Riverside Healthcare Center: Incontinence Care Failures - MI
Nobody on the morning shift had checked him before breakfast.
The aide assigned to R102 that morning, identified in inspection records as CNA E, explained what happened in an interview at 9:20 AM. The previous shift had gotten R102 up and into his chair at around 5:30 AM. CNA E said she knew she should have checked him for incontinence before he went to eat, but another staff member had already walked him to the dining room before she had the chance. She hadn't checked him after breakfast either.
CNA E also said she didn't think R102 had an order for any barrier cream. She told inspectors that aides use barrier cream when it's sitting in the resident's room, but if it's stored on the treatment cart, a nurse handles it.
The charge nurse, identified as RN F, said something different. In an interview at 12:52 PM, she told inspectors she was confident the previous shift had applied Calmoseptine ointment when they got R102 up that morning, because that was the process. She said she hadn't known about the bowel movement at all. Then she added a detail that complicated the picture further: CNAs had apparently been going to the treatment cart to get the Calmoseptine themselves, which she said they shouldn't do, because the ointment is medicated and applying it is a nurse's responsibility.
RN F also acknowledged she hadn't known that R102's Calmoseptine order was written for use as needed specifically during incontinence episodes.
The Director of Nursing confirmed that Calmoseptine is a medicated product, that it must stay locked in the treatment cart, and that only a nurse should apply it. The DON also confirmed the facility's standard expectation: incontinent residents are to be checked and changed every two hours.
What the inspection found, then, was a resident who had been placed in a chair before 5:30 in the morning and was still sitting in soaked clothing and stool when inspectors arrived. The aide responsible for his morning care hadn't checked him. The nurse in charge of his medicated skin treatment didn't know he'd had a bowel movement. The ointment meant to protect his skin from exactly this kind of prolonged moisture exposure had not been applied.
Moisture-associated skin damage, caused by prolonged contact with urine and stool, is a documented and preventable condition. The inspection report cited a nursing textbook, Fundamentals of Nursing, 11th edition, for the proposition that preventing skin breakdown in incontinent patients requires consistent use of barrier products, regular skin assessment, and a clear management plan. The same source notes that incontinence should not be treated as inevitable or normal in older adults.
The violation was cited at a level of minimal harm or potential for actual harm, with few residents affected. But the inspection record captures something that goes beyond a single missed check. The aide didn't know whether a cream order existed. The nurse didn't know the order's specific trigger. The nurse believed the previous shift had applied the cream, without confirming it. The Director of Nursing confirmed the rules without explaining how the morning had unfolded the way it did.
R102 sat in that chair, in soaked clothing, while the staff responsible for his care each assumed someone else had handled it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Healthcare Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
Riverside Healthcare Center in St. Louis, MI was cited for violations during a health inspection on September 4, 2025.
Nobody on the morning shift had checked him before breakfast.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.