed:
-Proper hand hygiene/hand washing technique will be accomplished at all ties that
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 – Few

(continued… from page 53)
handwashing is indicated;
-Hand hygiene/hand washing is the most important component for preventing the spread of
infection;
-Hand hygiene/hand washing is done-
–Before resident contact;
–Before starting work;
–Before taking part in a procedure;
–After contact with soiled or contaminated articles, such as articles that are
contaminated with body fluids;
–After resident contact;
–After contact with a contaminated object or source where there is a concentration of
microorganisms, such as mucous membranes, non-intact skin, body fluids or wounds and
–After removal of gloves;
–After contact with a resident’s intact skin;
–After contact with environmental surfaces in the immediate vicinity of residents; and
-When hands are contaminated with proteinaceous materials or visibly soiled with blood or
body fluids or are dirty, wash hands with soap and water.
Record review of Drugs.com information regarding Foley catheter care dated (YEAR) showed:
– Keep the drainage bag below the level of your waist; and
– This helps stop urine from moving back up the tubing and into your bladder.
1. Record review of Resident #50’s Face Sheet showed he/she was originally admitted t the
facility on 12/23/16 with the following Diagnoses: [REDACTED].
-Neuromuscular dysfunction of bladder (also called [MEDICAL CONDITION] bladder, a problem
in which a person lacks bladder control due to a brain, spinal cord, or nerve condition);
-Diabetes (a chronic disease associated with abnormally high levels of the sugar glucose
in the blood); and
-History of [MEDICAL CONDITION] (an open sore below the ankle, commonly on the bottom of
the foot that occurs as a serious complication of diabetes).
Record review of the resident’s care plan dated 6/14/18 with revisions dated 9/17/18
showed:
-He/she had [MEDICAL CONDITION], a Foley catheter, and was on contact precautions;
-Interventions included –
–Complete treatments as ordered;
–Use proper isolation protocol; and
–Position his/her catheter bag and tubing below the level of his/her bladder and in a
privacy bag.
Record review of the resident’s POS dated 9/1/18 showed his/her physician ordered:
-Foley catheter;
-Cleanse area to right fifth toe with saline, apply calcium alginate and cover with a dry
dressing once daily and as needed;
-Cleanse Right third and fourth toes with saline, apply skin prep (a topical barrier for
use between skin and adhesives) daily and as needed;
-Apply triple antibiotic ointment to right fourth toe every day and as needed
-Cleanse area on left ankle with saline, apply skin prep around the wound area, apply
Vaseline gauze, secure with bordered gauze dressing (a non-adherent pad and adhesive
border wound covering), change daily and as needed; and
-Cleanse area to left foot with saline, apply skin prep to around the wound area, apply
collagen pad, secure with bordered gauze dressing daily and as needed.
During an interview on 9/24/18 at 11:00 A.M., Licensed Practical Nurse (LPN) C said the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 – Few

(continued… from page 54)
resident was on contact precautions because he/she had ESBL in his/her urine.
Observation on 9/24/18 at 11:11 A.M. showed:
-He/she was alert and laying on his/her bed; and
-Two large isolation barrels located between his/her bed and the wall.
During an interview on 9/25/18 at 3:18 P.M. Certified Nursing Assistant (CNA) D said:
-He/she was never told to wear a gown when in close contact with the resident, just to use
gloves and wash his/her hands; and
-The charge nurse talked to the nursing staff on duty on the resident’s hall when he/she
was placed on isolation.
Observation during on 9/26/18 at 12:33 P.M. showed:
-No PPE cart or PPE supplies near the resident’s room door;
-CNA B and CNA C entered the resident’s room without placing PPE gowns on, washed their
hands, put on gloves and transferred the resident from his/her wheelchair to his/her bed
with a mechanical lift (a machine for lifting resident’s with a sling), then positioned
him/her on his/her left side;
-During the transfer CNA B lifted the resident’s catheter bag above the level of his/her
bladder and then placed it first on the resident’s lap when seated) and then on the
resident’s abdomen (when laying on his/her bed) and placed the resident’s catheter bag and
dignity bag (a privacy cover) on the left side of the resident’s bed;
-CNA B then positioned the resident in his/her right side and then switched his/her
catheter bag and dignity bag to the right side of his/her bed by passing his/her catheter
bag over his/her hip, above the level of his/her bladder.
-CNAs B then lowered the resident’s bed to the lowest position and the residents catheter
tubing rested on the resident’s floor;
-CNAs C asked CNAs B if he/she left the bed up high enough to float (place the catheter
bag in a manner that would prevent it and the catheter tubing from contacting and resting
on the floor) the resident’s catheter bag;
-CNA B responded by saying he/she always places the resident’s bed in the lowest position
but did not clean and remove the resident’s catheter tubing from the floor and placed the
extra tubing in the dignity bag; and
-CNA B said he/she was running behind and needed to show CNA C where the laundry area was.
Observation on 9/26/18 at 8:38 A.M. showed:
-No PPE available near the resident’s room door;
-Without obtaining and putting gowns on, LPN C and the Director of Nursing (DON) entered
the resident’s room, washed their hands and put on gloves;
-LPN C and the DON turned the resident from side to side, using a turn sheet (a folded top
sheet placed under the resident to assist in turning and positioning) and positioned the
resident on his/her back and sides and also positioned the resident’s legs and feet while
LPN C completed the resident’s wound care;
-While positioning the resident from side to side, the DON twice passed the resident’s
catheter bag over the resident’s hip above the level of the resident’s bladder; causing
the resident’s catheter bag to
-After applying skin prep around the resident’s diabetic ulcer on his/her right fourth toe
and antibiotic ointment on the wound bed with an applicator, LPN C removed his/her gloves,
did not wash his/her hands, put on new gloves, cleansed the resident’s open wound on
his/her left ankle with saline and applied skin prep around the wound; and
-Also during the resident’s wound care, LPN C removed his/her gloves, did not wash his/her
hands, opened the resident’s room door, did not use hand sanitizer and obtained additional
skin prep from the treatment cart just outside the resident’s door, then washed his/her
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 – Few

(continued… from page 55)
hands and proceeded to complete the resident’s treatment.
During an interview on 9/26/18 at 12:33 P.M. LPN C said:
-During the resident’s wound care that morning, the resident’s catheter bag was lifted and
moved over the resident’s hips above the level of his/her bladder two times; and
-The resident’s catheter bag and tubing needed to be kept below the level of his/her
bladder.
During an interview on 10/2/18 at 1:18 P.M. the Assistant Director of Nursing
(ADON)/Infection Control Nurse said:
-Regarding the Resident’s ESBL in his/her urine, he/she was on contact precautions;
-Nursing staff needed to make sure the resident’s urine was not contaminating objects and
surfaces, practice good handwashing and there were isolation barrels in the resident’s
room;
-Gowns were only needed if there was a risk of staff getting splashed with urine or bodily
fluids;
-In general the policy was to wear a gown in staff might be splashed with body fluids, but
especially when a resident had ESBL;
-No gowns were kept outside the resident’s room door but were available in a closet
located a couple of doors down from the resident’s room; and
-The facility did not have isolation carts or isolation stations outside for use outside
resident rooms when a resident was on isolation precautions.
During an interview on 10/3/18 at 10:30 A.M. the DON said:
-The resident’s catheter bag and tubing should have been kept below the level of the
resident’s bladder and his/her catheter tubing off the floor;
-LPN C should have washed his/her hands each time he/she removed his/her gloves during
wound treatment for [REDACTED].>-The resident was on contact isolation for ESBL;
-He/she had not yet had a clear culture clear of ESBL so the facility was just leaving the
barrels in the resident’s room until the resident had a clear culture;
-There was no need for nursing staff to wear gowns unless they think they are going to
splash urine all over themselves when they change the resident’s catheter or empty the
resident’s catheter bag;
-He/she did not have gowns kept outside the resident’s room door;
-If nursing staff did not have on a gown and urine did splash on them, it would be too
late for a gown – they would not be protected from a spill if they did not have on a gown;
and
-Regarding if there was a potential for cross contamination during close contact with the
resident or objects in the resident’s room, the DON said staff did wear gloves.

F 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and
all bed rails and mattresses must attach safely to the bed frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to complete
inspection of bed frames, mattresses, and bed rails as part of a regular maintenance
program to ensure bed rails/grab bars were properly secured, and to identify areas of
possible entrapment for five sampled residents (Residents #54, #64, #5, #15 and #50) out
of 32 residents. The facility census was 65 residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 56)
Record review of the facility’s Bed Rails/Side Rails (Use and Implementation) Policy and
Procedure showed:
-The facility will ensure correct installation, use and maintenance of bed rails/ side
rails when their use is determined to be appropriate,
-The facility will ensure the resident’s bed dimensions are appropriate based on the
resident’s height and weight prior to installation to minimize potential for entrapment,
and
-The facility will install and maintain bed rails/side rails according to the
manufacturer’s recommendations and specifications for the duration of use.
1. Record review of Resident #54’s Face Sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].>-[DIAGNOSES REDACTED] (MG – an [DIAGNOSES
REDACTED] neuromuscular disease that leads to muscle weakness which can result in double
vision, drooping eyelids, difficulty speaking and trouble walking);
-[MEDICAL CONDITION] (difficulty falling or staying asleep);
-Generalized muscle weakness;
-Difficulty walking;
-A history of [MEDICAL CONDITION] (TIA – a brief episode of neurological dysfunction
causing a loss of blood flow in the brain, spinal cord or retina without tissue death. A
TIA can cause the same symptoms associated with stroke such as paralysis, weakness or
numbness on one side of the body), and
-History of falling.
Record review of the resident’s Physician order [REDACTED].
Record review of the resident’s Activities of Daily Living (ADL – eating, dressing,
transferring, bathing, toileting and personal hygiene) Care Plan, dated 8/31/18 showed on
9/4/18 an intervention for one-half side rails times two to assist with bed positioning
and mobility was added to the plan.
During observations on 9/24/18 at 11:00 A.M. and 9/28/18 at 8:57 A.M., the resident was
noted to have side rails on his/her bed.
2. Record review of Resident #64’s Face Sheet showed the resident was admitted to the
facility on [DATE] and had the following Diagnoses: [REDACTED].
-Muscle weakness;
-Lack of coordination;
-Reduced mobility; and
-Agitation and anxiety.
Record review of the resident’s Evaluation for the use of side rails dated 10/17/17
showed:
-The side rails were being used for medical symptoms including weakness, orthostatic
hypertension (a sudden and abrupt increase in blood pressure when a person stands up);
-The side rails would assist the resident with bed mobility of turning side to side,
moving up and down in bed, holding themselves to the side, pulling themselves from a
laying position to a sitting position;
-The side rails would assist the resident with balance, supporting self, exiting and
entering the bed more safely, and transferring more safely;
-The side rails would prevent the resident from rolling out of bed and provide a sense of
security; and
-The side rails were re-evaluated on 1/5/18, 1/30/18, 5/11/18, 6/4/18, 6/10/18, and 9/6/18
for continued use of two half side rails on the resident’s bed.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool required to the completed by the facility staff for care
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 57)
planning) dated 6/16/18 showed the resident:
-Was severely cognitively impaired;
-Needed extensive assistance of staff for transfers; and
-Needed limited assistance of staff for bed mobility.
Record review of the resident’s fall care plan revised 6/19/18 showed the resident had
half side rails up to assist in positioning and bed mobility.
Record review of the resident’s POS dated (MONTH) (YEAR) showed a physician’s orders
[REDACTED].
Observation on 9/26/18 at 5:49 A.M. showed:
-The resident was asleep in his/her bed on a low air loss mattress with two half side
rails up on both sides of his/her upper bed;
-There was a four inch gap between the mattress and the side rail on the left side of the
bed and a two inch gap between the mattress and the side rail on the right side of the
bed.
3. Record review of Resident #5’s Face Sheet showed he/she was admitted to the facility on
[DATE] with the following Diagnoses: [REDACTED].
–Dementia (a progressive organic mental disorder characterized by chronic personality
disintegration, confusion, impulsiveness, disorientation stupor deterioration of
intellectual capacity and function, and impairment of memory, and judgment);
–[MEDICAL CONDITION] (a brain disorder that leads to shaking, stiffness, and difficulty
with walking, balance and coordination; and
–Muscle weakness.
Record review of the resident’s Consent for Use of Side Rails dated 11/8/14 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
-The resident’s responsible party gave consent for 2 full side rails on the upper part of
the resident’s bed for indications of uncontrolled movements secondary to his/her brain
damage and [MEDICAL CONDITION] disorder;
-The side rails were to be released every two hours for 15 minutes and could also be
released during activities and supervised visits;
-The area to check boxes that the person signing the form did or did not give consent to
the use of side rails was blank; and
-The form was signed by the resident’s legally responsible person on 4/20/18 and had not
been updated or a new form signed to reflect that he/she had one-half or one quarter side
rails.
Record review of the resident’s annual MDS dated [DATE] showed he/she:
-Was severely cognitively impaired;
-Received extensive staff assistance for bed mobility;
-Was totally dependent on staff for transfer, locomotion, dressing, and personal hygiene;
-Did not walk; and
-Had limitations in range of motion of his/her upper and lower extremities.
Record review of the resident’s care plan dated 6/29/18 showed:
-He/she had limited physical mobility and all his/her cares were completed by staff;
-He/she would be free of complications including fall related injuries;
-Interventions included-
–One quarter side rails up on both sides of his/her bed to aide in positioning and
mobility related to his/her weakness; and
–Keep his/her bed in the lowest position.
Observation on 9/28/18 at 2:08 P.M. showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 58)
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed; and
-His/her one quarter side rails fit next to his/her mattress without obvious gap.
Record review of the resident’s medical record on 10/2/18 showed no Evaluation for Use of
Side Rails.
On 10/2/18 the facility administrator provided requested Evaluation for Use of Side Rail
forms for sampled resident’s that had been requested, but no Evaluation for the Use of
Side Rails for the resident.
4. Record review of Resident #15’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
–[MEDICAL CONDITION] (disease or damage that affects the function or structure of the
brain); and
-Unspecified [MEDICAL CONDITION].
Record review of the resident’s Consent for Use of Side Rails dated 4/20/12 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
-The resident’s responsible party gave consent for 2 full side rails on the upper part of
the resident’s bed for indications of uncontrolled movements secondary to his/her brain
damage and [MEDICAL CONDITION] disorder;
-The side rails were to be released every two hours for 15 minutes and could also be
released during activities and supervised visits;
-The area to check boxes that the person signing the form did or did not give consent to
the use of side rails was blank; and
-The form was signed by the resident’s legally responsible person on 4/20/18 and had not
been updated or a new form signed to reflect that her/she had one-half or one quarter side
rails.
Record review of the resident’s Evaluation for use of Side Rails dated 6/308/17 showed:
-The side rails were being considered for safety;
-Medical symptom that contributed to the resident’s need for side rails was that he/she
was unable to support his/her turn in an upright position;
-The side rails would assist the resident to avoid rolling out of bed;
-Two full side rails were recommended at that time;
-Side rail precautions and alternatives had been discussed with the resident and the
resident’s family/representative was not checked as completed;
-No documentation that showed alternatives to the side rails were tried prior to the use
of the side rails; and
-The comments section showed that the resident had one-half side rails and a bolster
mattress pads (a parameter mattress cover) on 6/30/17 and no changes on 2/12/19, 1/3/18,
4/19/18, and 5/24/18 and 6/30/1.
Record review of the resident’s MDS dated [DATE] showed he/she:
-Was totally dependent on staff for all his/her care needs including bed mobility,
transfer and dressing and
-Did not walk;
-Had limitations in range of motion (ROM) of his/her upper extremities (shoulder, elbow,
wrist, hand); and
-Had limitations in ROM of his/her lower extremities (leg, knee, ankle, foot).
Record review of the resident’s care plan date 7/6/18 showed:
-Place rolled wash clothes in his her hands daily for contractures daily;
-He/she needed to be evaluated for an supplied with a High-Low bed (a bed frame capable of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 59)
being lowered close to the floor and raised for performing care) one quarter side rails, a
perimeter mattress (also known as bolster cover – a mattress cover with long rounded
cushions that surround and define the edge of the mattress to promote a safe bed
environment without the need for side rails);
-Side rails may be removed (lowered) for cares;
-He/she needed to be turned and repositioned by staff; and
-He/she had a [MEDICAL CONDITION] disorder and staff was to keep his/her bed in the lowest
position with the bakes locked.
Record review of the resident’s POS dated 9/1/18 showed his/her physician ordered:
-One-half side rails on both sides of his/her bed to aide in positioning due to immobility
and [MEDICAL CONDITION];
-Rolled wash cloth to both his/her hands; and
-Place inside his/her hands daily for contracture (shortening and hardening of muscles,
tendons or other tissue, often leading to the deformity and rigidity of joints) daily.
Observation on 10/3/18/18 at 9:10 A.M. showed:
-He/she was alert and laying in his/her bed;
-His/her one quarter side rails were up on both sides of his/her bed;
-His/her bed was a low position;
-His/her mattress had a perimeter cover;
-His/her arms were in front of his/her chest and flexed at his/her elbows;
-His/her fingers were pressed tightly onto his/her palms and his/her thumbs were pressed
against his/her ring fingers;
-He/she had a rolled wash cloths in his/her right and left hands; and
-There was a gap of approximately one inch between his/her side rail and his/her mattress
perimeter cover.
During an interview on 10/3/18 the DON said:
-The resident had [MEDICAL CONDITION];
-He/she had not had a [MEDICAL CONDITION] in a long time;
-Side rails have risks and the facility could look at eliminating his/her side rails; and
-There was no longer an indication for him/her to have side rails on his/her bed.
5. Record review of Resident #50’s Face Sheet showed he/she was originally admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
–Contracture of his/he right and left hands; and
– History of [MEDICAL CONDITION] (TIA – a neurological event caused by a temporary lack of
adequate blood and oxygen to the brain, with the signs and symptoms of a stroke, but which
go away within a short period of time; also called a mini-stroke).
Record review of the resident’s Evaluation for use of Side Rails dated 2/8/17 showed:
-The side rails were being considered for safety;
-Medical symptoms that contributed to the resident’s need for side rails were weakness and
balance deficit;
-The side rails would assist the resident in turning side to side, moving up and down in
bed, holding himself/herself to one side, pulling himself/herself from laying to sitting
position, avoiding falling out of bed and providing a sense of security;
-One-Half right and left upper side rails were recommended at all times when the resident
was in bed due to his/her request and his/her medical symptoms;
-Side rail precautions and alternatives had been discussed with the resident and the
resident’s family/representative;
-No documentation that showed alternatives to the side rails were tried prior to the use
of the side rails; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 60)
-The comments section showed continue to use side rails and/or no changes at this time
dated quarterly on 5/19/17, 11/10/18, 2/12/18, 4/19/18 and 7/5/18.
Record review of the resident’s Consent for Use of Side Rails dated 2/14/17 showed:
-The negative outcomes were getting caught in the side rails, getting caught between the
mattress and rails, strangulation, causing skin tears and/or bruising, injury or death;
and
-The resident’s responsible party gave consent for 2 side half side rails on the upper
part of the resident’s bed at all times when he/she was in bed related to weakness and a
history of stroke.
Record review of the resident’s care plan dated 6/14/18 with revisions dated 9/17/18
showed:
-He/she had limited physical mobility, a risk for falls, cognitive deficits, a
communication problem, weakness an hand contractures; and
-He/she needed one-half side rails up to assist him her with bed mobility and positioning,
an air mattress (a specialized mattress with an air pump to provide a pressure
re-distribution surface) and his/her bed in the lowest position.
Record review of the resident’s POS dated 9/1/18 showed his/her physician ordered:
-One-half side rails up on both sides of his/her bed while in bed to aid in positioning
due to mobility due to weakness; and
-An air mattress.
During an interview on 9/26/18 at 8:38 A.M. the DON said:
-In the past the resident had used his/her side rails for bed mobility; and
-The resident did not use his/her side rails and he/she had to turn him/her and hold
him/her over on his/her side when he/she assisted in the resident’s care the other day (on
9/26/18 at 8:38 A.M.).
Observation on 10/3/18 at 9:03 A.M. showed:
-He/she was alert and laying on his/her air mattress with a parameter cover;
-His/her one-half side rails were up on both sides of his/her bed;
-His/her bed was in a low position;
-His/her side rail on his/her right hand side had a gap of about one inch between his/her
side rail and his her parameter mattress; and
-His/her side rail on his/her left hand side had a gap of about two inches between his/her
side rail and his her parameter mattress.
6. During an interview on 10/1/18 at 11:00 A.M. the Maintenance Supervisor said:
-He/she was recently working as a Maintenance Worker;
-He/she had been asked by the previous Maintenance Supervisor to install bed rails for
residents’ beds;
-He/she had never been provided guidelines for installing the bed rails or looked at
guidelines for installation; and
-He/she had never been instructed on proper spacing between the mattress and the side
rails and had never measured the spacing.
During an interview on 10/01/18 at 2:37 P.M., LPN A said:
-The nurses did not measure the gaps from the mattress or the side rails or look at the
manufacturers recommendations for the side rails with the use of the mattress; and
-The nurses assess to ensure the side rails were not a restraint.
During an interview on 10/2/18 at 3:15 P.M. the DON said the facility should follow the
manufacturer’s recommendations when installing bed rails.
During an interview on 10/03/18 at 10:30 A.M., the DON said:
-The maintenance staff should be putting the correct side rails on the bed and measuring
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265358

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

NAME OF PROVIDER OF SUPPLIER

RIVERBEND HEIGHTS HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1221 HIGHWAY 13 SOUTH
LEXINGTON, MO 64067

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 0909

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 61)
gaps for risk of entrapments; and
-He/she did not think the maintenance staff were measuring for gaps between the mattresses
and the side rails.