Riverbend Heights Health & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) was in place which had the potential to affect all residents in the facility. The facility census was 80 residents. Review of the facility's policy titled Antibiotic Stewardship dated December 2016 showed the purpose of the Antibiotic Stewardship Program was to monitor the use of antibiotics taken by the residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate psychotropic (relating to drugs that affect a person's mental state) medication side effect monitoring was in place for five sampled residents (Resident #1, #2, #4, #8, and #69) out of 18 sampled residents. The facility census was 80 residents. Review of the facility's policy titled Antipsychotic Medication Use dated December 2016 showed:-Residents would only receive antipsychotic medication when necessary to treat specific conditions for which they were indicated and effective.-The nursing staff should monitor for and report side effects and adverse consequences of antipsychotic medications to the attending physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized activities of the resident's preference that provided a sense of comfort and connection, sensory engagement, and purpose for three sampled residents (Resident #40, Resident #16, and Resident #2) out of 18 sampled residents. The facility census was 80 residents. Review of the facility's Activities Program policy, revised June 2018 showed:-The following records will be maintained by the Activities department: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage (DS) room, walk in refrigerator, and walk in freezer floors clean; failed to ensure food preparation items/equipment were kept in a sanitary condition; failed to safeguard against foreign material possibly getting into food; failed to maintain plastic and/or rubber cutting boards, plate covers, room trays, and utensils in good condition to avoid food safety hazards (cross-contamination); in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 80 residents with a licensed capacity for 154 residents at the time of the survey. [...]

Inspectors wroteBased on interview, and record review, the facility failed to refer one sampled resident (Resident #10) diagnosed after his/her admission with a serious mental disorder (SMD)/mental illness to the appropriate State-designated authority for review, out of 18 sampled residents. The facility census was 80 residents. Review of the facility's Pre admission Screening and Record Review (PASRR- a federally-mandated tool for Medicaid-certified nursing facility applicants to be screened for SMI, ID, or related conditions. If positive, a Level II, in-depth evaluation is indicated ensuring appropriate placement and services) policy, dated 11/28/27 showed:-The nursing facility must notify the state mental health (SMH)/intellectual disability (ID) authority of significant changes in residents with mental disorders or ID. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to incorporate person-centered interventions that had the potential to proactively impact the resident's mood and offer comfort to him/her when the resident was upset into the behavioral care plan of one sampled resident (Resident #40) out of 18 sampled residents. The facility census was 80 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #72) had orders and a plan of care in place for a peripherally inserted central catheter (PICC tube/catheter inserted into a vein for medication administration) for one resident out of 18 sampled residents' facility census was 80 residents. A facility policy was requested for PICC lines and was not received prior to exit from the facility.1. Review of Resident #72's admission Record showed he/she was admitted to the facility with a diagnosis of unspecified severe protein-calorie malnutrition (a severe deficiency of protein and calories, causing muscle wasting, weight loss, and fatigue). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #3) received Zerbaxa (a specialty compounded medication) as ordered 12/13/25 and 12/14/25 resulting in the resident returning to the hospital in order to receive the needed medication out of 16 sampled residents. The facility census was 84 residents. Review of the facility's policy, Medication Therapy, dated April 2007 showed:-Each resident's medication regimen should have included only those medications necessary to treat existing conditions and address significant risks.-Medication use should have been consistent with an individual's condition, prognosis, values, wishes, and responses to such treatment. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the floor under the deep fat fryer and the six burner stove free of a heavy grease buildup, maintain the wall mounted fan without dust; failed to identify an item in a 3 quart container in the reach-in fridge; failed to maintain the floors under the reach-in fridge and under the steam table free from debris and food particles; failed to refrigerate items which stated refrigerate after opening on the label; failed to maintain light fixtures and sprinkler heads in the kitchen, free of dust and grease; failed to store the utensils in a container free from food debris; failed to label two containers of a powdery substance; failed to maintain the lower spray wand of the dishwasher free from debris in the nozzles; [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure the walk-in fridge operated at a temperature of 41 ºF (degrees Fahrenheit) or below, and failed to maintain the automated dishwasher in good working order. This practice potentially affected all residents. The facility census was 92 residents. 1. Observation on 6/10/24 at 11:13 A.M., during the initial kitchen tour, showed the temperature of the walk-in fridge was 46.5 ºF (degrees Fahrenheit) after the thermometer was left in the walk-in fridge for about 10 minutes. Observation on 6/11/24 at 12:23 P.M., showed the temperature of the walk-in fridge was 46.4 ºF after the thermometer was left in the walk-in fridge for over an hour. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the commode riser in resident room [ROOM NUMBER] in an easily cleanable condition; failed to maintain the restroom ceiling vents free of a heavy buildup of dust inside the ceiling vents in resident rooms 17, 60, 61, 71, 83, 81, 80; failed to maintain the ceiling vent in Greystone shower room free from a heavy buildup of dust; failed to maintain the commode seat in the Greystone shower room fee of numerous indentations; failed to maintain a personal fan free of dust in resident room [ROOM NUMBER]; failed to maintain the ceiling fans in the resident smoke room free of a buildup of dust. The facility census was 92 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to have parameters listed in the medication orders for medications that contained Acetaminophen (medication used to treat pain and reduce fever) for three sampled residents (Residents #38, #52, and #54) of out of 19 sampled residents. The facility census was 92 residents. A policy was requested on medication parameters and the facility did not provide one. 1. Review of Resident #54's admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Medication Review Report, dated June 2024, showed the following orders: -Acetaminophen 325 milligram (mg) give two tablets by mouth every six hours as needed for pain, order was dated 2/6/22 -The order failed to have the parameters of not to exceed three grams of Acetaminophen in 24 hours from all sources. 2. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the sewer pipe, in the area between the dry goods storage room and the walk-in refrigerator, in good repair to prevent drainage from backing up into the storage room and the walk-in refrigerator; failed to maintain the fans in the laundry room free of a heavy buildup of dust; failed to maintain the area under the vending machines in the Serenity dining room free from a heavy buildup of dust; and failed to ensure the restroom ceiling vent was securely attached to the ceiling in resident room [ROOM NUMBER]. This practice potentially affected an unknown number of residents who used the Serenity Unit dining room and other resident use areas in the facility. The facility census was 92 residents. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the area that was close to the window and the two-compartment sink, free of food debris and soiled dishes, which attracted ants to that area of the kitchen. This practice affected the kitchen. The facility census was 92 residents. 1. Observation on 6/13/24 at 6:16 A.M., 7:28 A.M., and 8:03 A.M., showed numerous dishes from the night before that were not washed and the presence of ants around the two compartment sink in the kitchen. During an interview on 6/13/24 at 8:43 A.M., after seeing the ants crawl in that area around the soiled dishes, the Dietary Manager (DM) said the dishes that were left at the window sill area should have been washed the previous night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities identified as being of interest were offered daily on a 1:1 basis or adapted to meet the resident's cognitive and physical limitations and offered at bedside or at a time when the resident was likely to be out of bed for one sampled resident (Resident #72) out of 19 sampled residents. The facility census was 92 residents. Review of the facility's Resident Self-Determination and Participation policy, revised February, 2021 showed: -Each resident is allowed to choose activities consistent with his/her interests. -Staff will: --Gather information about the residents' personal preferences on initial assessment and periodically thereafter and document preferences in the medical record. --Include information about the resident's preferences in the care planning process. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #80) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition that is triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, severe anxiety, uncontrollable thoughts about the event and feelings of isolation) received trauma based interventions including ensuring the resident received meal service when he/she was in full view of staff during meal service, out of 19 sampled residents. The facility census was 92 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/), copyright 2021, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that dietary staff followed the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs, which resulted in the eggs being unpalatable. This practice potentially affected two residents with pureed diets. The facility census was 92 residents. 1. Observation on 6/13/24 from 6:08 A.M. to 6:24 A.M., during the breakfast meal preparation, showed: -A disorganized recipe book on one of the tables with numerous amount of the pages which were not in order. -Dietary [NAME] (DC) A made pureed eggs with no recipe book open. -DC A added cold milk to the eggs and an unmeasured amount of thickener. -The state surveyor tasted the pureed eggs, and the eggs had a bland taste. -DC A did not taste the eggs himself/herself. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate protective oversight for one sampled resident (Resident #1) when the resident obtained access to a sharps container on the medication cart, found the tip/needle portion of an insulin pen and poked his/her finger out of ten sampled residents. The facility census was 94 residents. Review of the facility policy for Sharps Disposal revised January 2021 showed: -The facility staff was to discard contaminated sharps into designated containers immediately or as soon as feasible, into designated containers. -All containers used for discarding contaminated sharps were to be closable, puncture resistant, leakproof on sides and bottom, labeled or color-coded in accordance with the established labeling system and impermeable and capable of maintaining impermeability through final waste disposal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two sampled residents (Resident #3 and #4) remained free from abuse. On 9/29/23, Resident #3 hit Resident #4 resulting in Resident #3 sustained a fractured right leg and cut to his/her right arm and Resident #4 sustained a cut to his/her nose, a cut on the foot and bruising to his/her face out of nine sampled residents. The facility census was 102 residents. Review of the Abuse Prevention Program Policy dated 12/16 showed: -Policy Statement: --The residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. --This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff received training to maintain the highest practicable physical, mental, and psychosocial well-being, for four sampled residents (Resident #3, #4, #5 and #6) out of nine sampled residents. The facility census was 102 residents. Review of the Facility Behavioral Health Services Policy dated 2/19 showed: -Policy: -The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -Staff training regarding behavioral health services includes, but is not limited to: --Recognizing changes in behavior that indicated psychological distress. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify two sampled residents (Resident #3 and #4) representatives of the injuries sustained as result of an altercation on 9/29/23 out of nine sampled residents. The facility census was 102 residents. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate interventions necessary to prevent a resident to resident altercation for two sampled residents (Resident's #1 and #2) out of three sampled residents. The facility census was 101 residents. Review of the facility Abuse Prevention Program dated 12/16 showed: -Policy: -Our residents have the right to be free from abuse. -As part of the resident abuse prevention the administration will: --Protect our residents from abuse by anyone. --Require staff training and orientation programs that include such topics as abuse prevention, identification and reporting abuse, stress management, and handling verbally and physically aggressive resident behavior. Review of the facility policy Recognizing Signs and Symptoms of Abuse and Neglect dated 1/11 showed: -Our facility will not condone any form of abuse or neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff received training to maintain the highest practicable physical, mental, and psychosocial well-being, for two sampled residents (Resident #1 and #2) out of three sampled residents. The facility census was 101 residents. Review of the Facility Assessment Tool dated 9/12/22 showed: -The facility served residents with the following: Psychiatric/Mood, Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions. -The facility had 154 licensed beds, with an average daily census of 97-103. -The facility had 22 residents with behavioral health needs. -The facility had one dementia unit. - Services and care offered based on resident needs: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the Dry Storage room, walk-in refrigerator, and walk-in freezer floors clean; to maintain sanitary utensils and food preparation equipment; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; to separate damaged foodstuff; and to ensure the proper refrigeration and/or disposal of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 95 residents with a licensed capacity for 160 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 9/18/22 between 2:06 P.M. and 3:33 P.M. showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly contain waste and refuse in kitchen garbage cans and outdoor dumpster's, to prevent the harboring and/or feeding of pests. This deficient practice potentially affected all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility and/or ate food from the kitchen. This facility had a capacity of 160 residents with a census of 95 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 9/18/22 between 2:06 P.M. and 3:21 P.M. showed an unlidded large garbage can by the west exit door was approximately (appx.) 3/4 full and another unlidded large garbage can by the ice machine was appx. 2/3 full; no lids were seen in the immediate vicinity of either. Observations during the facility inspection on 9/18/22 at 3:58 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one staff member that was Cardiopulmonary Resuscitation/Basic Life Support (CPR/BLS an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function) certified was on duty at all times; to ensure the Staffing Coordinator knew to schedule one CPR certified staff member on each shift; to keep accurate staffing files to ensure they knew who was CPR certified and when CPR certification would expire; and to ensure the facility van driver was CPR certified when he/she had transported nine supplemental residents on 11 different trips (Residents #15, #39, #58, #5, #48, #342, #18, #67, and #33). [...]

Inspectors wrote3. Record review of Resident #27's face sheet, dated 9/26/22, showed: -The resident was admitted to the facility on [DATE]. -The diagnoses included: schizophrenic disorder, altered mental status, Alzheimer's disease (progressive mental worsening due to generalized degeneration of the brain). Record review of the resident's Consultant Pharmacist Recommendation to Physician, dated 9/3/21, showed: -The resident was taking Haloperidol (an antidepressant drug used to treat psychotic conditions), 2 mg daily, 15 mg at bedtime since July 2020 without a Gradual Dose Reduction (GDR). -Recommendation from the pharmacist was to attempt a reduction to 1 mg daily, 15 mg at bed time. -There was no physician response. Record review of the facility's Consultant Pharmacist Recommendation: DON/Medical Director, dated 10/26/21, showed: [...]

Inspectors wrote3. Record review of Resident #1's face sheet, undated, showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). -Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication cart was kept locked when not in direct observation of the staff; to ensure the medication room was in a sanitary condition; to ensure staff was checking the temperatures in the refrigerator used to store the resident's medications; to ensure the nursing staff had a key to unlock the medication refrigerator; to ensure other objects were stored with the resident's medications; and to ensure the resident's open medication bottles were kept in a sanitary condition. The facility census was 95 residents. Record review of the facility's policy, Storage of Medications, dated November 2020 showed: -The facility stored all drugs and biologicals in a safe, secure, and orderly manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure testing/screening for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) was completed for one sampled resident (Resident #69) and four supplemental residents (Residents #63, #71, #80 and #342) out of five residents sampled for TB testing/screening and to follow infection control procedures by not for ensuring staff cleansed their hands while feeding one supplemental resident (Resident #18) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's TB policy, dated 2001, showed: -The facility screened all residents for TB. -The admitting nurse screened residents for admission and readmission for information regarding exposure to or symptoms of TB. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure the resident was free from a merry walker (combination walker/chair ambulation device with tubular rectangular gated frame) restraint without an assessment, a physician's order including a medical symptom and without informed consent for the use of a merry walker restraint for one sampled resident (Resident #77) out of 19 sampled residents. No other residents had a restraint. The facility census was 95 residents. Record review of the facility's Unauthorized Physical Restraints policy dated April 2021 showed: -Residents were to be free from the use of any physical restraint not required to treat their medical condition. -A physical restraint was defined as any manual method, physical or mechanical device, equipment or material that meets all of the following criteria: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate completion, submission and retention of a Level I Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (PASARR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid (program that helps with medical costs for some people with limited income and resources) certified beds in a nursing facility regardless of the source of payment. [...]

Inspectors wroteBased on interview and record review, the facility failed to do thorough weekly skin assessments and to document current skin issues for one sampled resident (Resident #37) who had several skin injuries out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy, Wound Evaluations, dated September 2018 showed: -Evaluation of wounds would be performed on admission, weekly and on discovery. -Wound assessments would be completed by the facility Nursing staff or the designated wound care company. -Components of wound documentation should include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the gastrostomy tube ( G-tube is a tube inserted through the belly that brings nutrition directly to the stomach) was securely fastened and to keep the feeding tube and surrounding skin clean for one sampled resident (Resident #8) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy, Maintaining Patency of a Feeding Tube, revision date 2018 showed: -Confirm placement of the tube. -Flush enteral feeding tubes with 30 Millimeters (ml) of warm water before and after intermittent feedings. -Verify that there was a physician's order for this procedure. -NOTE: There was no mention of how to secure the feeding tube to prevent pulling and possible dislodgement. -NOTE: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained for oxygen tubing and a Continuous Positive Airway Pressure (CPAP a machine that uses mild air pressure to keep breathing airways open while you sleep) machine for two sampled residents (Resident #58 and #8) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy, Use of Oxygen and Nebulizer, revised July 2016 showed: -The oxygen tubing cannula or mask, nebulizer tubing would be changed weekly and as needed. -The tubing should be kept off of the floor and in a dated bag or container when not in use. -The oxygen equipment should be cleaned regularly. 1. Record review of Resident #58's face sheet showed he/she was re-admitted on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide influenza (a highly contagious viral infection of the respiratory passages causing fever, severe aching, and catarrh, and often occurring in epidemic) and pneumococcal (lung inflammation caused by bacterial or viral infection) vaccines for two sampled residents (Resident #71 and #342) out of five residents sampled for immunizations. This practice had the potential to effect all residents. The census was 95 residents. Record review of the facility's Pneumococcal Vaccine Policy, dated March 2022, showed: -All residents were offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 (a respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) immunization education for one supplemental resident (Resident #342) out of five residents sampled for immunizations. This practice had the potential to effect all residents. The census was 95 residents. Record review of Centers for Medicare and Medicaid Services (CMS) memorandum QSO-21-19-NH, dated 5/11/21, showed: -Each facility must develop and implement policies and procedures that meet each resident's informational needs and provides vaccines to all residents that elect them. -All residents and or resident representatives must be educated on the COVID-19 vaccine they were offered. [...]