RIVERSIDE PLACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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