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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Keep residents’ personal and medical records private and confidential.

Based on observation, interview, and record review, facility staff failed to maintain
resident privacy when they did not ensure the door was closed during the provision of care
for one resident (Resident #37) and and failed to maintain personal medical information in
a manner to protect all residents on the Special Care Unit (SCU). Additionally, staff
failed to maintain resident privacy when they failed to knock and announce themselves
before entering resident rooms for two residents (Resident #7 & Resident #26), and
failed to protect personal medical information for one resident (Resident #9). The
facility census was 40.
1. Review of the facility’s Admission Agreement, undated, showed staff are directed as
follows:
-A resident has the right to personal privacy and confidentiality of his or her personal
and clinical records;
-Personal privacy shall include accommodations, medical treatment, written and telephone
communications, personal care, and visits and meetings with family and resident groups.
2. During an interview on 4/15/19 at 12:08 P.M., Resident #27 said, We don’t get privacy
here, they don’t knock they just come right in, and we can’t even use the phone in
private.
3. Observation on 4/15/19 at 12:49 P.M., showed Certified Nursing Assistant (CNA) H and
CNA I entered Resident #37’s room to provide perineal care. CNA H and CNA I did not
utilize the resident’s privacy curtain. Further observation showed an unidentified staff
member opened the door to the resident’s room during care, and did not close the door when
he/she left. Additional observation showed CNA H and CNA I continued to provide resident
care with the door open, and exposed the resident to the hallway.
4. Observation on 4/16/19 at 11:29 A.M., showed LPN A pushed the treatment cart into
Resident #26’s room. Further observation showed he/she did not knock on the door or obtain
permission prior to entering.
During an interview on 4/16/19 at 11:36 A.M., LPN A said, I should have knocked before I
went into the room, I am not sure why I didn’t, I always do. He/She said staff are
expected to knock before entering any resident’s room.
Observation on 4/16/19 at 11:37 A.M., showed CNA E entered Resident #7’s room with the
Hoyer lift. Further observation showed he/she did not knock or announce him/herself prior
to entering the room. Additional observation showed CNA B entered Resident #7’s room
without knocking or announcing him/herself.
During an interview on 4/17/19 at 12:28 P.M., CNA C said staff should knock and get
permission before entering any resident’s room whether they are cognitive or not.
5. Observation on 4/17/19 at 9:06 A.M., showed the Medication Administration Record
[REDACTED]. Additional observation showed Resident #9’s medical information unprotected.
6. During an interview on 4/18/19 at 11:53 A.M., Licensed Practical Nurse (LPN) A said
he/she expects staff to utilize the privacy curtain in resident rooms when providing care.
Furthermore, he/she said he/she expects staff members to stop providing care and close the
door if someone else opened it during care. Additionally, he/she said the MAR indicated
[REDACTED]. LPN A said he/she also expects staff to knock on resident doors and announce
themselves before entering.
During an interview on 4/18/19 at 11:58 A.M., CNA F said staff are directed to utilize the
privacy curtain in the resident’s room while providing care, and that staff is also
directed to knock and announce themselves before they enter a resident’s room.
During an interview on 4/18/19 at 12:31 P.M., the Director of Nursing (DON) said 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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
expects the staff to pull the privacy curtain during care, and if someone were to open the
door, he/she would expect the staff to stop the care and close the door to ensure the
resident’s privacy. He/She said he/she expects staff to maintain resident confidentially
by closing the MAR indicated [REDACTED].

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, facility staff failed to maintain sound levels at a
comfortable level to provide a homelike environment. The facility census was 40.
1. Observation on 4/15/19 at 12:22 P.M., showed a loud beeping sound in the main dining
room (MDR) during lunch. Further observation showed an unidentified resident covered
his/her ears with his/her hands, and shook his/her head.
Observation on 4/15/19 at 1:11 P.M., showed a loud beeping sound throughout the building.
Further observation showed the loud beeping came from the Special Care Unit (SCU) door.
Observation on 4/16/19 at 11:51 A.M., showed a loud beeping sound throughout the building.
Further observation showed the loud beeping came from the SCU door.
Observation on 4/17/19 at 2:00 P.M., showed a loud beeping sound at the nurse’s station.
Further observation showed the loud beeping came from SCU door. Additional observation
showed several residents at the nurses station shook their heads.
2. During an interview on 4/15/19 at 12:23 P.M., Resident #33 said the loud beeping is the
SCU door. He/she said the door goes off all the time because staff does not properly close
it. Furthermore, he/she said the door beeps until staff shuts it off and it is loud and
annoying.
During a group interview on 4/16/19 at 10:30 A.M., multiple residents said the noise level
in the facility is very loud. Furthermore, the residents said the SCU door goes off all
the time and it bothers them. Additionally, the residents said they can hear the alarm
through the entire building. The residents said they have mentioned that the noise bothers
them, but staff have not done anything about it.
During an interview on 4/18/19 at 11:52 A.M., Licensed Practical Nurse (LPN) A said he/she
does not see the residents get upset about the loud beeping from the SCU door. He/she said
that if anything the residents laugh.
During an interview on 4/18/19 at 12:02 P.M., Certified Nursing Assistant (CNA) J said the
loud beeping startles most of the residents. He/she said he/she does not know if it can be
turned down. He/she said he/she knows the beeping is from the SCU door.
During an interview on 4/18/19 at 12:39 P.M., the Director of Nursing (DON) said he/she
jumps when the door alarm sounds. He/She said it is loud enough that you can hear it
through the entire building, and it does bother the residents and they have complained
that it is loud. He/she is not aware if the volume of the alarm could be turned down.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident when there is a significant change in condition

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview facility staff failed to complete a Comprehensive
Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool,
for three residents (Resident #34, #36, and #40) out of 13 sampled residents. The census
was 40.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, showed it
directs staff as follows:
-Comprehensive Assessments are required comprehensive assessments include the completion
of both the Minimum Data Set (MDS) (a federally required resident assessment) and the Care
Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are
completed upon admission, annually, and when a significant change in a resident’s status
has occurred or a significant correction to a prior comprehensive assessment is required.
They consist of:
-Admission Assessment
-Annual Assessment
-Significant Change in Status Assessment
-Significant Correction to Prior Comprehensive Assessment
-The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a
resident that must be completed when the interdisciplinary team (IDT) has determined that
a resident meets the significant change guidelines for either major improvement or
decline. It can be performed at any time after the completion of an Admission assessment,
and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s
determination was made that the resident had a significant change. A significant change is
a major decline or improvement in a resident’s status that:
-Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, the decline is not considered
self-limiting;
-Impacts more than one area of the resident’s health status; and
-Requires interdisciplinary review and/or revision of the care plan.
-Assessment Completion refers to the date that all information needed has been collected
and recorded for a particular assessment type and staff have signed and dated that the
assessment is complete.
-For required Comprehensive assessments, assessment completion is defined as completion of
the CAA process in addition to the MDS items, meaning that the registered nurse (RN)
assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item
V0200B) completion attestations. Since a Comprehensive assessment includes completion of
both the MDS and the CAA process, the assessment timing requirements for a comprehensive
assessment apply to both the completion of the MDS and the CAA process.
2. Review of the facility’s MDS Completion and Submission Timeframes Policy, dated (MONTH)
(YEAR), showed resident assessments shall be developed and reviewed in accordance with
current federal and state submission timeframes.
-The assessment coordinator or designee is responsible for ensuring that resident
assessments are submitted to CMS Assessment Submission and Processing (ASAP) system in
accordance with current federal and state guidelines; and
-Timeframes for completion and submission of assessments is based on the current
requirements published in the Resident Assessment Instrument Manual.
3. Review of the facility’s Change in a Resident’s Condition or Status Policy, dated
(MONTH) (YEAR), showed staff are directed as follows:
-A significant change of condition is a decline or improvement in the resident’s status
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
that;
-Will not normally resolve itself without interventions by staff or by implementing
standard disease-related clinical interventions;
-Impacts more than one area of the resident’s health status;
-Requires interdisciplinary review and/or revision to the care plan;
-And ultimately on the judgement of the clinical staff and the guidelines outlined in the
resident assessment instrument and 42 CFR 483.20(b)(ii).
-If a significant change in the resident’s physical or mental condition occurs, a
comprehensive assessment of the resident’s condition will be conducted as required by
current OBRA regulations governing resident assessments and as outlined in the MDS RAI
Instruction Manual.
4. Review of Resident #34’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-Independent with bed mobility;
-Required limited assistance of one staff for transfers, eating, dressing, and personal
hygiene;
-Required extensive physical assistance of one staff member for toileting and bathing;
-Mood indicators as follows: short tempered and a poor appetite 7-11 days; and
-Behaviors as follows: no verbal behaviors, no delusions, and wandered daily.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Severe cognitive impairment;
-Supervision and set up assistance with eating;
-Required limited assistance of one staff for bed mobility and dressing;
-Required total assistance of one staff for personal hygiene and bathing;
-Required total assistance of two staff for transfers and toileting;
-Mood indicators as follows: short tempered and poor appetite 1-3 days; and
-Behaviors as follows: verbal behaviors 1-3 days, experienced delusions, and wandered 1-3
days.
Review of the resident’s record showed it did not contain a significant change MDS to
address the resident’s changes in care needs and behaviors.
5. Review of Resident #36’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively Intact;
-Inattention fluctuates;
-Disorganized thinking fluctuates;
-No mood indicators;
-Required limited assistance of one staff for toileting, eating, dressing, and personal
hygiene;
-Required extensive physical assistance of one staff members for bathing.
Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severe cognitive impairment;
-Mood indicators as follows: little interest and being short tempered 7-11 days, and
trouble falling asleep and trouble concentrating 1-3 days;
-Supervision and set up assistance with eating, and transfers;
-Requires supervision of one staff for bed mobility;
-Required limited assistance of one staff for toileting, personal hygiene, and dressing;
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-Required extensive assistance of one staff for bathing.
Review of the resident’s record showed it did not contain a significant change MDS to
address the resident’s changes in care needs, cognition, and mood indicators.
6. Review of Resident #40’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-Required limited assistance with transfers;
-Pain Frequency, not assessed;
-Mood indicators as follows: feeling depressed, down or hopeless 2-6 days (several days),
tired and a poor appetite never or 1 day.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as follows:
-Cognitively intact;
-Required total assistance of two staff for transfers;
-Pain Frequency, Frequently and pain rated as 8 on a scale of 1-10;
-Mood indicators as follows: feeling depressed, down or hopeless 12-14 days (nearly every
day), tired and a poor appetite 12-14 days.
Review of the resident’s record showed it did not contain a significant change MDS to
address the resident’s changes in care needs, pain, and mood indicators.
7. During an interview on 4/18/19 at 9:55 A.M., the MDS coordinator said he/she is
responsible to complete the MDS assessments and is to follow the RAI manual. He/She said a
significant change MDS should be done after three or more changes in care areas, anytime
there is something new that affects the resident’s care, and anytime a resident goes on or
off hospice. He/She said the position is new to him/her and he/she is still learning the
process.
During an interview on 4/18/19 at 12:43 P.M., the Director of Nursing said he/she is
responsible to sign the MDS assessments when they are completed. Furthermore, he/she said
he/she expects staff to complete the MDS assessments per CMS guidelines.

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 observation, interview, and record review, facility staff failed to update the
plan of care with changes in the resident’s needs for four residents (Resident #18, #34,
#36, and #37) out of 13 sampled residents. The facility census was 40.
1. Review of the facility’s Care Plans, Comprehensive Person-Centered Policy, dated
(MONTH) (YEAR), showed staff are directed:
-The care plan interventions are derived from a thorough analysis of the information
gathered as part of the comprehensive assessment;
-The care plan will include an assessment of the resident’s strengths and needs;
-Describe the services that are to be furnished to attain or maintain the residents’
highest practicable physical, mental, and psychological well-being; and
-Assessments of residents are ongoing and care plans are revised as information about the
residents and the resident’s conditions change.
2. Observation on 4/15/19 at 11:49 A.M., showed Resident #18 in his/her room. Further

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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)
observation showed the resident did not have a water pitcher at bedside.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated 4/01/19, showed staff are directed to
restrict fluids for the resident to 2000 cc per day. Staff did not update the resident’s
care plan to reflect the change in the resident’s fluid orders.
3. Observation on 4/15/19 at 11:49 A.M., showed Resident #34 in the Main Dining Room
(MDR). Further observation showed the resident required a sectional plate at meals and
used his/her hands to consume meals.
Review of the resident’s POS’s, dated 3/15/19-4/14/19, showed the resident had a diet
order for a regular diet and did not contain direction to use a sectional plate.
Review of the resident’s plan of care, dated 12/05/18, showed staff identified the
resident at risk for weight loss. The care plan did not contain direction for staff
related to adaptive plates, utensils, or finger foods.
4. Observation on 4/15/19 at 12:28 P.M., showed Resident #36 in the MDR in a wheelchair at
the table. Further observation showed the resident received a mechanically altered diet.
Review of the resident’s POS’s, dated 3/15/19-4/14/19 showed the resident had a diet order
for mechanical soft diet.
Review of the resident’s plan of care, dated 12/11/18, showed staff are directed the
resident is at risk for weight loss. The care plan did not contain direction for staff to
provide the resident with a mechanical soft diet.
5. Observation on 4/15/19 at 12:49 P.M., showed Resident #37 in the Main Dining Room
(MDR). Further observation showed the resident drank thickened liquids with the assistance
of one staff member.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s plan of care, dated 3/19/19, showed staff are directed the
resident is at risk for weight loss. The care plan did not contain direction for the staff
to provide the resident with thickened liquids.
6. During an interview on 4/18/19 at 9:55 A.M., the MDS Coordinator said that the care
plan should be updated with any new information or any change to the residents care that
is expected to last longer than two weeks.
During an interview on 4/18/19 at 12:02 P.M., Certified Nursing Assistant (CNA) J said
that the resident receives thickened liquids. He/she said he/she knows this because that’s
what the nurses’s have told her.
During an interview on 4/18/19 at 12:52 P.M.,. the Director of Nursing (DON) said he/she
expects the careplans to be accurate and up to date. Furthermore, he/she said he/she
expects the care plan to contain information such as the resident’s current diet and fluid
orders and any care they require.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, facility staff failed to ensure staff
provided four residents (Resident #15, #32, #34, and #36), who were unable to complete
their own activities of daily living, the necessary care and services to maintain adequate
grooming. In addition, facility staff failed to assist three residents in the dining room

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
(Resident #7, #34, and #36), who required staff assistance with meals, with the necessary
care and services to maintain good nutrition. The facility census was 40.
1. Review of the facility’s Shaving the Resident Policy, dated (MONTH) 2010, showed it did
not contain direction for staff in regards to timeliness of shaving for residents.
2. Review of the facility’s Assistance with Meals Policy, dated (MONTH) 2013, showed it
directs the staff as follows:
-All residents will be encouraged to eat in the dining room;
-Facility staff will serve resident trays and will help residents who require assistance
with eating;
-Residents who cannot feed themselves will be fed with attention to safety, comfort, and
dignity.
3. Review of Resident # 7’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 1/18/19, showed the facility assessed
the resident with cognitive impairment, requires supervision and set up assistance of one
person for eating, requires extensive assistance of one staff member for personal hygiene,
has limitations on one side to both upper and lower extremities, and requires a
mechanically altered diet.
Observation on 4/15/19 at 12:31 P.M., showed the dining room full of residents but no
staff were present.
Observation on 4/15/19 at 12:32 P.M., showed the resident in a wheelchair in the dining
room with unkempt hair. Further observation showed the resident had a whole biscuit on
his/her plate covered in gravy as he/she tried to get a bite the food just kept falling
off the fork. Additional observation showed the resident unable to use his/her left side
as he/she leaned over the plate and attempted to take bites of the biscuit as food fell
into his/her lap. Staff passed trays in the dining room but did not offer the resident
assistance or cues. He/She continued to try to eat his/her meal for approximately 30
minutes until he/she pushed the plate away and a staff member came over and pushed him/her
out of the dining room.
4. Review of Resident # 15’s quarterly MDS, dated [DATE], showed staff assessed the
resident with cognitive impairment, and requires extensive assistance of one person for
personal hygiene.
Observation on 4/15/19 at 11:49 A.M., showed the resident walked in the hallway. Further
observation showed the resident with unkempt hair, and long chin hair.
Observation on 4/17/19 at 12:14 P.M., showed the resident in the dining room. Further
observation showed the resident with unkempt hair, and long chin hair.
5. Review of Resident # 32’s Quarterly MDS, dated [DATE], showed staff assessed the
resident with cognitive impairment, and required supervision of one person for personal
hygiene.
Observation on 4/15/19 at 12:19 P.M., showed the resident in a chair in the dining room.
Further observation showed the resident with long chin hair.
6. Review of Resident #34’s Quarterly MDS, dated [DATE], showed staff assessed the
resident with cognitive impairment, dependent on assistance of one person for personal
hygiene and required supervision of one person for eating.
Observation on 4/15/19 at 12:14 P.M., showed the resident sitting in the dining room.
Further observation showed the resident with unkempt hair and long chin hairs.
Observation on 4/15/19 at 12:23 P.M., showed the resident in a wheelchair in the dining
room. Further observation showed the resident with a red sectional plate and as he/she
picked up the red plate and lifted it to his/her mouth the food fell into his/her face and
lap. Additional observation showed him/her picking up pieces of salad with 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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
fingers. An unidentified staff member moved the resident to a different table but did not
assist the resident to eat his/her salad. Staff continued to pass trays in the dining room
and did not assist the resident to eat his/her meal.
7. Review of Resident #36’s Annual MDS, dated [DATE], showed staff assessed the resident
with cognitive impairment, limited assistance of one person for personal hygiene, required
supervision of one person for eating, and required a mechanical soft diet.
Observation on 4/15/19 at 11:49 A.M., showed the resident in his/her bed. Further
observation showed the resident with unkempt facial hair.
Observation on 4/15/19 at 12:28 P.M., showed the resident in the dining room with unkempt
facial hair. Further observation showed the resident with a whole biscuit covered in gravy
on his/her plate. Additional observation showed the resident used his/her fork to pick up
the biscuit and tried to take bites. The biscuit fell into his/her lap.
8. During an interview on 4/17/19 at 12:28 P.M., Certified Nurse Assistant (CNA) C said
residents should be shaved during their shower and all staff are responsible to make sure
residents are clean and groomed. He/She said if a resident received a whole biscuit and
was on a mechanical soft diet, he/she would return it back to the kitchen because they are
supposed to send trays out already cut up.
During an interview on 4/17/19 at 12:30 P.M., Certified Nurse Assistant (CNA) B said
female residents are only shaved upon request, and male residents are shaved during their
showers. He/She said if there was a resident with an order for [REDACTED].
During an interview on 4/18/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said he/she
expects staff to do shaves everyday both for male and female residents. He/She said female
residents should not have long chin hairs and anytime a resident refuses a shower or a
shave staff should keep trying. All residents’ hair should be washed with showers and
anytime it appears greasy. The staff have dry shampoo available to use anytime a resident
may refuse a shower. Staff are expected to assist residents during meals and he/she
expects staff to cut up any resident’s biscuit into small bite size pieces for someone on
a mechanically altered diet.
During an interview on 4/18/19 at 12:54 P.M., the Director of Nursing (DON) said he/she
expects if a resident requires assistance with grooming that they ask for assistance.
Furthermore, he/she said if the resident is unable to ask for assistance he/she expects
the staff to ensure they are neat in appearance. He/she said if a resident refused to eat
something or was unable to eat something, he/she expects the staff to assist the resident
in getting something else to eat, and that if the the resident required assistance from
the staff to setup their meal that he/she expects the staff to do so.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to ensure the
residents’ environment remained free of accident hazards when they failed to lock
medication/treatment cart when not in eyesight, and failed to ensure adequate supervision
and/or develop interventions to prevent eight falls for (Resident #15). The facility
census was 40.
1. Review of the Facility’s Fall Policy, dated (MONTH) 2010, showed staff are directed 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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
follows:
-After an observed or probable fall, the staff will clarify the details of the fall, such
as when the fall occurred and what the individual was trying to do at the time the fall
occurred;
-Within 24 hours of a fall, the staff will clarify the details of the fall, such as when
the fall occurred and what the individual was trying to do at the time the fall occurred;
-When a resident falls, the following should be recorded in the resident’s medical record:
Appropriate Interventions taken to prevent future falls.
2. Review of Resident #15’s care plan, dated 8/03/18, showed staff are directed:
-The resident is at risk for falls due to cognitive impairment, high risk medication,
incontinence, fall history, and wandering;
-Needs frequent cues and reminders due to short attention span and confusion;
-Potential to wander due to [MEDICAL CONDITION]; and
-Resides on a special care unit.
Further review of the resident’s care plan showed it did not contain direction for staff
on interventions to prevent future falls.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident
assessment, dated 1/31/19, showed staff assessed the resident as follows:
-Brief Interview for Mental Status (BIMS) score of 7 (score of 0-7 indicates a severe
cognitive impairment);
-[DIAGNOSES REDACTED].
-Sustained two or more non injury falls since prior assessment;
-Sustained two or more minor injury falls since prior assessment.
Review of the resident’s Physician order [REDACTED].
-[MEDICATION NAME] (a medication used to treat anxiety) 0.5 milligrams (mg) take ½ tab by
mouth (PO) once daily for [MEDICAL CONDITION];
-[MEDICATION NAME] (a medication used for [MEDICAL CONDITION] disorders) Delayed Release
(DR) 250 mg one po twice daily (BID) for [MEDICAL CONDITION];
-Quetiapine [MEDICATION NAME] (an antipsychotic medication) 25 mg three tablets po at
bedtime (HS) for anxiety;
-Trazadone (a medication used to treat depression) 100 mg po at hs for [MEDICAL
CONDITION].
Review of the facility’s Fall Logs showed the resident sustained [REDACTED].
-April 15, at 7:00 p.m., staff did not document in the action taken column;
-April 15, at 11:45 a.m., staff did not document in the action taken column;
-April 2, at 11:45 a.m., staff did not document in the action taken column;
-April 1, at 16:45 p.m., staff did not document in the action taken column;
-March 18, at 7:00 p.m., staff did not document in the action taken column;
-March 12, at 4:00 p.m., staff did not document in the action taken column;
-January 20, at 5:00 p.m., staff did not document in the action taken column; and
-January 3, at 11:15 a.m., staff did not document in the action taken column.
Observation on 4/15/19 at 11:49 A.M., showed the resident walked in the hallway. Further
observation showed the resident shuffled his/her feet and leaned forward as he/she walked.
Additional observation showed he/she continued to shuffle his/her feet as he/she walked
slowly into his/her room, leaned more forward, reached the edge of his/her bed, and fell
across the bed.
Observation on 4/15/19 at 11:52 A.M., showed the resident lay on the hallway floor without
any staff present. Licensed Practical Nurse A and a second unidentified staff member
entered the area and one staff said What were they doing, they are supposed to be walking
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
with him/her. Additional observation showed staff assessed the resident and said the
resident complained of pain to his/her knee.
Observation on 4/15/19 at 12:07 P.M., showed the resident in a wheelchair in the dining
room at a table. Further observation showed the resident stood up out of the wheelchair
and walked out of the dining room with an unsteady gait. CNA E looked up at her while
he/she passed drinks but did not stop passing the drinks. As the resident neared the
nurse’s station his/her gait worsened and he/she leaned forward toward the floor, CNA B
came out of the nurse’s station and assisted him/her. CNA B assisted him/her back to the
dining room and told CNA E, That was a close one he/she almost did it again, he/she was
almost in the floor.
During an interview on 4/16/19 at 9:35 A.M., CNA B said staff are supposed to assist the
resident to walk at all times. He/She said with the newest fall staff are expected to be
sure the resident uses a wheelchair and monitor him/her one on one. CNA B said he/she went
to monitor a door but he/she shouldn’t have left the resident because there was no one to
supervise him/her.
During an interview on 4/17/19 at 12:28 P.M., CNA C said prior to the resident’s fall
today he/she was up independently and did fairly well taking care of him/herself.
During an interview on 4/18/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said he/she
expected staff to walk with the resident due to his/her unsteady gait and risk for falls.
He/She said the resident stumbles when he/she walks.
During an interview on 4/18/19 at 12:58 P.M., the Director of Nursing (DON) said if a
resident has a fall, he/she expects the staff to assess the resident for injury, and
attempt to determine how they fell , why they fell , and how they can prevent another fall
in the future. He/she said he/she expects the staff to implement a new intervention for
each fall, and ensure that all staff are aware of the new intervention. He/she said the
careplan should be updated with the information.
3. Observation on 04/16/19 at 11:41 A.M., showed LPN A left the medication/treatment cart
next to room [ROOM NUMBER], he/she then drew up insulin for the resident. Further
observation showed LPN A entered the room and closed the curtain. Additional observation
showed the cart was unlocked and unattended, with insulin and needles left on the top of
the cart in the dementia care unit and with residents observed walking in the hallway
unattended.
During an interview on 4/17/19 at 11:47 A.M., LPN A said, I shouldn’t have left the cart
unlocked, unattended, and with medications on it, I know that is a no, no, especially back
here.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to provide
adequate fluids to ensure proper hydration and health for six residents (Resident #7, #15,
#18, #34, #36, and #40) of 13 sampled residents in the Behavior/Memory Care Unit. The
facility census was 40.
1. Review of the facility’s Resident Hydration and Prevention of Dehydration, dated
(MONTH) 2011, showed staff are directed as follows:
-Nursing will assess for signs and symptoms of dehydration during 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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
-Nurses’ Aides will provide and encourage intake of bedside, snack and meal fluids, on a
daily and routine basis as part of the daily care. Intake will be documented in the
medical records. Aides will report intake of less than 1200 ml/day to nursing staff;
-Nursing will monitor and document fluid intake.
2. Review of Resident #7’s care plan, dated 8/01/18, showed it directs the staff as
follows:
-Observe for changes in appetite;
-Offer an alternative if refuses;
-At risk for weight loss/poor fluid intake; and
-There was no direction for staff on how to assure the resident received fluids.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident
assessment tool, dated 1/18/19, showed staff assessed the resident as:
-Moderate cognitive impairment;
-Supervision of one staff member for eating;
-Dependent on one staff member for transfers, and toilet use.
Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s
orders [REDACTED].
Observation on 4/15/19 at 12:32 P.M., showed staff served one glass 180 cc of fluids to
the resident during the lunch meal. Staff did not serve additional fluids to the resident
during the meal.
Observation on 4/16/19 at 11:37 A.M., showed staff provided care to the resident in
his/her room. Further observation showed staff did not offer fluids to the resident
before, during, or after care. Additional observation showed the resident did not have a
water pitcher or fluids in his/her room.
3. Review of Resident #15’s care plan, dated 8/03/18, showed it directs the staff as
follows:
-Observe for changes in appetite;
-Offer an alternative if refuses;
-At risk for weight loss/poor fluid intake due to being easily distracted; and
-There was no direction for staff on how to assure the resident received fluids.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Moderate cognitive impairment;
-Supervision of one staff member for bed mobility, transfers, eating, and toileting;
-Limited assistance with one staff member for dressing;
-Extensive assistance of one staff member for personal hygiene;
-Dependent on one staff member for bathing.
Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s
orders [REDACTED].
Observation on 4/16/19 at 9:53 A.M., showed the resident did not have a water pitcher at
his/her bedside.
Observation on 4/17/19 at 9:13 A.M., showed the resident did not have a water pitcher or
fluids to drink in his/her room.
Observation on 4/17/19 at 12:14 P.M., showed staff served one glass 180 cc of fluids to
the resident during the meal. Staff did not serve the resident additional fluids during
the meal.
4. Review of Resident #18’s Annual MDS, dated [DATE], showed the staff assessed the
resident as:
-Moderate cognitive impairment;
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-Independent with toileting;
-Limited assistance with one staff member for bed mobility, transfers, personal hygiene,
and eating;
-Extensive assistance of one staff member for dressing, and bathing.
Review of the resident’s care plan, dated 4/01/19, directs the staff as follows:
-Offer an alternative if refuse;
-At risk for weight and fluid fluctuations due to [MEDICAL CONDITION] and diuretic
therapy;
-There was no direction for staff on how to assure the resident received fluids.
Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, shows a physician’s
orders [REDACTED]. Additional review showed a physician’s orders [REDACTED].
Observation on 4/16/19 at 9:54 A.M., showed the resident did not have a water pitcher at
his/her bedside.
Observation on 4/17/19 at 9:14 A.M., showed the resident did not have a water pitcher or
fluids to drink in his/her room.
Observation on 4/17/19 at 12:15 P.M., showed staff served one glass 180 cc of fluids to
the resident during the lunch meal. Additional observation showed staff did not offer
additional fluids to the resident at the meal.
5. Review of Resident #34’s care plan, dated 12/05/18, directs the staff as follows:
-Offer an alternative if refuses;
-At risk for weight loss/poor fluid intake due to poor appetite; and
-There was no direction for staff on how to assure the resident received fluids.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Severe cognitive impairment;
-Supervision of one staff member for eating;
-Limited assistance with one staff member for dressing, and bed mobility;
-Dependent on one staff member for personal hygiene;
-Dependent on two staff members for toileting, and transfers.
Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s
orders [REDACTED].
Observation on 4/16/19 at 9:55 A.M., showed the resident did not have a water pitcher at
his/her bedside.
Observation on 4/17/19 at 9:15 A.M., showed the resident did not have a water pitcher or
fluids to drink in his/her room.
6. Review of Resident #36’s care plan, dated 12/11/18, showed it directs the staff as
follows:
-Observe for changes in appetite;
-Provide supplements per physician’s orders [REDACTED].>-Provide a divided plate at
meals;
-Offer an alternative if refuses;
-At risk for weight loss/poor fluid intake; and
-Did not provide direction for staff on how to assure the resident received fluids.
Review of the resident’s annual MDS, dated [DATE], showed the staff assessed the resident
as:
-Severe cognitive impairment;
-Supervision with set up of one staff member for transfers, and eating;
-Supervision of one staff member for bed mobility;
-Limited assistance with one staff member for dressing, toileting, and personal hygiene;
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Extensive assist of one staff member for bathing.
Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s
orders [REDACTED].
Observation on 4/15/19 at 12:28 P.M., showed the resident in a wheelchair in the dining
room. Further observation showed one cup of purple fluid in a 180 cc glass. Additional
observation showed staff did not serve any other fluids to the resident at the meal.
Observation on 4/16/19 at 9:56 A.M., showed the resident did not have a water pitcher or
fluids to drink in his/her room.
Observation on 4/17/19 at 10:50 A.M., showed the resident did not have a water pitcher or
fluids to drink in his/her room.
7. Review of Resident #40’s Admission Minimum Data Set (MDS), a federally mandated
resident assessment tool, dated 3/27/19, showed the staff assessed the resident as
follows:
-Cognitively intact;
-Required total assistance of two staff members for transfers;
-Supervision of one staff member for eating;
-Required total assistance of one staff member for personal hygiene, dressing, and
bathing;
Review of the resident’s care plan, undated, showed it directs the staff as follows:
-Offer an alternative if consumes less than 50% of meal;
-Observe while eating meals, snacks and food in activities for any intolerance to the
foods served;
-Provide thickened liquids;
-There was no direction for staff on how to assure the resident received fluids.
Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s
orders [REDACTED].
Observation on 4/15/19 at 1:45 P.M., showed the resident did not have fluids in his/her
room.
During an interview on 4/15/19 at 1:45 P.M., the resident said I have a hard time getting
a drink because it has to be thickened. A couple weeks ago my cup went missing and I
haven’t had anything in my room since.
Observation on 4/15/19 at 2:15 P.M., showed an unknown CNA provided a drink for the
resident. Additional observation showed the DON said we do not leave drinks in the room.
Observation on 4/16/19 at 1:45 P.M., showed the resident did not have fluids in his/her
room.
Observation on 4/17/19 at 10:00 A.M., showed resident did not have fluids in his/her room.

8. During an interview on 4/17/19 at 9:36 A.M., Certified Nurses Aid (CNA) B said, We only
provide fluids on the unit upon request, we have a lot of residents back here with
behaviors and there are no water pitchers in their rooms. He/She said staff are expected
to offer fluids at snack times and at meals, it has just been busy today.
During an interview on 4/17/19 at 10:37 A.M., Licensed Practical Nurse (LPN) A said staff
do not leave fluids at bedside or pass ice to the residents on the unit. He/She said staff
are expected to go through and offer fluids with care and throughout the shift.
During an interview on 4/18/19 at 12:10 P.M., CNA J said staff are expected to pass ice
water every shift. There are a few residents who require thickened liquids in the facility
and the CNAs are expected to prepare those fluids. CNA J said the residents are allowed to
have drinks in their room unless its ordered otherwise, but he/she does not know of anyone
who is not allowed to have drinks in their room.

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
During an interview on 4/18/19 at 1:03 P.M., the Director of Nursing (DON) said he/she
expects the staff to pass ice and water to all the residents at the beginning of each
shift. He/she said staff should offer dependent residents water every time they enter the
room. Furthermore, he/she said each resident should have a cup with water in it at their
bedside, including the residents on the SCU. He/she said if the residents did not have a
cup in their room, he/she expects the staff to provide one.

F 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe, appropriate pain management for a resident who requires such services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide
further interventions to relieve pain for one resident (Resident #28) and failed to notify
the physician for additional guidance when the resident had complaints of unrelieved pain.
The facility census was 40.
1. Review of the facility’s Pain Assessment & Management policy, dated (MONTH) (YEAR),
shows facility staff are directed as follows:
-Pain Management is defined as the process of alleviating the resident’s pain to a level
that is acceptable to the resident based on his or her clinical condition and established
treatment goals;
-Pain Management is a multidisciplinary care process that includes the following:
Assessing the potential for pain, effectively recognizing the presence of pain,
Identifying characteristics of pain, addressing the underlying causes of the pain,
developing and implementing approaches to pain management, monitoring the effectiveness of
interventions and modifying approaches as necessary;
-Observe the resident for physiologic and behavioral signs of pain, such as, facial
expressions such as grimacing, frowning, and clenching of the jaw. Behavior such as
resisting care, irritability, depression, decreased participation in usual activities.
Limitation in his or her level of activity due to the presence of pain, and evidence of
depression, anxiety, fear or hopelessness;
-Ask the resident if he or she is experiencing pain;
-Non-pharmalogical interventions (interventions that do not involve medications, such as
adjusting the temperature of the room, ice packs, cool or warm compresses, baths, massage,
acupuncture, range of motion exercises, relaxation, and music diversion) may be
appropriate alone or in conjunction with medications;
-If pain has not been adequately controlled, the multidisciplinary team, including the
physician, shall reconsider approaches and made adjustments as indicated.
2. Review of Resident #28’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 2/22/19, showed facility staff assessed
the resident as follows:
-Cognitively Intact;
-Showing little interest or pleasure in doing things, nearly every day;
-Feeling tired or having little energy, nearly every day;
-The resident did not reject evaluation or care necessary to achieve goals;
-[DIAGNOSES REDACTED]. (a syndrome in which age-related wear and tear on a spinal disc
causes low back pain);
-Requires scheduled and as needed (PRN) pain medication regimens;

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-Receives no non-medication intervention for pain;
-Has pain almost constantly;
-Pain has made it hard to sleep at night;
-Pain has limited day-to-day activities;
-Pain rated a 6 on a scale of 1-10;
-And received no therapy services.
Review of the resident’s Face Sheet, dated 1/7/19, showed the resident had the additional
Diagnoses: [REDACTED].>-[MEDICAL CONDITION] (a disorder characterized by widespread
musculoskeletal pain accompanied by fatigue, sleeplessness, memory and mood issues);
-Spondylolysis (cracks or stress fractures in the vertebrae), of the cervical region
(neck);
-And low back pain.
Review of the resident’s Pain Evaluation, dated 2/22/19, showed the facility staff
assessed the resident as follows:
-Currently in pain;
-At risk for pain;
-And experienced pain the past.
Review of the resident’s plan of care, dated 3/26/19, showed staff are directed as
follows:
-Refer me to Occupational Therapy (OT)/Physical Therapy (PT) as needed;
-Measure my pain level daily using pain scale of one to ten;
-Coordinate with my physician to manage my pain medication for optimum control of my pain;

-Observe me for effectiveness of medication;
-Please administer my PRN pain medication in a timely manner if my routine medication is
not holding.
Review of the resident’s Physician order [REDACTED].
-12/13/18- [MEDICATION NAME] (Narcotic pain patch, that is delivered through the skin) 15
micrograms (MCG)/hour (hr), Apply patch topically and change every week;
-7/11/18- [MEDICATION NAME] 5% (Patch applied to the skin to relieve pain) Apply one patch
daily, and remove at bedtime (HS)- Discontinued on 4/7/19;
-4/14/16-[MEDICATION NAME]-[MEDICATION NAME] (Narcotic pain relief medication) 5/325
milligrams (mg), take 1 tablet by mouth once daily for pain control;
-8/4/15- [MEDICATION NAME] (medication used to help relieve pain caused by [MEDICAL
CONDITION]) 200 mg 1 capsule three times per day for [MEDICAL CONDITION];
-10/29/15- [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg 1 tablet by mouth once daily PRN
for pain;
Review of the resident’s medical record showed staff notified the Medical Director on
4/3/19 of the following:
-Resident dislikes, and refuses the [MEDICATION NAME]es for his/her low back pain. States
it’s ineffective and doesn’t stay on. Has refused it greater than three days consistently.
Further review showed the physician discontinued the order on 4/4/19 without further
orders for pain management.
Review of the resident’s Medication Administration Record, [REDACTED]
-3/15/19:
7-3 Shift- 5 on a scale of 1-10;
-3/16/19:
7-3 Shift- 5;
3-11 Shift- 5;

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-3/17/19:
7-3 Shift-5;
3-11 Shift- 5;
-3/18/19:
7-3 Shift- 7;
3-11 Shift- 5;
-3/19/19:
7-3 Shift, did not document pain scale assessment;
3-11 Shift- 5;
3/20/19:
7-3 Shift- 6;
3-11 Shift- 5;
3/21/19:
7-3 Shift- 5;
3-11 Shift- 7;
3/22/19:
7-3 Shift- 4;
3-11 Shift- 8;
3/23/19:
7-3 Shift- 5;
3-11 Shift- 4;
3/24/19:
7-3 Shift- 4;
3-11 Shift- 6;
3/25/19:
7-3 Shift- 7;
3-11 Shift- 5;
3/26/19:
7-3 Shift- 7;
3-11 Shift- 6;
3/27/19:
7-3 Shift- 6;
3-11 Shift- 6;
3/28/19:
7-3 Shift- 7;
3-11 Shift- 8;
3/29/19:
7-3 Shift- 8;
3-11 Shift- 8;
3/30/19:
7-3 Shift- 5;
3-11 Shift- 5;
3/31/19:
7-3 Shift- 7;
3-11 Shift- 5;
4/1/19:
7-3 Shift- 7;
3-11 Shift- 6;
4/2/19:
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
7-3 Shift- 5;
3-11 Shift- 4;
4/3/19:
7-3 Shift- 5;
3-11 Shift- 5;
4/4/19:
7-3 Shift- 5;
3-11 Shift- 5;
4/5/19:
7-3 Shift- 2;
3-11 Shift- 6;
4/6/19:
7-3 Shift- 4;
3-11 Shift- 5;
4/7/19:
7-3 Shift- 7;
3-11 Shift- Did not document pain scale assessment;
4/8/19:
3-11 Shift- 6;
4/9/19:
7-3 Shift- 5;
3-11 Shift- 5;
4/10/19:
7-3 Shift- 5;
3-11 Shift- 5;
4/11/19:
3-11 Shift- 7;
4/12/19:
3-11 Shift- Did not document pain scale assessment;
4/13/19:
7-3 Shift- 5;
3-11 Shift- 5;
4/14/19:
7-3 Shift- 5;
3-11 Shift- 5;
Review of the resident’s MAR, dated 4/15/19-5/14/19 showed staff assessed the resident’s
pain as follows:
4/15/19;
3-11 Shift- 7;
4/16/19:
7-3 Shift- 5;
3-11 Shift-7;
4/17/19:
7-3 Shift- 5;
3-11 Shift- 5;
Additional review of the resident’s Medical Record showed a pharmacy consultation, dated
4/1/19-4/8/19 that showed the following:
-Resident receives [MEDICATION NAME] 15 mcg patch once weekly and [MEDICATION NAME]/Apap
(Tylenol) 5/325 mg once daily for pain, but is not attaining adequate pain control
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
according to recent assessments and documentation in the medical record. Patient states
that on an average his pain scale is a 7;
-Recommendation: Please reevaluate pain status. If pain is uncontrolled, please consider
increasing [MEDICATION NAME]/Apap 5/325 mg to three times daily for pain. Additional
review of the consultation showed the Medical Director documented: Patient will say a
seven no matter what. The consultation did not contain any further documentation or
guidance.
Observation and interview on 4/15/19 at 3:16 P.M., showed the resident is his/her room.
Further observation showed the resident to have a furrowed brow and making several
position changes in his/her recliner. The resident said he/she has a lot of pain in
his/her lower back and neck, due to disc deterioration. He/she said staff give him/her
pain medication for the pain, but it does not always help his/her pain. He/she said at one
time he/she was getting patches to his/her back and that the patches did not work, so
he/she refused to use them. The resident said he/she would be ok with a pain level of two
to 4 on a scale of one to ten. He/she said he/she did not remember the last time he/she
felt relief from pain. He/she rated his/her pain a seven on a scale of one to ten.
Observation on 4/17/19 at 12:52 P.M., showed the resident in the Dining Room. Further
observation showed the resident made frequent position changes in his/her chair, and had a
furrowed brow.
Observation and interview on 4/18/19 at 10:02 A.M., showed the resident in his/her room.
Further observation showed the resident was rigid, and making frequent position changes in
his/her recliner. The resident said that he/she is having a lot of pain today in his/her
back. He/she said that he/she has notified someone, but he/she could not remember who it
was.
During an interview on 4/17/19 at 4:55 P.M., Licensed Practical Nurse (LPN) G said the
resident has enough medication to alleviate his/her pain. He/she said the resident does
have complaints of pain, and states he/she does have pain, but it does not keep the
resident from walking to the snack cart. He/she said the resident does not cry out in
pain, so he/she does not know if the resident is having pain.
During an interview on 4/18/19 at 10:01 A.M., LPN A said the resident has a lot of
complaints of pain. He/she said the resident used to get pain medication more often but it
was reduced. LPN A said the resident says he/she is hurting, but he/she is not.
Furthermore, LPN A said the resident does have pain with walking due to decreased
circulation to his legs, but that he/she does not like to keep his/her legs elevated.
Additionally, LPN A said the physician is updated weekly in regards to the resident’s
pain, but he/she does not know where they document it. LPN A said the resident has no
interest in non-pharmalogical pain relief.
During an interview on 4/18/19 at 10:07 A.M., Certified Medication Technician (CMT) D said
the resident is always in pain, but he is not a complainer, he/she said the resident is
the silent type, but when he/she is asked he/she will say that his/her pain is between a
five or an eight on a scale of one to ten. He/she said that the nurses have spoken to the
doctor about his/her pain, but that he/she does not know any more than that. He/She said
that he/she has not seen the nurses offer the resident any alternative pain relief options
other than medication.
During an interview on 4/18/19 at 10:10 A.M., the Director of Nursing (DON) said the
resident shows no signs and symptoms of pain, and he/she never complains to him/her about
pain. Furthermore, he/she said he/she expects the nurses to complete a pain assessment,
and notify the physician if the resident was having unrelieved pain. Additionally, he/she
said he/she expects the staff to try non-pharmalogical interventions to relieve 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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0697

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
resident’s pain, or at least mention these options to the physician.
During an interview on 4/18/19 at 11:58 A.M , Certified Nursing Assistant (CNA) F said the
resident does not complain about pain unless you ask him/her. Furthermore, he/she said you
can tell when the resident’s legs hurt because he/she walks slower than usual. He/she said
he/she has not seen the nurses offer the resident any alternative pain relief options
other than medication.
During an interview on 5/1/19 at 1:43 P.M., the Medical Director said the resident always
has complaints of pain, and he/she always rates his/her pain a 7. He/she said the resident
does not appear to have pain because he/she walks the length of his/her hall with a walker
at a steady pace. The Medical Director said when the resident was initially admitted to
the facility he/she received a lot of pain medication, and said I don’t think he/she has
that much pain. Additionally, the physician said the resident has been seen by a pain
clinic in the past and all they wanted to do was increase his/her pain medication, and
said Why should they? The physician said he/she expects the facility staff to attempt
non-pharmalogical interventions for pain, such as redirection, ice packs, and hot packs.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to avoid use of unnecessary
medications or medication without an appropriate diagnosis. In addition the facility
failed to perform gradual dosage reductions for four residents (Resident #15, #28, #34,
and #37) out of 13 sampled residents. The facility census was 40.
1. Review of the Facility’s Tapering Medications and Gradual Drug Dosage (GDR) Reduction
Policy, dated (MONTH) 2007, directs staff as follows:
-Periodically, the staff and practitioner will review the continued relevance of each
resident’s mediations;
-The Attending Physician and staff will identify target symptoms for which a resident is
receiving various medications. The staff will monitor for improvement in those symptoms,
and provide the Physician with that information;
-The staff and practitioner will consider tapering of medications as one approach to
finding optimal dose or determining whether continued use of medication is benefiting the
resident;
-The Physician will review periodically whether current medications are still necessary in
their current doses;
-The Physician will order appropriate tapering of medications;
-Residents who use antipsychotic drugs shall receive gradual dose reductions, unless
clinically contraindicated, in an effort to discontinue the use of such drugs; and
-Within the first year after a resident is admitted on an antipsychotic medication or
after the resident has been started on an antipsychotic medication, the staff and
practitioner shall attempt a GDR in two separate quarters (with at least one month between
attempts), unless clinically contraindicated. After the first year , the facility shall
attempt a GDR at least annually, unless clinically contraindicated.

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
2. Review of Resident #15’s quarterly MDS, dated [DATE], showed the facility staff
assessed the resident as follows:
-Cognitively Impaired;
-[DIAGNOSES REDACTED].
-Trouble falling asleep, nearly everyday;
-No physical behaviors;
-No verbal behaviors;
-Delusions; and
-Wandered daily.
Review of the resident’s Physician order [REDACTED].
-[MEDICATION NAME] (a medication used to treat anxiety) 0.5 milligrams (mg) take ½ tab by
mouth (PO) once daily for [MEDICAL CONDITION];
-[MEDICATION NAME] (a medication used for [MEDICAL CONDITION] disorders) Delayed Release
(DR) 250 mg one po twice daily (BID) for [MEDICAL CONDITION];
-Quetiapine [MEDICATION NAME] (an antipsychotic medication) 25 mg three tablets po at
bedtime (HS) for anxiety;
-Trazadone (a medication used to treat depression) 100 mg po at HS for [MEDICAL
CONDITION].
Review of the resident’s medical record showed it did not contain documentation of a
[DIAGNOSES REDACTED].
Further review of the resident’s medical record showed a pharmacy consultation, dated
4/1/19-4/8/19, showed the following recommendation:
-[MEDICATION NAME] 0.25 mg daily for anxiety; please consider a trial discontinuation of
the [MEDICATION NAME].
-[MEDICATION NAME] 250 mg twice daily for [MEDICAL CONDITION] disorder; Quetiapine 75 mg
at bedtime for [MEDICAL CONDITION] disorder; and Trazadone 100 mg at bedtime for [MEDICAL
CONDITION]; please consider a GDR of the above medications at this time.
Additional observation showed the physician did not approve the recommendations, or
provide a rationale for the continued use of the [MEDICAL CONDITION] medications without a
GDR.
3. Review of Resident #28’s quarterly MDS, dated [DATE], showed the facility staff
assessed the resident as follows:
-Cognitively Intact;
-Showing little interest or pleasure in doing things, nearly every day;
-Feeling tired or having little energy, nearly every day;
-Free of hallucinations (perceptual experiences in the absence of real external sensory
stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to
reality);
-No physical behaviors symptoms, no verbal behavioral symptoms, or other behavioral
symptoms directed towards others;
-No rejection of care or evaluation of care;
-[DIAGNOSES REDACTED]. to think, feel, and behave clearly), and [MEDICAL CONDITIONS];
-Received Antipsychotic medication seven out of seven days in the look back period (a
period of time, typically seven days in which the facility gathers information to complete
the mandated assessment);
-And received Antidepressant medication seven out of seven days in the look back period;
Review of the resident’s Physician order [REDACTED].
-8/4/15- Duloxetine [MEDICATION NAME] (HCL) Direct Release (DR) (for depression) 60
milligrams (mg) two times a day (BID) for anxiety and depression;
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-8/4/15- [MEDICATION NAME] (an anticonvulsant medication used to treat [MEDICAL CONDITION]
Disorder) 225 mg BID for [MEDICAL CONDITION] Disorder;
-8/4/15-Ziprasidone HCL (medication used to treat [MEDICAL CONDITION] and [MEDICAL
CONDITION] Disorder) 40 mg two times per day for [MEDICAL CONDITION];
-10/05/18-[MEDICATION NAME] (an anxiety medication) one mg three times per day (TID) for
anxiety;
-3/30/16- [MEDICATION NAME] (medication used in the treatment of [REDACTED].
-1/9/17- [MEDICATION NAME] 150 mg at HS for sleep;
Review of the resident’s medical record showed a pharmacy consultation dated
8/1/2018-8/28/2018 that showed staff administered the following:
-Duloxetine 60 mg twice daily for depression;
-[MEDICATION NAME] 225 mg twice daily for [MEDICAL CONDITION];
-[MEDICATION NAME] (Ziprasidone HCL) 40 mg twice daily for [MEDICAL CONDITION];
-[MEDICATION NAME] 1 and ½ mg three times daily for anxiety;
-[MEDICATION NAME] 3 mg at HS for [MEDICAL CONDITION];
-Trazadone 150 mg at bedtime for [MEDICAL CONDITION]/depression;
Further review showed the pharmacy consultant recommended the physician consider a GDR of
the resident’s [MEDICATION NAME] to 1 mg TID. Additionally, the review showed the pharmacy
consultant recommended a review with possible reduction for the Duloxetine, [MEDICATION
NAME], and Ziprasidone. The physician approved the GDR of the [MEDICATION NAME], but did
not provide further guidance for the staff in regards to the additional medications, or
documented contraindications for their continued use.
4. Review of Resident #34’s Quarterly MDS, dated [DATE], showed the facility staff
assessed the resident as follows:
-Severe Cognitive Impairment;
-[DIAGNOSES REDACTED].
-Trouble falling asleep, nearly every day;
-Poor appetite, nearly every day;
-Feeling tired, nearly every day;
-Trouble concentrating, nearly every day;
-Short tempered, nearly every day;
-Physical behavior symptoms, less than daily;
-Verbal behavior symptoms, less than daily;
-Delusions; and
-Wandered, less than daily.
Review of the resident’s Physician order [REDACTED].
-[MEDICATION NAME] 0.5 mg ½ tablet twice daily for anxiety;
-[MEDICATION NAME] DR 500 mg one po BID for dementia;
-Quetiapine [MEDICATION NAME] 25 mg ½ tablet po daily for anxiety;
-Quetiapine [MEDICATION NAME] 50 mg one tablet po at HS for anxiety.
Review of the resident’s medical record showed a pharmacy consultation, dated
3/1/19-3/5/19, showed the following recommendation:
-Quetiapine 12.5 mg twice daily and Quetiapine 50 mg at bedtime; please attempt a GDR to
Quetiapine 25 mg twice daily with the end goal of discontinuation of the above medications
at this time.
Additional observation showed the physician did not approve the recommendations, or
provide a rationale for the continued use of the [MEDICAL CONDITION] medications.
5. Review of Resident #37’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-Cognitively Impaired;
-Having little interest or pleasure in doing things, nearly every day;
-Free of hallucinations or delusions;
-No physical behaviors noted towards others;
-Verbal behaviors directed toward others occurred one to three days out of the seven day
look back period;
-[DIAGNOSES REDACTED].
-And received antidepressant medication seven out of the seven days in the look back
period.
Review of the resident’s POS, dated 3/15/19-4/14/19, showed the following orders:
-10/23/17- [MEDICATION NAME] (HBR) ( a medication used to treat depression) 5 mg daily for
depression;
-And [MEDICATION NAME] Delayed Release (DR) 125 mg BID for Dementia/Anxiety.
Further review of the resident’s medical record showed a pharmacy consultation, dated
8/1/18 – 8/28/18, that showed staff administered the following [MEDICAL CONDITION]
medications: [REDACTED]
-[MEDICATION NAME] 250 mg twice daily for depression;
-And [MEDICATION NAME] 5 mg daily for depression.
Further review showed the pharmacy consultant recommended a GDR of the resident’s
[MEDICATION NAME] to 125 mg twice daily. Additionally, the review showed the pharmacy
consultant recommended a review with possible reduction for the [MEDICATION NAME]. The
physician approved the GDR of the [MEDICATION NAME], but did not provide further guidance
for the staff in regards to the [MEDICATION NAME], or document a rationale for the
medication’s continued use.
Staff did not ensure the resident did not receive unnecessary [MEDICAL CONDITION]
medications.
6. During an interview on 4/18/19 at 9:58 A.M., Certified Medication Technician (CMT) D
said the pharmacy consultant comes once per month and is responsible for tracking the
medications for gradual dosage reductions and the Director of Nursing sends those
recommendations to the physician for review.
During an interview on 4/18/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the
pharmacy consultant is responsible for GDR recommendations once per month. LPN A said
he/she and the Director of Nursing are responsible to take off the new orders. He/She said
if they aren’t addressed by the physician, staff are expected to send them back to
him/her.
During an interview on 4/18/19 at 1:07 P.M., the Director of Nursing said he/she is now
responsible for monitoring and ensuring the GDR’s are completed from the pharmacy
consultant. He/she said the pharmacy consultant is responsible for monitoring when the
GDR’s are due, and the physician is to document a rationale or contraindication if the
medication is not reduced.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

Based on observation, interview, and record review facility staff failed to change gloves,
and handle linens to prevent the spread of infection during care and treatments for three

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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 22)
residents (Residents #37, #23, and #9). Facility staff also failed to provide a barrier
for the glucometer in a manner to prevent the spread of infection during blood sample
collection for two residents (Resident #26 and #41). The facility census was 40.
1. Review of the facility’s Perineal Care Policy, dated (MONTH) 2010, showed staff are
directed as follows:
The following equipment and supplies will be necessary when performing this procedure:
1. Wash basin;
2. Washcloth;
3. Soap;
4. Personal protective equipment.
Steps in the Procedure for a female resident:
1. Wet washcloth and apply soap or skin cleansing agent
2. Wash perineal area, wiping front to back;
3. Do not reuse the same washcloth or water to clean the urethra or labia.
2. Review of the facility’s implementing the Body Substance Precautions System, not dated,
showed staff are directed as follows:
Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances and/or persons with a rash.
Gloves must be changed between residents and between contacts with different body sites of
the same resident.
3. Observation on 4/15/19 at 12:49 P.M., showed Certified Nursing Assistant (CNA) H and
CNA I entered Resident #37’s room to provide perineal care. CNA I washed the resident’s
front perinal area, and swiped multiple times with same portion of the wash cloth. Further
observation showed CNA H cleansed the resident’s bottom and swiped multiple times using
the same, already used, portion of the washcloth. Additional observation showed CNA H did
not remove his/her soiled gloves prior to touching the resident’s legs, the hoyer sling,
the resident’s sheet, blankets, and other assistive devices in the resident’s room.
4. Observation on 4/16/19 at 10:30 A.M., showed CNA H and CNA J entered Resident #23’s
room to provide perineal care. Both CNA H and CNA J washed their hands in the resident’s
sink, then afterwards CNA H placed several washcloths into the sink under the running
water and sprayed them with a cleansing agent. CNA H wrung out the washcloths and placed
them in a bag next to the bed and used the cloths to clean the resident.
5. Observation on 4/17/19 at 2:45 P.M., showed CNA K and CNA H entered Resident #9’s room
to provide perineal care. Both CNA K and CNA H washed their hands in the resident’s sink,
then afterwards CNA H placed several washcloths into the sink under the running water and
sprayed them with a cleansing agent. CNA H wrung out the washcloths and placed them in a
bag next to the bed and used the cloths to clean the resident.
6. During an interview on 4/15/19 at 1:14 P.M., CNA H said staff are directed to use
different parts of the washcloth with every swipe while cleansing a resident. Furthermore,
he/she said staff are directed to change their gloves and wash their hands from dirty to
clean tasks.
During an interview on 4/17/19 at 4:00 P.M., CNA L said when staff provide care for a
resident they are expected to wash hands then glove, wet the washcloths by holding them
under the running water, and spray with cleansing soap.
During an interview on 4/18/19 at 11:49 A.M., LPN A said he/she expects staff to use a
different part of the washcloth with each swipe while performing perineal care, or use a
new wipe each time. He/She also said staff are directed to change their gloves from dirty
to clean tasks, and he/she expects staff to change their gloves before touching anything
in a resident’s room if they had just provided perineal 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:

265434

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

NAME OF PROVIDER OF SUPPLIER

RIVERVIEW NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

10303 STATE ROAD C
MOKANE, MO 65059

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 23)
During an interview on 4/18/19 at 12:30 P.M., Licensed Practical Nurse (LPN) A said during
perineal staff are to use clean rags and either get a clean basin to put water in or hold
the washcloths under the running water to get them wet. The washcloths should not touch
the sink.
7. Review of the facility’s undated, Blood Glucose Monitoring Policy, showed it did not
direct the staff on how to handle the glucometer in a manner to prevent the spread of
infection once the blood sample had been collected.
Observation on 4/19/19 at 11:29 A.M., showed Licensed Practical Nurse (LPN) A obtained
Resident #26’s blood sample with a glucometer. Further observation showed he/she placed
the glucometer on the top of the open MAR indicated [REDACTED].
8. Observation on 4/19/19at 11:41 A.M., showed LPN A obtained Resident #41’s blood sample
with a glucometer. Further observation showed he/she placed the glucometer on the
resident’s bed without a barrier.
During an interview on 4/16/19 at 11:45 A.M., LPN A said, I shouldn’t have laid the
glucometer down on the bed, I should have held it or put a barrier down. I always do, I
don’t know why I didn’t this time.
9. During an interview on 4/18/19 at 1:12 P.M., the Director of Nursing (DON) said he/she
expects staff to use a different portion of the wipe for each swipe during perineal care,
and that he/she expects the staff to change their gloves from dirty to clean tasks.
Furthermore, he/she said he/she expects staff to wash their hands or use hand sanitizer
between glove changes. Additionally, he/she said staff are expected to barrier between
washcloths and the sink and when moisten washcloths for care. Also, he/she said during
glucometer checks he/she would expect staff to place a barrier on any surface before
placing a clean or dirty glucometer on it.