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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to be treated with respect and dignity and to retain and use
personal possessions.

Based on observation and interview staff did not treat one resident (Resident #34) out of
16 sampled residents with dignity. The facility census was 70.
1. Observation, interview and record review on 4/02/19 at 12:30 P.M., showed Resident #34
in the front hall dining room. The resident was upset and stated staff served him/her a
sandwich for lunch that was not what he/she ordered. The Registered Dietician (RD) was
across the room behind the steam table to get the resident the sandwich he/she wanted.
Cook A stood next to the RD and spoke in a loud voice that could be heard from where the
resident sat and told the RD that he/she should have seen the big bowl of oatmeal the
resident ate for breakfast. Cook A told the RD that the resident had eaten so much that
he/she would not eat the sandwich. Cook A then came across the room and sat Cheetos on the
resident’s table while stating in an abrupt tone of voice you are to have ground food and
walked away.
In an interview on 4/2/19 at 12:45 P.M., the resident said:
– He/she rarely came to the dining room for lunch because of the way staff treated
him/her.
– Staff make him/her feel like he/she is in trouble because he/she comes to the dining
room before meal service time. Staff serve others before serving him/her. A week ago
during lunch, he/she complained about having to wait and Cook B told him/her there was no
ice cream when he/she requested it. Then, Cook B went into the kitchen got two cups of ice
cream and set them on the table next to him/her for other residents. He/she complained
about Cook B’s treatment to Nurse Aide (NA) A.
In an interview on 4/4/19 at 1:15 P.M., NA A said he/she assisted residents in the dining
room with food service and monitoring. Cook B got testy with residents and loses his/her
temper. Resident #34 would eat ice cream all day if he/she could and also loved deserts.
Cook B has told the resident he/she has had enough ice cream and is rude with the
resident. After Cook B gave the resident a second or third cup of ice cream, Cook B would
become sterner with the resident. The resident loved ice cream and use to work in an ice
cream factory.
In an interview on 4/4/19 at 1:58 P.M., Cook B said:
– He/she worked the evening service in the kitchen and dining room. Resident #34 liked ice
cream.
– When staff took Resident #34’s food order he/she asked for the deserts and ice cream. If
staff did not give the resident two ice creams the resident will state You are annoying me
now go away. He/she told the resident the rule is one ice cream per meal. If he/she gave
the resident several ice creams then they would have to give other residents several ice
creams. Residents are only to get one dessert so should only get one ice cream. He/she
told the resident he/she could not have two to three ice creams. Some days the resident is
confused. The resident did not like eating until everything was in place and was very
picky.
– He/she was trying to work on his/her loudness in the dining room. His/her voice carried.
Staff were busy in the dining room and it caused him/her to talk to residents across the
room instead of talking to them at their tables which could upset some residents.
In interviews on 4/4/19 at 12:03 P.M. and 4/5/19 at 11:50 A.M., the dietary manager (DM)
said:
– It was undignified for Cook A to state Resident #34 would not eat the lunch he/she
ordered because he/she had a big breakfast.

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
– Cook A and Cook B both stated they should not have spoken loudly or across the room
regarding or toward residents in the dining room. Both needed re-educated on how they
spoke to residents.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to promote an environment
respectful of the rights of each resident to make choices about significant aspects of
their lives when staff did not offer evening (HS) snacks to all residents. This affected
any residents wishing to have an HS snack. The facility census was 70.
Review of the facility’s policy for HS Snacks, dated 8/1/12, showed:
– To offer nourishment or snacks to residents before bedtime;
– A snack will be offered at bedtime to all residents. Those residents with dietary
constraints will receive snacks according to physician orders;
– Dietary department will deliver appropriate snacks for general resident consumption in a
dated sealed container to the Nursing areas. The types and amounts of the snacks will be
determined by the Food Service Manager and the Director of Nursing;
– The charge nurse will ensure that these snacks are given to the appropriate residents
and the percent consumed is to be recorded. Document percentage consumed on Dietary Form
provided.
1. Review of Resident #2’s care plan, showed:
– Problem onset: 9/3/17- activities of daily living (ADL) maintenance. Offer snack at
bedtime and record whether accepted or refused;
– Problem onset: 11/3/17- the resident had labile (easily altered) blood sugars related to
diabetes mellitus. Teach the resident about appropriate nutrition to maintain blood
sugars;
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated, 3/21/19, showed:
– Cognitive skills intact;
– Supervision with eating;
– [DIAGNOSES REDACTED].
– Had seven insulin injections in the last seven days.
During an interview on 4/2/19, at 4:05 P.M., the resident said:
– Staff do not bring snacks to his/her room at bedtime;
– He/she would take a snack if it was offered, especially if it was crunchy and salty.
3. Review of Resident #52’s care plan, showed:
– Problem onset: 3/6/19 – ADL maintenance care. Offer snack at bedtime and record whether
accepted or refused.
Review of the resident’s admission MDS, dated , 3/13/19, showed:
– Cognitive skills intact;
– Somewhat important to have snacks at bedtime;
– Supervision with eating;
– [DIAGNOSES REDACTED].
– Had seven insulin injections in the last seven days.

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
During an interview on 4/2/19, at 11:17 A.M., the resident said:
– Staff do not bring snacks to the resident’s room at bedtime;
– He/she would take a snack if it was yogurt or something he/she was supposed to have
since he/she was diabetic.
4. During the resident group interview on 4/3/19, at 1:54 P.M., residents said:
– There’s a snack cart but it does not get passed from one hall to another;
– Residents who were diabetic did not get offered a snack at bedtime;
– If you put on your call light and ask for a sandwich it consisted of one slice of
cheese, a slice of dry bread and either one slice of turkey or ham;
– All would like to have a snack at bedtime if it was offered to them.
5. During an interview on 4/5/19, at 7:49 A.M., Licensed Practical Nurse (LPN) A said:
– The kitchen brings out snacks in a cooler;
– The Certified Nurse Aides (CNA’s) pass the snacks from one hall to another;
– The CNA’s fill out a sheet of paper with all the resident’s names on it and document it.
During a telephone interview on 4/15/19, at 1:35 P.M., CNA B said:
– The kitchen sends out a cart with a cooler on top and place it at the nurse’s station;
– The residents who smoke will get a snack from it if they want;
– The CNA’s are supposed to pass the snacks room to room;
– The CNA’s document if the resident accepted or refused the snack and enter it in the
computer system and on the piece of paper the snacks come out with.
During a telephone interview on 4/15/19, at 2:22 P.M., LPN C said:
– The kitchen sends out the carts by 8:00 P.M., when they leave for the night;
– It’s the aides responsibility to make sure there’s enough snacks on the cart and go room
to room to pass the snacks;
– He/she monitored the CNA’s to make sure it has been completed;
– The CNA’s document it in the computer and in the notebook at the nurse’s station.
During an interview on 4/5/19, at 6:08 P.M., the Director of Nursing (DON) said:
– Dietary sends a cart out and the team member should pass them;
– Staff should go room to room and offer all resident’s a snack;
– Staff should document if the resident accepted or refused the snack;
– The charge nurse (CN) should monitor if it is completed.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review, the facility failed to check the Nurse Assistant
(NA) Registry prior to employment to ensure all newly hired employees did not have a
Federal Indicator (marker given to individuals who have committed abuse/neglect. This
affected six out of eight sampled employees hired since August, (YEAR). The facility
census was 70.
1. Review of personnel records for the following staff hired since August, (YEAR), showed:
– Certified Nurse Aide (CNA) F hired 10/25/18, NA Registry check 11/6/18;
– Licensed Practical Nurse (LPN) C hired 10/2/18, NA Registry check 11/6/18;
– Maintenance Man A hired 10/9/18, NA Registry checked 11/6/18;
– Assistant Director of Nurses hired 10/8/19, NA Registry checked 11/6/18;
– Human Resource Manager hired 8/23/18, NA Registry checked 12/31/18;

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
– CNA G hired 12/28/18, NA Registry checked 4/2/18.
During an interview on 4/5/19 at 4:54 P.M., the Human Resource Manager said:
– He/she started working at the facility 8/23/18 as HR and had received training for HR
duties;
– He/she had not completed NA Registry checks on all employees hired prior to them working
at the facility;

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure discharge/transfer
documentation was completed to include when and the reasons for the discharge/transfer for
one of 16 sampled residents, Resident #215. The facility census was 70.
1. Review of Resident #215’s admission record showed:
– Original admitted [DATE];
– Did not indicate when the resident was discharged .
Review of the resident’s admission Minimum Data Set, MDS, a federally mandated assessment
instrument completed by facility staff, dated, 3/22/19, showed:
– admitted [DATE];
– discharged to an acute hospital 4/1/19.
Review of the resident’s physician order [REDACTED].
– No documentation of the resident being transferred from the facility to the local
hospital.
Review of the resident’s electronic medical chart, showed:
– No progress note to indicate the resident was transferred from the facility to the
hospital.
During an interview on 4/5/19, at 6:08 P.M., the Director of Nursing (DON) said:
– She was in the facility when the resident was transferred and should have asked if staff
documented the transfer.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
developed and updated a care plan consistent with resident’s specific conditions and needs
which affected three of 16 sampled residents, (Resident #213, #55 and #215). The facility
census was 70.
1. Review of Resident #213’s admission Minimum Data Set, MDS, a federally mandated
assessment instrument completed by facility staff, dated, 1/10/19, showed:
– Cognitive skills intact;

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
– Required extensive assistance of one staff for bed mobility and toilet use;
– Limited assistance of one staff for transfers;
– Always continent of bowel and bladder.
Review of the resident’s care plan, showed:
– Problem onset: 1/15/19 – the resident required assistance for all activities of daily
living (ADL’s);
– Continent of bowel and occasionally incontinent of bladder;
– Did not address the resident having a Foley catheter (a sterile tube inserted into the
bladder to drain urine).
Observation on 4/2/19, at 9:49 A.M., showed:
– Certified Nurse Aide (CNA) D propelled the resident into his/her room;
– CNA D removed the drainage bag from under the resident’s wheelchair, placed it on the
floor then pulled it through to the front of the wheelchair and hung it on the resident’s
recliner with the catheter tubing resting on the floor.
2. Review of Resident #215’s admission MDS, dated , 3/22/19, showed:
– Cognitive skills intact;
– Limited assistance of one staff with bed mobility, transfers and toilet use;
– Had one fall with minor injury;
– [DIAGNOSES REDACTED].
Review of the resident’s progress notes, dated, 3/22/19, at 6:12 P.M., showed:
– The resident was found on the floor next to his/her bed and wheelchair;
– The resident stated he/she was trying to get in bed without any assistance;
– He/she did not have any non skid socks or shoes on at the time;
– Reopened a skin tear on his/her arm.
Review of the resident’s care plan, showed:
– Problem onset: 3/15/19 – the resident was at risk for falls related to history of falls,
[DIAGNOSES REDACTED].
– The care plan was not updated after the resident had fallen.
3. Review of Resident # 55’s Minimum Data Set, (MDS) a federally mandated assessment
instrument completed by facility staff, dated 3/23/19, showed:
– Unable to make daily decisions;
– Dependent on staff for activities of daily living except eating and moving from place to
place in the facility;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan for behaviors, with an onset date of 6/26/17, showed:
– Resident has a history of behaviors towards others and will often display aggressive
behaviors at meal times and will curse at others:
-11-15-17 yelling at others;
– 11-17-17 yelling at night and stomping feet;
– Staff to talk to me in a calm manner;
– Staff to remind me to be patient with others and not yell at people;
– 11-15-17 offered different interventions and not effective, nursing gave [MEDICATION
NAME] and still not effective;
– 11-17-17 Staff offered foods and fluids when requested and has instant coffee in room;
– Staff to assist with cares as he allows;
-Please attempt to redirect me when my behavior becomes disruptive and praise me for
positive behaviors.
Observation and interviews during the initial tour on 4/2/19 at various times throughout
the day 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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
– The resident either lay in his/her bed or sat in his/her wheelchair in his/her room, in
the hall way, or up in the dining room, and intermittently yelled and screamed making
unintelligible sounds at times.
During an interview on 4/5/19 at 9:25 A.M., the Social Service Worker said:
– She had the resident sent to a behavioral hospital a month or so again but had not
re-evaluated to see if there had been any improvement with the resident’s yelling since
he/she returned from the behavioral hospital;
– She thought the care plan should have been updated during the past two years, she did
not know why the care plan still contained approached from (YEAR) in the care plan.
During an interview on 4/5/19 at 2:56 P.M., the MDS Coordinator said:
– Resident #55 had a behavior care plan before he/she started working at the facility;
– The resident’s care plan did not address when his/her behaviors affected other
residents;
– He/she had not updated Resident #55’s care plan, not even after he/she returned from the
behavioral hospital.
– He/she updated the care plans, quarterly, annual, with significant changes and as
needed;
– If a resident had a fall, the care plan should be updated with each fall and with new
interventions;
– The Charge Nurse (CN) does the immediate intervention then the interdisciplinary team
(IDT) meets every morning Monday through Friday and discuss the residents’ falls and
interventions;
– He/she was aware the resident had fallen but did not update the care plan;
– The resident’s care plan should have been updated after his/her fall on 3/22/19.
During an interview on 4/5/19, at 6:08 P.M., the Director of Nursing (DON) said:
– The care plans should be current and have current interventions.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure two of 16
sampled residents (Resident #4 and #58) dependent on staff assistance for activities of
daily living, received complete perineal care. The facility census was 70.
Review of the undated Peri Care Audit Tool provided as the facility policy, showed:
– Staff must gather supplies, wash hands and put on gloves;
– Wash front to back, changing side of cloth or disposable wipe with each wipe;
– Wash the middle first then the sides, clean all perineal folds;
– Wash middle of the buttocks first then the middle;
– STOP. Wash hands/sanitize and apply new gloves, apply brief and dress resident.
1. Review of Resident #4’s care plan with an onset problem date of 4/12/16, showed:
– Bowel and bladder – Assist as needed with toilet use and record amounts each shift;
– Assist as needed with toilet use and record amount voided each shift
– Check the resident’s brief as needed.
Review of the residents Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, dated 3/20/19, 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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
– Both short and long term memory problems;
– Toilet use did not occur;
– Personal hygiene only occurred once or twice during the look back period and required
one person assist.
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation and interview on 4/4/19 at 1:36 P.M., showed staff transferred the resident to
his/her bed and completed peri care as follows:
– Certified Nurse Aide (CNA) D and F removed the resident’s pants;
– CNA D placed a towel over the resident’s upper leg and said every time staff rolled the
resident to provide peri care, the resident urinated, sometimes quite a bit.
-CNA F used pre moistened wipes and wiped once down the right groin and once down the left
groin and once down the middle of the perineal folds;
– Staff rolled the resident to his/her side, the resident urinated and a large pool of
urine settled under the resident’s hip and upper thigh soaking through the bedsheet to the
mattress;
– CNA F cleaned fecal material from the resident’s buttocks. The fifth pre moistened wipe
had fecal matter on it;
– Staff rolled the resident to his/her other side and CNA D wiped more fecal material from
the resident’s rectal and coccyx area;
– Staff wiped the urine soaked mattress with a pre-moistened wipe and laid a towel over
the urine soaked area;
– Staff removed the towel, changed the bed sheets, placed a brief on the resident and
pulled up the resident’s pants, never cleaning the hip or upper legs that lay where the
resident urinated in bed;
– Staff did not re clean the front perineal folds after the resident urinated in bed;
– Staff left the resident on the clean linens on top of the wet urine soaked mattress.
During an interview on 4/5/19 at 11:46 A.M., CNA D said:
– Peri care should be one swipe left groin, one wipe right groin and the one wipe in the
middle, if not clean in the middle should wipe again;
– He/she would clean the resident’s bottom one wipe each side and one wipe in the middle;
– Resident #4 wets every time we roll her, We should have re-cleaned the front after
he/she wet again;
– We have a bottle of disinfectant in the shower we should use on the urine soiled
mattresses.
2. Review of Resident #58’s MDS dated [DATE], showed:
– Difficulty making daily decisions;
– Dependent on staff for toilet use and required extensive assist of staff for personal
hygiene;
– Occasionally incontinent of urine, continent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/9/19, showed:
Resident is occasionally incontinent of bladder;
– Please assist resident with peri care after incontinent episodes and as needed.
Observation on 4/4/19 at 1:20 P.M., showed the resident lay in a bariatric bed incontinent
of fecal matter and urine. CNA H provided peri care as follows;
– CNA H wiped once down each groin and three times in the center of the perineal fold;
– When staff rolled the resident to his/her side there was fecal matter in the resident’s
gluteal folds.
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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– CNA H wiped from rectal area to the coccyx area and then wiped the gluteal fold but did
not clean all fecal matter from the gluteal fold.
During an interview on 4/5/19 at 12:13 P.M., CAN H said;
– He/she wiped down each groin and then three times down the center;
– He/she cleaned the back side the same as the front, one wipe down each side of the
buttocks and down the center;
– He/she should clean any fecal material in the gluteal folds.
3. During an interview on 4/5/19 at 6:09 P.M., the Director of Nurses said:
– Staff should clean all areas that feces and urine touches;
– Staff should maneuver and clean all perineal cracks and folds to clean fecal matter;
-If a resident urinates when staff turn him/her then staff should rewash the front peri
area and any skin that urine touched.

F 0684

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to respond timely to assure one
resident (Resident #14) of 16 sampled residents received needed medical attention and
services to address his/her change in condition. The facility census was 70.
1. Review of Resident #14’s care plan showed a plan starting 7/16/18, for activities of
daily living (ADL). Staff to provide the resident with assistance of one for morning care
and showers. The resident walked with a walker in his/her room and in the halls. At times,
the resident forgot his/her walker. Staff to remind the resident to use his/her walker for
stability. There were times when the resident had dribbling of urine.
Review of Resident #14 Quarterly Review Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/11/19, showed:
– [AGE] years old.
– Adequate hearing.
– Clear speech.
– Made self-understood.
– Had ability to understand others.
– Had short and long-term memory problems.
– Had moderately impaired skills for daily decision making.
– Rejected care one to three days weekly.
– Only required set-up help with walking in corridor and with locomotion on and off the
unit.
– Required one-person physical assistance with toileting and personal hygiene.
– Had no upper or lower limitations with range of motion.
– Did not use mobility devices.
– Had occasional urinary incontinence.
– Always continent of bowel.
– [DIAGNOSES REDACTED].
– Had no pain.
Review of nurse’s notes showed on 3/10/19, staff prevented the resident from getting into
cupboards in the common area, stomped off to his/her room and slammed the door.

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 8)
In an interview on 4/2/19 at 3:20 P.M., Certified Nurse Aide (CNA) E said sometime around
3/11/19, the resident walked to supper in the dining room and walked back to his/her room
with no problems. The resident then came back out of his/her room limping and a staff
person caught him/her to prevent him/her from falling. From that point on, the resident
stayed in his/her room and became incontinent of bladder and bowel. Prior to this, the
resident took him/herself to toilet. The resident slowly stopped eating, drinking and
stopped normal ADL’s. The resident stayed in bed. The resident had a limp that was on and
off. He/she complained of pain but was confused. This went on for two weeks. He/she
notified every nurse who worked on the special care dementia unit where the resident
resided. He/she reported the residents’ condition change to the Assistant Director of
Nursing (ADON) and all the charge nurses who worked with the resident those two weeks.
He/she thought if he/she told them about the residents decline, something would be done.
During interviews on 4/15/19 at 4:23 P.M., and 4/16/19 at 11:10 A.M., Registered Nurse
(RN) A said:
– The resident stopped walking a week prior to 3/17/19. The resident went from walking
independently to refusing to walk and staff assisting him/her in a wheelchair. Staff
communicated the change during shift change reporting. He/she monitored the resident and
the only change he/she noted was in the resident’s mobility. The CNA’s reported the
resident had stopped walking. Staff initiated assisting the resident with mobility by
using a wheelchair. Staff wondered what caused the residents change. They wondered if the
resident fell or hurt him/herself. No one knew why the resident stopped walking. He/she
did a head to toe assessment and everything was fine. He/she should have completed the
rest of his/her job by notifying the physician of the residents condition change. The
staff all talked to each other about the residents change but nobody thought to call the
physician.
– He/she assured all notes he/she documented in the facility electronic records system
were saved in the system.
Review of departmental notes, showed on 3/17/19 at 11:12 A.M., RN A documented that the
resident had a change in mobility, will not walk and needs to use a wheelchair to come to
the dining room to eat. Staff have to check the resident every two hours for incontinence
of bladder and bowel.
In an interview on 4/5/19 at 4:04 P.M., the ADON said:
– On 3/18/19, he/she became aware of a small change in the residents condition when he/she
reviewed RN A’s 3/17/19 departmental notes. RN A should have assured the change in the
condition was reported to the physician.
– On 3/19/19, he/she discussed the residents’ condition with Licensed Practical Nurse
(LPN) D and instructed him/her to assess the resident and call the physician for follow-up
on the resident’s condition change. In passing, he/she observed the resident sitting at a
dining room table and talking normally.
– On 3/20/19, he/she worked overnight and checked the resident’s departmental notes and
found LPN D had not followed-up with assessing the resident’s condition and reporting to
the physician.
– On 3/21/19 at 7:15 A.M., he/she asked LPN D if he/she followed-up as instructed. LPN D
had not. LPN D said he/she thought the resident was better. He/she educated LPN D that
he/she should have followed-up by assessing the resident on 3/19/19 and calling the
physician regarding the 3/17/19, documented change in the resident from walking to now
using a wheelchair. He/she again told LPN D to assess the resident and call the physician
and took it that LPN D would follow his/her instruction.
During an interview on 4/15/19 at 5:22 P.M., LPN D 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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 9)
– The morning of 3/21/19, was the only time the ADON asked that he/she look at the
resident and see what was going on. Between 1:00 P.M. to 2:00 P.M., he/she assessed the
resident who winced when he/she touched the resident’s right upper thigh and acted like it
was bothering him/her. He/she contacted the physician’s office, notified the receptionist
that the resident was not walking and asked for an x-ray to see if the resident’s hip was
broken. The physician’s receptionist told him/her to fax the notification. He/she told the
receptionist that this was not a fax situation and he/she needed a nurse to call him/her
back. He/she got busy with other task and never heard back from the physicians’ nurse.
He/she documented the contact with the physician’s office in the facility electronic
system records under nurse’s notes. He/she was unaware there were no records to show
he/she notified the physician’s office. He/she had a problem getting his/her notes to save
in the electronic system.
– Sometime near 3/21/19, Certified Nurse Aide (CNA) E told him/her that on 3/14/19, the
resident was walking, stumbled, almost fell and staff intervened to keep the resident from
falling. CNA E said no one did anything. He/she noticed the resident had started using a
wheelchair. He/she thought the physician should have been notified of the 3/14/19 incident
that CNA E reported to him/her.
In an interview on 4/16/19 at 9:48 A.M., Provider Nurse (PN) A said their office did not
receive notification from LPN D regarding the resident not walking and a need for an
x-ray. Their staff would have taken a message from LPN D if he/she had contacted them.
Review of a facility Stop and Watch Early Warning Tool completed by CNA E showed on
3/22/19 at 6:33 P.M., CNA E reported to staff including LPN D and the Director of Nursing
(DON) that Resident #14 seemed:
– Different than usual;
– Overall needs more help;
– Pain new or worsening, Participated less in activities;
– Ate less.
In an interview on 4/2/19 at 3:20 P.M., CNA E said despite his/her reports to the nurses,
nothing was done until he/she completed the 3/22/19 Stop and Watch Warning Tool. On
3/23/19, the ADON sent the resident out to the hospital.
Review of departmental notes, showed:
– On 3/23/19 at 2:04 P.M., the ADON documented that the resident declined over the past
few days. On 3/23/19, the resident was lethargic, warm and clammy to the touch. The
resident was normally resistive and combative with care but today was not. The resident
had been up independent and walking up until a few days ago and had begun using a
wheelchair for mobility. Over the past few days, the resident had not gotten or wanted out
of bed. He/she was very fatigued and slept most of the day and night. The resident only
ate 25% of his/her breakfast and was slow to respond. Assessment of the resident included
labored respirations at 26, lung sounds diminished throughout and an elevated pulse at
132. The resident opened his/her eyes and shook his/her head but would not respond
verbally. The ADON obtained physician orders [REDACTED].
– On 3/23/19 at 6:45 P.M., the resident was admitted to the hospital [MEDICAL CONDITION]
urinary tract infection [MEDICAL CONDITION].
In an interview on 4/5/19 at 4:04 P.M., the ADON said:
– On 3/23/19 at 4:30 A.M., he/she checked to see if there was a note showing LPN D
followed-up as instructed and found LPN D had not. By 5:00 A.M. on 3/23/19, he/she
instructed RN B to check on the resident, assess and notify the physician that the
resident went from walking to needing a wheelchair. RN B told him/her said he/she would.
– On 3/23/19 at 11:00 A.M., he/she found out that RN B did not follow-up either. He/she
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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 10)
then completed the assessment on the resident and notified the physician his/herself.
In an interview on 4/15/19 at 5:14 P.M. and 4/16/19 at 4:45 P.M., RN B said:
– The resident use to be up walking. The last time he/she saw the resident the resident
was in bed. Staff were trying to figure out what was wrong with him/her. He/she was not
involved in the resident’s care although it shocked him/her that the resident declined so
quickly.
– The ADON did not instruct him/her to assess the resident and notify the physician.
– He/she had no problems with his/her nurse’s notes being saved in the facility electronic
records system.
During an interview on 4/16/19 at 10:05 A.M., Family Member (FM) A said:
– On 3/23/19, staff informed him/her of the resident’s change of condition. Staff said the
resident had not been doing well and his/her health was declining. Staff informed him/her
that the resident needed to be sent to the hospital.
– The hospital staff found the resident had a UTI.
Review of the hospital History Physical documents showed:
– On 3/23/19, the emergency room (ER) found the resident to be septic with clots and blood
in the urine, diffuse abdominal pain and was admitted to the hospital. Review of systems
showed the resident is so demented that he/she does not follow commands. He/she does not
answer questions. Per facility, the resident had mental status changes, is weak and had
abdominal discomfort. Abdominal x-ray showed a mild to moderate [MEDICATION NAME]
distention of the colon and small bowel, most likely representing an adynamic ileus
(Paralysis of intestinal ability to move independently).
– The resident admitted to the hospital with [REDACTED]. The most common cause of acute
[MEDICAL CONDITION].)
Review of departmental notes, showed on 3/24/19 at 4:12 A.M., the resident admitted to the
hospital [MEDICAL CONDITION] UTI.
In an interview on 4/10/19 at 11:38 A.M., Physician A said:
– On 3/23/19, the facility called the on-call physician and said the resident was very
sick. The resident was normally ambulatory. The resident had dementia and was unable to
report what happened. The facility did not provide information to show the duration of the
resident’s change in condition. Once the resident went to the hospital, he/she was found
to [MEDICAL CONDITION] UTI and was really sick. He/she seemed to get better for 48 hours
during his/her hospital stay.
– It was possible the residents’ health decline would have happened regardless if he/she
was notified sooner. Since the resident was able to be up in a wheelchair, it was likely
harder for the staff to catch the cause of his/her condition.
– He/she expected staff to monitor the residents’ condition change of going from walking
to not walking, by assessing the resident daily at every shift and documenting the
assessment. Without assessments and documenting assessment results, staff did not have the
information needed to determine the cause of the condition. Documentation was key to
protecting the resident.
– The resident was placed on hospice with a [DIAGNOSES REDACTED].
2. In an interview on 4/5/19 at 3:23 P.M., the DON said:
– On 3/17/19, RN A should have and did not call the nurse manager to report the resident’s
change of condition. Administrative staff monitored nursing notes to catch where staff may
have missed something and to figure out what to do. She did not discover the 3/17/19 note
until 3/20/19. There was a discussion about the resident during daily connect team
meeting. The resident went from walking to not walking. They had discussed that something
might be going on with the resident. It ended up being worse than what they thought. As
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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 11)
soon as the resident’s condition worsened, they sent him/her to the ER. Staff should have
requested orders for labs and x-rays for the resident once his/her condition changed in
order to identify the conditions that were not found until the resident was sent to the
ER. The physician was not notified until 3/23/19. If staff had acted sooner they could
have prevented the resident’s need for hospitalization .
– On 4/4/19, the resident returned to the facility from the hospital on hospice.
– When staff discover a resident to have a change of condition they should notify nursing
management on call and that did not happen for the resident. If staff had called nurse
management, then a plan of action to find a root cause for the resident’s condition could
have occurred.
– She thought staff education was needed on communication to administration on change of
condition. They needed to assure nurse’s reports to administration was accurate.
MO 0

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to lower one of
16 sampled residents (Resident #49’s) bed during wound treatment and failed to provide
trained staff to monitor and intervene for safety during meal service in the front dining
room. The facility census was 70.
1. Review of Resident #49’s care plan, showed:
– Problem onset: 3/5/19 – the resident required staff assistance for all activities of
daily living (ADL’s) related to stroke with left sided [MEDICAL CONDITION] (paralysis on
one side of the body);
– The resident was at risk for falls related to the [DIAGNOSES REDACTED].
– Keep the bed in the lowest position.
Review of the resident’s admission Minimum Data Set, MDS, a federally mandated assessment
instrument completed by facility staff, dated, 3/12/19, showed:
– Cognitive skills moderately impaired;
– Required extensive assistance of two staff for bed mobility and toilet use;
– Dependent on the assistance of two staff for transfers;
– Had a Foley (sterile tube inserted into the bladder to drain urine) catheter;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 4/4/19, at 1:42 P.M., showed:
– Certified Nurse Aide (CNA) A entered the resident’s room and closed the privacy curtain
between the resident and his/her roommate;
– CNA A raised the resident’s bed up to the level of his/her waist and turned the resident
on his/her side;
– Licensed Practical Nurse (LPN) C provided wound treatment to the resident’s coccyx;
– LPN C removed his/her gloves and left the room;
– CNA A left the resident with the bed elevated and went into the bathroom to assist the
resident’s roommate;
– LPN C entered the room and CNA A returned to the resident’s bed side;

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
– After LPN C finished the wound treatment, he/she removed his/her gloves and went into
the bathroom to wash his/her hands;
– CNA A also went into the bathroom to wash his/her hands and left the resident with the
bed elevated, privacy curtain closed and unable to visualize the resident;
– LPN C and CNA A washed their hands, applied gloves and completed cares with the resident
and lowered the bed.
During a telephone interview on 4/15/19, at 2:22 P.M., LPN C said:
– He/she should have lowered the bed when he/she had to leave the room to get supplies or
wash his/her hands.
During a telephone interview on 4/15/19, at 2:43 P.M., CNA A said:
– He/she should not have walked away from the resident’s bed with it elevated.
During an interview on 4/5/19, at 6:08 P.M., the DON said:
– Staff should place the bed in the low position or staff should stay by the resident if
the bed is left in the high position.

2. Observation, interview and record review on 4/02/19 at 12:30 P.M., showed:
– Three residents eating in the front hall dining room with no staff in the room to
monitor and assist them.
– Resident #34 wanted staff assistance but no one was in the room.
– Resident #136 hollered out for staff. The resident said he/she would like staff
assistance but none were in the dining room to help him/her.
In an interview on 4/2/19 at 3:46 P.M., Resident #136 said staff were not available in the
dining room to provide assistance. He/she thought the facility needed more staff to help
residents in the dining room during meal service.
Observation on 4/3/19 at 7:17 A.M., showed three residents in the front hall dining room.
No staff were in the room. The dietary staff were behind the steam cart area.
In an interview on 4/4/19 at 1:24 P.M., Dietary Aide (DA) A said he/she worked the evening
shift and served the residents meals in the dining room. They do not have enough staff in
the dining room to monitor resident to prevent choking or other hazards. A staff person
was supposed to be available to residents in the dining room at all times. An aide who was
trained to help residents if they choked was supposed to be in the dining room. The aide
only stayed in the dining room for part of the meal service. He/she and another kitchen
staff person went back and forth from the dining room to the kitchen but no one stayed in
the dining room to monitor residents.
In an interview on 4/4/19 at 1:58 P.M., Cook B said he/she worked the evening service in
the kitchen and dining room. There is not always someone in the dining room to monitoring
residents for safety. The kitchen staff tried to monitor resident’s needs from behind the
food service area but it was difficult. A nurse aide was supposed to monitor the dining
room but had to leave the room in order to deliver hall trays.
In an interview on 4/4/19 at 1:15 P.M., Nurse Aide (NA) A said he/she was trained to help
with dining room services. He/she was confused if he/she was to be in the dining room the
whole time. He/she left the dining room during meal services to remind residents to come
to the dining room to eat. He/she was not able to be in the dining room for the entire
meal service.
In an interview on 4/4/19 at 12:03 P.M., the dietary manager (DM) said:
– Nursing staff was to monitor residents in the dining room during meal service for safety
in case someone started choking or needed help. Nursing staff were to be in the dining
room all through the meal service until all the residents were done eating.
In an interview on 4/5/19 at 6:09 P.M., the Director of Nursing (DON) said staff were to

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
continuously monitoring residents in the front dining room.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
provided appropriate catheter (a sterile tube inserted into the bladder to drain urine)
care in a manner to prevent a urinary tract infection [MEDICAL CONDITION] or the
possibility of a UTI which affected two of 16 sampled residents, (Resident #56 and #213).
The facility census was 70.
Review of the facility’s Indwelling Catheter Audit Tool, showed:
– Provide complete peri care;
– Starting close to the urinary meatus, clean the catheter tubing in a circular motion
along its length for about six inches, washing away from the body times two while changing
position of the catheter;
– Apply appropriate leg or stabilizing the tube so it will not be tugged on during care;
– Drainage bag maintained below the level of the bladder.
1. Review of Resident #56’s admission Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 2/9/19, showed:
– Cognitive skills moderately impaired;
– Required extensive assistance of two staff for bed mobility and toilet use;
– Dependent on the assistance of two staff for transfers;
– Had a Foley catheter;
– Occasionally incontinent of bowel.
Review of the resident’s care plan, showed:
– Problem onset: 2/14/19 – the resident used an indwelling catheter to promote wound
healing;
– Catheter care every shift.
Observation on 4/3/19, at 7:58 A.M., showed:
– The resident lay in bed on his/her side with a leg strap on his/her right upper thigh;
– Certified Nurse Aide (CNA) B unfastened the resident’s incontinent brief;
– CNA B used a different wipe each time and wiped the gluteal folds, coccyx and rectal
area with fecal material;
– CNA B removed gloves, did not wash his/her hands and applied new gloves.
– Licensed Practical Nurse (LPN) C removed the undated dressing from the resident’s
coccyx;
– LPN C cleaned the wound with wound cleanser;
– LPN C cleaned fecal material from the rectal area then applied a new dressing;
– LPN C removed gloves, did not wash his/her hands and donned new gloves;
– LPN C placed a clean incontinent brief under the resident;
– LPN C wiped the rectal area with fecal material, used the same area of the wipe and
cleaned the rectal area with fecal material;
– LPN C used the same gloved hands and applied A & D ointment (skin protectant) and
[MEDICATION NAME] (skin protectant) to the resident’s buttocks;

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
– LPN C removed gloves, did not wash his/her hands and assisted CNA B to turn the resident
on his/her back;
– CNA C used the same area of the wipe and cleaned the front skin folds;
– CNA C used a new wipe and used the same area of the wipe and cleaned the front skin
folds;
– CNA C anchored the catheter tubing and wiped down the tubing then used the same area of
the wipe and wiped down the tubing again;
– CNA B and CNA C fastened the clean incontinent brief.
During a telephone interview on 4/15/19, at 1:35 P.M., CNA B said:
– When cleaning fecal material, should removed gloves, wash hands.
During a telephone interview on 4/15/19, at 1:47 P.M., CNA C said:
– He/she should not use the same area of the wipe to clean different areas of the skin and
should not use the same area of the wipe to clean different areas of the catheter tubing.
During a telephone interview on 4/15/19, at 2:22 P.M. LPN C said:
– Should wash his/her hands after cleaning fecal material and between glove changes;
– Should not use the same area of the wipe to clean different areas of the skin.
2. Review of Resident #213’s admission MDS, dated , 1/10/19, showed:
– Cognitive skills intact;
– Required extensive assistance of one staff for bed mobility and toilet use;
– Limited assistance of one staff for transfers;
– Always continent of bowel and bladder.
Review of the resident’s care plan, showed:
– Problem onset: 1/15/19 – required assistance for all activities of daily living (ADL’s);
– Continent of bowel and occasionally incontinent of bladder;
– Did not address the resident having a Foley catheter.
Observation on 4/2/19, at 9:49 A.M., showed:
– CNA D propelled the resident into his/her room;
– CNA D removed the drainage bag from under the resident’s wheelchair, placed it on the
floor then pulled it through to the front of the wheelchair and hung it on the resident’s
recliner with the catheter tubing resting on the floor;
– CNA D used the gait belt (a special belt placed around the resident’s waist to provide a
handle to hold onto during transfers) and transferred the resident into his/her recliner.
Observation on 4/4/19, at 12:54 P.M., showed:
– The resident lay in bed;
– CNA A placed the drainage bag from the side of the bed onto the foot of the bed;
– CNA A transferred the resident from the bed to his/her wheelchair;
– CNA A placed the drainage bag under the resident’s wheelchair with the drainage bag
resting on the floor
– CNA A propelled the resident into the bathroom and the drainage bag dragged on the
floor;
– CNA A placed the drainage back on the toilet paper holder;
– CNA A provided incontinent care then used a new wipe and with the same area of the wipe,
cleaned the port and the connection tubing;
– CNA A completed catheter care, placed the drainage bag under the resident’s wheelchair
and it dragged on the floor from the bathroom to the resident’s bed;
– CNA A transferred the resident onto the bed and hung the drainage bag on the side of the
bed.
During an interview on 4/4/19, at 2:57 P.M., CNA A said:
– The drainage bag or tubing should not rest or be dragged on the floor;
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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
– He/she should not have used the same area of the wipe to clean different areas of the
catheter tubing.
During an interview on 4/5/19, at 6:08 P.M., the Director of Nursing (DON) said:
– Staff should not have the drainage bags or the catheter tubing rest or be dragged on the
floor;
– Staff should not use the same area of the wipe to clean different areas of the catheter
tubing.

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation, interview and record review, the facility failed to post the nurse
staffing data in a prominent place readily accessible to all residents and visitors on a
daily basis at the beginning of each shift. The facility census was 70.
1. Observation on 4/2/19 through 4/5/1 showed the nurse staffing sheets not visible on any
walls by the nurse’s station or hanging in the facility hallways.
During an interview on 4/5/19 at 6:09 P.M., the Director of Nurses said:
– Staffing sheets were kept in a binder called the Communication Book;
– The staffing sheets were in the back f that book;
– The charge nurses should know who was working and fill the sheets out for their shifts;
– There should be sheets that posted how many of the different nurse positions were filed
and working;
– The midnight shift was responsible to post the staffing sheets;
– She should probably monitor that the staffing sheets were posted as they should be in
the facility.

F 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident must receive and the facility must provide necessary behavioral
health care and services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation interview and record review showed the facility failed to provide
necessary behavioral care and services for one of 16 sampled residents (Resident #55’s)
psychosocial well-being after other residents voiced concerns about how disruptive the
resident’s behaviors were to them. The facility census as 70.
Review of the facility’s policy for Behavior Acutely Disturbed and Disruptive Residents,
dated 5/1/12, showed:
-To ensure that residents maintain usual reality orientation; to recognize change in
thinking and behavior that could trigger acute episodes; and to to identify interventions
to deal effectively with situations;
– To ensure a safe and caring environment will be provided during their acute
disturbed/disruptive episodes;
– Follow the resident’s care plan.
1. Review of Resident # 55’s Minimum Data Set, (MDS) a federally mandated assessment

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
instrument completed by facility staff, dated 3/23/19, showed:
– Unable to make daily decisions;
– Dependent on staff for activities of daily living except eating and moving from place to
place in the facility;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan for behaviors, with an onset date of 6/26/17, showed:
– Resident has a history of behaviors towards others and will often display aggressive
behaviors at meal times and will curse at others:
-11-15-17 yelling at others;
– 11-17-17 yelling at night and stomping feet;
– Staff to talk to me in a calm manner;
– Staff to remind me to be patient with others and not yell at people;
– 11-15-17 offered different interventions and not effective, nursing gave [MEDICATION
NAME] and still not effective;
– 11-17-17 Staff offered foods and fluids when requested and has instant coffee in room;
– Staff to assist with cares as he allows;
-Please attempt to redirect me when my behavior becomes disruptive and praise me for
positive behaviors.
– The care plan did not indicate any new approaches since 11/2017.
Observation and interviews during the initial tour on 4/2/19 at various times throughout
the day showed:
– The resident either lay in his/her bed or sat in his/her wheelchair in his/her room, in
the hall way, or up in the dining room, and intermittently yelled and screamed making
unintelligible sounds.
– Resident #21 said the resident, next door, yells out all the time, day and night. It
bothers me a lot. Resident #55 yells to get up, to be laid down, to go and eat and
sometimes just yells. Sometimes he/she had to miss therapy because Resident #55 yelled
throughout the night. He thought the resident started yelling out at about 2:00 until
about 4:00 A.M., the resident kept him/her awake long enough that he/she was often too
tired to go to therapy.
– Resident #21’s roommate said he used to have to be in the same room as Resident #55.
He/she said he/she could not take any more of the resident’s yelling and told them they
had to move him/her. He/she then pointed to his/her bed, then his/her wall and said, Do
you hear that? That is what I have to listen to all the time. Yeah, they fixed the problem
when I told them I couldn’t take anymore, they moved me right next door. He/she then said
someone is going to snap with that guy yelling all the time, someone is going to end up
hurt.
Observation on 4/2/19 at 11:31 A.M., showed the resident laid in bed yelling out, I don’t
like it, I don’t like it, I don’t like it. After a couple of minutes the resident yells
out the previous sentence over again.
Observation on 4/5/19 at 6:55 A.M., showed Resident #41 seated in his/her wheelchair in
the dining room repeating, Help me, Help me, Help me. The resident said he/she was just
telling the dining room staff what he/she had to listen to all morning, since 4:00 A.M.,
because again this morning Resident # 55 had started yelling out that early.
During an interview on 4/5/19 at 2:56 P.M., the MDS Coordinator said:
– Resident #55 had a behavior care plan before he/she started working at the facility;
– He/she had not updated Resident #55’s care plan, not even after he/she returned from the
behavioral hospital.
Review of the resident council notes, dated, 1/31/19, 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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0740

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
– Residents were informed their comments would be confidential and their names would not
be in the notes;
– New month business: All residents complained about the male resident that still
continues to yell about 3:00 A.M., to get up and eat.
Review of the resident council notes, dated, 2/18/19, showed:
– One complained bout roommate’s yelling;
– The male resident yelling is better.
During the resident council meeting on 4/3/19 at 1:54 P.M., showed:
– Male/female resident hollers all hours of the day and night;
– It has kept the residents awake or woke them up;
– The male/female resident yells during the meal times and no on wants to eat in the
dining room because you can’t enjoy your meal;
– All five of the residents said it bothers them and they would rather eat in their rooms;
– One resident told a Certified Nurse Aide (CNA) he/she did not like to go to the dining
room because the male/female resident yelled all the time;
– The kitchen manager has told the resident to quit yelling or they will take him/her to
their room;
– When staff do take the resident to his/her room, he/she continues to yell and if the
other residents eat in their room, they still the resident yelling;
– The resident who yells all the time also went to another resident’s room and was using
curse words, when he/she told the resident not to use that language in front of his/her
door, the staff told him/her not to talk to the resident like that, but did nothing about
the language the resident was using;
– The residents are afraid the resident who yells all the time will hit someone or one of
the residents may have enough of it and hit the resident who is yelling.
During an interview on 4/5/19 at 9:25 A.M., the Social Service Worker said:
– The facility had not had psychiatric care for at least six months, the facility was
trying to get tele psyche on board at the facility;
– She had the resident sent to a behavioral hospital a month or so again but had not
re-evaluated to see if there had been any improvement with the resident’s yelling since
he/she returned from the behavioral hospital;
– The residents told her, they enjoyed the quiet when the resident was out of the
facility;
– She thought the care plan should have been updated during the past two years, she did
not know why the care plan still contained approached from (YEAR) in the care plan.
– She had not visited with other residents since Resident #55 came back to the facility to
see if the yelling situation had improved.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to ensure staff
properly stored and discarded resident medications, failed to store nebulizer vials in the
correct resident’s boxes, failed to discard expired medications, failed to date insulin

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
flex pens when opened and did not discard an insulin flex pen 28 days after it was opened.
The facility census was 70.
1. Observation and interview on 4/5/19, at 10:48 A.M., of the treatment cart on the 150
hall showed:
– Nine packages of petroleum jelly, expired 1/2019;
– Two [MEDICATION NAME] vials, 0.5 mg./3 mg., did not have a label to indicate who they
belonged to;
– One [MEDICATION NAME] pen with the pharmacy label torn off and did not have a date when
it was opened;
– Levimir insulin pen with an opened dated of 2/28/19;
– An opened vial of [MEDICATION NAME]did not have a date when it was opened and did not
have a pharmacy label on it;
– An opened container of integrity medical packing strip, expired (YEAR);
– One unopened container of integrity medical packing strip, expired 4/2018;
– Seven packages of gold dust super absorbent wound filler, expired 1/2019;
– Licensed Practical Nurse (LPN) B said he/she thought each nurse should date medications
when it was opened and should check to see if it was expired. Insulin vials, insulin pens
or any medication should be dated when opened. Should not use medications or wound
treatment supplies which are expired, they should be destroyed.
During an interview on 4/5/19, at 6:08 P.M., the Director of Nursing (DON) said:
– The insulin pens should have dates on them when opened and should have a label on them;
– The nurse’s should check the medications for expiration dates before they administer the
medication;
– Staff should not use expired treatment supplies;
– Insulin vials and pens should be dated when opened;
– [MEDICATION NAME] should not be used after 28 days.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide dietary services that
meet resident preferences. The facility census was 70.
1. During an interview on 4/2/19, at 12:37 P.M., Resident #37 said:
– The vegetables are gross.
During the resident group meeting on 4/3/19, at 1:54 P.M., the residents said:
– The vegetables are overcooked to hell.
Observation, interview and record review on 4/02/19 at 12:30 P.M., showed Resident #34 in
the front hall dining room. The resident’s meal ticket had an order for [REDACTED]. He/she
ordered a cheeseburger. Staff were not available in the dining room to address the
resident’s dissatisfaction with his/her food. Latter, the registered dietician (RD) said
staff served the resident ground ham, when they were supposed to serve the resident a
cheeseburger. The RD returned to the resident’s table with a ground hamburger. The
resident tasted it and said it was cold.
In an interview on 4/2/19 at 12:45 P.M., Resident #34 said it upset him/her that that for
his/her meals he/she asked for a cup of milk, coffee and water. Staff never gave 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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
all of the drinks he/she wanted. He/she comes to dining room but staff were too busy to
help him/her.
Observation on 4/2/19 at 5:15 P.M., showed the resident had milk and water but no coffee.
The resident said he/she wanted coffee but the staff did not serve it to him/her.
In an interview on 4/4/19 at 12:03 P.M., the dietary manager (DM) said during lunch on
4/2/19, the resident was served cold hamburger. The resident was on a ground meat diet. By
the time meat was ground in the processor, it lost temperature and should have been heated
up.
2. During observation and interview on 4/2/19 at 11:21 A.M., of the Special Care Unit
(SCU) for residents with [DIAGNOSES REDACTED]. LPN D stated the chicken served in the
facility tended to be tough.
3. Observation and interview on 4/2/19 at 12:48 P.M., showed Resident #163 hollered out
for staff to bring him/her a roll to eat. The resident ate a piece of grilled chicken by
hand. The resident said he/she would have liked for staff to have offered to cut the
chicken up but they did not and no one was in the dining room to assist him/her.
Observation on 4/2/19 at 12:56 P.M., showed Resident #163 told the registered dietician
(RD) and the dietary manager (DM) that the chicken was tough. The RD responded that he/she
assisted residents in the SCU to cut their chicken and it was not tough.
In an interview on 4/2/19 at 3:46 P.M., Resident #136 said the chicken was tough. He/she
needed help cutting the chicken but no one was in the dining room to help him/her so,
he/she ate it with his/her hands. He/she thought they needed more staff to help residents
in the dining room.
4. In an interview on 4/4/19 at 1:24 P.M., Dietary Aide (DA) A said he/she worked the
evening shift and served the residents meals in the dining room. Staff were to ask
residents what they want to drink.
– Resident #34 usually wanted coffee, milk and ice water. Sometimes when other staff
served the resident he/she did not get all of his/her drinks. They only had two staff
serve the resident food and it was not enough to meet the resident’s food service needs.
– Residents were not getting the help they needed with cutting food, getting drinks and
following-up with food concerns as there were not enough staff and it got very hectic.
– The dining room use to be a social experience with music and visiting. Now staff were
too busy and could not make the dining experience enjoyable.
In an interview on 4/4/19 at 1:58 P.M., Cook B said he/she worked the evening service in
the kitchen and dining room. They did not have enough help in the dining room and
residents had to wait for help with cutting up food which caused the food to become cold.
In an interview on 4/4/19 at 1:58 P.M., Cook B said they had a problem with mushy
vegetables and tough meat. Staff needed to batch cook. Cauliflower and broccoli tended to
get mushy.
5. During observation an interview on 4/4/19 at 12:03 P.M. and 4/5/19 at 11:50 A.M, the
dietary manager (DM) said:
– Resident #34’s meal ticket says beverage. If the resident wants milk, water and coffee,
staff should serve it. The meal tickets the facility used just said milk beverage for
everyone and did not show resident’s drinking preferences. He/she was aware that Resident
#34 liked three drinks with his/her meal. Staff probably overlook all residents drink
preference as they are short staffed in the dining room and everyone is trying to do
several things at once. He thought it would be frustrating for residents who did not
receive their drinking preferences. The meal ticket needed to be changed to assure
resident preferences were shown.
– The milk temperature served at lunch showed it was 52 degrees Fahrenheit (F) and 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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
pudding was served at 42 F. The DM said cold foods should be served at 40 F or below. The
facility had a problem with the cold steam table. The table had been broken for a year.
Staff tried to put the cold food in the coolers anytime they have a pause in serving but
due to open and closing the cooler it kept them from keeping cold temperatures. They had
not been able to get the cold steam table repaired.
– Residents complained of mushy broccoli. They had not been able to fix the problem.
– They needed to change their system to improve food temperatures and to encourage
residents eating in the dining room. Currently the nursing staff and dietary staff were
unable to keep up with all residents needs for food service.
In an interview on 4/5/19 at 6:09 P.M., the Director of Nursing (DON) said staff was to be
available for residents who needed assistance in the dining room.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to assure proper
infection control practices when staff failed to wash hands between dirty and clean tasks
during wound treatments and during peri care, which affected one of 16 sampled residents
(Resident #49). The facility census was 70.
1. Resident #49’s admission Minimum Data Set, MDS, a federally mandated assessment
instrument completed by facility staff, dated, 2/9/19, showed:
– Cognitive skills moderately impaired;
– Required extensive assistance of two staff for bed mobility and toilet use;
– Dependent on the assistance of two staff for transfers;
– Had a Foley catheter;
– Occasionally incontinent of bowel;
– Had one stage 2 pressure ulcer (a partial thickness loss of skin layers that presents
clinically as an abrasion, blister or shallow crater) and one stage 4 pressure ulcer (a
full thickness of skin is lost, exposing the subcutaneous tissues, presents as a deep
crater with or without undermining adjacent tissue).
Review of the resident’s care plan, showed:
– Problem onset: 2/14/19 – the resident had a stage 4 pressure ulcer to sacrum, stage 1
pressure ulcer to right heel and a stage 2 pressure ulcer to right upper back;
– Wound care as ordered by the physician.
Observation on 4/3/19, at 8:17 A.M., showed:
– Licensed Practical Nurse (LPN) C entered the resident’s room, washed his/her hands,
applied gloves and placed the treatment supplies on the resident’s bed;
– LPN C removed the old undated dressing from the resident’s coccyx, cleaned and measured
the wound, and administered the treatment;
– LPN C removed his/her gloves, did not wash his/her hands and applied new gloves and
cleaned fecal material from around the resident’s rectal area then applied the new
dressing to the resident’s coccyx;
– LPN C removed his/her gloves, did not wash his/her hands and applied new gloves;
– LPN C placed a clean incontinent brief under the resident;
– LPN C wiped the rectal area with fecal material, used the same area of the wipe and
cleaned the rectal area with fecal material;

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:

265827

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

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE PLACE

STREET ADDRESS, CITY, STATE, ZIP

1616 WEISENBORN ROAD
SAINT JOSEPH, MO 64507

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
– LPN C used the same gloved hands and applied A & D ointment (skin protectant) and
[MEDICATION NAME] (skin protectant) to the resident’s buttocks;
– LPN C removed gloves and did not wash his/her hands;
– LPN C and Certified Nurse Aide (CNA) C turned the resident on his/her back.
During a telephone interview on 4/15/19, at 2:22 P.M., LPN C said:
– He/she should have washed his/her hands after cleaning fecal material and between glove
changes;
– He/she should have had a clean field to put the wound supplies on.
During an interview on 4/5/19, at 6:08 P.M., the Director of Nursing (DON) said:
– Staff should wash their hands when they enter the resident’s room, between activities of
daily living (ADL’s), before they leave the room, when soiled, and between glove changes;
– When staff are cleaning fecal material, should remove their gloves and wash their hand
and apply new gloves;
– Staff should not use the same gloves to clean fecal material and then apply a wound
dressing.