RIVERSIDE NURSING & REHABILITATION CENTER, LLC

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff treated residents in a manner that maintained his/her dignity when they did not clean and cut two of 26 residents (Resident #91 and Resident #110) fingernails whose nails were long and filled with a black substance beneath the all 10 nails; failed to assure Resident #110’s hair and beard were trimmed and neatly groomed. The facility census was 130. 1. Review of the facility’s Fingernails/Toenails Care policy, dated October, 2009, showed: – Purpose: To clean the nail bed, to keep nails trimmed, and to prevent infection; – Performed by certified nurse aides (CNA) or licensed nurses; – Nails can be partially cleaned during bath care; – CNAs do not trim nails of diabetic residents; – Nail care included daily cleaning and regular trimming; – Report any issues with the nails to a nurse. 2. Review of Resident #91’s demographics sheet showed: – [DIAGNOSES REDACTED]. Review of the care plan, updated on 6/26/18, showed: – Incontinent care frequently and after each incontinent episode; – Preferred two showers per week. Review of the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/18, showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made his/her own decisions; – Extensive assist of one staff for bathing; – No functional limitations of the upper or lower extremities were marked; – [DIAGNOSES REDACTED]. Review of resident’s shower sheets showed: – 8/28/18: staff did not not any nail care on the sheet; – 8/30/18: Nails cut- no; any problems with feet or with cutting nails that need to be taken care of – no. Review of the September, (YEAR), physician’s orders [REDACTED]. – Venous ulcers to bilateral lower extremities with ordered treatments. Review of the shower sheets showed: – 9/4/18: Nails cut – no; – 9/6/18: Nails cut – no; any problems with feet or with cutting nails that need to be taken care of – no; – 9/11/18: Nails cut – no; Any problems with feet or with cutting nails that need to be taken care of – no. Observation on 9/10/18, 9/11/18, 9/12/18 and 9/13/18, showed: – The resident’s finger nails were long with a black substance beneath each nail on both hands. – The left hand was stiff and the resident had difficulty using the hand. During an interview on 9/13/18, at 9:00 A.M., the resident said: – He/she needed his/her finger nails cut and cleaned. – A CNA tried to cut his/her nails the other day but did not do a good job. – Staff did not cut or clean his/her nails often. – It was difficult for him/her to cut or clean his/her nails, he/she could not use his left hand very well.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
treated residents in a manner that maintained his/her dignity when they did not clean and
cut two of 26 residents (Resident #91 and Resident #110) fingernails whose nails were long
and filled with a black substance beneath the all 10 nails; failed to assure Resident
#110’s hair and beard were trimmed and neatly groomed. The facility census was 130.
1. Review of the facility’s Fingernails/Toenails Care policy, dated October, 2009, showed:
– Purpose: To clean the nail bed, to keep nails trimmed, and to prevent infection;
– Performed by certified nurse aides (CNA) or licensed nurses;
– Nails can be partially cleaned during bath care;
– CNAs do not trim nails of diabetic residents;
– Nail care included daily cleaning and regular trimming;
– Report any issues with the nails to a nurse.
2. Review of Resident #91’s demographics sheet showed:
– [DIAGNOSES REDACTED].
Review of the care plan, updated on 6/26/18, showed:
– Incontinent care frequently and after each incontinent episode;
– Preferred two showers per week.
Review of the Minimum Data Set (MDS), a federally mandated assessment instrument completed
by facility staff, dated 7/27/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– Extensive assist of one staff for bathing;
– No functional limitations of the upper or lower extremities were marked;
– [DIAGNOSES REDACTED].
Review of resident’s shower sheets showed:
– 8/28/18: staff did not not any nail care on the sheet;
– 8/30/18: Nails cut- no; any problems with feet or with cutting nails that need to be
taken care of – no.
Review of the September, (YEAR), physician’s orders [REDACTED].
– Venous ulcers to bilateral lower extremities with ordered treatments.
Review of the shower sheets showed:
– 9/4/18: Nails cut – no;
– 9/6/18: Nails cut – no; any problems with feet or with cutting nails that need to be
taken care of – no;
– 9/11/18: Nails cut – no; Any problems with feet or with cutting nails that need to be
taken care of – no.
Observation on 9/10/18, 9/11/18, 9/12/18 and 9/13/18, showed:
– The resident’s finger nails were long with a black substance beneath each nail on both
hands.
– The left hand was stiff and the resident had difficulty using the hand.
During an interview on 9/13/18, at 9:00 A.M., the resident said:
– He/she needed his/her finger nails cut and cleaned.
– A CNA tried to cut his/her nails the other day but did not do a good job.
– Staff did not cut or clean his/her nails often.
– It was difficult for him/her to cut or clean his/her nails, he/she could not use his
left hand very well.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265379

If continuation sheet
Page 1 of 21

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 1) During an interview on 9/13/18, at 9:07 A.M., CNA C (also the shower aide) said: – The resident would refuse showers and nail care. – The resident would not shower for him/her so they moved the resident to showers on the evening shift. – He/she would refuse for hair to be combed or to be shaved at times. 3. Review of Resident #110’s quarterly MDS, dated [DATE], showed the resident had mild cognitive impairment. Observation throughout the survey, 9/10/18 through 9/13/18, showed the resident’s hair and beard were long and shaggy over his/her eyes and his/her finger nails were long and dirty. During an interview on 9/12/18, at 10:00 A.M., Unit Manager A said that several residents on B hall refuse showers and personal hygiene. 4. During an interview on 9/13/18, at 2:00 P.M., the Director of Nursing (DON) said: – She expected staff to cut and clean resident’s finger nails as needed and on shower days. – If a resident refused, staff should ask again at a later time and try again to cut or clean the nails.
	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Honor the resident’s right to share a room with spouse or roommate of choice and receive written notice before a change is made. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents had the right to share a room with whomever they wish as long as both were in agreement and the resident’s preferences were considered when changing rooms when staff failed to find a suitable room for a resident who requested a private room, and when staff failed to assist one resident who asked to transfer to a different facility. This affected two of 26 sampled residents (Resident #54 and #91). The facility census was 130. 1. Observation of the facility’s Resident Bill of Rights posted in the facility’s hallway showed: – Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion, including those rights specified: – Retain and use personal possessions, including furnishings and clothing as space permits unless to do so would infringe upon the rights or health and safety of other residents. – Share a room with his/her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement. – A safe clean and comfortable home like environment. 2. Review of Resident #54’s Social History/Psychosocial Assessment, dated 12/27/17, showed: – [MEDICAL CONDITION] (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves); – Struggles with fairness; – Goals: To be less argumentative and improve hygiene;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
During an interview on 9/13/18, at 9:07 A.M., CNA C (also the shower aide) said:
– The resident would refuse showers and nail care.
– The resident would not shower for him/her so they moved the resident to showers on the
evening shift.
– He/she would refuse for hair to be combed or to be shaved at times.
3. Review of Resident #110’s quarterly MDS, dated [DATE], showed the resident had mild
cognitive impairment.
Observation throughout the survey, 9/10/18 through 9/13/18, showed the resident’s hair and
beard were long and shaggy over his/her eyes and his/her finger nails were long and dirty.
During an interview on 9/12/18, at 10:00 A.M., Unit Manager A said that several residents
on B hall refuse showers and personal hygiene.
4. During an interview on 9/13/18, at 2:00 P.M., the Director of Nursing (DON) said:
– She expected staff to cut and clean resident’s finger nails as needed and on shower
days.
– If a resident refused, staff should ask again at a later time and try again to cut or
clean the nails.

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to share a room with spouse or roommate of choice and
receive written notice before a change is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
had the right to share a room with whomever they wish as long as both were in agreement
and the resident’s preferences were considered when changing rooms when staff failed to
find a suitable room for a resident who requested a private room, and when staff failed to
assist one resident who asked to transfer to a different facility. This affected two of 26
sampled residents (Resident #54 and #91). The facility census was 130.
1. Observation of the facility’s Resident Bill of Rights posted in the facility’s hallway
showed:
– Each resident has a right to a dignified existence, self-determination, and
communication with and access to persons and services inside and outside the facility in a
manner and in an environment that promotes maintenance or enhancement of his/her quality
of life, regardless of diagnosis, severity of condition or payment source and to exercise
those rights as a citizen of the United States without interference, coercion, including
those rights specified:
– Retain and use personal possessions, including furnishings and clothing as space permits
unless to do so would infringe upon the rights or health and safety of other residents.
– Share a room with his/her roommate of choice when practicable, when both residents live
in the same facility and both residents consent to the arrangement.
– A safe clean and comfortable home like environment.
2. Review of Resident #54’s Social History/Psychosocial Assessment, dated 12/27/17,
showed:
– [MEDICAL CONDITION] (a chronic and severe mental disorder that affects how a person
thinks, feels, and behaves);
– Struggles with fairness;
– Goals: To be less argumentative and improve 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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 2) – Behaviors: Refuses to bathe, refused incontinent care and changing clothes; – The resident reported a history of poor hygiene. Review of Resident #54’s Departmental Note written by Social Worker (SW) B, dated 3/7/18, at 10:23 A.M., showed: – Continued to resist bathing and assistance with hygiene; – His/her room had an odor that was offensive to his roommate and staff; – Showed dysfunctional mood and behaviors this week and staff observed him/her pouring urine purposefully on the floor of his/her room. Review of a Departmental Note written by the Director of Social Services (DSS) for Resident #54, dated 4/3/18, at 5:20 P.M., showed: – The resident said he/she was interested in transferring to a different facility. – The DSS discussed with the Veterans’ Administration (VA) Transition SW and would follow up with another facility. – Verbally aggressive and argumentative with staff at times; – Refused incontinent care, changing soiled clothing, and bathing. Review of a Departmental Note written by the DSS for Resident #54, dated 6/13/18, at 6:16 P.M., showed: – He/she is interested in transferring to another facility. Review of a Departmental Note written by the DSS for Resident #54, dated 7/2/18, at 6:37 P.M., showed: – The resident spilled coffee on another resident (unknown roommate) and the residents yelled and cursed at each other. – Staff redirected the resident to his/her room and was offered a room change, but he/she refused to move. – He/she alleged the other resident (unknown roommate) broke a glass that was on his/her table and the other resident (unknown roommate) hit him/her on the back of the head with his/her (the unknown roommate’s) open hand. – Resident #54 said he/she was not injured. Review of a Departmental Note written by the DSS for Resident #54, dated 7/3/18, at 5:04 P.M., showed: – Visited with Resident #54 and he/she was angry and agitated; – He/she wanted to know who would replace his/her broken glass. – Advised a plastic glass would be a safer choice. – He/she yelled at the DSS and refused to speak and said the conversation was over. Review of a Departmental Note written by the DSS for Resident #54, dated 7/6/18, at 6:07 P.M., showed: – Attempted to speak with Resident #54 and he/she ignored the DSS; – Said the glass needed to be replaced by the resident (roommate) who broke the glass by the end of the day or he/she would file assault charges; – No other documentation was found regarding this incident. Review of Resident #54’s quarterly Minimum Data Set (MDS), ad federally mandated assessment instrument completed by facility staff, dated 7/12/18, showed: – admitted [DATE]. – A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made his/her own decisions; – Verbal behaviors directed towards others occurred one to three days; – Rejection of care occurred daily; – Limited assist of one staff for bed mobility; – Extensive assist of one staff for transfers, dressing, toileting, and bathing;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
– Behaviors: Refuses to bathe, refused incontinent care and changing clothes;
– The resident reported a history of poor hygiene.
Review of Resident #54’s Departmental Note written by Social Worker (SW) B, dated 3/7/18,
at 10:23 A.M., showed:
– Continued to resist bathing and assistance with hygiene;
– His/her room had an odor that was offensive to his roommate and staff;
– Showed dysfunctional mood and behaviors this week and staff observed him/her pouring
urine purposefully on the floor of his/her room.
Review of a Departmental Note written by the Director of Social Services (DSS) for
Resident #54, dated 4/3/18, at 5:20 P.M., showed:
– The resident said he/she was interested in transferring to a different facility.
– The DSS discussed with the Veterans’ Administration (VA) Transition SW and would follow
up with another facility.
– Verbally aggressive and argumentative with staff at times;
– Refused incontinent care, changing soiled clothing, and bathing.
Review of a Departmental Note written by the DSS for Resident #54, dated 6/13/18, at 6:16
P.M., showed:
– He/she is interested in transferring to another facility.
Review of a Departmental Note written by the DSS for Resident #54, dated 7/2/18, at 6:37
P.M., showed:
– The resident spilled coffee on another resident (unknown roommate) and the residents
yelled and cursed at each other.
– Staff redirected the resident to his/her room and was offered a room change, but he/she
refused to move.
– He/she alleged the other resident (unknown roommate) broke a glass that was on his/her
table and the other resident (unknown roommate) hit him/her on the back of the head with
his/her (the unknown roommate’s) open hand.
– Resident #54 said he/she was not injured.
Review of a Departmental Note written by the DSS for Resident #54, dated 7/3/18, at 5:04
P.M., showed:
– Visited with Resident #54 and he/she was angry and agitated;
– He/she wanted to know who would replace his/her broken glass.
– Advised a plastic glass would be a safer choice.
– He/she yelled at the DSS and refused to speak and said the conversation was over.
Review of a Departmental Note written by the DSS for Resident #54, dated 7/6/18, at 6:07
P.M., showed:
– Attempted to speak with Resident #54 and he/she ignored the DSS;
– Said the glass needed to be replaced by the resident (roommate) who broke the glass by
the end of the day or he/she would file assault charges;
– No other documentation was found regarding this incident.
Review of Resident #54’s quarterly Minimum Data Set (MDS), ad federally mandated
assessment instrument completed by facility staff, dated 7/12/18, showed:
– admitted [DATE].
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– Verbal behaviors directed towards others occurred one to three days;
– Rejection of care occurred daily;
– Limited assist of one staff for bed mobility;
– Extensive assist of one staff for transfers, dressing, toileting, and bathing;

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 3) – Independent in personal hygiene; – Always continent of urine; – Frequently incontinent of bowel; – Not steady, only able to stabilize with staff assist for moving from seated to standing position, moving on and off toilet, and transfers between bed and chair or wheelchair; – No impairment of any extremity; – Used wheelchair; – Antipsychotic medications in last seven days; – [DIAGNOSES REDACTED]. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). Review of a Departmental Note written by the DSS for Resident #54, dated 7/17/18, at 5:22 P.M., showed: – Poor hygiene; – Wore dirty clothes and refused to regularly take showers or baths; – Good hygiene encouraged. Review of Departmental Note written by the DSS, dated 7/26/18, at 7:14 P.M., for Resident #54 showed: – Refused bath every day this week; – Refused incontinent care and refused to change soiled clothing. Review of a Departmental Note written by the DSS for Resident #54, dated 7/31/18, at 6:19 P.M., showed: – Continues to refuse baths and had an offensive odor; – Unsuccessful in attempts to talk the resident into taking a bath. Review of a Departmental Note written by the DSS for Resident #54, dated 8/1/18 and 8/2/18, showed: – The DSS spoke with VASW about concerns of behaviors and refusal to bathe and other issues. – The DSS asked the VASW to assist with arranging a psychiatric appointment. Review of a Departmental Note written by DSS for Resident #54, dated 8/6/18, at 5:53 P.M., showed: – Discussed his/her hygiene and refusal of care; – Advised him/her of his/her strong body odor and urine smell which negatively affected the quality of life for his/her roommate and others; – He/she was unconcerned about the roommate and voiced several critical comments about the roommate; – Offered a shower or bath but he/she did not commit to taking one; – He/she asked the DSS to attempt to have him/her transferred to a different facility. – No other documentation found related to transfer to another facility. Review of a Departmental Note written by the DSS for Resident #54, dated 8/22/18, at 8:53 P.M., showed: – Argumentative and angry, yelled and cursed at Unit Manager; – The DSS attempted to contact the VASW and left message to request assistance for scheduling an appointment with a psychiatrist. Review of a Departmental Note written by the DSS for Resident #54, dated 8/27/18, at 5:37 P.M., showed: – Late entry for 8/24/18; – No appointment available for his/her psychiatrist per the VASW; – Offered an appointment with another psychiatrist on 8/27/18, or go to the walk-in clinic;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
– Independent in personal hygiene;
– Always continent of urine;
– Frequently incontinent of bowel;
– Not steady, only able to stabilize with staff assist for moving from seated to standing
position, moving on and off toilet, and transfers between bed and chair or wheelchair;
– No impairment of any extremity;
– Used wheelchair;
– Antipsychotic medications in last seven days;
– [DIAGNOSES REDACTED]. Symptoms may include flashbacks, nightmares and severe anxiety, as
well as uncontrollable thoughts about the event).
Review of a Departmental Note written by the DSS for Resident #54, dated 7/17/18, at 5:22
P.M., showed:
– Poor hygiene;
– Wore dirty clothes and refused to regularly take showers or baths;
– Good hygiene encouraged.
Review of Departmental Note written by the DSS, dated 7/26/18, at 7:14 P.M., for Resident
#54 showed:
– Refused bath every day this week;
– Refused incontinent care and refused to change soiled clothing.
Review of a Departmental Note written by the DSS for Resident #54, dated 7/31/18, at 6:19
P.M., showed:
– Continues to refuse baths and had an offensive odor;
– Unsuccessful in attempts to talk the resident into taking a bath.
Review of a Departmental Note written by the DSS for Resident #54, dated 8/1/18 and
8/2/18, showed:
– The DSS spoke with VASW about concerns of behaviors and refusal to bathe and other
issues.
– The DSS asked the VASW to assist with arranging a psychiatric appointment.
Review of a Departmental Note written by DSS for Resident #54, dated 8/6/18, at 5:53 P.M.,
showed:
– Discussed his/her hygiene and refusal of care;
– Advised him/her of his/her strong body odor and urine smell which negatively affected
the quality of life for his/her roommate and others;
– He/she was unconcerned about the roommate and voiced several critical comments about the
roommate;
– Offered a shower or bath but he/she did not commit to taking one;
– He/she asked the DSS to attempt to have him/her transferred to a different facility.
– No other documentation found related to transfer to another facility.
Review of a Departmental Note written by the DSS for Resident #54, dated 8/22/18, at 8:53
P.M., showed:
– Argumentative and angry, yelled and cursed at Unit Manager;
– The DSS attempted to contact the VASW and left message to request assistance for
scheduling an appointment with a psychiatrist.
Review of a Departmental Note written by the DSS for Resident #54, dated 8/27/18, at 5:37
P.M., showed:
– Late entry for 8/24/18;
– No appointment available for his/her psychiatrist per the VASW;
– Offered an appointment with another psychiatrist on 8/27/18, or go to the walk-in
clinic;

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 4) – The resident preferred to go to walk-in clinic next week. – Said he/she could easily become upset and was prone to verbal outbursts. Review of the September, (YEAR), Behavior Intervention Monthly Flow Record for Resident #54 showed: – Nine out of 12 days on the day shift, the resident continuously refused care and staff provided one on one (1:1, one staff to resident) intervention or education to the resident; – Eight out of 12 days on the evening shift, the resident continuously refused care and staff provided redirection, 1:1 interventions or education to the resident; – Eight out of 12 days on the night shift, the resident continuously refused care and staff provided redirection, 1:1 interventions and education to the resident. Review of a Departmental Note written by the DSS for Resident #54, dated 9/4/18, showed: – Does not want to move; – Talked with him/her about organizing room but he/she declined. Review of One on One Time Log for Resident #54, dated 9/4/18, showed: – Does not want to move; discussed room organization. Review of Resident #54’s care plan last updated on 9/7/18, showed: – At risk for demonstrating poor hygiene; – Encourage to shower at least two times per week; – Provide 1:1 supportive visits as needed on the importance of maintaining good hygiene; – Resident often refuses cares – bathing and pericare; – Resident purposely messes up room, piles items in bed despite staff efforts to keep clean and tidy; – Complains about roommate but refuses to move; – At risk of showing dysfunction of mood and/or situational awareness, misperception of reality related to [MEDICAL CONDITION] and [MEDICAL CONDITION]; – Report any potential misperception signs and symptoms to the nurse; – Frequent episodes of urinary incontinence related to left above the knee amputation; – Frequently refuses cares, bathing, pericare, and changing clothes; – Encourage resident to change soiled clothing after incontinent episode. Observation and interview on 9/11/18,at 8:50 A.M., showed: – Verbal altercation between Resident #54 and roommate (Resident #91); – Unit Manager (UM) C said Resident #91 opened the door of the room and Resident #54 yelled and cursed at Resident #91 to shut the door. – Resident #91 became upset at Resident #54. – An argument ensued and UM C attempted to diffuse the argument. – Resident#54 cursed at UM C and called UM C and Resident #91 names. During an interview on 9/11/18, at 8:50 A.M., the DON said: – Resident #54 and Resident #91 have frequent verbal altercations. – Staff have attempted to move both residents to different rooms but they both refused. During an interview on 9/11/18, at 8:55 A.M., the DSS said: – Resident #54 wanted a private room for some time, but there were no private rooms available. – The facility planned to move Resident #54 to a private room as soon a one became available but she did not know when that would be. – Resident #54 smelled strongly of urine and refused incontinent care and baths. – He/she did pour urine onto the floor of his/her room. – The resident’s room smelled strongly of urine. During an interview on 9/11/18, at 9:00 A.M., Housekeeping Aide (HA) A said:

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
– The resident preferred to go to walk-in clinic next week.
– Said he/she could easily become upset and was prone to verbal outbursts.
Review of the September, (YEAR), Behavior Intervention Monthly Flow Record for Resident
#54 showed:
– Nine out of 12 days on the day shift, the resident continuously refused care and staff
provided one on one (1:1, one staff to resident) intervention or education to the
resident;
– Eight out of 12 days on the evening shift, the resident continuously refused care and
staff provided redirection, 1:1 interventions or education to the resident;
– Eight out of 12 days on the night shift, the resident continuously refused care and
staff provided redirection, 1:1 interventions and education to the resident.
Review of a Departmental Note written by the DSS for Resident #54, dated 9/4/18, showed:
– Does not want to move;
– Talked with him/her about organizing room but he/she declined.
Review of One on One Time Log for Resident #54, dated 9/4/18, showed:
– Does not want to move; discussed room organization.
Review of Resident #54’s care plan last updated on 9/7/18, showed:
– At risk for demonstrating poor hygiene;
– Encourage to shower at least two times per week;
– Provide 1:1 supportive visits as needed on the importance of maintaining good hygiene;
– Resident often refuses cares – bathing and pericare;
– Resident purposely messes up room, piles items in bed despite staff efforts to keep
clean and tidy;
– Complains about roommate but refuses to move;
– At risk of showing dysfunction of mood and/or situational awareness, misperception of
reality related to [MEDICAL CONDITION] and [MEDICAL CONDITION];
– Report any potential misperception signs and symptoms to the nurse;
– Frequent episodes of urinary incontinence related to left above the knee amputation;
– Frequently refuses cares, bathing, pericare, and changing clothes;
– Encourage resident to change soiled clothing after incontinent episode.
Observation and interview on 9/11/18,at 8:50 A.M., showed:
– Verbal altercation between Resident #54 and roommate (Resident #91);
– Unit Manager (UM) C said Resident #91 opened the door of the room and Resident #54
yelled and cursed at Resident #91 to shut the door.
– Resident #91 became upset at Resident #54.
– An argument ensued and UM C attempted to diffuse the argument.
– Resident#54 cursed at UM C and called UM C and Resident #91 names.
During an interview on 9/11/18, at 8:50 A.M., the DON said:
– Resident #54 and Resident #91 have frequent verbal altercations.
– Staff have attempted to move both residents to different rooms but they both refused.
During an interview on 9/11/18, at 8:55 A.M., the DSS said:
– Resident #54 wanted a private room for some time, but there were no private rooms
available.
– The facility planned to move Resident #54 to a private room as soon a one became
available but she did not know when that would be.
– Resident #54 smelled strongly of urine and refused incontinent care and baths.
– He/she did pour urine onto the floor of his/her room.
– The resident’s room smelled strongly of urine.
During an interview on 9/11/18, at 9:00 A.M., Housekeeping Aide (HA) A 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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 5) – He/she attempted to clean Resident #54’s room, but he/she had so many belongings on his/her bed and floor it was hard to clean. – Resident #54 refused to allow housekeeping or nursing to clean anything or touch anything in his/her room. – HA A had to clean Resident #54’s room when he/she left the room or he/she would yell and curse at him/her. – The smell of urine came from the mattress. – He/she could not clean the mattress because of all the things on the resident’s bed. – He/she tried to wipe the mattress when Resident #54 left the room. – The resident had a bowel movement on the mattress and would not let staff clean it up. – After the resident left the room, staff went in and removed the fecal material. – The room always smell strongly of urine. Review of a Departmental Note written by the DSS for Resident #54, dated 9/11/18, showed: – Offered a room change but he/she declined unless it was a private room; – He wanted to move once, not twice. Review of a Departmental Note written by the DSS for Resident #54, dated 9/11/18, at 6:44 P.M., showed: – The Director of Nursing (DON) and the DSS met with the resident and offered him/her a room change to a semiprivate room on the F hall near the smoking patio. – He/she decline and said he/she preferred a private room. – He/she was advised that a private room was not available currently. – He/she complained about his/her roommate blocking the door and falling asleep in the way of Resident #54. – He/she was encouraged to compromise with the roommate while staff worked on a solution. Review of the 1:1 Time Log for Resident #54, dated 9/11/18, showed: – Offered a room change but declined unless it was a private room; – He/she obtained price from the business office. During an interview on 9/13/18, at 2:15 P.M., the DON said: – Resident #54 had behaviors of anger, pouring urine on the floor, refused to allow staff to clean room and mattress, verbally confrontational with staff and roommate, and refused care bathing, changing clothes, and incontinent care. – Resident #54 requested a private room and staff tried to find a private room but one was not available. – Resident #54 could be cantankerous. – Resident #54 agreed to pay for a private room. 3. Review of Resident #91’s MDS staff, dated 7/27/18, showed: – admitted [DATE]; – A BIMS score of 15 which indicated he/she made his/her own decisions; – No discharge plan into the community; – No behaviors, no mood changes; – Wheelchair; – Hospice; – medications: [REDACTED]. – [DIAGNOSES REDACTED]. Review of a Grievance Intake/Decision Form for Resident #91, dated 9/5/18, showed: – Statement: Disliked sharing room with Resident #54; – Resident #54 was messy and belongings are not organized; – Resident #54 had an odor; – Immediate Response: Room change offered but declined;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– He/she attempted to clean Resident #54’s room, but he/she had so many belongings on
his/her bed and floor it was hard to clean.
– Resident #54 refused to allow housekeeping or nursing to clean anything or touch
anything in his/her room.
– HA A had to clean Resident #54’s room when he/she left the room or he/she would yell and
curse at him/her.
– The smell of urine came from the mattress.
– He/she could not clean the mattress because of all the things on the resident’s bed.
– He/she tried to wipe the mattress when Resident #54 left the room.
– The resident had a bowel movement on the mattress and would not let staff clean it up.
– After the resident left the room, staff went in and removed the fecal material.
– The room always smell strongly of urine.
Review of a Departmental Note written by the DSS for Resident #54, dated 9/11/18, showed:
– Offered a room change but he/she declined unless it was a private room;
– He wanted to move once, not twice.
Review of a Departmental Note written by the DSS for Resident #54, dated 9/11/18, at 6:44
P.M., showed:
– The Director of Nursing (DON) and the DSS met with the resident and offered him/her a
room change to a semiprivate room on the F hall near the smoking patio.
– He/she decline and said he/she preferred a private room.
– He/she was advised that a private room was not available currently.
– He/she complained about his/her roommate blocking the door and falling asleep in the way
of Resident #54.
– He/she was encouraged to compromise with the roommate while staff worked on a solution.
Review of the 1:1 Time Log for Resident #54, dated 9/11/18, showed:
– Offered a room change but declined unless it was a private room;
– He/she obtained price from the business office.
During an interview on 9/13/18, at 2:15 P.M., the DON said:
– Resident #54 had behaviors of anger, pouring urine on the floor, refused to allow staff
to clean room and mattress, verbally confrontational with staff and roommate, and refused
care bathing, changing clothes, and incontinent care.
– Resident #54 requested a private room and staff tried to find a private room but one was
not available.
– Resident #54 could be cantankerous.
– Resident #54 agreed to pay for a private room.
3. Review of Resident #91’s MDS staff, dated 7/27/18, showed:
– admitted [DATE];
– A BIMS score of 15 which indicated he/she made his/her own decisions;
– No discharge plan into the community;
– No behaviors, no mood changes;
– Wheelchair;
– Hospice;
– medications: [REDACTED].
– [DIAGNOSES REDACTED].
Review of a Grievance Intake/Decision Form for Resident #91, dated 9/5/18, showed:
– Statement: Disliked sharing room with Resident #54;
– Resident #54 was messy and belongings are not organized;
– Resident #54 had an odor;
– Immediate Response: Room change offered but declined;

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 6) – DSS to assist roommate (Resident #54) with organizing belongings; – Housekeeping to clean room twice daily. Review of Resident #91’s 1:1 Time Log, dated 9/5/18, showed: – Voiced concern about roommate with the DSS; – Offered a room change but declined; – He/she wanted Resident #54 to move, Move him/her. Review of Resident #91’s care plan last, updated 9/7/18, showed: – At risk for displaying mood signs and symptoms, history of depression, anxiety, and [MEDICAL CONDITION]; – Provide emotional support through 1:1 visits; – Complained about roommate but refused to move. Review of the Psychological Services Progress Note, dated 9/10/18, showed: – Plan: Continue supportive psychotherapy to provide relief to distressing symptoms. – Resident #91 stated he/she had trouble with his/her roommate. Review of Resident #91’s 1:1 Time Log, dated 9/10/18, showed: – Charge nurse reported the resident and his/her roommate exchanged words. – DSS visited the Resident #91, offered room change, but he/she declined. – He/she wants Resident #54 to move. Review of the Communication Tool for Resident #91, dated 9/10/18, written by Human Resources (HR) showed: – Complained of issues with roommate (Resident #54); – Roommate messy, does not want to share a room with him/her anymore; – The roommate had an odor and leaves drinks out. – DSS notified. Review of Resident #91’s 1:1 Time Log, dated 9/11/18, showed: – DSS visited the resident. – He/she wants Resident #54 moved. – He/she declined a room change. Observation and interview on 9/11/18, at 8:50 A.M., showed: – Verbal altercation between Resident #54 and roommate (Resident #91); – Unit Manager (UM) C said Resident #91 opened the door of the room and Resident #54 yelled and cursed at Resident #91 to shut the door. – Resident #91 became upset at Resident #54. – An argument ensued and UM C attempted to diffuse the argument. – Resident #54 cursed at UM C and called UM C and Resident #91 names. During an interview on 9/11/18, at 8:50 A.M., the DON said: – Resident #54 and Resident #91 have frequent verbal altercations. – Staff have attempted to move both residents to different rooms but they both refused. During an interview on 9/12/18, at 1:00 P.M., Resident #91 said: – Resident #54 was messy and smelled bad. – The room always smelled bad and he/she did not like that. – He/she wanted staff to move Resident #54 to another room. – Resident #54 always shouted for Resident #91 to shut the door every time he/she entered the room. – Resident #91 and Resident #54 argued a lot. – Resident #91 did not want to move because he/she was in the room first and the roommate should have to move. – The hallway smelled because of Resident #54. During an interview on 9/12/18, at 1:00 P.M., the DSS said:

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
– DSS to assist roommate (Resident #54) with organizing belongings;
– Housekeeping to clean room twice daily.
Review of Resident #91’s 1:1 Time Log, dated 9/5/18, showed:
– Voiced concern about roommate with the DSS;
– Offered a room change but declined;
– He/she wanted Resident #54 to move, Move him/her.
Review of Resident #91’s care plan last, updated 9/7/18, showed:
– At risk for displaying mood signs and symptoms, history of depression, anxiety, and
[MEDICAL CONDITION];
– Provide emotional support through 1:1 visits;
– Complained about roommate but refused to move.
Review of the Psychological Services Progress Note, dated 9/10/18, showed:
– Plan: Continue supportive psychotherapy to provide relief to distressing symptoms.
– Resident #91 stated he/she had trouble with his/her roommate.
Review of Resident #91’s 1:1 Time Log, dated 9/10/18, showed:
– Charge nurse reported the resident and his/her roommate exchanged words.
– DSS visited the Resident #91, offered room change, but he/she declined.
– He/she wants Resident #54 to move.
Review of the Communication Tool for Resident #91, dated 9/10/18, written by Human
Resources (HR) showed:
– Complained of issues with roommate (Resident #54);
– Roommate messy, does not want to share a room with him/her anymore;
– The roommate had an odor and leaves drinks out.
– DSS notified.
Review of Resident #91’s 1:1 Time Log, dated 9/11/18, showed:
– DSS visited the resident.
– He/she wants Resident #54 moved.
– He/she declined a room change.
Observation and interview on 9/11/18, at 8:50 A.M., showed:
– Verbal altercation between Resident #54 and roommate (Resident #91);
– Unit Manager (UM) C said Resident #91 opened the door of the room and Resident #54
yelled and cursed at Resident #91 to shut the door.
– Resident #91 became upset at Resident #54.
– An argument ensued and UM C attempted to diffuse the argument.
– Resident #54 cursed at UM C and called UM C and Resident #91 names.
During an interview on 9/11/18, at 8:50 A.M., the DON said:
– Resident #54 and Resident #91 have frequent verbal altercations.
– Staff have attempted to move both residents to different rooms but they both refused.
During an interview on 9/12/18, at 1:00 P.M., Resident #91 said:
– Resident #54 was messy and smelled bad.
– The room always smelled bad and he/she did not like that.
– He/she wanted staff to move Resident #54 to another room.
– Resident #54 always shouted for Resident #91 to shut the door every time he/she entered
the room.
– Resident #91 and Resident #54 argued a lot.
– Resident #91 did not want to move because he/she was in the room first and the roommate
should have to move.
– The hallway smelled because of Resident #54.
During an interview on 9/12/18, at 1:00 P.M., the DSS 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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0559 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 7) – She was working on providing a private room for Resident #54 but there was not one available now. – She hoped a room might come available next week for Resident #54. – Resident #54 did not want to move to an open semi-private room at this time. – Resident #91 did not want to move because he/she was in the room first and wanted Resident #54 to move.
	F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to provide comprehensive care plans for two 26 sampled residents (Resident #76 and #116). The facility had a census of 130. Review of the facility’s Comprehensive Person Centered Care Plan policy, updated (MONTH) of (YEAR), showed: – Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care. – Staff approaches are to be developed for each problem/strength/need. 1. Review of Resident #76’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/18, showed: – A Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact to make his/her own daily decisions; – Independent with care; – Open [MEDICAL CONDITION] (an area of abnormal tissue); – Receives skin treatment of [REDACTED]. – [DIAGNOSES REDACTED]. Review of the resident’s September, (YEAR), physician’s orders [REDACTED]. – A [DIAGNOSES REDACTED]. – Wash right lower extremities with soap and water, pat dry, use non-adhesive foam dressing to weeping areas, wrap with [MEDICATION NAME] (a type of gauze bandage roll) and cover with tubi or ace wrap; Change daily; Start date 7/17/18; – Wash left lower extremities with soap and water, pat dry, use ABD (army battle dressing/highly absorbent dressing) to cover and wrap with [MEDICATION NAME] Change daily; start date 8/3/18. Observation and interview on 9/11/18, at 11:32 A.M. and 9/11/18, at 2:40 P.M., showed the resident sat in a wooden chair with his/her legs down. The resident’s ankles contained white bandages. A white towel under the resident’s feet contained spots of a yellow substance. Small spots of a yellow substance showed on the bandages. A trash can was overturned and contained a towel on top of the plastic trash can. The resident said he/she was unable to lie down because he/she could not breath. Staff asked him/her to put his/her legs up but it was uncomfortable to put his/her legs on the trash can. Observation and interview on 9/12/18, at 5:30 A.M., showed the resident sat in a wooden chair with his/her legs down. The resident was asleep. Licensed Practical Nurse (LPN) B said he/she was the night charge nurse. The resident always slept in his/her wooden chair

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0559

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– She was working on providing a private room for Resident #54 but there was not one
available now.
– She hoped a room might come available next week for Resident #54.
– Resident #54 did not want to move to an open semi-private room at this time.
– Resident #91 did not want to move because he/she was in the room first and wanted
Resident #54 to move.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to provide
comprehensive care plans for two 26 sampled residents (Resident #76 and #116). The
facility had a census of 130.
Review of the facility’s Comprehensive Person Centered Care Plan policy, updated (MONTH)
of (YEAR), showed:
– Each resident will have a person-centered plan of care to identify problems, needs,
strengths, preferences and goals that will identify how the interdisciplinary team will
provide care.
– Staff approaches are to be developed for each problem/strength/need.
1. Review of Resident #76’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/12/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was
cognitively intact to make his/her own daily decisions;
– Independent with care;
– Open [MEDICAL CONDITION] (an area of abnormal tissue);
– Receives skin treatment of [REDACTED].
– [DIAGNOSES REDACTED].
Review of the resident’s September, (YEAR), physician’s orders [REDACTED].
– A [DIAGNOSES REDACTED].
– Wash right lower extremities with soap and water, pat dry, use non-adhesive foam
dressing to weeping areas, wrap with [MEDICATION NAME] (a type of gauze bandage roll) and
cover with tubi or ace wrap; Change daily; Start date 7/17/18;
– Wash left lower extremities with soap and water, pat dry, use ABD (army battle
dressing/highly absorbent dressing) to cover and wrap with [MEDICATION NAME] Change daily;
start date 8/3/18.
Observation and interview on 9/11/18, at 11:32 A.M. and 9/11/18, at 2:40 P.M., showed the
resident sat in a wooden chair with his/her legs down. The resident’s ankles contained
white bandages. A white towel under the resident’s feet contained spots of a yellow
substance. Small spots of a yellow substance showed on the bandages. A trash can was
overturned and contained a towel on top of the plastic trash can. The resident said he/she
was unable to lie down because he/she could not breath. Staff asked him/her to put his/her
legs up but it was uncomfortable to put his/her legs on the trash can.
Observation and interview on 9/12/18, at 5:30 A.M., showed the resident sat in a wooden
chair with his/her legs down. The resident was asleep. Licensed Practical Nurse (LPN) B
said he/she was the night charge nurse. The resident always slept in his/her wooden chair

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 8) because it was hard for the resident to breath unless he/she was upright. Observation and interview on 9/12/18, at 9:37 A.M., showed the resident sat in a wooden chair with his/her legs down and a clean towel under his/her feet. The resident said his/her legs have oozed and wept for a long time. During an interview on 9/12/18, at 9:40 A.M., Unit Manager A said staff are to change the resident’s leg bandages daily or anytime they are soiled. The resident’s legs weep because he/she has [MEDICAL CONDITION] (a bacterial skin infection). Review on 9/12/18, at 9:44 A.M., of the treatment administration record (TAR) showed staff treated the resident’s legs daily. Staff documented they washed the resident’s left leg with soap and water and covered legs with [MEDICATION NAME] daily. Staff also documented they washed the right leg with soap and water and used a non-adherent foam dressing to the weeping areas. Staff wrapped both legs with [MEDICATION NAME] and cover with tubi grip or ace wrap daily. Review of the resident’s care plan, developed on 7/11/17 with no dates of when staff last updated the plan, showed: – Resident at risk for skin break down due to impaired mobility; – No information related to the resident’s weeping legs and treatment; – No information related to the residents need to elevate his/her legs; – The care plan said the resident had a potential for falls due to [MEDICAL CONDITION] of bilateral lower extremities with an onset of the problem dated 7/11/17. During an interview on 9/12/18, at 11:55 A.M., the Director of Nursing (DON) said the resident’s legs had wept for a long time. The resident should keep his/her legs up. The issues with the resident’s legs weeping and the need for his/her legs to be elevated should have been addressed in his/her care plan. 2. Review of Resident #116’s quarterly MDS, dated [DATE], showed: – No cognitive impairment; – Totally dependent on staff for all activities of daily living (ADLs) with limited assistance for personal hygiene; – [DIAGNOSES REDACTED]. Review of Resident #116’s care plan, updated on 8/22/18, showed staff did not document comprehensive goals and approached for ADL care. During an interview on 9/13/18, at 3:07 P.M., the DON said all care areas should be care planned and updated, within twenty-four hours, after a change occurred.
	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 staff provided perineal care in a manner to prevent infection or the possibility of infection when they wiped the perineal area from front to back which affected one of 26 sampled residents (Resident #97); and failed to provide complete perineal care for one sampled resident (Resident #6). The facility census was 130. 1. Review of the facility’s Incontinent Care policy dated July, 2012, showed: – Purpose: To provide routine, preventive skin, perineal care to residents after an incontinent episode;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
because it was hard for the resident to breath unless he/she was upright.
Observation and interview on 9/12/18, at 9:37 A.M., showed the resident sat in a wooden
chair with his/her legs down and a clean towel under his/her feet. The resident said
his/her legs have oozed and wept for a long time.
During an interview on 9/12/18, at 9:40 A.M., Unit Manager A said staff are to change the
resident’s leg bandages daily or anytime they are soiled. The resident’s legs weep because
he/she has [MEDICAL CONDITION] (a bacterial skin infection).
Review on 9/12/18, at 9:44 A.M., of the treatment administration record (TAR) showed staff
treated the resident’s legs daily. Staff documented they washed the resident’s left leg
with soap and water and covered legs with [MEDICATION NAME] daily. Staff also documented
they washed the right leg with soap and water and used a non-adherent foam dressing to the
weeping areas. Staff wrapped both legs with [MEDICATION NAME] and cover with tubi grip or
ace wrap daily.
Review of the resident’s care plan, developed on 7/11/17 with no dates of when staff last
updated the plan, showed:
– Resident at risk for skin break down due to impaired mobility;
– No information related to the resident’s weeping legs and treatment;
– No information related to the residents need to elevate his/her legs;
– The care plan said the resident had a potential for falls due to [MEDICAL CONDITION] of
bilateral lower extremities with an onset of the problem dated 7/11/17.
During an interview on 9/12/18, at 11:55 A.M., the Director of Nursing (DON) said the
resident’s legs had wept for a long time. The resident should keep his/her legs up. The
issues with the resident’s legs weeping and the need for his/her legs to be elevated
should have been addressed in his/her care plan.
2. Review of Resident #116’s quarterly MDS, dated [DATE], showed:
– No cognitive impairment;
– Totally dependent on staff for all activities of daily living (ADLs) with limited
assistance for personal hygiene;
– [DIAGNOSES REDACTED].
Review of Resident #116’s care plan, updated on 8/22/18, showed staff did not document
comprehensive goals and approached for ADL care.
During an interview on 9/13/18, at 3:07 P.M., the DON said all care areas should be care
planned and updated, within twenty-four hours, after a change occurred.

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 staff
provided perineal care in a manner to prevent infection or the possibility of infection
when they wiped the perineal area from front to back which affected one of 26 sampled
residents (Resident #97); and failed to provide complete perineal care for one sampled
resident (Resident #6). The facility census was 130.
1. Review of the facility’s Incontinent Care policy dated July, 2012, showed:
– Purpose: To provide routine, preventive skin, perineal care to residents after an
incontinent episode;

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 9) – Put on gloves before removing wet or soiled items; – Wash the resident’s entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes; – Wash the entire area moving from front to back. 2. Review of Resident #97’s undated care plan showed: – At risk for urinary incontinence related to dementia and diabetes; – Observe for signs and symptoms of a urinary tract infection [MEDICAL CONDITION]; – Encourage to call for assistance with toileting; – Cleanse skin with soap and water after each incontinent episode. Review of the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/27/18, showed: – A Brief Interview for Mental Status (BIMS) score of seven which indicated the resident did not make his/her own daily decisions; – Extensive assist of two or more staff for bed mobility; – Total dependence of two or more staff for toileting; – Limited assist of one staff for personal hygiene; – Always incontinent of bowel and bladder; – [DIAGNOSES REDACTED]. Review of the September, (YEAR), physician’s orders [REDACTED]. – [DIAGNOSES REDACTED]. – UTI Stat (a natural urinary system cleansing medication), 30 milliliters (ml) daily as a [MEDICATION NAME]; – [MEDICATION NAME] 0.4 milligram (mg) two capsules at bedtime for [MEDICAL CONDITION]; – Cranberry tablet 450 mg BID (twice daily) as a UTI [MEDICATION NAME]. Observation and interview on 9/12/18, at 10:56 A.M., Certified Nurse’s Aide (CNA) A and CNA B did and said: – Both provided perineal care to the resident. – CNA A wiped the rectal area from back to front the perineal area three times with three different wipes. – A smear of fecal material was noted to the first perineal wipe. – CNA A said he/she thought he/she wiped from front to back. – CNA A said he/she should wipe the perineal area from front to back to prevent infection. – CNA B said he/she should always wipe front to back the perineal area to prevent infection. 3. Review of Resident #6’s MDS, dated [DATE], showed: – Cognitively intact; – Extensive assist of one staff with toileting; – Impaired on one side both lower and upper extremities; – Incontinent of bowel and occasionally bladder; – [DIAGNOSES REDACTED]. Review of the resident’s care plan, updated 8/2/18, showed: – Requires assistance with toileting due to impaired mobility; – Assist to bathroom and commode as needed. Observation on 9/12/18, at 3:02 P.M., showed: – CNA C and CNA D provided perineal care to the resident. – CNA C and CNA D removed the urine saturated brief. – CNA C wiped the down the right groin with one wipe and then the left groin with one wipe. – CNA C cleansed the perineal folds.

(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 9)
– Put on gloves before removing wet or soiled items;
– Wash the resident’s entire perineal area, and all areas affected by incontinence with a
washcloth, soap, warm water, peri-wash or wipes;
– Wash the entire area moving from front to back.
2. Review of Resident #97’s undated care plan showed:
– At risk for urinary incontinence related to dementia and diabetes;
– Observe for signs and symptoms of a urinary tract infection [MEDICAL CONDITION];
– Encourage to call for assistance with toileting;
– Cleanse skin with soap and water after each incontinent episode.
Review of the Minimum Data Set (MDS), a federally mandated assessment instrument completed
by facility staff, dated 7/27/18, showed:
– A Brief Interview for Mental Status (BIMS) score of seven which indicated the resident
did not make his/her own daily decisions;
– Extensive assist of two or more staff for bed mobility;
– Total dependence of two or more staff for toileting;
– Limited assist of one staff for personal hygiene;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the September, (YEAR), physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– UTI Stat (a natural urinary system cleansing medication), 30 milliliters (ml) daily as a
[MEDICATION NAME];
– [MEDICATION NAME] 0.4 milligram (mg) two capsules at bedtime for [MEDICAL CONDITION];
– Cranberry tablet 450 mg BID (twice daily) as a UTI [MEDICATION NAME].
Observation and interview on 9/12/18, at 10:56 A.M., Certified Nurse’s Aide (CNA) A and
CNA B did and said:
– Both provided perineal care to the resident.
– CNA A wiped the rectal area from back to front the perineal area three times with three
different wipes.
– A smear of fecal material was noted to the first perineal wipe.
– CNA A said he/she thought he/she wiped from front to back.
– CNA A said he/she should wipe the perineal area from front to back to prevent infection.
– CNA B said he/she should always wipe front to back the perineal area to prevent
infection.
3. Review of Resident #6’s MDS, dated [DATE], showed:
– Cognitively intact;
– Extensive assist of one staff with toileting;
– Impaired on one side both lower and upper extremities;
– Incontinent of bowel and occasionally bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 8/2/18, showed:
– Requires assistance with toileting due to impaired mobility;
– Assist to bathroom and commode as needed.
Observation on 9/12/18, at 3:02 P.M., showed:
– CNA C and CNA D provided perineal care to the resident.
– CNA C and CNA D removed the urine saturated brief.
– CNA C wiped the down the right groin with one wipe and then the left groin with one
wipe.
– CNA C cleansed the perineal 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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 10) – CNA C did not clean the abdomen or inner thighs that came into contact with the urine. – CNA C and CNA D rolled the resident. – CNA C wiped down the rectum with one wipe and did not clean the buttocks, back, and legs that had been in contact with urine. During an interview on 9/12/18, at 3:24 P.M., CNA C said: – He/she should have cleansed all areas that had been in contact with urine. – He/she should have cleaned the residents hand that came into contact with urine. 4. During an interview on 9/13/18, at 2:15 P.M., the Director of Nursing (DON) said: – Staff should wipe front to back during perineal care. – Staff should clean all areas soiled with urine or feces. – Staff should provide complete perineal care.
	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 observation, interview and record review, the facility failed to ensure staff provided appropriate indwelling catheter care (tube inserted into the bladder for urine drainage) care in a manner to prevent infection or the possibility of infection when they did not provide complete perineal care and failed to keep the urinary drainage bag off the floor for one of how many sampled resident (Resident #5) with a history of urinary tract infections [MEDICAL CONDITION]. The facility census was 130. Review of the facility’s Catheter Care policy, dated (MONTH) (YEAR), showed: – Catheter care is performed to keep the catheter insertion site clean; – Complete perineal care; – Cleanse around the area where the catheter enters the body. Review of #5’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 5/24/18, showed: – Cognitively impaired; – Indwelling catheter; – Extensive assist of one staff for toileting; – [DIAGNOSES REDACTED]. Review of the care plan, updated 8/21/18, showed: – Problem: potential for UTI related to presence of indwelling catheter; – Approaches: report signs and symptoms of UTI, change drainage bag as needed, secure catheter with a leg strap, position urine collection bag below the level of the bladder; – Antibiotics for UTI started on 8/21/18 and completed on 9/1/18. Observation on 9/12/18, at 4:38 P.M., showed Certified Nurse Aide (CNA) F performed perineal and catheter care as follows, assisted by CNA F: – Cleaned with one wipe each to the left groin, right groin, and abdomen; – Cleaned the catheter tubing from the insertion site in a downward motion; – Did not clean all perineal skin folds; – The resident’s catheter bag came out of the dignity bag while CNA F performed perineal care and stayed on the floor while he/she performed care and drained the catheter bag. During an interview on 9/12/18, at 5:00 P.M., CNA F said:

(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 10)
– CNA C did not clean the abdomen or inner thighs that came into contact with the urine.
– CNA C and CNA D rolled the resident.
– CNA C wiped down the rectum with one wipe and did not clean the buttocks, back, and legs
that had been in contact with urine.
During an interview on 9/12/18, at 3:24 P.M., CNA C said:
– He/she should have cleansed all areas that had been in contact with urine.
– He/she should have cleaned the residents hand that came into contact with urine.
4. During an interview on 9/13/18, at 2:15 P.M., the Director of Nursing (DON) said:
– Staff should wipe front to back during perineal care.
– Staff should clean all areas soiled with urine or feces.
– Staff should provide complete perineal care.

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 observation, interview and record review, the facility failed to ensure staff
provided appropriate indwelling catheter care (tube inserted into the bladder for urine
drainage) care in a manner to prevent infection or the possibility of infection when they
did not provide complete perineal care and failed to keep the urinary drainage bag off the
floor for one of how many sampled resident (Resident #5) with a history of urinary tract
infections [MEDICAL CONDITION]. The facility census was 130.
Review of the facility’s Catheter Care policy, dated (MONTH) (YEAR), showed:
– Catheter care is performed to keep the catheter insertion site clean;
– Complete perineal care;
– Cleanse around the area where the catheter enters the body.
Review of #5’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by staff, dated 5/24/18, showed:
– Cognitively impaired;
– Indwelling catheter;
– Extensive assist of one staff for toileting;
– [DIAGNOSES REDACTED].
Review of the care plan, updated 8/21/18, showed:
– Problem: potential for UTI related to presence of indwelling catheter;
– Approaches: report signs and symptoms of UTI, change drainage bag as needed, secure
catheter with a leg strap, position urine collection bag below the level of the bladder;
– Antibiotics for UTI started on 8/21/18 and completed on 9/1/18.
Observation on 9/12/18, at 4:38 P.M., showed Certified Nurse Aide (CNA) F performed
perineal and catheter care as follows, assisted by CNA F:
– Cleaned with one wipe each to the left groin, right groin, and abdomen;
– Cleaned the catheter tubing from the insertion site in a downward motion;
– Did not clean all perineal skin folds;
– The resident’s catheter bag came out of the dignity bag while CNA F performed perineal
care and stayed on the floor while he/she performed care and drained the catheter bag.
During an interview on 9/12/18, at 5:00 P.M., CNA F 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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 11) – He/she should have provided complete perineal care and should have cleansed all perineal skin folds. – Catheter drainage bags should not be in contact with the floor, but in the dignity bag. During an interview on 9/13/18, at 3:07 P.M., the Director of Nursing (DON) said: – Staff should provide complete catheter care and cleanse all perineal folds. – Staff should make sure the catheter bag is off the floor and placed in a dignity bag. – Staff should notifiy the charge nurse if the catheter bag is on the floor so it can be replaced.
	F 0744 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a dementia care plan was developed for two of 26 sampled resident (Resident #68 and Resident #108) diagnosed with [REDACTED]. 1. Review of Resident #68’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff dated 7/9/18 showed: -Cognitive impairment. -[DIAGNOSES REDACTED]. Review of Resident #68’s Physicians Orders Statement (POS) showed: – [DIAGNOSES REDACTED]. Review of Resident #68’s care plan showed: -Staff did not document goals, treatment or services to address the dementia diagnosis. 2. Review of Resident #108’s quarterly MDS completed by facility staff dated 8/4/18 showed: -Cognitive impairment. -[DIAGNOSES REDACTED]. Review of Resident #108’s Physicians Orders Statement (POS) showed: – [DIAGNOSES REDACTED]. Review of Resident #108’s care plan showed: -Staff did not document goals, treatment or services to address the dementia diagnosis. During an interview on 9/13/18 at 3:00 PM, the Director if Nursing said she would expect the care plans for residents with dementia to include treatment and services to address the diagnosis.
	F 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff provided care and treatment in accordance with professional standards of practice when staff failed to reconcile and document controlled medications when dispensed for four

(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 11)
– He/she should have provided complete perineal care and should have cleansed all perineal
skin folds.
– Catheter drainage bags should not be in contact with the floor, but in the dignity bag.
During an interview on 9/13/18, at 3:07 P.M., the Director of Nursing (DON) said:
– Staff should provide complete catheter care and cleanse all perineal folds.
– Staff should make sure the catheter bag is off the floor and placed in a dignity bag.
– Staff should notifiy the charge nurse if the catheter bag is on the floor so it can be
replaced.

F 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide the appropriate treatment and services to a resident who displays or is
diagnosed with dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure a dementia care plan
was developed for two of 26 sampled resident (Resident #68 and Resident #108) diagnosed
with [REDACTED].
1. Review of Resident #68’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, completed by facility staff dated 7/9/18 showed:
-Cognitive impairment.
-[DIAGNOSES REDACTED].
Review of Resident #68’s Physicians Orders Statement (POS) showed:
– [DIAGNOSES REDACTED].
Review of Resident #68’s care plan showed:
-Staff did not document goals, treatment or services to address the dementia diagnosis.
2. Review of Resident #108’s quarterly MDS completed by facility staff dated 8/4/18
showed:
-Cognitive impairment.
-[DIAGNOSES REDACTED].
Review of Resident #108’s Physicians Orders Statement (POS) showed:
– [DIAGNOSES REDACTED].
Review of Resident #108’s care plan showed:
-Staff did not document goals, treatment or services to address the dementia diagnosis.
During an interview on 9/13/18 at 3:00 PM, the Director if Nursing said she would expect
the care plans for residents with dementia to include treatment and services to address
the diagnosis.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided care and treatment in accordance with professional standards of practice when
staff failed to reconcile and document controlled medications when dispensed for four

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
additionally sampled residents (Resident #48, #65, #105 and #111). The facility census was
130.
Review of the facility’s Controlled Medications Administration policy, dated (MONTH)
(YEAR), showed:
– Medications included in the Drug Enforcement Administration (DEA) classification as
controlled substances are subject to special handling, storage, disposal, and record
keeping in the facility, in accordance with federal and state laws and regulations.
– When administering controlled medication, the authorized personnel records the
administration on the Medication Administration Record [REDACTED].
Observation of the F hall nurse medication cart and interview on 9/12/18, at 11:03 A.M.,
Registered Nurse (RN) A and Licensed Practical Nurse (LPN) C did and said:
– Resident #48’s [MEDICATION NAME] (narcotic pain medication) medication card with 44
pills and the controlled drug record indicated the resident should have 45 pills.
– Resident #65’s [MEDICATION NAME] (narcotic pain medication) medication card with 70
pills and the controlled drug record indicated the resident should have 72 pills.
– Resident #111’s [MEDICATION NAME] medication card with 106 pills and the controlled drug
record indicated the resident should have 107 pills.
– Resident #105’s [MEDICATION NAME] sulfate (narcotic pain medication) medication card
with 8 pills and the controlled drug record indicated the resident should have 9 pills.
– RN A said he/she did not sign out the narcotic medications on the controlled drug record
when administering the morning medications.
– RN A said he/she should have signed out the narcotic medications on the controlled drug
record as he/she administered the medication.
During an interview on 9/13/18, at 3:07 P.M., the Director of Nursing (DON) said:
– Staff should reconcile and sign out narcotic/controlled medications on the controlled
drug record immediately upon administering the medication.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
labeled bottles of [MEDICATION NAME] liquid (an anti-anxiety medication) with an opening
date which affected four residents (Residents #47, #52, #68 and #87) and failed to label
liquid [MEDICATION NAME] sulfate (narcotic pain medication) with an opening date for one
resident (Resident #32); failed to store [MEDICATION NAME] liquid in the refrigerator
after opening for one resident (Resident #32; failed to discard expired [MEDICATION NAME]
liquid for three residents (Resident #32, #68 and #87); failed to label multiple-use
bottles of insulin and insulin pens with an opening date or a discard date for four
residents (Resident #5, #17, #51 and #95); failed to label two bottles of [MEDICATION
NAME] (TB) testing solution with an opening date; failed to label over the counter (OTC)
mediations; and failed to ensure staff did not store food in the medication refrigerator.
The facility census was 130.
Review of the facility’s Medication Storage policy, dated (MONTH) 2010, showed:
– All drugs, treatments, and biological must be stored securely and follow 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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

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 – Many

(continued… from page 13)
manufacturer’s labeled recommendations, or per facility policy.
– The following medications must be removed from stock and disposed of properly on a
continuing basis: outdated, contaminated, recalled, deteriorated, unlabeled medications,
or those with soiled or broken/cracked containers.
1. Review of the [MEDICATION NAME] liquid manufacture’s guidelines, updated (MONTH) 2012,
showed:
– Store at a cold temperature/refrigerate 36 degree Celsius to 46 degrees Celsius.
– Discard opened bottle after 90 days.
Observation on 9/12/18, at 9:02 A.M., of the F hall refrigerator showed:
– Resident #68’s [MEDICATION NAME] bottle not labeled with an open or discard date; the
narcotic sheet indicated staff opened the [MEDICATION NAME] on 7/13/17, and last
administered it on 9/2/18.
– Resident #47’s [MEDICATION NAME] bottle not labeled with an open or discard date; the
narcotic sheet indicated staff opened the [MEDICATION NAME] on 4/23/18 and last
administered it on 8/6/18.
– Resident #52’s [MEDICATION NAME] bottle not sealed or labeled with an open or discard
date.
– Resident #87’s [MEDICATION NAME] bottle not labeled with an open or discard date; the
narcotic sheet indicated staff opened the [MEDICATION NAME] on 12/15/17, and last
administered it on 6/4/18.
– Staff had their personal lunches in the medication refrigerator.
– A large jar of grape jelly in the refrigerator.
During an in interview on 9/12/18, at 9:30 A.M., the Unit Manager A said:
– Staff should label all medications when opened.
– Staff should not dispense and administer expired medications.
– Staff should not store food or personal lunches in the medication refrigerators.
– [MEDICATION NAME] is good for one year after opening.
2. Observation on 9/12/18, at 9:40 A.M., of the C hall refrigerator showed:
– Two bottles of multiple-use TB solution not labeled when opened with a manufacturer’s
expiration date of 5/31/18 on the bottle.
Observation on 9/12/18, at 9:50 A.M., of the C hall medication cart showed:
– Resident #32’s [MEDICATION NAME] bottle not refrigerated with an open date of 9/12/17.
– Resident #32’s narcotic sheet indicated staff last administered the [MEDICATION NAME] on
9/11/18.
– Resident #32’s [MEDICATION NAME] sulfate bottle not labeled with an open or discard
date.
During an interview on 9/12/18, at 10:00 A.M., the Unit Manager C said:
– TB should be labeled upon open and discard when expired.
– He/she did not know if [MEDICATION NAME] should be refrigerated.
– Residents’ medications should be dated and labeled upon opening.
3. Observation on 9/12/18, at 11:03 A.M., of the F hall medication cart showed:
– Resident #51’s [MEDICATION NAME]not labeled with an open or discard date.
– Resident #17’s [MEDICATION NAME] flex insulin pen not labeled with an open or discard
date.
– Resident #95’s Humalog flex insulin pen not labeled with an open or discard date.
– Resident #5’s [MEDICATION NAME] flex insulin pen not labeled with an open or discard
date.
– 5 bottles of OTC medications were open and did not have an opening date recorded on the
bottle.

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

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 – Many

(continued… from page 14)
During an interview on 9/12/18, at 11:15 A.M., Registered Nurse (RN) said:
– All medications should be labeled upon opening.
– Insulin should be labeled upon opening and expires in 28 days.
4. During an interview on 9/13/18, at 3:07 P.M., the Director of Nursing (DON) said:
– Staff should label all medications when opened including [MEDICATION NAME], TB testing
solution and OTC medications.
– Staff should label insulin when opened and discard in 28 days.
– Staff should not administer expired medications.
– Staff should follow manufactures’ guidelines.
– [MEDICATION NAME] should be refrigerated and discarded after 90 days.
– No food should be in the medication refrigerators.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation, interview and record review, the facility failed to ensure they
prepared enough food from the menu for the residents that chose that meal. This affect
residents at the end of meal service and during survey 12 residents who wanted the main
menu items did not receive them. The facility census was 130.
During a resident group interview on 9/11/18, at 10:37 A.M., all eight residents said the
kitchen often ran out of the main menu items.
Review of the facility’s meal menu showed on 9/12/18, staff should serve for the supper
meal meatloaf, loaded mashed potatoes, buttered cabbage and apple crisp.
Observation on 9/12/18, at 5:36 P.M., showed staff served a substitute meal of tuna
casserole and peas. At 7:02 P.M., while dietary staff were plating the hall trays to send
out to halls on a cart, the last twelve residents were served tuna casserole because they
had ran out of meatloaf. The meal tickets all showed the residents wanted meatloaf.
During an interview on 9/12/18, at 7:22 P.M., Resident #72 said he/she filled out the menu
ticket all the time, but would get whatever they sent. The Dietary Manager (DM) came into
the room and ask what he/she wanted to eat. The resident said meatloaf. The DM said they
were out of meatloaf. They could fix him/her a cheeseburger.
During an interview on 9/13/18, at 10:18 A.M., Cook A said he/she had heard that other
staff had run out of food before.
During an interview on 9/13/18, at 10:30 A.M., the DM said they did not run out of food
very often. This was an isolated incident. More residents wanted main meal than the
substitute and there were several double meat portion diets. She spoke with all the
residents that wanted meatloaf and they were ok with it. Some ordered cheeseburgers.

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.

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

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 15)
Based on observation, interview and record review, the facility failed to ensure dietary
staff served hot foods hot and cold foods cold. This affect approximately 100 residents
who were served from a cart. The facility census was 130.
Review of the facility’s (YEAR) edition policy of meal service temperatures showed the
holding/serving temperature of a hot food item is at or higher than 135°F. Cold food item
or beverage should be 41°F or below.
Observation on 9/11/18, at 5:53 A.M., showed Cook A started cooking breakfast which
included bacon, eggs, muffins and hot cereal. He/she fried bacon. At 6:38 A.M., he/he took
the bacon off the grill and put it in a pan uncovered on the counter until he/she took the
bacon to the steamtable at 7:50 A.M. At 8:19 A.M., the cook removed the lids on the steam
table to serve and left the lids off. At 8:35 A.M., staff took the meal cart to the
B-wing. The test tray temperatures were 100 degrees (°) Fahrenheit (F) scrambled eggs,
97°F fried eggs, and the bacon was cold to the touch and taste. Dietary staff poured
drinks at the begining of service and sat them on a table in the dining room. The milk
temperature was 48.9°F. Milk which set on top of ice on a cart on the C hall for service
to residents at breakfast and the temperature was 46.8°F.
During a resident group interview on 9/11/18, at 10:37 A.M., all eight residents said the
food was often cold.
During an interview on 9/13/18, at 10:18 A.M., Cook A said hot food should be served at
145°F or above and cold food should be served at 35°F.
During an interview on 9/13/18, at 10:25 A.M., the dietary manager said hot food should be
served at least at 120°F.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure meals and snacks are served at times in accordance with resident’s needs,
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

Based on observation, interview and record review, the facility failed to serve meals to
residents in a reasonable amount of time of posted times. This affected all residents. The
facility census was 130.
Review of the facility’s current posted meal service times showed:
Location Breakfast Lunch Supper
E-Hall 7:15-7:30 A.M. 11:00-11:45 A.M. 5:30-5:45 P.M.
Main Dining room 7:30-7:45 A.M. 11:45-12:00 P.M. 5:45-6:00 P.M.
B-Hall 7:45-8 :00 A.M. 12:00-12:15 P.M. 6:00-6:15 P.M.
TCU Dining room 8:00-8:15 A.M. 12:15-12:30 P.M. 6:15-6:30 P.M.
Hall Trays 8:15-8:30 A.M. 12:30-12:45 P.M. 6:30-6:45 P.M.
Review of the (YEAR) edition of the Dining Service Meal Times policy showed meals will be
served no more than 30 minutes after the scheduled meal times.
Observation on 9/12/18, at 5:50 P.M., showed the staff took food cart to the E wing. Staff
started serving the main dining room at 6:02 P.M. and served the last resident at 6:27
P.M. Staff sent the B-hall cart out of kitchen at 6:38 P.M. Staff sent out the TCU hall
cart at 6:50 P.M. Staff sent the hall trays out of kitchen at 7:02 P.M.
Observation on 9/12/18, during the evening meal, showed Resident #93 and Resident #94 on

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 16)
the F hall received their meals at 7:14 P.M. During an interview at that time they said
their meals were always late.
During an interview on 9/12/18, at 7:25 P.M., Resident #72 said he/she had not received a
supper hall tray yet tonight, supper was always served after 7:00 P.M. At 7:34 P.M., the
Dietary Manager (DM) came into the resident’s room and asked if he/she liked what he/she
got for supper. The resident said he/she did not get anything yet and he/she wanted
meatloaf. The DM said they were out of meatloaf and the resident could have a
cheeseburger. Observation showed the resident got the cheeseburger at 7:50 P.M.
During an interview on 9/13/18, at 10:18 A.M., Cook A said the residents should not have
to wait longer than 15 minutes past posted times to receive their meal.
During an interview on 9/13/18, at 10:30 A.M., the DM said they had just switched meal
times a couple of weeks ago. They had not gotten them worked out yet.

F 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Dispose of garbage and refuse properly.

Based on observation and interview, the facility failed to properly dispose of garbage and
trash when large amounts of trash was located on the ground and in the bushes between the
dumpsters and the back parking lot. This had the potential to invite pest and was visually
unpleasant. The facility had a census of 130.
1. Observation and interview on 9/12/18, at 4:45 P.M., showed paper cups, plastic gloves,
paper plates, hair nets, pieces of foil and plastic wrap, cardboard boxes with food
labels, Styrofoam food boxes, paper trash and other trash behind the dumpsters and strung
along the wood and bush lined area in front of the back parking lot. The area measured
more than 35 feet long and up to 5 feet wide. The Maintenance Supervisor said staff had
not picked up the trash lately. The trash company often spilled items when they empted the
dumpsters and then the wind blows the trash into the wooden area behind the back parking
lot.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided care in a manner to prevent infection or the possibility of infection when staff
used soiled gloves to handle clean wipes from a multiple resident use container when
providing perineal care for two of 26 sampled residents (Residents #6 and #52); failed to
properly dispose of wipes soiled with fecal material for one sampled resident (Resident
#124); failed to provide clean field when preparing insulin administration for one sampled
resident (Resident #111); and failed to provide a clean field and not cross contaminate
multiple resident use Kleenex for one sampled resident (Resident #105). The facility
census was 130.
Review of the facility’s Standard Precautions policy, dated (MONTH) 2009, showed:
– Standard precautions will be utilized to provide a primary strategy for the prevention

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
of healthcare-associated infectious (HAI) agents among patients and healthcare
professionals.
– Avoid unnecessary touching of surfaces in close proximity to the patient to prevent both
contamination of clean hands from environmental surfaces and transmission of pathogens
from contaminated hands to surface.
– Do not recap, bend, cut, break or hand manipulate used needles.
1. Review of Resident #52’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/2/18, showed:
– Severe cognitive impairment;
– Totally dependent of two staff for toileting;
– Incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 9/11/18, at 5:45 A.M., showed:
– Certified Nurse Aide (CNA) E and Certified Medication Technician (CMT) B provided
perineal care.
– CNA E removed urine saturated brief and performed perineal care.
– CNA E used his/her soiled gloves and reached into the wipe container for more wipes
multiple times.
– After providing perineal care, CNA E took the wipes out of the resident’s room and back
into storage room.
During an interview on 9/11/18, at 6:15 A.M., CNA E said:
– He/she should have gotten wipes out of the container prior to performing perineal care.
– Staff should not put their soiled gloves in the clean wipe container.
– He/she should have asked CMT B who had on clean gloves to get him/her wipes.
2. Review of Resident #6’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Extensive assist of one staff for toileting;
– Impaired on on side both lower and upper extremities;
– Incontinent of bowel and occasionally bladder;
– [DIAGNOSES REDACTED].
Observation on 9/12/18, at 3:02 P.M., showed:
– CNA C and CNA D provided perineal care;
– The CNAs removed the resident’s urine saturated brief and performed perineal care.
– CNA C placed the wipe container on the resident’s bed.
– CNA C used his/her soiled gloves and reached into the wipe container for more wipes
multiple times.
– After providing perineal care, CNA C took the wipes out of the resident’s room and back
into storage room.
During an interview on 9/12/18, at 3:24 P.M., CNA C said:
– He/she should have not put soiled gloves in the clean wipe container.
– He/she should have placed the wipe container on a clean field in the resident’s room and
not on his/her bed.
3. Review of Resident #105’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Indwelling catheter (drains urine from the bladder);
– Ostomy (opening in the abdomen which drains bowel or urine);
– Urinary tract infection [MEDICAL CONDITION];
– [DIAGNOSES REDACTED].
Observation on 9/12/18, at 4:26 P.M., showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
– CMT B entered the resident’s room to administer eye drops.
– CMT B took the eye drop medication and Kleenex tissues into the resident’s room and
placed on the resident’s bed.
– CMT B administered the eye drops and handed the resident a tissue.
– CMT B took the Kleenex from the resident’s bed and placed back on the medication cart.
During an interview on 9/12/18, at 4:45 P.M., CMT B said:
– He/she should have placed the Kleenex on a clean field in the resident’s room and not on
the resident’s bed or back on the medication cart.
4. Review of Resident #124’s quarterly MDS, dated [DATE], showed:
– Moderate cognitively impaired;
– Total dependence of two staff for toileting;
– Incontinent of bladder;
– [DIAGNOSES REDACTED].
Observation on 9/12/18, at 4:56 P.M., showed:
– CNA E and CNA F provided incontinent care of bowel and bladder.
– Both CNAs tossed soiled urine and fecal material wipes towards the trash sack but ended
up on the floor.
– After providing perineal care, CNA E picked up the soiled urine and fecal material wipes
off the floor and placed them in a trash sack.
– CNA E and CNA F did not clean the floor or tell housekeeping of the soiled material on
the floor.
During an interview on 9/12/18, at 5:30 P.M., CNA E and CNA F said:
– They should have used a trash can to dispose of the soiled wipes.
– Soiled wipes should not be placed on the resident’s floor.
– They should have cleaned the floor after coming in contact with urine and fecal
material.
5. Review of Resident #111’s quarterly MDS, dated [DATE], showed:
– Cognitively intact
– Independent with activities of daily living (ADLs);
– [DIAGNOSES REDACTED].
Observation on 9/12/18, at 5:45 P.M., showed:
– Registered Nurse (RN) A placed a clean field on the top of the medication cart and
placed the accucheck machine (used to measure blood sugar levels) and supplies on the
clean field.
– Multiple medication books slid onto the clean field and on top of the supplies and
accucheck machine.
– RN A took the insulin needle, placed the cap in his/her mouth and prepared the insulin,
took the cap out of his/her mouth, recapped the needle, and administered the insulin to
the resident.
During an interview on 9/12/18, at 5:55 P.M., RN A said:
– He/she should have removed the medication books and had an adequate amount of space for
a clean field.
– He/she should not place insulin needle caps in his/her mouth and recap the needle.
6. During an interview on 9/13/18, at 3:07 P.M., the Director of Nursing (DON) said:
– Staff should place wipe containers and Kleenex boxes on a clean field in the resident’s
room and not on the resident’s bed.
– Staff should prepare all wipes needed for perineal care prior to care and should not use
soiled gloves to get wipes out of the container.
– Staff should dispose of urine and fecal material wipes in a trash sack in a trash can

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
and not on the floor.
– Staff should use a clean field when completing accuchecks and insulin injections and
should have a workable space.
– Staff should not place needle caps in their mouths and recap the needle.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

Based on observation and interview, the facility failed to ensure a safe environment for
residents, staff and visitors when hydraulic oil coated about 75% of the elevator
equipment room floor and soaked multiple pieces of cloth. The facility had a capacity of
180 and a census of 130 at the time of the survey.
1. Observation and interview during the Life Safety Code tour on 9/12/18, at 4:15 P.M.,
showed hydraulic oil coated about 75% of the elevator equipment room floor. Hydraulic oil
soaked multiple pieces of cloth, such as old towels and bed spreads. The Maintenance
Supervisor said the leak had gotten worse since he first noticed the leak in April. He
contacted the elevator company a while ago to have the leak repaired but the company gave
him no time line on when they would be able to fix the leak.

F 0923

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have enough outside ventilation via a window or mechanical ventilation, or both.

Based on observation and interviews, the facility failed to ensure they maintained the
bathroom vents in good repair. This affected all of the residents on the TCU and E hall
and residents in sporadic locations on the other hallways such as those in rooms F98, F99
and C70. The facility had a census of 130.
1. Observation on 9/11/18, at 8:30 A.M., showed the ventilation fans in rooms F98 and F99
did not work. The rooms contained an odor of urine.
2. Observation on 9/12/18, during the Life Safety Code (LSC) tour of the facility starting
at 1:45 P.M., showed the bathroom ventilation fans did not work on TCU and E hall.
3. Observation on 9/13/18, at 9:25 A.M., showed a strong, unpleasant odor in resident room
C70. The bathroom vent did not hold a tissue when checked to see if it was working.
4. During an interview on 9/12/18, at 11:52 A.M., Unit Manager A said he/she had worked at
the facility for about a year. The bathroom ventilation fans had not worked during his/her
duration. He/she usually worked on the E and F halls.
Observation and interview on 9/13/18, at 10:40 A.M., the Maintenance Supervisor (MS) said
they had some of the vents repaired in the building while others still needed to be
repaired. The vents on TCU and the E hall had not been repaired. The F98, F99 and C70
bathroom vents were supposed to be working. He checked vents using the tissue test and
when the vents were on the tissue held when placed over the vent and said this is how he
normally checked to see if vents were working properly.

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:

265379

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

RIVERSIDE NURSING & REHABILITATION CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

4700 NW CLIFFVIEW DRIVE
RIVERSIDE, MO 64150

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 0923 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some

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