Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0553

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Allow resident to participate in the development and implementation of his or her
person-centered plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to notify a resident and/or
family/representative of Care Plan (written out plan for the care of the resident)
meetings for one sampled resident (Resident #13) out of 13 sampled residents. The facility
census was 49 residents.
Record review of the facility’s undated Quarterly Review of Care Plans Policy showed:
-Each resident’s care plan shall be reviewed at least quarterly;
-The care planning/interdisciplinary team (May consist of, but not be limited to the
Director of Nursing (DON), Assistant Director of Nursing (ADON), charge nurse, Social
Service Director (SSD), the facility’s medical director, activities director, dietary
manager, etc.) was responsible for maintaining care plans on a current status;
-The care planning/interdisciplinary team was responsible for the periodic review and
updating of care plans:
–When there had been a significant change in the resident’s condition;
–When the desired outcome was not met;
–When the resident had been readmitted to the facility from a hospital stay;
–At least quarterly.
1. Record review of Resident #13’s Admission Face Sheet showed he/she admitted on[DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] disorder (a form of mental illness);
-Major [MEDICAL CONDITION] (a state of intense sadness or despair that has advanced to the
point of being disruptive to an individual’s social functioning and/or activities of daily
living);
-[MEDICAL CONDITION] (a chronic nervous disease characterized by a fine slowly spreading
tremor, muscle weakness, muscle stiffness and a peculiar gait).
Record review of the resident’s Annual Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 4/15/18;
Reentry MDS dated [DATE]; and Quarterly MDS dated [DATE] each showed:
-BIMS (Brief Interview for Mental Status) of 15;
-Behavioral symptoms of delusions (fixed false beliefs).
During an interview on 1/7/19 at 9:54 A.M., the resident said:
-He/She did not know what a care plan meeting was or when it was;
-He/She did not know if his/her family was notified of the meetings or if they attended.
During an interview on 1/11/19 at 11:55 A.M., the MDS/Care Plan Coordinator said:
-Care Plan meetings are quarterly for each resident;
-The resident and family/representative are notified in advance of when the meetings are;
-The resident is notified of the care plan meetings and he/she usually declined to attend;
-The resident’s son is notified of the care plan meetings and does not attend;
-He/She keeps a record of when the resident and family/representative were notified;
-He/She could not find any record of the resident or of his/her son being notified of the
care plan meetings.
During an interview on 1/11/19 at 11:55 A.M., the Director of Nursing (DON) said:
-The resident and family/representative, should be notified of the care plan meetings;
-The MDS coordinator calls the family to let them know when the care plan meeting will be;
-A phone meeting is done when a family/representative is out of the area or prefers to
attend by a phone call;
-The MDS coordinator should document that the family was notified and if they attended or

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0553

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
refused.
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, the facility failed to maintain the dining room and
kitchen floors in a condition that did not pose a safety risk. This deficient practice had
the potential to create tripping hazards affecting numerous residents, visitors, and staff
using, passing through, or working in the facility. The facility had a capacity of 60 and
a census of 49 residents at the time of the survey.
1. Observation during the kitchen’s Life Safety Code inspection on 1/8/19 at 10:40 A.M.,
showed an open crack approximately 3 ½ inches (in.) by 1 ¼ in. with a depth of 3/8 in. at
the passageway between the cooking area and the Dietary Office and a larger open crack in
the adjacent resident dining/activities area that was approximately 10 in. by 3 ¼ in. with
a depth of ½ in.
During an interview on 1/9/19 at 2:37 P.M., the Maintenance Services Director said the
building had been added on to some years ago and the openings and cracks appear
periodically after each repair.
2. Observations during a segment of the facility’s environmental/life safety tour on
1/9/19 at 3:30 P.M., showed a floor crack and tile depression that was approximately 9 3/4
in. by 5 in. near the east wall of the dining/activities area.
During an interview on 1/10/19 at 8:47 A.M., the Dietary Manager said the open crack in
the kitchen floor had been there for about a year.

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility staff failed to report alleged sexual
activity/abuse (non-consensual sexual contact of any type with a resident) to the
administrator in a timely manner, failed to report to the state agency; the physician; and
on one of two occasions, the family; when on two separate occasions a resident (Resident
#3) was found in compromising situations involving other residents (Resident #39 and
Supplemental Resident #29), out of 13 sampled residents and four supplemental residents
sampled for behaviors. The facility census was 49 residents.
Record review of the facility’s undated policy titled Reporting Abuse to Facility
Management showed:
-It is the responsibility of our employees, facility consultants, attending physicians,
family members, and visitors etc., to promptly report any incident or suspected incident
of neglect or resident abuse, including injuries of unknown, source, and theft or
misappropriation of resident property to facility management;
-Employees, facility consultants and/or attending physicians must immediately report any
suspected abuse or incidents of abuse to the administrator and the Director of Nursing
services (DON). In the absence of the DON such reports may be made to the nurse supervisor

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
on duty;
-The administrator must be immediately notified of suspected abuse or incidents of abuse.
If such incidents occur or were discovered after hours, the administrator and DON must be
called at home or must be paged and informed of such incident;
-Sexual abuse is defined as, but not limited to, non-consensual sexual contact of any
type, including sexual harassment, sexual coercion, or sexual assault.
Further review of the facility’s undated policy titled, Reporting Abuse to Facility
Management, showed when an alleged or suspected case of mistreatment, neglect, injuries of
unknown source or abuse is reported, the facility Administrator, and his/her designee,
will immediately (within 24 hours of the alleged incident) notify the following persons or
agencies of such incident:
-The state licensing/certification agency responsible for surveying/licensing the
facility;
-The local/state ombudsman;
-The resident’s representative of record;
-Adult Protective Services;
-Law Enforcement Officials;
-The attending physician;
-The medical director.
Record review of the facility’s undated policy titled Abuse and Neglect: Clinical Protocol
showed the management and staff, with the support of the physicians, will address
situations of suspected or identified abuse and report them in a timely manner to
appropriate agencies, consistent with applicable laws and regulations.
1. Record review of Resident #3’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED].
-Unspecified Dementia with Behavioral Disturbance (Common behavioral disturbances can be
grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep
disorders ([MEDICAL CONDITION], hypersomnia, night-day reversal); psychotic symptoms
(delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual
disinhibition, aggression);
-Altered Mental Status, Unspecified (general changes in brain function, such as confusion,
amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or
place), defects in judgment or thought, unusual or strange behavior, poor regulation of
emotions, and disruptions in perception).
Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, used for care planning
purposes, dated 6/14/18, showed the resident:
-Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively
impaired.
-Stated, during the Resident Mood interview, he/she had little pleasure or interest in
doing things several days, felt down, depressed or hopeless several days, had trouble
falling or staying asleep or sleeping too much, and had trouble concentrating on things
such as reading the newspaper or watching television;
-Had no presence of behaviors during the seven day look-back period and no overall
presence of behaviors;
-Had no presence of wandering;
-Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion,
and eating;
-Needed extensive assistance with personal hygiene and bathing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-Used a walker for mobility assistance;
-Had frequent pain;
-Received antipsychotic, antidepressant and opioid medications;
-Used a wander/elopement alarm daily.
Record review of the resident’s Nurse’s Note, dated 6/13/18, showed the following:
-At 3:32 A.M., the resident was found in another resident’s room (identified as
Supplemental Resident #29);
-The resident (Resident #3) was on the bed with Resident #29;
-Staff heard smacking lips;
-Resident #3 was kissing Resident #29;
-Resident #3 stated he/she had known Resident #29 for years;
-Resident #3 was easily redirected to his/her room.
Record review of Supplemental Resident #29’s electronic medical record showed the resident
was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES
REDACTED].
Record review of the resident’s admission MDS, dated [DATE], showed the resident:
-Was cognitively intact;
-Had no hearing or vision impairment;
-Did not display any indicators of mood disturbance;
-Did not have the presence of any behaviors;
-Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and
eating;
-Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene;
-Used a wheelchair for mobility assistance.
Record review of the resident’s Nurses’ Notes, dated 6/13/18 at 3:34 A.M., showed:
-A resident of the opposite sex (identified as Resident #3) went into the resident’s room,
laid in bed with the resident and was kissing the resident;
-The resident did not appear to be in distress;
-When the Certified Nursing Assistant (CNA) told the resident he/she was going to empty
his/her Foley bag (bag to collect the urine that drains through a catheter), the resident
said I thought you were talking about this old bag as the resident was rubbing Resident #3
on his/her back;
-The resident was easily redirected.
During observation and brief interview in the course of the initial tour of the facility
on 1/7/19, at 11:00 A.M., Resident #29 had no concerns. Further observations showed:
-The resident was not very responsive;
-He/She remained covered in bed and closed his/her eyes;
-He/She did not wish to be interviewed.
During an interview as of part of the survey initial pool process on 1/7/19 at 2:10 P.M.,
Resident #3 said he/she had no problems getting along with other residents, and did not
recall any concerns or issues encountered.
During an interview on 1/11/19 at 1:14 P.M., Resident #3’s responsible party said:
-He/She was not told about the incident that occurred on 6/13/18;
-He/She had only been told about an incident that occurred in (MONTH) (YEAR), and
occurrences such as skin tears.
2. Record review of Resident #39’s initial care plan dated 7/31/18 showed the resident:
-Used a walker;
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s admission MDS dated [DATE], showed the following staff
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
assessment of the resident:
-Cognitively intact;
-Did not have any hearing or vision impairment;
-Had clear speech;
-Understands others and others understand him/her;
-Did not display any behaviors;
-The most assistance he/she required during the look-back period was:
–Limited assistance of one person with moving around in his/her bed;
–Limited assistance of two people with dressing;
–Supervision when walking and transferring from one surface to another such as from
standing to sitting on his/her bed or chair.
Record review of the resident’s nurse’s note, dated 10/8/18 showed:
-The nurse went into the resident’s room about 5:00 A.M.;
-The resident was standing next to his/her bed naked;
-The nurse found Resident #3 laying on his/her back in the resident’s bed with his/her
pants down around his/her ankles;
-The nurse asked the resident what was going on and he/she said that he/she did not know;
-The resident told the nurse that nothing happened between him/her and Resident #3;
-Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between
the two residents;
-Resident #3 initially refused to leave the resident’s room, but staff were able to remove
Resident #3 from the resident’s room.
Record review of the incident report dated 10/8/18 at 5:00 A.M. showed:
-Resident #3 was found in Resident #39’s room;
-Resident #3 was lying on Resident #39’s bed with his/her pants pulled down to his/her
ankles;
-Resident #39 was naked and standing next to Resident #3;
-Resident #39 denied touching Resident #3;
-Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between
the two residents;
-Notification of the physician was left blank;
-There was no documentation regarding whether the incident was reported to the
Administrator;
-The incident was reported to the Assistant Director of Nursing (ADON);
-The incident report was signed by Licensed Practical Nurse (LPN) C.
Record review of the resident’s late entry nurse’s note dated 10/8/18 at 7:22 A.M., showed
LPN D spoke with the resident’s family member regarding the 10/8/18 incident.
Record review of the resident’s significant change MDS dated [DATE], showed the staff
assessment of the resident showed the resident was cognitively intact.
During an interview on 1/11/19 at 10:05 A.M., LPN A said:
-LPN C wrote the note about the 10/8/18 incident between the resident and another resident
of the opposite sex who resided on a different hall;
-He/She was told that nothing happened.
During an interview on 1/11/19 at 10:30 A.M., the Wound Nurse said:
-When an incident occurs, the physician and families/responsible party should be called;
-The incident (referring to the incident on 10/8/18) should have been reported to the
state agency;
-It was reported to the DON;
-There have been no further incidents between the two residents.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
During an interview on 1/11/19 at 10:46 A.M., CNA D said:
-He/She was not at work the day Resident #3 was found in Resident #39’s room on another
hall, lying in bed with his/her pants down;
-Incidents should be reported to the charge nurse;
-He/She would report an incident to the ADON next and then to the DON if he/she felt it
wasn’t being addressed.
During an interview on 1/11/19 at 10:52 A.M., the DON said:
-Resident #3 is happily confused;
-Resident #3 roams and wanders into rooms;
-All that was reported to him/her regarding the incident that occurred on 10/8/18, was
that Resident #3 was found in Resident #39’s bed, and that Resident #39 went to go to bed
and Resident #3 was in his/her bed;
-LPN C, who was the charge nurse at the time of the incident, said Resident #39 was naked
and they weren’t sure what happened;
-They didn’t do a full investigation, because LPN C thought Resident #3 only wandered into
Resident #39’s room.
During an interview on 1/11/19 10:57 A.M., the Administrator said:
-He/She knew of the incident between Resident #3 and Resident #39;
-He/She didn’t know exactly what happened;
-He/She probably heard about the incident later;
-Sometimes things don’t come straight to him/her, for example if it happened on a Sunday,
they might have talked to him/her about it in Tuesday morning meeting;
-He/She must not have known the full extent of the occurrence;
-A full investigation should have been done and it should have been reported to him/her
immediately.
During an interview on 1/11/19 at 11:18 A.M., the ADON said:
-The night shift charge nurse called him/her at around 5:00 A.M. and the charge nurse
reported he/she went to Resident #39’s room to check his/her blood sugar that morning.
When he/she walked in, Resident #39 was standing by his/her bed using the urinal. He/She
noticed Resident #3 in Resident #39’s bed, and asked Resident #39 what Resident #3 was
doing there. Resident #39 said I don’t know. I want him/her out of my bed. When he/she
asked Resident #3 what he/she was doing there, Resident #3 said he/she didn’t know. Both
residents denied anything inappropriate happening. They couldn’t explain why Resident #3’s
pants were down to his/her ankles;
-Resident #3 is confused;
-Resident #39 is not confused;
-Staff immediately separated the two residents;
-Resident #3 wanders down Resident #39’s hall and into resident rooms;
-He/She asked the day shift nurse to notify the residents’ Durable Power of Attorney
(DPOA)/responsible party;
-Resident #3’s responsible party said he/she was not upset by it. He/she knew exactly what
happened;
-Staff notified Resident #39’s family member;
-He/She reported the incident to the DON and Social Services;
-He/She told the DON that Resident #3 was in Resident #39’s bed naked;
-He/She didn’t remember if the physician was notified;
-The ADON reviewed notes in front of this writer and said he/she did not see any
documentation that showed the doctor was notified, but it should be documented if the
doctor was notified;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
-They should have notified the physician.
-He/She didn’t know if anyone reported the incident to the administrator;
-He/She said he/she did not make any notes about the incident;
-CNA F was one of the aides present;
-CNA F helped get the Resident #3 out of Resident #39’s bed;
-Staff reported Resident #3 was sleepy and not happy about having to get out of bed;
-Resident #39 doesn’t typically take his/her clothes off;
-He/She interviewed the night shift CNA;
-He/She did not talk to CNA G who was the CNA on the other hall.
-He/She told the charge nurse to watch Resident #3 closely and to prevent Resident #39
from wandering down that hall;
-He/She instructed Resident #39 to call if Resident #3 wandered down the hall or into
his/her room;
-He/She didn’t document what his/her investigation consisted of;
-Typically the DON or Social Services report to state agency;
-He/She told the DON that day, 10/8/18, about the incident;
-He/She was not aware of any further incidents between the two residents;
-He/She had never seen Resident #39 be inappropriate with any other residents;
-They don’t take statements from staff interviewed;
-The nurse said there was no bruising, no redness and no semen;
-They said Resident #39 was facing the bed and Resident #3 was in the bed lying in bed in
a normal position;
-The urinal was at the resident’s bedside on the trash can and there was urine in it;
-The call light was not on;
-According to the night shift CNA, he/she thought the last time he/she checked that room
was around 4:00 A.M.
During an interview on 1/11/19 at 2:00 P.M., CNA F said:
-He/She was working on Resident #39’s hall during the incident on 10/8/18;
-The charge nurse was the one who found the residents;
-He/She did not see what happened;
-The charge nurse told him/her that Resident #3 was in Resident #39’s bed with his/her
pants down and that Resident #39 was standing by the bed naked;
-The charge nurse told him/her that Resident #39 said nothing happened.
During an interview on 1/11/19 at 2:20 P.M., LPN C said:
-He/She went into Resident #39’s room on 10/8/18;
-Nothing was going on when he/she walked into Resident #39’s room;
-It was very dark in the room and he/she did not notice Resident #3 was there until he/she
sat some supplies on the bed and felt Resident #3’s leg;
-Resident #3 was lying in Resident #39’s bed;
-Resident #3 was on his/her back with his/her pants down to his/her ankles;
-Resident #39 was standing next to the bed and was naked;
-Resident #39 told him/her that he/she was trying to use his/her urinal, which was on on
his/her bedside table;
-Resident #3 was almost asleep;
-He/She did not assess Resident #3;
-He/She tried to get Resident #3 to get out of Resident #39’s bed and Resident #3 was very
argumentative;
-He/She assisted Resident #3 in pulling his/her pants up and got him/her out of Resident
#39’s room;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-Resident #3 and Resident #39 said nothing happened, so he/she did not assess Resident #3;
-Another staff member took Resident #3 to his/her room.
-He/She thinks he/she notified both the ADON and the DON regarding the incident;
-He/She completed an incident report;
-He/She told the day shift nurse in report about the incident and that the family and
physician still needed to be notified;
-He/She asked staff to keep an eye on both residents;
-He/She did not talk to any other residents about whether they had any problems with any
resident(s) wandering into their rooms.
During an interview on 1/11/19 at 3:00 P.M., LPN D said:
-He/She was told by the night shift charge nurse about the incident on 10/8/18;
-He/She was told to pass on to staff to keep Resident #3 off of Resident #39’s hall;
-They try to keep Resident #3 up toward the front of the hall;
-He/She talked to the ADON and DON about what needed to be done regarding the incident on
10/8/18;
-Resident #3 said nothing happened;
-He/she didn’t know he/she was supposed to call the doctor (that was not passed down from
the night shift as something that still needed to be done);
-He/She called both families.
During an interview on 1/11/19 at 3:20 P.M., the resident said:
-Another resident (Resident #3) came into his/her room early one morning around 4:00 A.M.
or 4:30 A.M. and woke him/her up;
-It scared him/her when the other resident came into his/her room;
-The other resident went over by his/her window;
-He/She asked the other resident what he/she was doing;
-He/She told the other resident he/she was in the wrong place;
-He/She told the other resident that he/she thought he/she needed to leave;
-The other resident got into his/her bed;
-He/She then got out of his/her bed by himself/herself;
-A nurse came in to check his/her blood and told the other resident he/she needed to go to
his/her own room;
-The nurse asked him/her if anything happened between him/her and the resident that came
into his/her room and he/she told the nurse no;
-The other resident tried to come into his/her room about a week after the first incident,
but he/she had not tried to come in his/her room since then.
During a telephone interview on 1/15/19 at 5:58 P.M., CNA G said:
-He/she works the night shift;
-During the 10/8/18 incident he/she first saw Resident #3 at the nurse’s station;
-The charge nurse asked him/her to take Resident #3 back to his/her room and ask the
Resident #3 what happened;
-Resident #3 said nothing happened;
-Currently staff try to keep an eye on Resident #3, checking on him/her four times during
every eight hour shift;
-He/she said if he/she were to find residents in inappropriate situations, he/she would
make sure the residents were safe and separate them, then would tell the charge nurse.
During an interview on 1/16/19 at 10:48 AM, the DON said:
-The incident reports are filled out by the nurse and the nurse gives the incident report
to him/her;
-He/She did not read the nurse’s note regarding the incident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-The incident was reported to the ADON, because the ADON was on call;
-He/She would not have expected the ADON to call him/her with what the ADON was told;
-If the ADON knew both residents were naked, the ADON should have called the DON and the
DON would have called the Administrator;
-Family was probably called the next morning;
-Their process for notification of the physician if it’s non-emergent was to send a fax or
call next day;
-They should have called the doctor;
-They were lacking in communication.
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to investigate alleged sexual
activity/abuse (non-consensual sexual contact of any type with a resident) when on two
separate occasions a resident (Resident #3) was found in compromising situations involving
other residents (Resident #39 and Supplemental Resident #29), out of 13 sampled residents
and four supplemental residents sampled for behaviors. The facility census was 49
residents.
Record review of the facility’s undated policy titled Abuse Investigations showed:
-All reports of resident abuse, neglect and injuries of unknown source shall promptly and
thoroughly investigated by facility management;
-Should an incident or suspected incident of resident abuse, mistreatment, neglect or
injury or unknown source be reported, the Administrator and his/her designee, will appoint
a member of management to investigate the alleged incident;
-The individual conducting the investigation will, at a minimum:
–Review the completed Potential Resident Abuse Report Form;
–Review the resident’s medical record to determine events leading up to the incident;
–Interview the person(s) reporting the incident;
–Interview any witnesses to the incident;
–Interview the resident (as medically appropriate);
–Interview the resident’s attending physician as needed to determine the resident’s
current level of cognitive function and medical condition;
–Interview staff member (on all shifts) who have had contact with the resident during the
period of the alleged incident;
–Review all events leading up to the alleged incident;
-Witness reports will be reduced to writing. Witnesses will be required to sign and date
such reports. (Note: A copy of such reports must be attached to the Resident Abuse
Investigation Report Form;)
-The results of the investigation will be recorded on the Resident Abuse Investigation
Report Form;
-The investigator will give a copy of the completed Resident Abuse Investigation Report
Form to the Administrator within two working days of the reported incident;
-The Administrator will provide a written report of the results of all abuse
investigations and appropriate action taken to the state survey and certification agency,
the local police department, the ombudsman, and others as may be required by state and
local laws, within five working days of the reported incident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
Record review of the facility’s undated policy titled Abuse and Neglect: Clinical Protocol
showed the staff, with the physician’s input (as needed), will investigate alleged
occurrences of abuse and neglect to clarify what happened and identify possible causes.
1. Record review of Resident #3’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED].
-Unspecified Dementia with Behavioral Disturbance (Common behavioral disturbances can be
grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep
disorders ([MEDICAL CONDITION], hypersomnia, night-day reversal); psychotic symptoms
(delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual
disinhibition, aggression);
-Altered Mental Status, Unspecified (general changes in brain function, such as confusion,
amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or
place), defects in judgment or thought, unusual or strange behavior, poor regulation of
emotions, and disruptions in perception).
Record review of Resident #3’s Nurse’s Note dated 6/13/18, showed the following:
-At 3:32 A.M., the resident was found in another resident’s room (identified as Resident
#29);
-The resident (Resident #3) was on the bed with Resident #29;
-Staff heard smacking lips;
-Resident #3 was kissing Resident #29;
-Resident #3 stated he/she had known Resident #29 for years;
-Resident #3 was easily redirected to his/her room.
Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, used for care planning
purposes, dated 6/14/18, showed the resident:
-Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively
impaired;
-Stated, during the Resident Mood interview, he/she had little pleasure or interest in
doing things several days, felt down, depressed or hopeless several days, had trouble
falling or staying asleep or sleeping too much, and had trouble concentrating on things
such as reading the newspaper or watching television;
-Had no presence of behaviors during the seven day look-back period and no overall
presence of behaviors;
-Had no presence of wandering;
-Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion,
and eating;
-Needed extensive assistance with personal hygiene and bathing;
-Used a walker for mobility assistance;
-Had frequent pain;
-Received antipsychotic, antidepressant and opioid medications;
-Used a wander/elopement alarm daily.
Record review on 1/11/19 showed the resident did not have a comprehensive Care Plan
completed following his/her most recent admission MDS that included the identified care
assessment areas.
Record review of Supplemental Resident #29’s electronic medical record showed the resident
was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES
REDACTED].
Record review of the resident’s admission MDS, dated [DATE], showed the resident:
-Was cognitively intact;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-Had no hearing or vision impairment;
-Did not display any indicators of mood disturbance;
-Did not have the presence of any behaviors;
-Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and
eating;
-Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene;
-Used a wheelchair for mobility assistance.
Record review on 1/11/19 of the incident reports provided showed there was no incident
report for 6/13/18.
During an interview on 1/15/19 at 3:30 P.M., the Director of Nursing (DON) and Assistant
Director of Nursing (ADON) said they were not aware of the incident that occurred on
6/13/18 between Resident #29 and Resident #3. The night nurse did not fill out an incident
report or tell the DON or the ADON about the incident, therefore there was no
investigation.
2. Record review of Resident #39’s initial care plan dated 7/31/18 showed the resident:
-Used a walker;
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s admission MDS dated [DATE] showed the following staff
assessment of the resident:
-Cognitively intact;
-Did not have any hearing or vision impairment;
-Had clear speech;
-Understands others and others understand him/her;
-Did not display any behaviors;
-Used a walker;
-The most assistance he/she required during the look-back period was:
–Limited assistance of one person with moving around in his/her bed;
–Limited assistance of two people with dressing;
–Supervision when walking and transferring from one surface to another such as from
standing to sitting on his/her bed or chair.
Record review of the resident’s medical records showed there was not a comprehensive care
plan for the resident.
Record review of the resident’s nurses’ notes showed the resident:
-Reached between a CNA’s legs three times on 8/12/18;
-Was verbally inappropriate with staff on 8/12/18;
-Walked by an employee and brushed him/her on his/her bottom on 8/14/18;
-Told an employee he/she was going to grab their butt on 8/14/18;
-Touched the stomach and breasts of an employee on 8/17/18.
Record review of the resident’s nurse’s note, dated 10/8/18 showed:
-The nurse went into the resident’s room about 5:00 A.M.;
-The resident was standing next to his/her bed naked;
-The nurse found Resident #3 laying on his/her back in the resident’s bed with his/her
pants down around his/her ankles;
-The nurse asked the resident what was going on and he/she said that he/she did not know;
-The resident told the nurse that nothing happened between him/her and Resident #3;
-Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between
the two residents;
-Resident #3 initially refused to leave the resident’s room, but staff were able to remove
Resident #3 from the resident’s room.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
Record review of the incident report dated 10/8/18 at 5:00 A.M. showed:
-Resident #3 was found in Resident #39’s room;
-Resident #3 was lying on Resident #39’s bed with his/her pants pulled down to his/her
ankles;
-Resident #39 was naked and standing next to Resident #3;
-Resident #39 denied touching Resident #3;
-Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between
the two residents;
-Notification of the physician was left blank;
-There was no documentation regarding whether the incident was reported to the
Administrator;
-The incident was reported to the ADON;
-The incident report was signed by Licensed Practical Nurse (LPN) C.
Record review of the resident’s significant change MDS dated [DATE], showed the staff
assessment of the resident showed he/she was cognitively intact.
During an interview on 1/11/19 at 10:05 A.M., Licensed Practical Nurse (LPN) A said:
-LPN C wrote the note about the 10/8/18 incident between the resident and another resident
of the opposite sex who resided on a different hall;
-He/She was told that nothing happened.
During an interview on 1/11/19 at 10:30 A.M., the Wound Nurse said the 10/8/18 incident
was reported to the DON.
During an interview on 1/11/19 at 10:52 A.M. the DON said:
-Resident #3 is happily confused;
-Resident #3 roams and wanders into rooms;
-All that was reported to him/her regarding the incident that occurred on 10/8/18, where
Resident #3 was found in Resident #39’s bed, was that the Resident #39 went to go to bed
and Resident #3 was in his/her bed;
-LPN C, who was the charge nurse at the time of the incident, said Resident #39 was naked
and they weren’t sure what happened;
-They didn’t do a full investigation, because LPN C thought Resident #3 only wandered into
Resident #39’s room.
During an interview on 1/11/19 10:57 A.M., the Administrator said:
-He/She knew of the incident between Resident #3 and Resident #39;
-He/She didn’t know exactly what happened;
-He/She must not have known the full extent of the occurrence;
-A full investigation should have been done and it should have been reported to him/her
immediately.
During an interview on 1/11/19 at 11:18 A.M., the ADON said:
-The night shift charge nurse called him/her at around 5:00 A.M. and the charge nurse
reported he/she went to Resident #39’s room to check his/her blood sugar that morning.
When he/she walked in Resident #39 was standing by his/her bed using the urinal. He/She
noticed Resident #3 in Resident #39’s bed, and asked Resident #39 what Resident #3 was
doing there. Resident #39 said I don’t know. I want him/her out of my bed. When he/she
asked Resident #3 what he/she was doing there, Resident #3 said he/she didn’t know. Both
residents denied anything inappropriate happening. They couldn’t explain why Resident#3’s
pants were down to his/her ankles;
-Resident #3 is confused;
-Resident #39 is not confused;
-Staff immediately separated the two residents;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-Resident #3 wanders down Resident #39’s hall and into residents’ rooms;
-He/She asked the day shift nurse to notify the residents’ Durable Power of Attorney
(DPOA)/responsible party;
-Resident #3’s responsible party said he/she was not upset by it. He/She knew exactly what
happened;
-They notified Resident #39’s family member;
-He/She reported the incident to the DON and Social Services;
-He/She told the DON that Resident #3 was in Resident #39’s bed naked;
-He/She didn’t remember if the physician was notified;
-The ADON reviewed notes in front of this writer and said he/she did not see any
documentation that showed the doctor was notified;
-He/She didn’t know if anyone reported the incident to the administrator;
-He/She said he/she did not make any notes about the incident;
-CNA F was one of the aides present;
-CNA F helped get the Resident #3 out of Resident #39’s bed;
-Staff reported Resident #3 was sleepy and not happy about having to get out of bed;
-Resident #39 doesn’t typically take his/her clothes off;
-He/She interviewed the night shift CNA;
-He/She did not talk to CNA G who was the CNA on the other hall;
-He/She told the charge nurse to watch Resident #3 closely and to prevent Resident #39
from wandering down that hall;
-He/She instructed Resident #39 to call if Resident #3 wandered down the hall or into
his/her room;
-He/She tells staff to chart on behaviors, aggression and wandering;
-He/She didn’t document what his/her investigation consisted of;
-Typically the DON or Social Services report to state agency;
-He/She told the DON that day, 10/8/18, about the incident;
-He/She was not aware of any further incidents between the two residents;
-He/She had never seen Resident #39 be inappropriate with any other residents;
-They don’t take statements from staff interviewed;
-The nurse said there was no bruising, no redness and no semen;
-They said Resident #39 was facing the bed and Resident #3 was in the bed lying in bed in
a normal position;
-The urinal was at the resident’s bedside on the trash can and there was urine in it;
-The call light was not on;
-According to the night shift CNA, he/she thought the last time he/she checked that room
was around 4:00 A.M.
During an interview on 1/11/19 at 2:00 P.M., CNA F said:
-He/She was working on Resident #39’s hall during the incident on 10/8/18;
-The charge nurse was the one who found the residents;
-He/She did not see what happened;
-The charge nurse told him/her that Resident #3 was in Resident #39’s bed with his/her
pants down to his/her ankles and that Resident #39 was standing by the bed naked;
-The charge nurse told him/her that Resident #39 said nothing happened;
-Resident #39 sleeps with pull-up briefs, but takes them off at night at times;
-He/She saw Resident #3 about half an hour before the incident;
-Resident #3 roams around a lot at night and it is hard for staff to keep an eye on
him/her;
-The charge nurse told him/her to keep an eye on Resident #3 after the incident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-Resident #3 has gone into other rooms before;
-Resident #3 climbs into empty beds at times.
During an interview on 1/11/19 at 2:20 P.M., LPN C said:
-He/She went into Resident #39’s room on 10/8/18;
-Nothing was going on when he/she walked into Resident #39’s room;
-It was very dark in the room and he/she did not notice Resident #3 was there until he/she
sat some supplies on the bed and felt Resident #3’s leg;
-Resident #3 was lying in Resident #39’s bed;
-Resident #3 was on his/her back with his/her pants down to his/her ankles;
-Resident #39 was standing next to the bed and was naked;
-Resident #39 told him/her that he/she was trying to use his/her urinal which was on on
his/her bedside table;
-Resident #3 was almost asleep;
-He/She did not assess Resident #3;
-He/She tried to get Resident #3 to get out of Resident #39’s bed and Resident #3 was very
argumentative;
-He/She assisted Resident #3 in pulling his/her pants up and got him/her out of Resident
#39’s room;
-Resident #3 and Resident #39 said nothing happened, so he/she did not assess Resident #3;
-Another staff member took Resident #3 to his/her room;
-He/She thinks he/she notified both the ADON and the DON regarding the incident;
-He/She completed an incident report;
-He/She told the day shift nurse in report about the incident and that the family and
physician still needed to be notified;
-He/She asked staff to keep an eye on both residents;
-He/She did not talk to any other residents about whether they had any problems with any
resident(s) wandering into their rooms;
-The ADON and/or DON do the investigations.
During an interview on 1/11/19 at 3:00 P.M., LPN D said:
-He/She was told by the night shift charge nurse (LPN C) about the incident on 10/8/18;
-He/She didn’t know he/she was supposed to call the doctor;
-He/She called both families;
-He/She was told to pass on to staff to keep Resident #3 off of Resident #39’s hall;
-They try to keep Resident #3 up toward the front of the hall;
-He/She talked to the ADON and DON about what needed to be done regarding the incident and
he/she was told to call the families and keep an eye on Resident #3;
-He/She made sure no blood was in Resident #3’s brief;
-He/She didn’t notice any bruising or redness around the inside of the resident’s thighs
when Resident #3’s brief was checked;
-Resident #3 said nothing happened.
During an interview on 1/11/19 at 3:20 P.M., the resident said:
-Another resident (Resident #3) came into his/her room one early one morning around 4:00
A.M. or 4:30 A.M. and woke him/her up;
-It scared him/her when the other resident came into his/her room;
-The other resident went over by his/her window.
-He/She asked the other resident what he/she was doing;
-He/She told the other resident he/she was in the wrong place;
-He/She told the other resident that he/she thought he/she needed to leave;
-The other resident got into his/her bed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-He/She then got out of his/her bed by himself/herself;
-A nurse came in to check his/her blood and told the other resident he/she needed to go to
his/her own room;
-The nurse asked him/her if anything happened between him/her and the resident that came
into his/her room and he/she told the nurse no.
During a telephone interview on 1/15/19 at 5:58 P.M., CNA G said:
-He/She works the night shift;
-During the 10/8/18 incident he/she first saw Resident #3 at the nurses’ station;
-The charge nurse asked him/her to take Resident #3 back to his/her room and ask Resident
#3 what happened;
-Resident #3 said nothing happened;
-Currently staff try to keep an eye on Resident #3, checking on him/her four times during
every eight hour shift;
-He/she said if he/she were to find residents in inappropriate situations he/she would
make sure the residents were safe and separate them.
During an interview on 1/16/19 at 10:48 AM, the DON said:
-The incident reports are filled out by the nurse and the nurse gives the incident report
to him/her.
-He/she did not read the nurse’s note regarding the incident.
-The incident was reported to the ADON, because the ADON was on call.
-He/she would not have expected the ADON to call him/her with what the ADON was told.
-He/she was responsible for investigations.
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the Minimum Data Set
(MDS a federally mandated assessment instrument completed by facility staff, used for care
planning) represented an accurate picture of the resident’s status during the observation
period (also known as the look-back period – the time period over which the resident’s
condition or status is captured) for one sampled resident (Resident #3), out of 13 sampled
residents. The facility census was 49 residents.
1. Record review of Resident #3’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. His/Her [DIAGNOSES REDACTED].
-Dementia (the loss of cognitive functioning: thinking, remembering, and reasoning; and
behavioral abilities to such an extent that it interferes with a person’s daily life and
activities);
-Major [MEDICAL CONDITION] (a serious mood disorder that causes a persistent feeling of
sadness and loss of interest; and handle daily activities, such as sleeping, eating, or
working);
-Altered Mental Status, Unspecified (general changes in brain function, such as confusion,
amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or
place), defects in judgment or thought, unusual or strange behavior, poor regulation of
emotions, and disruptions in perception);
-Anxiety Disorder (a feeling of worry, nervousness, or unease, typically about an imminent
event or something with an uncertain outcome).
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
resident had nightly behavioral episodes (MONTH) 9 – 14, during the MDS 7-day assessment
look back period:
-On 6/9/18 staff documented one episode of the resident having [MEDICAL CONDITION] (a
sleep disorder that is characterized by difficulty falling and/or staying asleep);
-On 6/10/18 staff documented one episode of the resident having [MEDICAL CONDITION];
-On 6/11/18 staff documented three episodes of the resident having [MEDICAL CONDITION];
-On 6/12/18 staff documented three episodes of the resident having [MEDICAL CONDITION];
-On 6/13/18 staff documented four episodes of the resident having [MEDICAL CONDITION];
-On 6/14/18 staff documented four episodes of the resident having [MEDICAL CONDITION].
Record review of the resident’s Behavior Monthly Flow Sheets showed:
-Forty-one behavior codes were on the list staff could choose from, which included
wandering.
-Episodes of wandering were not listed on the flow sheets.
-Staff documented episodes from only three (anxiety, depressed/withdrawn, and [MEDICAL
CONDITION]) of the forty-one behavior codes that were listed to choose from.
Record review of the resident’s Nurses’ Notes, dated (MONTH) (YEAR), showed the following
incidents that occurred during the MDS 7-day look back period:
-On 6/13/18, at 3:32 A.M., the resident was found in another resident’s room. The resident
was on the bed kissing the other resident;
-On 6/13/18, at 3:37 A.M., the resident was found in the room of another resident of the
opposite sex, I was just trying to get him/her up;
-On 6/13/18, at 4:50 A.M., the nurse documented the resident was up three times after
midnight and was assisted back to his/her room, re-orienting him/her to time and place.
Record review of the resident’s most recent Admission MDS, dated [DATE], showed the
resident:
-Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively
impaired;
-Had no presence of behaviors during the seven day look-back period and no overall
presence of behaviors;
-Had no presence of wandering;
-Used a wander/elopement alarm daily.
Record review of the resident’s Behavior Monthly Flow Sheets showed there was no record
for the month of (MONTH) (YEAR).
Record review of the resident’s Nurses’ Notes, dated (MONTH) (YEAR), showed the following
incidents that occurred during the MDS 7-day look back period:
-On 9/9/18 at 2:59 A.M., the nurse documented he/she had redirected the resident several
times that night; the resident was confused, irritable, wandering down Shady Hall (not
his/her hall) going into other residents’ rooms. The resident was given pain medication
and administered a topical pain cream at the beginning of the night shift, but said
neither helped;
-On 9/13/18 at 2:43 A.M., the nurse documented the resident had been up ambulating in the
hall several times during the night.
Record review of the resident’s Quarterly MDS, dated [DATE], showed the resident:
-Had a BIMS of 5, meaning he/she was severely cognitively impaired;
-Had no presence of wandering during the seven day look-back period;
-Had no presence of behaviors;
-Received antipsychotic, antidepressant and opioid medications;
-Used a wander/elopement alarm daily.
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
resident had behavior episodes during the MDS look back period that included:
-26 Episodes of anxiety;
-28 Episodes of [MEDICAL CONDITION].
Record review of the resident’s Nurses’ Notes, dated (MONTH) (YEAR), showed the following
incidents that occurred during the MDS 7-day look back period:
-On 12/8/18 at 1:27 A.M., the nurse documented the resident was awake so far that shift
sitting on his/her walker seat in the hallway. The resident was attempting to move another
resident’s wheelchair around in the hall. The nurse was unable to redirect the resident at
that time;
-On 12/10/18 at 5:32 A.M., the resident was found in the bathroom in another resident’s
room with his/her pants down around his/her hips. The resident was reoriented to the time
and place, reminding him/her that that was not his/her room. The resident said I know, I’m
just checking it out. The resident was assisted out of the bathroom and back to his/her
room;
-On 12/11/18 at 2:34 A.M., the resident continuously moved up and down the hallway sitting
on his/her walker seat, at times walking while pushing the walker. The resident came up to
the nurses’ station asking the nurse can you tell me where I can find some food? The
resident was directed to dining room snack area. The nurse attempted several times to
redirect the resident to time and place. The resident continued to pace around the
facility with his/her walker, at times moving in and out of other residents’ rooms;
-On 12/13/18 at 12:22 A.M., the resident was wheeling himself/herself up and down the hall
taking things off the aide’s cart and taking things off another resident’s wheelchair. The
aid asked the resident to leave the other resident’s things alone and the resident told
the aide to kiss his/her ass. The nurse asked the resident to go to his/her room, so that
he/she could administer pain medication and rub cream on the resident’s legs. The resident
was not cooperative with the nurse and stated he/she was not going to bed. The television
was turned on for the resident and the resident was offered coffee to try and make him/her
comfortable. The resident said he/she did not like being bossed around;
-On 12/15/18 at 5:46 A.M., the nurse documented the resident had been up several times
throughout the night, drinking coffee and getting into the cart in the hallway.
Record review of the resident’s quarterly MDS, dated [DATE], in progress during the
facility’s annual survey, showed the resident:
-Had a BIMS of 6, meaning he/she was severely cognitively impaired;
-Had no overall behavioral symptoms;
-Had no presence of wandering and no behaviors affecting others.
During an interview on 1/11/19 at 9:30 A.M., the MDS Coordinator said when completing a
resident’s MDS information is obtained from:
-The resident’s record;
-Through interviews and observations of the resident;
-Nurses that work with the residents.
During an interview on 1/15/19 at 10:00 A.M., the MDS Coordinator said he/she would be
submitting MDS corrections.
During an interview on 1/16/19 at 10:45 A.M., the Director of Nursing (DON) said:
-The Assistant Director of Nursing (ADON) looks at the behavior sheets each month;
-The sheets should be passed on to the MDS Coordinator for review during the MDS process
period;
-He/She expected the MDS to accurately reflect the resident’s status.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan for each resident that includes the instructions needed to provide
effective and person-centered care of the resident that meet professional standards of
quality care for one sampled resident (Resident #36) and failed to provide the resident or
the resident’s responsible party with a copy of the baseline care plan within 48 hours of
admission for two sampled residents (Residents #28 and #39) out of 13 sampled residents
and one closed record (Resident #50) out of two sampled closed records. The facility
census was 49 residents.
Record review of the facility’s undated policy Care Plans-Preliminary, showed:
-A preliminary plan of care to meet the resident’s immediate needs shall be developed for
each resident within 48 hours of admission by a Registered Nurse;
-The interdisciplinary team will review the attending physician’s orders [REDACTED].
-The preliminary care plan will be used until the staff can conduct the comprehensive
assessment and develop an interdisciplinary care plan.
1. Record review of Resident #36’s medical record showed he/she was admitted to the
facility on [DATE] and did not have a baseline care plan for review.
During an interview on 1/11/19 at 11:45 A.M., the Minimum Data Sheet (MDS-a federally
mandated assessment tool completed by facility staff for care planning) Coordinator/Care
Plan Coordinator said:
-He/She had not completed baseline care plans lately;
-He/She knew the baseline care plan was due within the first 48 hours after admission.
During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said:
-The admission nurse was responsible for assessing the new residents and making the
baseline care plan;
-The care plan then goes to the MDS Coordinator;
-He/She tried to get together with the resident’s family to develop the care plan.
2. Record review of Resident #28’s entry tracking form showed the resident was admitted to
the facility on [DATE].
Record review of the resident’s initial care plan showed it was not signed or dated by
staff and it was not documented that the resident received a copy of the initial care
plan.
Record review of the resident’s current profile in the electronic health record showed the
resident was his/her own responsible party.
During an interview on 1/8/18 at 9:31 A.M., the resident said he/she did not receive a
written care plan when he/she first came to the facility.
During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said the lines for the
nurse’s signature and date were missing on the bottom of the form that the resident’s
baseline care plan was on.
3. Record review of Resident #39’s entry tracking record showed the resident was admitted
to the facility on [DATE].
Record review of the resident’s initial care plan dated 7/31/18, showed it was not
documented that the resident or the resident’s responsible party received a copy of the
initial care plan.
During an interview on 1/15/19 at 10:05 A.M., the resident said he/she does not remember
being given a baseline care plan.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
4. Record review of Resident #50’s entry tracking record showed the resident was admitted
to the facility on [DATE].
Record review of the resident’s initial care plan dated 11/17/18, showed it was not signed
by the staff member completing it and it was not documented that the resident’s
responsible party received a copy of the initial care plan.
Record review of the resident’s current profile in the electronic health record showed the
resident had a designated person as his/her responsible party.
5. During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said:
-The charge nurses do baseline care plans;
-He/She does not check to make sure the baseline care plans were completed;
-They do not have a system in place to show if the resident and/or the resident’s
responsible party was given a copy of the baseline care plan.
During an interview on 1/16/19 at 10:48 AM, the DON said:
-The admission nurse was responsible for developing the baseline care plan;
-The MDS Coordinator was responsible for checking to ensure a baseline care plan was
completed;
-The nursing staff should sign and date the baseline care plan and put in the resident’s
medical record;
-They try to meet with family members within 24 hours and give them the baseline care
plan;
-He/She doesn’t know how to show if the resident or the resident’s responsible party
received the baseline care plan within 48 hours.
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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, interview and record review, the facility failed to develop a
comprehensive care plan (written out plan for the care of the resident) for ten sampled
residents (Residents #48, #28, #39, #14, #15, #36, #51, #3, #6, and #29) out of 13 sampled
residents and two closed records (Residents #50 and #57) out of two sampled closed
records. The facility census was 49 residents.
Record review of the facility’s undated policy, Care Plans – Comprehensive, showed:
-An individualized Comprehensive Care Plan includes measurable objectives and timetables
to meet the resident’s medical, nursing, mental and psychological needs is developed for
each resident.
-The resident’s Comprehensive Care Plan is developed within seven days of the completion
of the resident’s comprehensive assessment.
-Care plans are revised as changes in the resident’s condition dictate.
-Care plans are to be reviewed at least quarterly.
Record review of the facility’s undated policy, Quarterly Review of Care Plans, showed:
-Each resident’s care plan shall be reviewed at least quarterly.
-The Care Planning/Interdisciplinary Team is responsible for maintaining care plans on a
current status.
-The Care Planning/Interdisciplinary Team is responsible for the periodic review and
updating of care plans.
Record review of the facility’s undated, Change in a Resident’s Condition or Status policy

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
showed:
-The Nurse Supervisor/Charge Nurse will record in the resident’s medical record
information relative to changes in the resident’s medical/mental condition or status.
1. Record review of Resident #48’s Admission Face Sheet showed that he/she admitted on[DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (a progressive disease that destroys memory and other important
mental functions).
-Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness,
tension, fast heart rate, and breathing difficulty not associated with an apparent
stimulus).
-Major [MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound and
persistent sadness or despair and is frequently accompanied by a loss of interest in
things that were once pleasurable).
Record review of the resident’s Quarterly Minimum Data Set (MDS- a federally mandated
assessment tool completed by the facility staff for care planning), dated 8/26/18 and
11/26/18 showed the resident had:
-[MEDICAL CONDITION].
-Dementia Disorder.
-Anxiety Disorder.
-Major [MEDICAL CONDITION].
-No behaviors.
Record review of resident’s physician’s orders [REDACTED].
Record review of resident’s care plans with a next review date of 1/9/19 showed:
-No care plan for the use of a wander guard.
-No care plan for the risk of elopement.
During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said:
-He/she was not consistently doing the care plans.
-He/she knows they are to be done within 24 hours of admission, quarterly, annually, and
with a significant change in the resident’s condition.
During an interview on 1/16/18 at 10:49 A.M., the Director of Nursing (DON) said the
resident should have a care plan for the use of the wander guard and elopement risk.
2. Record review of resident #57’s closed record Admission Face Sheet showed that he/she
admitted on [DATE] and discharged to the community on 11/16/18 with the following
Diagnoses: [REDACTED].
-Atelectasis (partial or total collapse of a lung or a segment of a lung that was once
expanded).
-Debility (the quality or state of being weak, feeble, or infirm especially physical
weakness).
-Weakness.
Record review of the resident’s Baseline Care Plan (a plan of care to meet the resident’s
immediate needs developed within 48 hours of admission), dated 10/15/18, showed:
-Skilled services due to weakness, [MEDICAL CONDITION], and debility.
-Activities of daily living (ADL) areas as hygiene, toileting, bathing and dressing.
-Safety care for transfers and balance.
Record review of the resident’s Admission MDS, dated [DATE], showed the following
assessment areas marked as care planned:
-ADL function and Rehabilitation potential.
-Pain.
-Falls.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Urinary incontinence/indwelling catheter.
-Pressure ulcer.
-[MEDICAL CONDITION] drug use.
-Dental.
Record review of the resident’s medical records showed no care plans written.
During an interview on 1/16/18 at 10:49 A.M., the DON said:
-A comprehensive care plan should be written within 14 days after the resident’s
admission.
-The care plan should have a next quarterly review or target date.
-The care plan is reviewed each quarter by the MDS coordinator with any new concerns
added.
-If an incident occurs before the next quarter the care plan should be updated
immediately.
-The admitting nurse writes the baseline care plan.
-The MDS coordinator writes the comprehensive care plan and follows up on the care plan
for updates and changes to the resident’s conditions;
-The MDS coordinator is responsible for updating the care plans with necessary changes;
–He/She gets information by what staff tell her;
–He/She looks in the charts, looks at orders;
–He/She talks to residents a lot to find any major changes.
3. Record review of Resident #28’s entry tracking form dated 4/25/18 showed the resident
was admitted to the facility on [DATE].
Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff
assessment of the resident:
-Was cognitively intact;
-Required extensive assistance of at least two people with bed mobility, transferring from
one surface to another, locomotion off the unit and toileting;
-Required extensive assistance of one person for dressing and locomotion on the unit;
-Required set up or supervision for eating and personal hygiene;
-Did not walk;
-Used a wheelchair;
-Had a catheter;
-Was incontinent of bowel;
-Had impaired range of motion of both legs;
-Had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over
a bony prominence, as a result of pressure, or pressure in combination with shear).
Observation on 1/09/19 at 7:40 A.M., showed:
-The resident was asleep in his/her bed;
-A catheter drainage bag was visible;
-The resident’s bed was in a low position.
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said the resident’s care
plan was missed and it was never done.
During an interview on 1/16/19 at 10:48 AM, the DON said:
-Residents’ care plans should be developed within 14 days after the resident’s admission;
-The MDS Coordinator was responsible for developing the comprehensive care plans.
4. Record review of Resident #39’s entry tracking form, dated 7/31/18, showed the resident
admitted to the facility on [DATE].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
Record review of the resident’s significant change MDS, dated [DATE], showed the following
staff assessment of the resident:
-Was cognitively intact;
-Required limited assistance with bed mobility, dressing and toileting;
-Required supervision of transferring from one surface to another, walking, eating and
hygiene;
-Used a walker;
-Was frequently incontinent of bladder.
Observation on 1/7/19 at 11:53 A.M., showed the resident was in a room with a staff member
receiving a shot.
Observation on 1/8/19 at 11:20 A.M., showed the resident had a splint on one of his/her
fingers.
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
During an interview on 1/10/19 at 10:01 A.M., the MDS Coordinator said the resident’s care
plan was missed and it was never done.
During an interview on 1/16/19 at 10:48 AM, the DON said:
-Residents’ care plans should be developed within 14 days after the resident’s admission;
-The MDS Coordinator was responsible for developing the comprehensive care plans.
5. Record review of Resident #50’s entry tracking form, dated 11/17/18, showed the
resident admitted to the facility on [DATE].
Record review of the resident’s admission MDS, dated [DATE], showed the following staff
assessment of the resident:
-Cognitively intact;
-Required extensive assistance of two or more people with bed mobility, transferring from
one surface to another, locomotion off of the unit, dressing and toileting;
-Required extensive assistance of one person with locomotion on the unit and hygiene;
-Required set-up for eating;
-Did not walk;
-Used a wheelchair;
-Was occasionally incontinent of bladder;
-Experienced pain almost constantly;
-Had a pressure ulcer;
-Used oxygen.
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
Record review of the resident’s discharge assessment, dated 12/28/18, showed the resident
was discharged with his/her return anticipated.
During an interview on 1/11/19 at 9:35 A.M., the MDS Coordinator said the resident’s care
plan was missed and it was never done.
During an interview on 1/16/19 at 10:48 A.M., the DON said:
-Residents’ care plans should be developed within 14 days after the resident’s admission;
-The MDS Coordinator was responsible for developing the comprehensive care plans.
6. Record review of Resident #14’s face sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Urinary incontinence (loss of bladder control);
-Falls; and
-Pressure sores (an area of damaged skin caused by staying in one position too long).
Record review of the resident’s quarterly MDS, dated [DATE] showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-Cognitive loss/Dementia;
-Urinary incontinence;
-Falls;
-Pressure sores; and
-The resident was unable to make decisions independently.
Record review of the residents Physician order [REDACTED].
-The resident had an order for [REDACTED].>-The resident had an order for[REDACTED].>-The resident was admitted to hospice care (end of life care) with a[DIAGNOSES REDACTED].
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said:
-He/She was not consistently doing the care plans;
-He/She knows they are to be done within 24 hours of admission, quarterly, annually, and
with a significant change in the resident’s condition.
During an interview on 1/11/19 at 12:02 P.M., the DON said:
-The nurse who admits the resident is responsible for the baseline care plan;
-It goes to the MDS Coordinator to be dated and signed;
-Quarterly care plans should be updated;
-The nurses should tell him/her if there is no care plan.
7. Record review of Resident #15’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted to the facility on [DATE] with the following Diagnoses:[REDACTED].
-Urinary tract infection (an infection in any part of the urinary system);
-Dysphagia (a difficulty swallowing);
-Muscle weakness;
-Chronic pain;
-Hypertension (high blood pressure);
-Pacemaker (a medical device that regulates the electrical system of the heart);
-[MEDICAL CONDITION] (an excess of fluids that causes swelling);
-Heart block (a disease or inherited condition that causes an obstruction in the
electrical system of the heart);
-Peripheral Autonomic [MEDICAL CONDITION] (damage to the nerves that manage every day body
functions).
Record review of the resident’s Quarterly MDS, dated [DATE], showed the following staff
assessment of the resident:
-Was able to make every day decisions about his/her care;
-Required extensive assistance for transferring from one surface to another, toileting,
hygiene, using the sit to stand, transferring from bed to wheel chair;
-Was able to wheel 150 feet in his/her wheel chair;
-Needed supervision, encouragement or cueing during meals.
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
Observation on 1/7/19 at 9:31 A.M. showed the resident:
-Was wearing bilateral hearing aids and was still hard of hearing;
-Was using his/her wheelchair to pedal (move) around the hallway;
-Was missing his/her front teeth.
During an interview on 1/7/19 at 10:15 A.M., the resident said:
-He/She was missing his/her front teeth;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-He/She would like dentures;
-He/She just saw the dentist and the dentist told him/her that he/she is too old to get
dentures.
Observation on 1/9/19 at 7:38 A.M., showed Certified Nursing Assistant (CNA) A and
Certified Medication Technician (CMT) A transferred the resident from his/her bed to
his/her wheelchair using a sit to stand lift (a mechanical machine to move residents).
During an interview on 1/9/19 at 8:38 A.M., the Wound Nurse/Registered Nurse (RN) said:
-The CNA’s were instructed to keep the resident off of his/her buttock;
-A moisture barrier should be applied and his/her buttock should be left opened to air.
During an interview on 1/11/19 at 9:34 A.M. and 10:30 A.M., the Wound Nurse said:
-The resident was prone to wounds related to moisture;
-He/She gave the resident protein bars and snacks everytime he/she went in his/her room,
to increase healing.
-The resident had signed a waiver that he/she refused a special diet;
-The resident was noncompliant and would not lay down after meals;
-The resident was incontinent;
-The resident was changed after every meal;
-The resident refused to use a seat cushion in his/her wheelchair;
-All wound related information and issues should be care planned;
-The Wound Nurse could not find a care plan for (YEAR) or 2019.
During an interview on 1/11/19 at 9:51 A.M., the Social Services Director (SSD) said:
-The dental service was at the facility on 1/7/19;
-The Dental hygienist saw the resident and verified he/she wanted to get his/her teeth
fixed;
-The resident was put on the list to see the dentist for treatment next month;
-He/She verified there was no care plan for the resident.
During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said:
-He/She was not consistently doing the care plans;
-He/She knows they are to be done within 24 hours of admission, quarterly, annually, and
with a significant change in the resident’s condition.
During an interview on 1/11/19 at 12:02 P.M., the DON said:
-The nurse who admits the resident is responsible for the baseline care plan;
-It goes to the MDS Coordinator to be dated and signed;
-Quarterly careplans should be updated;
-The nurses should tell him/her if there was no care plan.
8. Record review of Resident #36’s face sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Neoplasm of adrenal gland and kidney (cancer);
-Increased level of lactic acid (an increased level related to heart failure, severe
infection or shock);
-[MEDICAL CONDITION] (a type of chest pain caused by reduced blood flow to the heart);
-Urinary tract infection (an infection in the urinary system);
-Kidney failure (longstanding disease of the kidney);
-Abdominal pain;
-Brain disorder (diseases that cause your brain and nerves to deteriorate over time);
-Muscle weakness;
-Back pain;
-Hematuria (blood in the urine);
-History of [MEDICAL CONDITION] embolism (one or more arteries in the lungs are blocked by
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
a blood clot);
-[MEDICAL CONDITION] (conditions which include diseased vessels, structural problems, and
blood clots);
-[MEDICAL CONDITION]-resistant Staphylococcus aureus (a group of hard to treat bacteria);
-Constipation;
-Diabetes (a group of diseases that result in too much sugar).
Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff
assessment of the resident:
-He/She was able to make decisions independently;
-Required limited assistance with mobility, transferring, locomotion on the unit, getting
dressed, toileting, and hygiene;
-Required set up help for eating and drinking;
-Required the use of a walker or wheelchair;
-Had a catheter;
-Was incontinent of bowel;
-Was on scheduled and as needed pain medication;
-Required non medication pain interventions;
-Was almost constantly in pain.
Record review of the resident’s medical record showed there was no comprehensive care plan
for the resident.
During an interview on 1/8/19 at 9:42 A.M., the resident said:
-He/She had glasses, but needed new ones;
-The Veteran’s Administration (VA) would not pay for them, because he/she owned a house
and did not qualify financially;
-He/She had missing teeth, would like dentures and would wear them;
-The resident saw the dentist and said it would not be feasible to get dentures since
he/she was on hospice;
-The physicians gave him/her two to six months to live in November;
-The resident went on Hospice for pain relief;
-He/She had general discomfort in his/her neck, spine, and knees;
-When the pain gets to a six on a zero to 10 scale he/she will ask for pain medication and
it will knock it down to a four.
During an interview on 1/10/19 at 9:52 A.M., the resident said:
-He/She would get a shower today and liked to have catheter care done then;
-He/She had a urinary tract infection when he/she came to the facility from the VA
Hospital;
-A course of antibiotics was given then another half course was given which cleared the
UTI up;
-The resident said he/she only chooses to have a dignity bag when he/she leaves the
facility, because everyone knows what it is anyway.
During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said:
-He/She was not consistently doing the care plans;
-He/She knows they are to be done within 24 hours of admission, quarterly, annually, and
with a significant change in the resident’s condition.
During an interview on 01/11/19 at 12:02 P.M., the DON said:
-The nurse who admits the resident is responsible for the baseline care plan;
-It goes to the MDS Coordinator to be dated and signed;
-Quarterly careplans should be updated;
-The nurses should tell me if there is no care plan.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
9. Record review of Resident #51’s face sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Generalized [MEDICAL CONDITION] (excess fluid that causes swelling);
-Lyme Disease (a tick-borne illness).
Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff
assessment of the resident:
-Was not cognitively intact;
-Had delusions;
-Required extensive assistance for mobility, transfers, dressing, toileting, hygiene, and
bathing;
-Required supervision when eating;
-Required a wheelchair for mobility;
-Was frequently incontinent of urine and stool.
Record review of the resident’s progress notes, dated 12/31/18, showed:
-The resident attempted to climb out of bed several times throughout night;
-The resident was assisted up to the wheelchair, watching television, rambling on mostly
nonsense;
-Staff were unable to redirect him/her;
-A personal alarm was in place.
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said:
-He/She was not consistently doing the care plans;
-He/She knows they are to be done within 24 hours of admission, quarterly, annually, and
with a significant change in the resident’s condition.
During an interview on 1/11/19 at 12:02 P.M., the DON said:
-The nurse who admitted the resident was responsible for the baseline care plan;
-It goes to the MDS Coordinator to be dated and signed;
-Quarterly careplans should be updated;
-The nurses should tell him/her if there is no care plan.
During an interview on 1/15/19 at 1:25 P.M., the Charge nurse/Licensed Practical Nurse
(LPN)said:
-The resident was on Hospice (end of life care);
-The resident had increased behaviors;
-The resident was non compliant;
-The staff needed to monitor the resident for safety awareness;
-The resident sometimes tried to get out of bed and had a bed alarm and two side rails up;
-The resident was vulgar and had been hateful;
-Staff was told to redirect the resident and to remove him/her from the situation when
he/she had behaviors;
-The charge nurse was not able to find a care plan for this resident.
Observation on 1/15/19 at 1:50 P.M., showed the resident:
-Was in his/her room sitting in wheelchair;
-Had a Personal alarm attached to the wheelchair;
-Was able to only tell me his/her name and started to talk about his/her stuffed cats;
-Had one side rail up on the bed; and
-Had a bed alarm.
During an interview on 1/15/19 at 2:25 P.M., Certified Medication Technician (CMT) A said:
-The resident can be verbally abusive at times;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-He/She is redirected when he/she has behaviors;
-The resident tries to get out of bed and has a bed alarm but doesn’t try to get out of
the wheelchair.
Surveyor: Gray, Laura
10. Record review of Resident #3’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. Record review of the resident’s most recent
Admission MDS, dated [DATE], showed the resident:
-Had a BIMS (brief mental interview status) of 3, meaning he/she was severely impaired
cognitively;
-Had no presence of behaviors during the seven day look-back period and no overall
presence of behaviors;
-Had no presence of wandering;
-Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion,
and eating;
-Needed extensive assistance with personal hygiene and bathing;
-Used a walker for mobility assistance;
-Had frequent pain;
-Received antipsychotic, antidepressant and opioid medications;
-Used a wander/elopement alarm daily.
Record review showed the resident did not have a comprehensive care plan completed
following his/her most recent admission MDS that included identified care assessment
areas.
Record review of the resident’s MDS tracking record showed the resident was admitted to
the facility 1/7/2018 and discharged [DATE], return not anticipated, and readmitted to the
facility 6/7/18.
Record review of the resident’s care plan showed the last care plan review was dated
2/2/18, prior to the resident’s latest admitted .
11. Record review of Resident #6’s electronic health record showed the resident was most
recently admitted to the facility on [DATE].
Record review of the resident’s most recent Admission MDS, dated [DATE], showed the
resident:
-Had a BIMS of 8, meaning he/she was moderately cognitively impaired;
-Was tired and had trouble concentrating (12-14 days), nearly every day during the
assessment period;
-Had delusions;
-Rejected care one to three days during the assessment period;
-Needed only supervision, encouragement or cueing with walking, locomotion, dressing,
eating, toilet use and personal hygiene;
-Needed extensive assistance with bathing;
-Used a walker and wheelchair for mobility assistance;
-Was continent of bowel and bladder;
-Had almost constant pain;
-Used tobacco;
-Received antianxiety, antibiotic, diuretic and opioid medications.
Record review showed the resident did not have a comprehensive care plan completed
following his/her admission MDS.
12. Record review of Supplemental Resident #29’s electronic medical record showed the
resident was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES
REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
Record review of the resident’s admission MDS, dated [DATE], showed the resident:
-Was cognitively intact;
-Had no hearing or vision impairment;
-Did not display any indicators of mood disturbance;
-Did not have the presence of any behaviors;
-Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and
eating;
-Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene;
-Used a wheelchair for mobility assistance;
-Had an indwelling catheter;
-Was continent of bowel.
Record review showed the resident did not have a comprehensive care plan completed
following his/her most recent admission MDS, that included the identified care assessment
areas.
During an interview on 1/11/19 at 9:30 A.M. the MDS Coordinator said:
-The Interdisciplinary Team (IDT) meets to discuss care plans;
-The team consist of Social Services, the DON, ADON, Charge Nurse, Medicare Nurse, and the
main direct care giver;
-The team meets to discuss cares and situations related to each resident;
-He/She also talks to the physician during rounds or Quality Assurance Meetings;
-He/She is responsible for making sure care plans are done;
-He/She has gotten behind with care plans;
-Comprehensive care plans should include the care assessments areas and be completed
within seven days after the comprehensive MDS is completed.
During an interview on 1/16/19 at 10:45 A.M., the DON said:
-The DON, ADON, MDS Coordinator, Social Services, family members and the resident
participate in care plan meetings;
-He/She thought the care plan were getting done;
-He/She expected each resident to have a comprehensive care plan completed.
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to update a care plan (written
out plan for the care of the resident) to reflect the resident’s current status for one
sampled resident (Resident #23) out of 13 sampled residents. The facility census was 49
residents.
Record review of the facility’s undated, Care Plans-Comprehensive Policy showed:
-Care plans are revised as changes in the resident’s condition dictate.
-Care plans are reviewed at least quarterly.
Record review of the facility’s undated, Change in a Resident’s Condition or Status policy
showed:
-The Nurse Supervisor/Charge Nurse will record in the resident’s medical record
information relative to changes in the resident’s medical/mental condition or status.
-If a significant change in the resident’s physical or mental condition occurs, a
comprehensive assessment of the resident’s condition will be conducted.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 28)
1. Record review of resident #23’s Admission Face Sheet showed he/she admitted on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED].
-Dementia (A general term for a decline in mental ability resulting in memory loss, and
other mental abilities severe enough to interfere with daily functioning) with behavioral
disturbance.
-History of falling.
-Difficulty in walking.
-Generalized muscle weakness.
-[MEDICAL CONDITION] (A chronic nervous disease characterized by a fine slowly spreading
tremor, muscle weakness, muscle stiffness and a peculiar gait).
Record review of the resident’s Care Plan, dated 12/13/17, showed he/she was at risk for
falls and required staff assistance to stand and transfer. Review showed staff had the
following interventions in place:
-Encourage him/her to use the arm-rest on his/her wheelchair when wanting to lean.
-Encourage him/her to sit up-right in his/her chair.
-Offer him/her to rest in bed or a recliner.
-Personal alarm to be on at all times due to fall risk.
-fell out of his/her wheelchair.
-Striking his/her head.
-Required stitches.
-Monitor when he/she is leaning forward in his/her chair.
-Offer him/her to rest in bed or a recliner.
Record review of the resident’s Fall Incident Report, dated 5/3/18 at 11:00 P.M., showed
the resident:
-Had an unwitnessed fall.
-Was lying on his/her left side next to the bed.
-Was not wearing his/her personal alarm.
-Had no noted injuries.
Record review of the resident’s Nurse’s Note, dated 5/4/18 at 3:28 A.M., showed the
resident:
-Had an unwitnessed fall.
-Was lying on his/her left side next to the bed.
-Was not wearing his/her personal alarm.
-Had no noted injuries.
-Had personal alarm turned back on.
Record review of the resident’s Fall Incident Report, dated 11/22/18 at 6:40 P.M., showed:
-The resident had an unwitnessed fall.
-The resident was on his/her hands and knees in front of his/her wheel chair in the dining
room.
-The resident had no noted injuries.
Record review of the resident’s Fall Incident Report, dated 12/30/18 at 7:09 P.M., showed:
-Staff pushed the resident in his/her wheelchair towards the bed.
-The resident leaned his/her head down and bumped the side rail of the bed.
-The resident had no injuries noted.
Record review of the resident’s Nurse’s Note, dated 12/30/18 at 8:09 P.M., showed:
-The resident was pushed by a staff member in his/her wheelchair towards the bed.
-The resident leaned his/her head down and bumped the side rail of the bed.
-The resident had no injuries noted.
Record review of the resident’s Nurse’s Note, dated 12/31/18 at 9:59 A.M., showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
resident:
-Had a hematoma (a localized collection of blood outside the blood vessels due to trauma
including injury or surgery) with a small puncture wound noted to his/her right side of
head.
Record review of the resident’s Fall Incident Report, dated 1/2/19 at 7:03 P.M., showed:
-The nurse heard a thump.
-The resident was on the floor.
-The resident had a large hematoma to his/her right forehead.
Record review of the resident’s Physician order [REDACTED].
Record review of the resident’s Care Plans showed no updated interventions for falls since
12/13/17 including after the resident’s falls on 12/30/18 and 1/2/219.
During an interview on 1/11/19 at 11:45 A.M., the MDS Coordinator said:
-He/She was not consistently doing the care plans;
-He/She knows they are to be done within 24 hours of admission, quarterly, annually, and
with a significant change in the resident’s condition.
During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said:
-The MDS Coordinator should update the Care Plan if an incident had occurred.
-The MDS Coordinator should follow-up on the Care Plans to be sure they are updated and
appropriate for the resident.
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the failed to follow professional
standards, when staff failed to document the resident’s refusal of the use of oxygen on
the Treatment Administration Record (TAR) and failed to clarify the order with the
physician for two sampled residents (Residents #52 and Resident #6), and by leaving a
medication at bedside for one sampled resident (Resident #36) out of 13 sampled residents.
The facility census was 49 residents.
Record review of the facility’s policy, revision date (MONTH) 2013, Administering
Medications said
the resident may self-administer their own medications only if the Attending Physician, in
conjunction with the Interdisciplinary Care Planning Team, has determined that they have
the decision-making capacity to do so safely.
Record review of the facility’s undated oxygen administration policy showed instructions
to staff to notify the supervisor if the resident refused the procedure.
1. Record review of Resident #52’s [MEDICAL CONDITION] ([MEDICAL CONDITION] – a disease
process that decreases the ability of the lungs to perform ventilation) care plan
initiated 1/23/18 showed the resident was to have oxygen at 2 liters per minute via nasal
cannula (a tubing device used to deliver oxygen) at night and there was no documentation
in the care plan regarding the resident refusing to use oxygen.
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment tool completed by facility staff for care planning) dated 11/18/18
showed the following staff assessment of the resident:
-Cognitively intact;
-Did not reject cares;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
-Had a [DIAGNOSES REDACTED].
-Used oxygen.
Record review of the resident’s interdisciplinary progress notes dated 12/1/18 through
1/9/19 showed no documentation regarding the resident refusing to use oxygen.
Record review of the resident’s (MONTH) (YEAR) TAR showed oxygen was checked as:
-Left blank on 12/14/18;
-Refused on 12/22/18, 12/23/18 and 12/31/18.
Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of the resident’s oxygen saturation levels for (MONTH) 1, 2019 through
(MONTH) 8, 2019 showed the resident’s oxygen saturation levels were:
-Not documented on five days.
-Was 94% or above on room air on three days.
Record review of the resident’s (MONTH) 2019 TAR showed oxygen was checked as:
-Refused 1/5/19-1/6/19.
Observation on 1/7/19 at 9:49 A.M., showed the resident was in his/her room and there was
no oxygen concentrator in the resident’s room.
Observation on 1/8/19 at 9:45 A.M., showed the resident was in his/her room and there was
no oxygen concentrator in the resident’s room.
Record review of the resident’s (MONTH) 2019 TAR showed oxygen was checked as administered
on 1/7/19-1/10/19.
During an interview on 1/10/19 at 2:35 P.M., Licensed Practical Nurse (LPN) A said the
resident refuses to wear oxygen and they don’t have a concentrator in his/her room.
Observation on 1/11/19 at 7:35 A.M., showed the resident was in bed in his/her room and
there was no oxygen concentrator in his/her room.
During an interview on 1/11/19 at 7:35 A.M., Registered Nurse (RN) A said the resident
refuses to use oxygen.
During an interview on 1/11/19 at 7:40 A.M., LPN A said:
-The doctor knows from doing rounds that the resident refuses to use oxygen;
-The resident’s oxygen order needs to be discontinued.
During an interview on 1/16/19 at 10:48 A.M., the Director of Nursing (DON) said:
-Staff should follow physician’s orders [REDACTED].>-The resident refuses to use
oxygen;
-The nurse should call the doctor regarding the resident’s refusal to use oxygen and ask
him/her what he/she wants to do;
-Staff should monitor the resident’s oxygen saturation levels;
-It should be documented that the resident refuses to use oxygen;
-They should change the oxygen order to either an as needed order or discontinue the
order.
2. Record review of Resident #6’s electronic medical record showed the resident was
admitted to the facility 9/19/18. His/her [DIAGNOSES REDACTED].>-Chronic [MEDICAL
CONDITION] (the permanent inability of the respiratory system to oxygenate the blood
and/or remove carbon [MEDICATION NAME]);
-[MEDICAL CONDITION];
-Pneumonia (an infection that inflames the air sacs in one or both lungs).
Record review of the resident’s Admission MDS, dated [DATE], showed the resident:
-Had a BIMS of 8, meaning he/she was moderately impaired cognitively;
-Was tired and had trouble concentrating (12-14 days), nearly every day during the
assessment period;
-Had delusions;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
-Rejected care one to three days during the assessment period;
-Needed only supervision, encouragement or cueing with walking, locomotion, dressing,
eating, toilet use and personal hygiene;
-Needed extensive assistance with bathing;
-Used a walker and wheelchair for mobility assistance;
-Was continent of bowel and bladder;
-Had almost constant pain;
-Used tobacco;
-Received antianxiety, antibiotic, diuretic and opioid medications;
-Received oxygen therapy.
Record review of the resident’s POS dated, (MONTH) (YEAR), showed an order for [REDACTED].
Observation of the resident on 1/7/19 at 11:14 A.M., showed:
-He/She was in bed watching television;
-He/She was not using his/her oxygen. There was an oxygen concentrator in his/her room.
Observation of the resident on 1/9/19 at 7:42 A.M., showed:
-The resident was in bed asleep;
-He/She was not using his/her oxygen;
-His/Her oxygen concentrator was at bedside and the nasal cannula in a bag.
Record review of the resident’s nurses’ notes for (MONTH) (YEAR) through (MONTH) 2019 did
not show documentation of the resident refusing to use his/her oxygen continuously.
During an interview on 1/9/19 at 7:43 A.M., with the resident and LPN A:
-LPN A said it is often by choice whether the resident is using his/her oxygen or not;
-The resident said he/she did not need his/her oxygen last night.
During an interview on 1/11/19 at 9:20 A.M., CNA B said:
-He/She didn’t think the resident had an order to wear his/her oxygen continuously;
-He/She thought it was to be used as needed;
-He/She used to work evenings and would see the resident using the oxygen more often then;
-He/She was to report anything unusual to the charge nurse;
-The resident not wearing the oxygen is usual;
-The resident is very set in his/her ways;
-If the resident does not want to wear it, he/she is going to take it off;
-The resident goes out to smoke.
During an interview on 1/16/19 at 10:45 A.M., the DON said:
-The physician should be notified of the resident’s refusal to use the oxygen;
-Staff should also check on getting a clarification for the order.
3. Record review of Resident #36’s face sheet showed the resident was admitted to the
facility on [DATE] with the following Diagnoses: [REDACTED].
-Neoplasm of adrenal gland and kidney (cancer);
-Increased level of lactic acid (an increased level related to heart failure, severe
infection or shock);
-[MEDICAL CONDITION] (a type of chest pain caused by reduced blood flow to the heart);
-Urinary tract infection (an infection in the urinary system);
-Kidney failure (longstanding disease of the kidney);
-Abdominal pain;
-Brain disorder (diseases that cause your brain and nerves to deteriorate over time);
-Muscle weakness;
-Back pain;
-Hematuria (blood in the urine);
-History of [MEDICAL CONDITION] embolism (one or more arteries in the lungs are blocked by
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
a blood clot);
-[MEDICAL CONDITION] (conditions which include diseased vessels, structural problems, and
blood clots);
-[MEDICAL CONDITION]-resistant Staphylococcus aureus (a group of hard to treat bacteria);
-Constipation; and
-Diabetes (a group of diseases that result in too much sugar).
Record review of the resident’s quarterly MDS, dated [DATE], showed the following staff
assessment of the resident:
-He/She was able to make decisions independently;
-Required limited assistance with mobility, transferring, locomotion on the unit, getting
dressed, toileting, and hygiene;
-Required set up help for eating and drinking;
-Required the use of a walker or wheelchair;
-Had a catheter;
-Was incontinent of bowel;
-Was on scheduled and as needed pain medication;
-Required non medication pain interventions;
-Was almost constantly in pain.
During an Oberservation and interview on 1/11/19 at 1:17 P.M. showed:
-The resident had a [MEDICATION NAME] (medication for heart burn or gas) pill at bedside
in a medicine cup;
-The resident said he/she can’t take two pills at the same time;
-The resident will take one;
-The staff will leave an additional one at bedside;
-The staff will come back later to see if he/she took it.
Record review of the (MONTH) Physician order [REDACTED].
-an order for [REDACTED].>-No order was present to leave medications at bedside.
Record review of the electronic medication administration showed:
-On 1/11/19 one tablet was given at 9:27 A.M.;
-One tablet was given at 11:57 A.M. by Certified Medication Technician (CMT) B.
During an interview on 1/11/19 at 11:30 A.M., the Charge nurse/Licensed Practical Nurse
(LPN) A said it was ok to leave a medication at bedside if there was a physician order,
otherwise it is not.
During an interview on 1/11/19 at 12:02 P.M., the DON said medications should never be
left at the resident’s bedside.
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide the
necessary treatment to promote healing to a pressure ulcer for one sampled resident
(Resident #15) out of 13 sampled residents. The facility census was 49 residents.
Record review of the facility policy was not able to be completed, as the policy was
requested and was not provided by the end of the survey process.
1. Record review of Resident #15’s face sheet showed he/she was admitted to the facility
on [DATE] and readmitted to the facility on [DATE] with the following Diagnoses:[REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
-Urinary tract infection (an infection in any part of the urinary system);
-Dysphasia (a difficulty swallowing);
-Muscle weakness;
-Chronic pain;
-Hypertension (high blood pressure);
-Pacemaker (a medical device that regulates the electrical system of the heart);
-[MEDICAL CONDITION] (an excess of fluids that causes swelling);
-Heart block (a disease or inherited condition that causes an obstruction in the
electrical system of the heart); and
-Peripheral Autonomic [MEDICAL CONDITION] (damage to the nerves that manage every day body
functions).
Record review of the Quarterly Minimum Data Set (MDS a federally mandated assessment tool
completed by facility staff for care planning), dated 10/11/18, showed the following staff
assessment of the resident:
-Was able to make every day decisions about his/her care;
-Required extensive assistance for transferring from one surface to another, toileting,
hygiene, using the sit to stand (a mechanical device to move residents), transferring from
bed to wheel chair;
-Was able to wheel 150 feet in his/her wheel chair;
-Needed supervision, encouragement or cueing during meals;
-Frequently incontinent of bowel and bladder.
Record review of the resident’s medical records showed there was no comprehensive care
plan for the resident.
Record review of the resident’s Progress notes, dated 1/7/19, showed:
-The Charge Nurse/Licensed Practical Nurse (LPN) A did a skin assessment which showed a 1
centimeter (cm) by 0.7 cm open area to the resident’s right buttock;
-It was first observed on 1/4/19;
-It was a stage 2 (Partial-thickness loss of skin with exposed dermis. The wound bed is
viable, pink or red, moist, and may also present as an intact or ruptured serum-filled
blister);
-The resident’s family was notified;
-The resident’s physician was notified (no orders);
-The resident was positioned off the area, the area was left open to air, and [MEDICATION
NAME] (a moisture barrier ointment) was applied.
Observation on 1/9/19 at 7:38 A.M., with Certified Medication Technician (CMT) A and
Certified Nursing Assistant (CNA) A of incontinent care showed:
-The resident had a shallow open ulcer with a red pink wound bed on his/her right buttock;

-CMT A applied [MEDICATION NAME] ointment to the area.
During an interview on 1/9/19 at 7:50 A.M., CMT A and CNA A said:
-They were instructed to keep the resident off his/her buttock;
-They were instructed to apply [MEDICATION NAME] ointment;
-They were instructed to let the area air dry;
-CMT A said the open area had been there more than a few days, but less than a week, maybe
since (MONTH) 4th;
-The wound was healed up before that;
-CMT A did not know if anyone had told the nurse.
During an interview on 1/9/19 at 12:00 P.M., the Wound Nurse said:
-He/She has not seen the wound and was not told about it;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
-If it was a stage 2 the CMTs and CNAs should not be putting ointment on it;
-He/She would call the physician and he/she will look at it when he/she comes this week.
During an interview on 1/10/19 at 8:23 A.M., the Wound Physician said:
-The resident had chronic wounds;
-The staff knew what he/she wanted to use and they could always call him/her to get an
order over the phone;
-He/She was at the facility every week;
-He/She was changing the residents treatment to a collagen treatment;
-He/She saw the wound and it was a stage 3 (sore gets worse and extends into the tissue
beneath the skin, forming a small crater. Fat may show in the sore, but not muscle,
tendon, or bone);
-It was due to moisture.
Record review of the Physician’s Order Sheet (POS), dated 1/10/19, showed:
-an order for [REDACTED].>-The treatment was to be applied daily.
During an interview on 1/11/19 at 9:30 A.M., the Wound Nurse said:
-The staff should have said something to him/her, as he/she was not aware of the problem;
-The physician had tried several things;
-The Wound Physician was at the facility every week;
-The resident was noncompliant and would not lay down after meals, did not like his/her
briefs changed, and refused to leave the area open to air;
-The issue was related to incontinence;
-He/She was changed after every meal;
-The resident refused to use a seat cushion in his/her wheelchair;
-The wound nurse frequently gave the resident protein snacks to increase healing;
-The resident has signed a waiver and had refused a special diet, he/she eats what he/she
wants to eat;
-The issue should be care planned;
-The nurse could not find a care plan for (YEAR) or 2019.
During an interview on 1/16/19 at 12:10 P.M. the Director of Nursing (DON) said:
-Staff should tell the nurse immediately if there is a new wound, so he/she can notify the
Wound Physician;
-The Wound Physician came to the facility every week.
F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
protective oversight and adequate supervision for one supplemental resident (Resident #3),
who exhibited multiple instances of wandering into other resident rooms, disrobing, and
getting into bed with other residents on the night shift. The facility did not accurately
assess and identify the behaviors and did not have a care plan in place to initiate
appropriate interventions and ensure appropriate supervision was provided. Additionally,
the facility failed to ensure the resident environment was free from accident hazards, by
failing to ensure a harmful chemical was not accessible to one resident (Resident #3); and
failed to safely transfer two sampled residents (#30 and #15), out of 13 sampled
residents. The facility census was 49.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 35)
Record review of the facility’s undated policy titled Wandering, Unsafe Resident showed:
-The facility will strive to prevent unsafe wandering while maintaining the least
restrictive environment for residents who are at risk for elopement.
-The staff will assess at-risk individuals for potentially correctable risk factors
related to unsafe wandering.
-The resident’s care plan will indicate the resident is at risk for elopement or other
safety issues.
-Interventions to try to maintain safety will be included in the resident’s care plan.
-Nursing staff will document circumstances related to unsafe actions, including wandering
by the resident.
-Staff will institute a detailed monitoring plan, as indicated for residents who are
assessed to have a high risk of elopement or other unsafe behavior.
-Staff will notify the Administrator and Director of Nursing immediately, and will
institute appropriate measures (including searching) for any resident who is discovered to
be missing from the unit or facility.
Record Review of the facility’s undated policy titled Behavior Assessment and Monitoring
showed:
-Problematic behavior will be identified and managed appropriately.
-As a part of the initial assessment, the nursing staff and attending physician will
identify individuals with a history of impaired cognition (e.g., dementia, mental [MEDICAL
CONDITION]), problematic behavior, or mental illness (e.g., [MEDICAL CONDITION] disorder
or [MEDICAL CONDITION]).
-The nursing staff will identify, document, and inform the physician about an individual’s
mental status, behavior, and cognition, including:
–Onset, duration and frequency of problematic behaviors or changes in behavior, cognition
or mood.
–Any precipitating or relevant factors (e.g., medication changes, infection, recent
transfer from the hospital).
-The staff will identify and discuss with the practitioner situations where
non-pharmacologic approaches are indicated, and will institute such measures to the extent
possible.
-If a resident is being treated for [REDACTED].
-The staff will document (either in progress notes, behavior assessment forms, or other
comparable approaches) the following information about specific problem behaviors:
–Number and frequency of episodes,
–Preceding or precipitating factor,
–Interventions attempted (if psychoactive drug is used as an intervention, institute
appropriate psychoactive drug monitoring), and
–Outcomes associated with intervention.
Record review of the facility’s policy titled Abuse and Neglect: Clinical Protocol showed:
-The nurse will assess the individual and document related findings.
-The nurse will report findings to the physician.
-The physician and staff will identify risk factors for abuse within the facility, for
example, significant numbers of residents with unmanaged problematic behavior.
-Along with other staff and management, the Medical Director will help identify situations
that might constitute or could be construed a neglect, for example, inappropriate
management of problematic behavior
-The facility management and staff will institute measures to address the needs of
residents and minimize the possibility of abuse and neglect.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 36)
-The management and staff, with the support of the physicians, will address situations of
suspected or identified abuse and report them in a timely manner to appropriate agencies,
consistent with applicable laws and regulations.
Record review of the facility’s undated policy related to Monitoring Residents for
Aggressive-Inappropriate Behavior showed:
-All altercations, including those that may represent resident-to-resident abuse, shall be
investigated and reported to the nursing Supervisor, the Director of Nursing Services and
to the Administrator.
-The facility staff will monitor residents for aggressive/inappropriate behavior towards
other residents, family members, visitors, or to the staff. Occurrences of each incident
shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to
the Administrator.
Record review of the facility’s undated policy titled Change in Resident’s Condition or
Status showed the nurse supervisor/charge nurse will notify the resident’s attending
physician or on-call physician when there has been an accident or incident involving the
resident.
1. Record review of the Resident #3’s MDS tracking record showed the resident was admitted
to the facility 1/7/2018 and discharged [DATE], return not anticipated; and readmitted to
the facility 6/7/18.
Record review of the resident’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED].
-Unspecified Dementia with Behavioral Disturbance (Common behavioral disturbances can be
grouped into four categories: mood disorders (e.g., depression, apathy, euphoria); sleep
disorders ([MEDICAL CONDITION], hypersomnia, night-day reversal); psychotic symptoms
(delusions and hallucinations); and agitation (e.g., pacing, wandering, sexual
disinhibition (refers to socially or contextually inappropriate sexual behavior and is
usually associated with frontal and temporal lobe pathology), aggression).
-Wandering in Diseases Classified Elsewhere.
-Persistent [MEDICAL CONDITION] Fibrillation (type of heart disorder marked by an
irregular or rapid heartbeat).
-Pain, Unspecified.
-Overactive Bladder (the frequent urge to urinate and waking up at night to urinate).
-Major [MEDICAL CONDITION] (a serious mood disorder that causes a persistent feeling of
sadness and loss of interest)
-Altered Mental Status, Unspecified (general changes in brain function, such as confusion,
amnesia (memory loss), loss of alertness, disorientation (not cognizant of self, time, or
place), defects in judgment or thought, unusual or strange behavior, poor regulation of
emotions, and disruptions in perception).
-Anxiety Disorder (a feeling of worry, nervousness, or unease, typically about an imminent
event or something with an uncertain outcome).
Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, used for care planning
purposes, dated 6/14/18, showed the resident:
-Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively
impaired.
-Stated, during the Resident Mood interview, he/she had little pleasure or interest in
doing things several days, felt down, depressed or hopeless several days, had trouble
falling or staying asleep or sleeping too much, and had trouble concentrating on things
such as reading the newspaper or watching television.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 37)
-Had no presence of behaviors during the seven day look-back period and no overall
presence of behaviors.
-Had no presence of wandering.
-Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion,
and eating.
-Needed extensive assistance with personal hygiene and bathing.
-Used a walker for mobility assistance.
-Had frequent pain.
-Received antipsychotic, antidepressant and opioid medications.
-Used a wander/elopement alarm daily.
Record review on 1/11/19 showed the resident did not have a comprehensive Care Plan
completed following his/her most recent admission MDS that included identified care
assessment areas.
Record review of the resident’s Care Plan showed the last care plan review was completed
2/2/18, prior to the resident’s latest admitted .
-Review of the resident’s care plan focus area related to his/her confusion, initiated
11/9/18, showed:
–The goal was for the resident to be able to make his/her needs known, with a target date
of 4/30/18, prior to the resident’s readmission to the facility and initiation of the
focus area.
–Certified Nurse Assistants (CNAs) should communicate with the resident’s
family/caregivers regarding the resident’s capabilities and needs.
–Social Services staff should discuss concerns about confusion, disease process, and
nursing home placement with the resident’s family.
–Nurses should monitor, document and report to the physician any changes in cognitive
function, specifically changes in decision making ability, memory, recall, and general
awareness, difficulty expressing self, difficulty understanding other, level of
consciousness, and mental status.
-Review of the resident’s focus area related to antianxiety medication, initiated 11/9/18,
showed:
–The goal was for the resident to show decreased episodes of signs and symptoms of
anxiety through the review date. The target date was 4/30/18, prior to the initiated date.
–Staff (no designation of position shown) should monitor target behavior symptoms
(wandering, inappropriate response to verbal communication, violence/aggression towards
staff/others, etc.) and document per facility protocol.
–The resident was taking antianxiety medications which were associated with an increased
risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like
dementia, falls, broken hips and legs. Monitor frequently for safety.
-Review of the resident’s focus area related to antidepressant medication, initiated
11/9/18, showed:
–The goals were for the resident to show decreased episodes of signs and symptoms of
depression through the review date, and for the resident to be free from discomfort or
adverse reactions related to antidepressant therapy through the review date. The target
date was 4/30/18, prior to the initiated date.
–Staff (no designation of position shown) was to give antidepressant medications ordered
by the physician. Monitor/document side effects and effectiveness.
–Monitor, document, and report to the physician as needed ongoing signs and symptoms of
depression, unaltered by antidepressant medications.
-Review of the resident’s focus area related to the resident receiving hypnotic and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 38)[MEDICAL CONDITION] medications, initiated 11/9/18, showed:
–The goal was for the resident to be free of drug related complications, including
movement disorder, discomfort, [MEDICAL CONDITION] (low blood pressure), gait disturbance,
constipation/impaction or cognitive impairment through the review date. The target date
was 4/30/18, prior to the initiated date.
–Staff (no designation of position shown) was to administer medications as ordered.
Monitor/document side effects and effectiveness.
–Consult with pharmacist/physician to consider dosage reduction when clinically
appropriate.
–Discuss with family for ongoing need for use of medication.
–Monitor and record occurrence of target behavior symptoms (wandering, inappropriate
response to verbal communication, violence/aggression towards staff/others, etc.) and
document per facility protocol.
–Monitor, record, and report to the physician as needed side effects and adverse
reactions of psychoactive medications.
–Try the following sleep encouragement techniques: Provide lighting that is conducive for
sleep, maximize daily activities, and encourage socialization.
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the
resident had nightly behavioral episodes (MONTH) 9 – 14, during the MDS 7-day assessment
look back period:
-On 6/9/18, staff documented one episode of the resident having [MEDICAL CONDITION] (inability to sleep.).
-On 6/10/18, staff documented one episode of the resident having [MEDICAL CONDITION].
-On 6/11/18, staff documented three episodes of the resident having [MEDICAL CONDITION].
-On 6/12/18, staff documented three episodes of the resident having [MEDICAL CONDITION].
-On 6/13/18, staff documented four episodes of the resident having [MEDICAL CONDITION].
-On 6/14/18, staff documented four episodes of the resident having [MEDICAL CONDITION].
Record review, of the resident’s Nurses’ Notes showed the following:
-On 6/13/18, at 3:32 A.M., the resident was found in another resident’s room (a resident
of the opposite sex, identified as Resident #29). The resident was on the bed with
Resident #29. Staff heard smacking lips. Resident #3 was kissing Resident #29. Resident #3
stated he/she had known Resident #29 for years. Resident #3 was easily redirected to
his/her room.
-On 6/13/18, at 3:37 A.M., the resident was found in the room of another resident of the
opposite sex, he/she stated, I was just trying to get him/her up.
-On 6/13/18, at 4:50 A.M., the nurse documented the resident was up three times after
midnight and was assisted back to his/her room, re-orienting him/her to time and place.
-On 7/1/18 at 12:30 A.M., the nurse documented the resident was up propelling
himself/herself while sitting on his/her walker seat. The resident had been up for a few
minutes. He/she was assisted back to his/her room. The resident stated the pain pill
he/she took helped his/her discomfort a little.
-On 7/7/18 at 12:24 A.M., the nurse documented the resident was up pacing in the hallways
with his/her walker.
-On 7/9/18 at 2:36 A.M., the nurse documented the resident was walking up and down the
halls.
-On 7/10/18 at 6:04 A.M., the nurse documented, the Certified Nursing Assistant (CNA)
reported the resident was found in the Nurse’s Station at approximately 4:00 A.M., sitting
in a chair removing his/her clothing from the waist down. The resident was re-directed to
his/her room. At approximately 5:30 A.M., the resident was found in another resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 39)
room with his/her walker, starting to climb into bed with the other resident. The resident
was taken to his/her room by wheelchair and shown his/her bed. At approximately 5:50 A.M.,
the resident was walking without his/her walker down the hall toward the exit door. The
resident was given his/her walker and he/she went to the common area by the fish tank.
-On 7/17/18 at 2:53 A.M., the resident was up, continuously pacing up and down the halls.
-On 7/18/18 at 12:33 P.M., the nurse documented the resident was refusing to get up that
day, the resident yelled at staff and told staff, if he/she had to get up, he/she was
going to leave. Staff offered to bring the resident a room tray for his/her meal and the
resident refused.
-On 7/25/18 at 6:19 A.M., the nurse documented the resident had been up and down all
night.
-On 7/26/18 at 2:55 A.M., the nurse documented the resident had been in and out of bed
several times; ambulates in hall and then goes back to his/her room; denied pain at that
time.
-On 7/27/18 at 6:07 A.M., the nurse documented the resident had been up most of the night
roaming the hallways, in and out of other residents rooms. The resident was re-directed
when found. Muscle rub was administered when the resident asked for something for his/her
legs and feet. Resident was asleep in bed at the time the nurse was documenting.
-On 8/6/18 at 3:39 A.M., the nurse documented the resident was up and continuously pacing
up and down the hallways, complaining of knee pain and right hip pain. Pain medication and
muscle rub was administered and follow-up noted as ineffective.
-On 8/7/18 at 1:11 A.M., the nurse documented the resident was up and continuously pacing
up and down the hallways with his/her walker, complaining of bilateral knee pain and right
hip pain. Pain medication and muscle rub was administered and follow-up noted as
ineffective.
-On 8/8/18 at 11:29 P.M., the resident found Lysol Spray on the CNA’s cart and sprayed it
on both of his/her legs, stating someone told him/her, that would help his/her legs quit
hurting and would help the swelling. The nurse encouraged the resident not to do that
again, but to let staff know and they would try to assist in other ways. The resident had
been given pain medication and cream applied to his/her legs to help with restless legs,
reportedly at around 10:20 P.M.
-On 9/4/18 at 12:41 A.M., the resident was found across the hall from his/her room without
any pants on, attempting to undercover the occupant in that room and push the occupant out
of bed. When the nurse walked in and asked the resident what he/she was doing, the
resident stated, the other resident was in his/her bed and he/she just wanted to lay down,
because he/she was tired. The nurse informed the resident that he/she was in the wrong
room, that it was not his/her bed and that his/her room was across the hall. The resident
instantly apologized and turned around and began to walk out of room. The resident said
he/she did not know why he/she did not have any pants on, and that he/she must have been
sleep walking. The nurse assisted the resident back to his/her room, where he/she got
dressed and got into his/her own bed.
-On 9/9/18 at 2:59 A.M., the nurse documented he/she had re-directed the resident several
times that night. The resident was confused, irritable, wandering down Shady Hall (not
his/her hall) going into other resident rooms. The resident was given pain medication and
administered a topical pain cream at the beginning of the night shift, but said neither
helped.
-On 9/13/18 at 2:43 A.M., the nurse documented the resident had been up ambulating in the
hall several times during the night.
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 40)
resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being
depressed/withdrawn; one time during the day shift (7:00 A.M. – 3:00 P.M.), 25 times
during the night shift (11:00 P.M. – 7:00 A.M.), and no occurrences during the evening
shift (3:00 P.M. – 11:00 P.M.)
Record review of the resident’s Behavior Monthly Flow Sheets showed there was no record
for the months of (MONTH) (YEAR) and (MONTH) (YEAR).
Record review of the resident’s quarterly MDS, dated [DATE], showed the resident:
-Had a BIMS of 5, meaning he/she was severely cognitively impaired.
-Had no presence of wandering during the seven day look-back period and the assessment did
not show whether there was an overall presence of behaviors.
-Was independent with bed mobility, transfers, locomotion on his/her unit,
-Needed only supervision, encouragement or cueing with walking, locomotion off his/her
unit, dressing eating, and personal hygiene.
-Needed extensive assistance with toilet use and bathing.
-Used a walker for mobility assistance.
-Was continent of bladder and bowel.
-Had occasional pain.
-Received antipsychotic, antidepressant and opioid medications.
-Used a wander/elopement alarm daily.
Record review, of the resident’s Nurses’ Notes showed the following:
-On 10/8/18 at 5:56 A.M., the nurse assistant reported the resident made a threatening
statement to his/her roommate as the roommate’s alarm was going off. The resident stated,
I’m going to kill you if that alarm goes off again. The nurse assistant was assisting the
roommate at that time and the personal alarm was going off. The resident was re-directed.
-On 10/8/18 at 8:20 A.M., the nurse documented it was reported to him/her this morning
that the resident was found in another resident’s (resident of the opposite sex,
identified as Resident #39) room lying in bed without his/her pants on. The resident was
assisted out of Resident #39’s room and back to his/her own bedroom. The nurse informed
the resident’s responsible party of the situation and the responsible party did not wish
to take any further action at that time.
-On 10/8/18, the nurse noted the aide on the evening shift (time not noted) asked the
resident if he/she would like to get up for dinner and the resident stated If you don’t
stop waking me up, I’m going to knock you on your ass. The resident then went back to
sleep and slept the rest of the shift.
-On 10/9/18 at 2:46 A.M., the resident was up in the hallway and at the nurse’s station,
pushing his/her walker. The resident was attempting to go down Shady Hall and was
re-directed by the CNA, who was close by. The resident then proceeded into the dining room
mumbling profanity, and sat on the seat of his/her walker.
-On 10/9/18 at 3:32 A.M., the resident was re-directed as he/she attempted to go down
Shady Hall. The nurse offered to show the resident to his/her room or to the common area
in the dining room. The resident said, Okay honey, I hate this place. At the time of
documentation, the resident was in the common area.
-On 10/10/18 at 4:31 A.M., the nurse documented the resident was up most of the night
walking on the hall where he/she resides and in the dining room area. The resident sat
down for a couple of short naps, complained of pain in bilateral knees, medication was
administered earlier in the shift and was effective. The resident had to be re-directed
two times, with difficulty, from going down the hall where he/she did not reside.
-On 10/11/18 at 1:37 A.M., the resident was found up wandering and assisted by staff to
his/her room. The resident was offered a drink and to be toileted both times.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 41)
-On 10/30/18 at 2:30 A.M., the resident had been up all of the night shift thus far,
pacing in the hallway, dining room, and going into other resident rooms. The nurse also
noted the resident complained of pain in bilateral knees. The resident was administered
pain medication and encouraged to go to bed and rest. At the time of documentation, the
resident was resting in bed.
-On 11/30/18 at 12:49 A.M., the nurse documented the resident was found messing with the
CNA cart on the hall. The CNA attempted to re-direct the resident, and then the resident
said, Well, you can shove that bottle up your ass. The cart was moved to the shower room.
When the CNA passed the resident in the hall, the resident called the CNA his/her name,
using profanity.
-On 12/8/18 at 1:27 A.M., the nurse documented the resident was awake so far that shift,
sitting on his/her walker seat in the hallway. The resident was attempting to move another
resident’s wheelchair around in the hall. The nurse was unable to re-direct the resident
at that time.
-On 12/10/18 at 5:32 A.M., the resident was found in the bathroom in another resident’s
room with his/her pants down around his/her hips. The resident was re-oriented to the time
and place, reminding him/her that that was not his/her room. The resident said, I know,
I’m just checking it out. The resident was assisted out of the bathroom and back to
his/her room.
-On 12/11/18 at 2:34 A.M., the resident continuously moved up and down the hallway sitting
on his/her walker seat, at times walking while pushing the walker. The resident came up to
the nurse’s station asking the nurse, can you tell me where I can find some food? The
resident was directed to the dining room snack area. The nurse attempted several times to
re-direct the resident to time and place. The resident continued to pace around the
facility with his/her walker, at times moving in and out of other resident rooms.
-On 12/13/18 at 12:22 A.M., the resident was wheeling himself/herself up and down the hall
taking things off the aide’s cart and taking things off another resident’s wheelchair. The
aide asked the resident to leave the other resident’s things alone and the resident told
the aide to kiss his/her ass. The nurse asked the resident to go to his/her room, so that
he/she could administer pain medication and rub cream on the resident’s legs. The resident
was not cooperative with the nurse and stated he/she was not going to bed. The television
was turned on for the resident and the resident was offered coffee to try and make him/her
comfortable. The resident said he/she did not like being bossed around.
-On 12/15/18 at 5:46 A.M., the nurse documented the resident had been up several times
throughout the night, drinking coffee and getting into the cart in the hallway.
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the
resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being
depressed/withdrawn; occurring 62 times during the day shift and 77 times during the night
shift. There was no documentation showing occurrences during the evening shift.
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the
resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being
depressed/withdrawn; occurring 60 times during the night shift.
Record review of the resident’s quarterly MDS, dated [DATE], in progress during the
facility’s annual survey, showed the resident:
-Had a BIMS of 6, meaning he/she was severely cognitively impaired.
-Had no overall behavioral symptoms.
-Had no presence of wandering and no behaviors affecting others.
-Was independent with walking and eating.
-Needed only supervision, encouragement or cueing with bed mobility, transfers,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 42)
locomotion, dressing, toilet use and personal hygiene.
-Needed extensive assistance with bathing.
-Used a walker for mobility assistance.
-Was continent of bladder and bowel.
-Had no presence of pain.
-Received antipsychotic, antidepressant and opioid medications.
Record review, of the resident’s Nurses’ Notes showed the following:
-On 12/16/18 at 12:32 A.M., the nurse documented the resident continued to roll up and
down the hallway while seated on his/her rolling walker.
-On 12/21/18 at 5:07 A.M., the nurse documented the resident was up several times during
the night. The resident was observed several times trying to go down the hall where he/she
did not reside, and was re-directed back to his/her room.
-On 12/24/18 at 6:10 A.M., the nurse documented the resident was found by the CNA, in
another resident’s room on the hall where he/she did not reside. The resident was
re-directed. The other resident started yelling at Resident #3, because the other resident
thought Resident #3 had his/her walker.
Record review of the resident’s (MONTH) (YEAR) Behavior Monthly Flow Sheet showed the
resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being
depressed/withdrawn; occurring 60 times during the night shift.
Record review of the resident’s (MONTH) 2019 Behavior Monthly Flow Sheet showed the
resident had behavior episodes that included anxiety, [MEDICAL CONDITION], and being
depressed/withdrawn; occurring 39 times during the night shift, (MONTH) 1 -14, 2019.
Observation on 1/11/19 at 11:00 A.M., showed the resident sitting on his/her walker seat
rolling from the far end of the hall where he/she did not reside. The resident was headed
toward 100/200/dining room hall intersection.
2. Record review of Supplemental Resident #29’s electronic medical record showed the
resident was most recently readmitted to the facility on [DATE]. The resident’s [DIAGNOSES
REDACTED].
Record review of the resident’s admission MDS, dated [DATE], showed the resident:
-Was cognitively intact.
-Had no hearing or vision impairment.
-Did not display any indicators of mood disturbance.
-Did not have the presence of any behaviors.
-Needed only supervision, encouragement or cueing with transfers, walking, locomotion, and
eating.
-Needed limited assistance with bed mobility, dressing, toilet use and personal hygiene.
-Used a wheelchair for mobility assistance.
-Had an indwelling catheter.
-Was continent of bowel.
The resident did not have a comprehensive Care Plan completed following his/her most
recent admission MDS.
Record review of the resident’s Nurses’ Notes dated 6/13/18 at 3:34 A.M., showed a
resident of the opposite sex (identified as Resident #3) went into the resident’s room,
laid in bed with the resident and was kissing the resident. The resident did not appear to
be in distress. When the CNA told the resident he/she was going to empty his/her Foley bag
(bag to collect the urine that drains through a catheter), the resident said, I thought
you were talking about this old bag as the resident was rubbing Resident #3 on his/her
back. The resident was easily re-directed.
During an interview on 1/11/19 at 1:14 P.M., Resident #3’s responsible party said he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 43)
was not told about the incident that occurred on 6/13/18. He/she had only been told about
an incident that occurred in (MONTH) (YEAR), and occurrences such as skin tears.
3. Record review of Resident #39’s initial care plan dated 7/31/18, showed the resident:
-Used a walker.
-Had a [DIAGNOSES REDACTED].
Record review of the resident’s order summary report dated 7/31/18, showed some of the
resident’s [DIAGNOSES REDACTED].
Record review of the resident’s admission MDS dated [DATE], showed the following staff
assessment of the resident:
-Cognitively intact.
-Did not have any hearing or vision impairment.
-Had clear speech.
-Understands others and others understand him/her.
-Did not display any behaviors.
-Used a walker.
-The most assistance he/she required during the look-back period was:
–Limited assistance of one person with moving around in his/her bed.
–Limited assistance of two people with dressing.
–Supervision when walking and transferring from one surface to another such as from
standing to sitting on his/her bed or chair.
Record review of the resident’s medical records showed there was not a comprehensive care
plan for the resident.
Record review of the resident’s nurses’ notes showed the resident:
-Reached between a CNA’s legs three times on 8/12/18.
-Was verbally inappropriate with staff on 8/12/18.
-Walked by an employee and brushed him/her on his/her bottom on 8/14/18.
-Told an employee he/she was going to grab their butt on 8/14/18.
-Touched the stomach and breasts of an employee on 8/17/18.
Record review of the resident’s nurse’s note dated 10/8/18 showed:
-The nurse went into the resident’s room about 5:00 A.M.
-The resident was standing next to his/her bed naked.
-The nurse found Resident #3 laying on his/her back in the resident’s bed with his/her
pants down around his/her ankles.
-The nurse asked the resident what was going on and he/she said that he/she did not know.
-The resident told the nurse that nothing happened between him/her and Resident #3.
-Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between
the two residents.
-Resident #3 initially refused to leave the resident’s room, but staff were able to remove
Resident #3 from the resident’s room.
Record review of the incident report dated 10/8/18 at 5:00 A.M. showed:
-Resident #3 was found in Resident #39’s room.
-Resident #3 was lying on Resident #39’s bed with his/her pants pulled down to his/her
ankles.
-Resident #39 was naked and standing next to Resident #3.
-Resident #39 denied touching Resident #3.
-Resident #3 said, What? Do you think I’m crazy? when asked if anything happened between
the two residents.
-Notification of the physician was left blank.
-The incident was reported to the ADON.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 44)
-The incident report was signed by Licensed Practical Nurse (LPN) C.
Record review of the resident’s significant change MDS dated [DATE] showed the staff
assessment of the resident showed that he/she was cognitively intact.
During an interview on 1/11/19 at 10:48 A.M., CNA E said:
-Resident #3 is the only resident that is being monitored for wandering.
-There are days when the residen
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 residents diagnosed
with [REDACTED]. and behavior) needs for two sampled (Residents #3 and #20), out of 13
sampled residents. The facility census was 49 residents.
Record review of the facility’s undated policy titled, Behavior Assessment and Monitoring,
showed:
-As a part of the initial assessment, the nursing staff and attending physician will
identify individuals with a history of impaired cognition (e.g., dementia, mental [MEDICAL
CONDITION]), problematic behavior, or mental illness (e.g., [MEDICAL CONDITION] disorder
or [MEDICAL CONDITION]);
-The staff will identify and discuss with the practitioner situations where
nonpharmacologic approaches are indicated, and will institute such measures to the extent
possible;
-If psychoactive medications are used to treat behavioral symptoms of dementia, the
nursing staff and attending physician will periodically reconsider their indication and
consider whether they can be tapered or document why tapering cannot or should not be
attempted.
1. Record review of Resident #3’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. His/Her [DIAGNOSES REDACTED].
Record review of the resident’s most recent Admission Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, used for care planning
purposes, dated 6/14/18, showed the resident:
-Had a BIMS (brief mental interview status) of 3, meaning he/she was severely cognitively
impaired;
-Stated, during the Resident Mood interview, he/she had little pleasure or interest in
doing things several days, felt down, depressed or hopeless several days, had trouble
falling or staying asleep or sleeping too much, and had trouble concentrating on things
such as reading the newspaper or watching television;
-Had no presence of behaviors during the seven day look-back period and no overall
presence of behaviors;
-Had no presence of wandering;
-Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion,
and eating;
-Needed extensive assistance with personal hygiene and bathing;
-Used a walker for mobility assistance;
-Had frequent pain;
-Received antipsychotic, antidepressant and opioid medications;
-Used a wander/elopement alarm daily; and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 45)
-Had a [DIAGNOSES REDACTED].
Record review on 1/11/19 of the resident’s care plan showed it did not address dementia
and the resident’s psychosocial well-being.
2. Record review of Resident #20’s electronic health record showed the resident was most
recently admitted to the facility on [DATE]. His/her [DIAGNOSES REDACTED].
Record review of the resident’s Admission MDS dated [DATE], showed the resident:
-Had a BIMS of 7, meaning he/she was severely cognitively impaired;
-Stated, during the Resident Mood interview, he/she felt down, depressed or hopeless and
felt tired or had little energy;
-Had no presence of behaviors;
-Needed only supervision, encouragement or cueing with bed mobility, walking, locomotion,
eating and personal hygiene;
-Needed limited assistance with dressing;
-Used a cane for mobility assistance;
-Received antidepressant and antianxiety medications; and
-Had a [DIAGNOSES REDACTED].
Record review on 1/11/19 of the resident’s care plan showed:
-It did not address Dementia and the resident’s psychosocial well-being;
-It was not personalized.
During an interview on 1/11/19 at 9:30 A.M., the MDS Coordinator said:
-He/She was responsible for completing the residents’ plan of care;
-He/She had gotten behind.
During an interview on 1/16/19 at 10:45 A.M., the Director of Nursing (DON) said:
-He/She thought the care plans were getting done.
-He/She expected residents with dementia to have a personalized plan of care that
addressed their dementia and psychosocial well-being.
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that the
medication error rate was less than five percent. The two medication errors involved the
administration of insulin (a hormone that helps glucose get into cells to provide energy)
out of 33 opportunities resulting in a medication error rate of 6.06 percent, which
affected one sampled resident (Resident #13), out of 13 sampled residents and one
supplemental resident (Resident #38). The facility census was 49 residents.
Record review of the facility’s undated Insulin Administration Policy showed:
-Forms of insulin delivery include pens (containing insulin cartridges that deliver
insulin subcutaneously (SQ beneath the skin) through a needle);
-No instructions for the administering of insulin via a pen.
Record review of the manufacturer’s instructions for the Humalog (a fast-acting insulin)
Kwikpen (a brand name) showed:
-Prime (the pen and needle) before each injection;
-To prime the pen:
–Turn the dose knob to select two units;
–Hold the pen with the needle pointing up;
–Tap the cartridge holder gently to collect air bubbles at the top;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 46)
–Push the dose knob in until it stops, and 0 is seen in the dose window;
–Hold the dose knob in and count to five slowly;
–Insulin should be seen at the tip of the needle;
-If you do not see insulin, repeat the priming steps, no more than four times;
-If still no insulin is seen, change the needle and repeat the priming steps;
-If you do not prime before each injection, you may get too much or too little insulin.
Record Review of the manufacturer’s instructions for the [MEDICATION NAME] (a long[MEDICATION NAME] insulin) [MEDICATION NAME] (a brand name) Pen showed:
-Always, perform the safety test (the manufacturer’s term for priming) before each
injection;
-Performing the safety test ensures that you get an accurate dose by:
–Ensuring that the pen and needle work properly;
–Removing air bubbles;
–Select a dose of two units by turning the dosage selector;
–Hold the pen with the needle pointing upwards;
–Tap the insulin reservoir so that any air bubbles rise up toward the needle;
–Press the injection button all the way in;
–Check if insulin comes out of the needle tip;
-Safety test may need to be performed several times before insulin is seen;
-If no insulin comes out, check for air bubbles and repeat the safety test two more times
to remove them;
-If still no insulin comes out, the needle may be blocked, change the needle and try
again.
1. Record Review of Resident #38’s Medication Administration Record [REDACTED] -Humalog three times a day (TID) before meals per a sliding scale (refers to the
progressive increase in the insulin dose, based on pre-defined blood glucose ranges);
–Sliding scale (SS) for a blood glucose of 244 showed give six units SQ;
-[MEDICATION NAME] 20 Units in the A.M., SQ.
During an observation on 1/9/19 at 7:49 A.M., of Licensed Practical Nurse (LPN) A during
insulin administration showed:
-He/She did not prime the Humalog pen before administering six Units SQ;
-He/She did not prime the [MEDICATION NAME] pen before administering 20 Units SQ.
2. Record Review of Resident #13’s MAR, dated (MONTH) 2019, showed:
-[MEDICATION NAME] five Units SQ in A.M., daily.
During an observation on 1/9/19 at 8:47 A.M., of LPN A during insulin administration
showed:
-He/she did not prime the [MEDICATION NAME] pen before administering five Units SQ.
During an interview on 1/9/19 at 8:55 A.M., LPN A said per the pharmacy that the facility
uses:
-They only prime an insulin pen when it is new;
-They do not prime an insulin pen with each subsequence use;
-He/She had been educated on the use of insulin pens during an annual in-service.
During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said:
-The facility’s Insulin Administration Policy should include the use of insulin pens.
-He/She expected that insulin pens would be primed according to the manufacturer’s
instructions.
-He/She would like the medication error rate to be zero percent at all times.
-He/She tries to keep the staff educated, so that medication passes are done correctly.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure that the
residents were free of any significant medication errors by incorrectly administering
insulin (a hormone that helps glucose get into cells to provide energy) medication for one
sampled resident (Resident #13) out of 13 sampled residents and one supplemental resident
(Resident #38). The facility census was 49 residents.
Record review of the facility’s undated Insulin Administration Policy showed:
-Forms of insulin delivery include pens (containing insulin cartridges that deliver
insulin subcutaneously (SQ beneath the skin) through a needle);
-No instructions for the administering of insulin via a pen.
Record review of the manufacturer’s instructions for the Humalog (a fast-acting insulin)
Kwikpen (a brand name) showed:
-Prime (the pen and needle) before each injection.
-To prime the pen:
–Turn the dose knob to select two units.
–Hold the pen with the needle pointing up.
–Tap the cartridge holder gently to collect air bubbles at the top.
–Push the dose knob in until it stops, and 0 is seen in the dose window.
–Hold the dose knob in and count to five slowly.
–Insulin should be seen at the tip of the needle.
-If you do not see insulin, repeat the priming steps, no more than four times.
-If still no insulin is seen, change the needle and repeat the priming steps.
-If you do not prime before each injection, you may get too much or too little insulin.
Record Review of the manufacturer’s instructions for the [MEDICATION NAME] (a long[MEDICATION NAME] insulin) [MEDICATION NAME] (a brand name) Pen showed:
-Always, perform the safety test (the manufacturer’s term for priming) before each
injection.
-Performing the safety test ensures that you get an accurate dose by:
–Ensuring that the pen and needle work properly.
–Removing air bubbles.
–Select a dose of two units by turning the dosage selector.
–Hold the pen with the needle pointing upwards.
–Tap the insulin reservoir so that any air bubbles rise up toward the needle.
–Press the injection button all the way in.
–Check if insulin comes out of the needle tip.
-Safety test may need to be performed several times before insulin is seen.
-If no insulin comes out, check for air bubbles and repeat the safety test two more times
to remove them.
-If still no insulin comes out, the needle may be blocked, change the needle and try
again.
1. Record Review of Resident #38’s Medication Administration Record [REDACTED] -Humalog three times a day (TID) before meals, per a sliding scale (refers to the
progressive increase in the insulin dose, based on pre-defined blood glucose ranges).
–Sliding scale (SS) for a blood glucose of 244 showed give six Units SQ.
-[MEDICATION NAME] 20 Units in the A.M., SQ.
During an observation on 1/9/19 at 7:49 A.M., of Licensed Practical Nurse (LPN) A during

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 48)
insulin administration showed:
-He/she did not prime the Humalog pen before administering six Units SQ.
-He/she did not prime the [MEDICATION NAME] pen before administering 20 Units SQ.
2. Record Review of Resident #13’s MAR indicated [REDACTED] -Humalog SS four times a day (QID), if blood glucose level is under 199 do not give.
-[MEDICATION NAME] five Units SQ in A.M., daily.
During an observation on 1/9/19 at 8:47 A.M., of LPN A during insulin administration
showed:
-He/she held Humalog due to the resident’s blood glucose level of 188.
-He/she did not prime the [MEDICATION NAME] pen before administering five Units SQ.
During an interview on 1/9/19 at 8:55 A.M., LPN A said per the pharmacy that the facility
uses:
-They only prime an insulin pen when it is new;
-They do not prime an insulin pen with each subsequence use;
-He/She had been educated on the use of insulin pens during an annual in-service.
During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said:
-The facility’s Insulin Administration Policy should include the use of insulin pens.
-He/she would expected that insulin pens would be primed according to the manufacturer’s
instructions.
-He/she tries to keep the staff educated so that medication passes are done correctly.
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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
medications were stored, labeled and dated correctly in one sampled medication room out of
one sampled medication room and one sampled medication cart out of two sampled medication
carts. The facility census was 49 residents.
Record review of the facility’s undated policy, Storage of Medications showed:
-The nursing staff shall be responsible for maintaining medication storage and preparation
areas in a clean, safe, and sanitary manner;
-Drug containers that have missing, incomplete, improper, or incorrect labels shall be
returned to the pharmacy for proper labeling before storing;
-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals;
-All such drugs shall be returned to the dispensing pharmacy or destroyed;
-Drugs for external use shall be clearly marked as such, and shall be stored separately
from other medications.
1. Observation on 1/7/19 at 10:39 A.M., of the facility’s one medication room with
Licensed Practical Nurse (LPN) D showed the following:
-The medication refrigerator’s temperature had not been checked on 1/3/19, 1/4/19, 1/5/19
and 1/6/19;
-[MEDICATION NAME] (an antibiotic to fight infections) 50 milligram (mg)/milliliter (ml) a
300 ml bottle had been opened without an opened date written on it;
-[MEDICATION NAME] cream (used to decrease inflammation) two opened 100 gram tubes, with
no resident’s name, date opened written on it, and did not have the original printed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 – Some

(continued… from page 49)
labels from the dispensing pharmacy on them. The labels were torn off;
-[MEDICATION NAME] sulfate ophthalmic solution (an eye medication) 1%, an opened 5 ml
bottle, with no resident’s name, date opened written on it, and did not have the original
printed labels from the dispensing pharmacy on them. The labels were torn off;
-[MEDICATION NAME] (a narcotic pain medication) oral solution, a 100 mg/5 ml bottle was
opened without an opened date written on it;
-One bottle of [MEDICATION NAME] (used for nausea and vomiting) containing 12 pills, that
did not have a resident’s name on it and was in a box that also had used hair clippers,
scissors, and [MEDICATION NAME] in it;
-An open tube of Vaseline petroleum jelly with a physician’s orders [REDACTED].
-An opened tube of Vaseline petroleum jelly with a physician’s orders [REDACTED].
Observation on 1/7/19 at 11:15 A.M., of the medication cart for the 200 hallway showed:
-[MEDICATION NAME] oral solution 100 mg/5 ml a 30 ml bottle, that had an opened date of
12/23/17 and had expired on 11/07/18;
-One open tube of antifungal cream (medication to get rid of fungus), with no residents
name or opened date on it and was in a drawer with resident’s food for medication
administration (applesauce and crackers).
During an interview on 1/7/19 at 11:30 A.M., LPN D said:
-The night nurse is to check the temperature of the refrigerator every night;
-The night nurse who was working was picking up shifts and may not have known it was
his/her duty;
-All opened medications should have a date that they were opened on them;
-Expired medications should have been disposed of;
-All medications should have a label on it or should be disposed of;
-Medications should not be in a drawer with food, phone chargers, hair brushes, and can
openers.
During an interview on 1/11/19 at 12:02 P.M., the Director of Nursing (DON) said:
-Medications should have a date written on them if they have been opened;
-The night nurse may not have known he/she needed to check the temperature on the
refrigerator;
-You should never use expired medications;
-Expired medications should be disposed of.
-The facility has a drug buster (container with chemicals used to dispose of drugs);
-Medications should have a label on them;
-There is no reason medications should be in a drawer with food and a brushes.
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to separate damaged cans in the
dry storage area; to keep the walk-in refrigerator and freezer floors clean; to maintain a
clean can opener blade; to refrigerate foods when necessary; and to ensure proper hand
hygiene practices were followed to prevent contamination. These deficient practices
potentially affected all residents who ate food from the kitchen. The skilled nursing
facility census was 49 residents with a licensed capacity for 60.
1. Observations during the kitchen inspection on 1/7/19 between 8:49 A.M. and 9:42 A.M.,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 50)
showed the following:
– There was a build-up of food debris on the manual can opener blade;
– A 105 ounce (oz.) can of diced pears and a six pound (lb.) 10 oz. can of tropical fruit
cocktail in the dry storage were dented, and not separated from undented cans.
Observations during the kitchen inspection on 1/8/19 between 9:42 A.M. and 12:53 P.M.,
showed the following:
– There was a build-up of food debris on the manual can opener blade;
– A one gallon (gal.) jug of soy sauce in the dry storage was marked as having been opened
on 2/1 and the label stated Refrigerate After Opening;
– The walk-in refrigerator and freezer floors had trash and food remains and dust build-up
under the storage racks;
– The dietary staff prepared foods and then moved cooked foods from the stove and placed
them in steam table pans without washing hands or re-gloving between tasks.
During an interview on 1/8/19 at 10:13 A.M., the Dietary Manager said dented cans are to
be discarded and reported to the food vendor sales representative for refund. The Dietary
Manager said the person who checks in the order should look for dents in the cans. The
Dietary Manager said if other staff find dented cans they should be discarded and reported
to the food vender sales representative.
During an interview on 1/10/19 at 8:47 A.M., the Dietary Manager said the following:
– The walk-in floors are swept on Fridays by the stock person after delivery;
– The can opener blade is cleaned nightly by the night Dietary Aide;
– If food needing refrigeration and had not been, it should be thrown out;
– The dietary staff had been educated to wash hands and re-glove between tasks.
F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Have a policy regarding use and storage of foods brought to residents by family and
other visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to educate all staff as to the
existence, whereabouts, and contents of a written, on-site policy regarding the
acceptance, usage, and storage of foods brought into the facility for residents by family
and other visitors, to ensure the food’s safe and sanitary handling and consumption. This
deficient practice had the potential to affect all residents who ate food brought in by
visitors. The facility census was 49 residents with a licensed capacity of 60 residents.
Record review of the undated policy entitled Foods Brought by Family/Visitors, showed the
dietician or nurse supervisor should ensure the food did not conflict with the resident’s
diet and contact the physician for approval if a diet can be liberalized, and counsel the
residents and families if a diet cannot be liberalized and document the discussion.
1. During an interview on 1/7/19 at 9:16 A.M., the Dietary Manager (DM) said outside food
was allowed, but he/she was unsure if there was an actual written policy anywhere.
During an interview on 1/8/19 at 12:27 P.M., the A.M. Cook said the following:
– If outside food is brought in for a resident, it is labeled with their name, dated, and
kept in the kitchen’s reach-in refrigerator;
– He/She had worked at the facility for [AGE] years and he/she did not know of any written
policy, but they could ask the DM.
During an interview on 1/8/19 at 1:42 P.M., Licensed Practical Nurse (LPN) A said the
following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 51)
– If outside food is brought in for a resident, they notify the kitchen, date and label
it;
– He/She was not sure where dietary staff put it;
– He/She was sure there was a policy in dietary;
– He/She was unsure if it was in the nursing procedures book.
During an interview on 1/10/18 at 12:33 P.M., the Administrator said that the outside food
policy was discussed a while ago with the dietary staff by the Dietician, but there hadn’t
been an all staff in-service on it, though it should probably be added.
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

Based on observation, interview and record review, the facility failed to ensure that
proper infection control procedures were maintained, by failing to perform proper hand
washing and/or hand sanitizing during a medication pass for three supplemental residents
(Residents #46, #53, and #32). The facility census was 49 residents.
Record review of the facility’s undated, Handwashing/Hand Hygiene Policy, showed:
-This facility considers hand hygiene the primary means to prevent the spread of
infections;
-All personnel shall be trained and regularly in-serviced on the importance of hand
hygiene in preventing the transmission of healthcare-associated infections;
-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the
spread of infections to other personnel, residents, and visitors;
-Hand hygiene products include: soap and water, and alcohol-based hand rub;
-Employees must wash their hands using soap and water before and after direct contact with
residents and when hands are visibly dirty or soiled;
-If hands are not visibly soiled (may) use an alcohol-based hand rub before and after
direct contact with residents, before preparing or handling medications, and after contact
with objects in the immediate vicinity of the resident.
1. Observation on 1/9/19 at 7:25 A.M., showed Certified Medication Technician (CMT) B:
-Sat two medication cups down, one with medications in it and the other with applesauce in
it, on a dining room table next to resident #46;
-Touched the resident’s left shoe with his/her left hand and lifted the resident’s foot;
-With his/her right hand lowered the resident’s left wheelchair footrest and placed the
resident’s foot on the footrest;
-Did not wash or sanitize his/her hands;
-Picked up the medication cups;
-Placed the medications, with a spoon into the applesauce and gave the medications to the
resident.
2. Observation on 1/9/19 at 7:29 A.M., showed CMT B:
-Did not wash or sanitize his/her hands;
-Prepared medications into a medication cup and gave them to resident #53.
3. Observation on 1/9/19 at 8:03 A.M., showed CMT B:
-Paced a hand held blood pressure cuff on resident #32.
-Did not wash or sanitize his/her hands.
-Prepared medications into a medication cup and gave them to resident #32.
During an interview on 1/11/19 at 8:15 A.M., CMT C said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 52)
-The CMT’s and nurses are to wash their hands before passing medications and between each
resident;
-Staff are to wash hands and apply gloves if administering eye drops and/or breathing
treatments;
-Staff are to wash hands and apply gloves if they will be touching any other items while
giving medications to a resident.
During an interview on 1/11/19 at 8:30 A.M., Licensed Practical Nurse (LPN) A said:
-The nurses and CMT’s are to wash their hands before passing medications;
-Staff may use hand sanitizer between each resident while passing medications;
-Staff should apply gloves if they know they will be touching the resident or other
objects when giving a resident his/her medications;
-If staff need to touch a resident or objects while giving medications, then they should
wash their hands afterward and before doing the next resident’s medications.
During an interview on 1/16/19 at 10:49 A.M., the Director of Nursing (DON) said:
-He/she expected the CMT’s and the nurses to give resident’s their medications first
before touching other objects.
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure residents were offered
the pneumococcal vaccine (a method of preventing a specific type of lung infection
(pneumonia) that is caused by the pneumococcus bacterium) in a timely manner, affecting
one sampled resident (Resident #42), out of 13 sampled residents. The facility census was
49 residents.
1. Record review of Resident #42’s electronic medical record showed the resident was
admitted to the facility 5/9/14, and most recently readmitted on [DATE].
Record review on 1/11/19 at 8:43 A.M. of the resident’s Immunization Record showed his/her
last pneumonia vaccine was administered 8/16/12 (more than five years ago).
During an interview on 1/11/19 at 8:55 A.M., Licensed Practical Nurse (LPN) A said:
-8/16/12 was the date of the last pneumonia vaccine he/she saw in the resident’s medical
record;
-Unless the resident had a pneumonia vaccine in the hospital, 8/16/12 was when the last
one was given.
During an interview on 1/11/19 at 9:13 A.M., the Wound Nurse said he/she would double
check the resident’s medical record to see if he/she saw anything else related to the
resident receiving a pneumonia vaccine.
During an interview on 1/11/19 at 11:02 A.M., the Wound Nurse said:
-He/She did not find any record of the resident having received a pneumonia vaccine within
the past five years;
-He/She got permission over the phone from the resident’s daughter with two nurses present
to give the resident a pneumonia vaccine and administered it on 1/11/19.
Record review of the hospital records for the resident’s most recent hospitalization
(8/22/18 thru 8/25/18) showed:
-Documented under problems: Pneumonia, Onset 8/22/18.
-Hospital Vaccine list: none.
During an interview on 1/16/19 at 10:45 A.M., the Director of Nursing (DON) said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265780

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

01/17/2019

NAME OF PROVIDER OF SUPPLIER

ADRIAN MANOR HEALTH & REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

402 WEST FIRST STREET
ADRIAN, MO 64720

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 53)
-The wound nurse was responsible for making sure vaccines were done;
-He/She expected the resident to have been up to date with his/her vaccines.
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