Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to organize and participate in resident/family groups in the
facility.

Based on interview and record review, the facility failed to provide the Resident Council
(RC) and one resident (Resident #21) a response to complaints and recommendations. This
had the potential to affect all the facility residents. The facility census was 38.
1. Review of the facility undated Grievance Policy and Procedure showed it is the policy
to ensure prompt resolution to all residents’ grievances.
Review of RC meeting minutes, showed:
– On 10/8/18, the Dietary Manager (DM) was present to address resident complaints. The
council complained they were tired of soup and sandwiches. The minutes showed no response
to resident complaints for this meeting or prior meetings.
– On 11/12/18, the minutes showed no response to resident complaints for this meeting or
prior meetings.
– On 12/10/18, the minutes showed no response to resident complaints for this meeting or
prior meetings.
In an interview on 1/8/19 at 6:30 P.M., Resident #4 said the kitchen served too much soup.
Residents were tired of the same food being served all the time. The kitchen needed to
serve a variety of foods.
Review of the Facility Menu for the week’s evening meal main, showed:
– 1/6/19, chili dog.
– 1/7/19, turkey soup.
– 1/8/19, chicken and noodles.
– 1/9/19, beef stew.
– 1/10/19, potato soup.
In an interview on 1/10/19 at 8:55 A.M., the DM said:
– She attended one RC meeting since becoming the DM six months ago. She received copies of
the RC monthly meetings. Residents complain if something is not right with the food or if
they are tired of certain foods. She did not know to provide feedback to the resident
council regarding their dietary complaints.
– Resident #21 came to her individually to complain that residents are tired of soup and
sandwiches. She told Resident #21 she had to serve what was listed on the menu, but an
alternate was available. Sometimes the alternate was another kind of soup.
– She did not know why the menu regularly scheduled soup, soup type foods and sandwiches
for supper. Five months ago, she became aware of resident complaints regarding the soup
and sandwiches. The Registered Dietician Representative (RDR) came to the facility
monthly. She did not inform the RDR or the Registered Dietician (RD) of residents’ menu
complaints. She agreed with the residents that too much soup was on the menu. She only
informed Social Services (SS) of the complaints. She did not know how to change the menu.
No one has addressed the residents’ menu complaints. They did not have a substitution
menu.
During the resident group meeting on 1/10/19 at 10:14 A.M., residents said:
– Resident #21, Resident #7 and Resident #12 wanted to know why they had to have soup and
sandwiches regularly for meals. They wanted a variety of foods.
– Resident #7 said staff response to their complaints of food was to say Go tell someone
else.
– Resident #12 said salads were only lettuce and cheese. They used to serve taco salads.
– Resident #21 said the facility served too many hot dogs and meat patties. Residents
wanted a variety of meats. Residents were tired of meat always being served in a patty

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
form. He/she talked to kitchen staff about wanting more meat in meals, such as pork steak,
ham, fried chicken and meatloaf. Staff served salads consisting of only lettuce and
cheese. Residents want lettuce salads to include meat and other vegetables. The DM and SS
told him/her it was left to the RD to change. He/she told the administrator about the food
service problem and nothing was done about it. He/she got up hungry from the table three
times last month due to dissatisfaction with the menu. The only response from staff was
there was nothing they could do about it, it was up to the RD. Staff told him/her they
expected him/her to tell the RD about the residents dissatisfaction with the menu.
In an interview on 1/10/19 at 3:30 P.M., the Administrator said:
– The DM was to respond to the RC and individual residents’ food complaints, but did not.
The DM should have communicated resident food complaints to the RD in order for the menu
to be adjusted.
– She agreed with the residents that there was too much soup served in the evenings. The
DM should have worked on preferences with the residents and responded to resident
complaints.
– The resident council meeting minutes showed no resolution to resident complaints.
In an interview on 1/11/19 at 9:20 A.M., the SS said:
– She had the DM come to the 10/2018 RC meeting to address resident complaints of too much
soup and wanting more meat and other food items served. She expected the DM to get back
with the council on their concerns. She was unaware that the DM had not done so.
– She agreed with the residents that there was too much soup served and the menu needed
more variety.
– The facility did not have a RC policy.
– RC meetings should, but did not include follow-up on RC complaints, resolutions and
result satisfaction.
In an interview on 1/14/19, Resident #21 said he/she told the DM a long time ago that
there was too much soup and not enough meats served. The issue had never been resolved.
Review of resident council meeting minutes dated 1/14/19, showed:
– The RC would like to meet with the dietician as a group to talk about menus.
– Residents want to be informed in advance of substitutions to the planned menu.
– No response to resident complaints from prior meetings.
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

Based on observation, interview and record review, the facility failed to follow their
Abuse Policy when staff reported one resident (Resident #33) wrapped nebulizer tubing
around another resident’s (Resident #13) neck. Staff failed to investigate, promptly
report and notify, promptly implement individualized abuse prevention care plans, complete
an incident report, obtain witness statements, conduct interviews, determine resident
psychological distress and determine investigation results. The facility census was 38.
1. Review of the facility undated Abuse Policy showed:
– The facility will thoroughly investigate all allegations of resident abuse. The facility
will not condone resident abuse by anyone, including other residents. All personnel must
promptly report any incident or suspected incident of abuse.
– Abuse prevention included implementing individualized resident specific care plans
identifying each resident’s needs and behaviors along with appropriate goals and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 2)
approaches.
– Any person witnessing or suspecting abuse shall immediately remove the resident from a
harmful environment. Upon receiving a report of physical abuse, the charge nurse shall
report to his/her supervisor.
– Staff was to notify the immediate supervisor, department head and administrator by
phone, if not present. Along with completing an Incident Report.
– Staff was to notify the primary care physician, or on-call physician if after hours, of
the incident.
– Failure to report occurred when a suspected abuse has taken place, a person is aware of
the situation and this person has allowed a period greater than two hours to elapse
without reporting suspected abuse to the Administrator.
– Any resident-to-resident altercation shall be reported to state agencies where there is
evidence of psychological distress to either resident involved.
– The Administrator or his/her designee must complete an Incident Report and obtain
written, signed and dated statements from the person reporting the incident. A completed
copy of the Incident Report and written statement from witnesses must be provided to the
Administrator within 24-hours of the incident occurrence. An immediate investigation will
be made and will include interviewing all staff who worked in the area where the incident
occurred and who worked during the 24-hours prior to the incident, and a copy of the
finding of such investigation will be provided to the Administrator within three working
days of the occurrence of such incident.
– Any person who has knowledge or reason to believe that a resident has been a victim of
mistreatment or abuse SHALL report, or cause a report to be made of the mistreatment or
offense.
– Report information to include a representative of the social services department monitor
the resident’s feelings concerning the incident.
– The administrator was to keep the residents’ representative informed of the progress of
the investigation on a daily basis.
2. Review of Resident #13’s nurses’ notes dated 1/6/19, showed Licensed Practical Nurse
(LPN) B documented that the resident was in bed asleep when another resident entered room,
took nebulizer tubing and wrapped it around the resident’s neck. This resident woke up,
grabbed the tubing away from his/her neck, while cursing at the other resident. Nebulizer
tubing and machine placed in night stand drawer.
In an interview on 1/11/19 at 8:15 A.M., the Interim Director of Nursing (IDON) said she
was unaware of the 1/6/19 nebulizer incident/altercation involving Resident #13. She did
not know who the resident was that wrapped tubing around Resident #13’s neck. At the time
of the incident, staff should have notified her and the administrator and started an
incident investigation.
Observation on 1/11/19 at 11:30 A.M., showed Resident #13’s nebulizer machine and plastic
tubing at his/her bedside.
During interviews on 1/11/19 at 10:44 A.M. and 11:35 A.M., the Administrator said:
– Staff did not inform her of the 1/6/19 incident involving Resident #13.
– She did not understand why staff did not report the incident.
– At the time of the incident, staff should have informed her, started an investigation
and implemented interventions to prevent reoccurrence.
– She did not know who wrapped tubing around Resident #13’s neck. She was trying to get in
touch with LPN B in order to find out incident details.
During interview and record review on 1/11/19, at 2:20 P.M.,
– The Administrator said she spoke with LPN B and found out on 1/6/19, Resident #33 put
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 3)
nebulizer tubing around Resident #13’s neck.
– Review of LPN B’s 1/11/19 written statement, showed a certified nurse aide (CNA) called
him/her to the special Care Unit (SCU) reporting he/she heard Resident #13 cursing. The
CNA entered Resident #13’s room and found tubing loosely around the resident’s neck.
Resident #13’s hands were on the tubing pulling it. Another resident was in Resident #13’s
room walking away from the resident’s bedside. The CNA stated he/she heard a noise and the
resident’s nebulizer machine was on the floor. The CNA did not witness the incident.
During an interview on 1/11/19 at 3:00 P.M., LPN B said:
– CNA F called him/her to the SCU on 1/6/19 at 8:00 P.M. and reported that Resident #33
put nebulizer tubing around Resident #13’s neck. The CNA said he/she heard Resident #13
cursing and then the resident’s nebulizer machine fall to the floor. The CNA then went
into Resident #13’s room to find Resident #33 wandering around the room and nebulizer
tubing wrapped around Resident #13’s neck.
– He/she assessed Resident #13 and completed quick charting without knowing all the
incident details. He/she was to complete an incident report, but did not. If he/she
followed the Incident Report process and obtained written statements then the facts of the
incident would be known. He/she should have called the Administrator at the time of the
incident.
3. During an interview on 1/11/19 at 2:40 P.M., the IDON said:
– LPN B never reported the incident to her.
– At the time of the incident, LPN B did not follow the facility policy. LPN B should have
followed the policy by assessing the residents involved, notifying the Administrator and
IDON, starting an incident investigation and completing an incident report.
In an interview on 1/14/19 at 11:17 A.M., the Administrator said she found the nurse’s
notes regarding the incident and staff interviews conflicted. Due to LPN B not following
the facility incident policy, there was no way to know what happened in order to implement
appropriate interventions for resident care.
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 facility failed to ensure staff
followed acceptable standards of practice for two of 14 sampled residents (Resident #6 and
Resident # 3). Staff failed to enter the physician’s laboratory order for Resident # 6
into the facility’s electronic medical records (EMR) correctly and therefore, failed to
obtain the laboratory test as ordered, and when staff failed to offer Resident #3 anything
to eat for an hour and five minutes after they administered Humalog (fast acting insulin).
The facility census was 38.
1. Record review of Resident #6’s care plan, dated as printed on [DATE], showed:
– Risk for unusual bleeding due to anticoagulant (medication that makes it harder for
blood clots to form) therapy
– The goal was to be free from complications from unusual bleeding.
– Interventions – [DATE], [MEDICATION NAME] (an anticoagulant that required routine lab
monitoring) 3 milligrams (gm) and 4 mg alternating doses every other day, help the
resident avoid bumps and jarring with transfers, will bruise easily, report any bruising
to the charge nurse. Immediately report black, tarry stools, coffee-ground emesis (a sign

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Few

(continued… from page 4)
of [MEDICAL CONDITION]), nosebleeds, pink or amber colored urine, or bleeding of the gums
to the charge nurse. Use hair removal product for legs and face as needed or safety razor.

Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed:
– No cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
– [MEDICATION NAME] time (PT, a blood test to measure how long it took blood to clot) and
international normalized ratio (INR, a standardized measure of the clotting ability of
blood, used to monitor the risk of bleeding when taking anticoagulation medication)
monthly on the second Tuesday.
– Hemoglobin A1C (HgbA1c, a test to show the average level of the blood sugar over the
last two to three months) and a basic metabolic panel (BMP a group of blood test to assess
important functions of the body) every six months.
During an interview on [DATE], at 10:50 A.M., and [DATE] at 10:40 A.M., Registered Nurse
(RN) A said:
– Pharmacy A entered physicians’ orders and printed the residents’ POS.
– In (MONTH) (YEAR), the facility switched to Pharmacy B, so the nurses had to enter all
the residents’ old and new orders into the facility’s Matrix computer system (EMR, an
electronic medical records system), because Pharmacy B did not offer that service.
– Pharmacy A’s POS showed the lab orders, but the new Matrix POS did not.
– When a physician gave lab orders, RN A entered those orders into the laboratory computer
system, but those orders did not show on the Matrix POS.
During an interview on [DATE], at 9:30 A.M., LPN A said:
– Matrix was the facility’s EMR system where staff entered orders for the POS. If staff
entered the orders in Matrix those orders went on the POS, but did not transfer to the lab
computer program to order the test. If staff entered the order into the laboratory system,
it only showed on the lab site and did not transfer to the POS.
During an interview on [DATE], at 11:30 A.M. Laboratory A’s Client Service Representative
said:
– Laboratory B took over their tong-term care accounts.
– The most recent PT/INR they did for Resident #6 was on [DATE].
– Facility staff could enter the lab orders into the lab’s computer program or call the
lab staff and they would enter the order.
During an interview on [DATE], at 11:13 A.M., Laboratory B’s Customer Service
Representative said:
– They started doing the facility’s labs in (MONTH) (YEAR).
– Resident #6 was not in their computer system and they had not done any labs for the
resident.
Review of the resident’s PT/INR, dated [DATE], showed:
– PT of 30.0 with an INR of 2.5
– A handwritten notation showed called to Physician A, no new orders. Continue [MEDICATION
NAME] 3 mg on even days and 4 mg on odd days.
Review of the resident’s POS, dated [DATE] through [DATE], showed:
– PT/INR, HgbA1c and BMP semi-annually (every six months);
– [MEDICATION NAME] 3 mg once a day, every other day;
– [MEDICATION NAME] 4 mg once a day every other day.
– The POS did not show the PT/INR monthly order.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Few

(continued… from page 5)
Review of the resident’s Medication Administration Record [REDACTED]
– Staff initialed to show they gave the [MEDICATION NAME] from [DATE] through [DATE].
Review of the resident’s POS, dated [DATE] through [DATE], showed:
– PT/INR, HgbA1c and BMP semi-annually (every six months)
– [MEDICATION NAME] 3 mg once a day, every other day;
– [MEDICATION NAME] 4 mg once a day, every other day.
– The POS did not show the PT/INR monthly order.
Review of the resident’s Medication Administration Record [REDACTED]
– Staff initialed to show they gave the [MEDICATION NAME] from [DATE] through [DATE].
During an interview on [DATE], at 11:15 A.M., Physician A said:
– He/she did not order the resident’s PT/INR every six months.
– He/she ordered a monthly PT/INR and the PT/INR should be done every month.
During an interview on [DATE], at 2:29 PM, [DATE], at 10:50 A.M., and [DATE] at 10:40
A.M., Registered Nurse (RN) A said:
– Resident #6 had a monthly PT/INR order for years.
– He/she did not know the order showed PT/INR every 6 months, and did not know how that
happened.
– When he/she received lab orders, he/she entered those orders into the laboratory
computer system, but those orders did not show on the Matrix system POS.
– Resident #6’s PT/INR orders expired in the laboratory computer system, in (MONTH)
(YEAR).
– On Friday [DATE], Physician A gave orders for Resident #6’s monthly PT/INR and he/she
entered those orders into the lab computer system.
During an interview on [DATE] 11:16 A.M., the Administrator said:
– LPN A reviewed the orders after he/she and staff entered all the orders into Matrix.
– LPN A checked the medications listed on Pharmacy A’s POS against the Matrix POS, to make
sure the medication orders matched, but did not check the lab orders to see that they were
entered and correct.
During an interview on [DATE], at 3:12 P.M., LPN A said:
– He/she was not told to check the residents’ Matrix system POS to ensure staff entered
the lab orders correctly.
2. Review of the facility’s undated policy for Fast Acting Insulin (Novalog – Humalog),
showed:
– Fast acting insulin is to be given no more than 15 minutes prior to a meal or
immediately after a meal due to its fast acting effect on blood sugars;
– All fast acting insulin will be given immediately after the meal; Certified Medication
Technician (CMT) or charge nurse will take resident from dining room table after they have
eaten to their room and administer the insulin;
– If for any reason the insulin has to be given before a meal, immediately after
administering insulin, a glass of milk or juice along with crackers will be given to the
resident and staff will sit with resident to ensure consumption.
3. Review of Resident #3’s current ,[DATE] physician’s orders [REDACTED].
Observation on [DATE] at 7:29 A.M., showed CMT A administered 6 units of Humalog to the
resident and pushed the resident to the breakfast table in the independent main dining
room and left him/her without offering the resident any type of snack or food. Glasses of
milk and tomato juice sat in front of the resident, which he/she did not consume. The
resident sat at the breakfast table without food to eat until staff served his/her
breakfast of biscuits and gravy at 8:40 A.M.
During an interview on [DATE] at 11:40 A.M., CMT A said the resident should have had
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Few

(continued… from page 6)
something to eat within 15 minutes after he/she received Humalog. Breakfast was served
very late that morning. He/she did not offer the resident a snack.
During an interview on [DATE] at 12:53 P.M., the Interim Director of Nurses said:
– When staff administered fast acting insulin, they should provide a snack or meal within
,[DATE] minutes.
F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

Based on interview and closed record review, the facility staff failed to complete a
comprehensive discharge summary for one resident (Resident #39) out of three discharged
residents. The facility census was 78.
1. Record review of Resident #39’s closed medical record, showed the resident discharged
to home and was to have Home Health services. Staff did not complete a recapitulation of
the resident’s stay at the facility or a complete discharge summary.
During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses (IDON) was
asked whether nurses or social services documented a discharge summary. She did not think
staff knew to include documentation of a recapitulation of the resident’s stay at the
facility.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, the facility failed to ensure four
residents (Resident #12, #16, #22 and #25) who required staff assistance received complete
perineal care and assistance with grooming. The facility census was 38.
Review of the 2001 Nurse Assistant in Long Term Care Facility Perineal Care, showed:
– Gently manipulate and cleanse all perineal folds;
– Clean front to back;
– Clean the anal area and wash the inner legs.
Review of the facility’s Care of Nails policy, dated 4/06, showed:
– Nursing assistants may perform nail care on residents who are not at risk for
complications of infection. Licensed nurse must perform nail care on high-risk residents,
and a podiatrist must perform nail care on residents suffering from diabetes or vascular
disease.
– To provide cleanliness, prevent spread of infection, for comfort to prevent skin
problems;
– Soak hands five minutes in warm water, scrub nails gently with brush if necessary, trim
and clean nails and file smooth;
– Apply lotion to hands.
Review of the facility’s Shaving the Resident policy, dated 4/06, showed:
– To remove facial hair and improve the residents appearance and morale;
– Pull skin taut in the opposite direction of the razor stroke. Use gentle firm [MEDICAL

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
CONDITION] and shave against the direction of hair growth;
– Encourage resident to participate in care as much as possible.
1. Review of Resident #25’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/19/18, showed:
– Both long and short term memory problems:
– Dependent on staff assistance for toilet use and personal hygiene;
– Always incontinent of urine and occasionally incontinent of bowel.
Review of the resident’s undated care plan, showed:
– The resident needed assistance in keeping clean and dry, since he/she was incontinent of
bladder;
– Provide incontinence care as needed, use house barrier after incontinence.
Observation on 1/11/19 at 10:14 A.M., showed Certified Nurse Assistant (CNA) B placed a
gait belt around the resident to transfer him/her from the wheelchair to the resident’s
recliner. CNA B said the resident did not like to lay in bed, so he/she would perform
perineal care if needed at the resident’s recliner. After CNA B assisted the resident to
stand, he/she pulled out the resident’s brief and said it was wet. The resident had much
difficulty walking, so CNA B sat the resident back in his/her wheelchair after he/she
pulled the resident’s pants and brief down. CNA B manipulated and cleaned the resident’s
front perineal folds, but did not clean between the resident’s legs or the resident’s
buttocks. CNA B applied a clean brief, assisted the resident to stand, pulled up the
resident’s clean brief and pants.
During an interview on 1/11/19 at 2:07 P.M., CNA B said:
– The resident did not act his/her normal self today;
– When doing perineal care on incontinent residents, he/she should clean all skin where
the urine touched;
– He/she should have washed the resident’s backside as he/she was incontinent in his/her
brief.
2. Review of Resident #22’s MDS, dated [DATE], showed:
– Both long and short term memory problems;
– Dependent on staff for personal hygiene and bathing.
Review of the resident’s undated care plan, showed:
– The resident needed supervision and cueing with activities of daily living, because of
dementia;
– Assist to keep the resident’s face clean daily;
– Monitor his/her ability to see if further assistance is needed;
– Monitor his/her skin with routine cares;
– Provide his/her showers if Hospice was unable to.
Observation on 1/10/19 at 8:51 A.M., showed the resident sat in a broda type chair that
rocked at the breakfast table. The resident had at least eight inch long white whiskers
that grew from the resident’s jaw line and from the resident’s neck.
3. Review of Resident #12’s MDS, dated [DATE], showed:
– Some difficulty with decision making skills;
– Independent with personal hygiene and needed assistance with bathing.
Review of the resident’s undated care plan, showed:
– The resident can bathe him/herself with staff set up;
– Monitor his/her activity of daily living ability and provide further assist if needed;
– Remind him/her to comb his/her hair, brush his/her teeth, wash his/her face in the
morning and at bedtime.
Observation and interview on 1/8/19 at 11:07 A.M., showed the resident sat in an easy
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
chair in his/her room. The resident had one quarter inch gray whiskers on both sides of
his/her upper lip. The resident said:
– Staff helped him/her with showers;
– He/she asked staff to remove his/her facial hair;
– The resident does not like when his/her facial hair gets long, it bothers me.
– When the resident lived at home, he/she kept the whiskers plucked.
During an interview on 1/14/19 at 10:45 A.M. CNA B said:
– Some days the facility did not have a shower aide and on those days, he/she gave showers
for the residents;
– During showers he/she shaved both the men and the women residents;
– He/she thought all the female residents wanted their chin whiskers shaved.
4. Review of Resident #16’s MDS, dated [DATE], showed:
– Short and long term memory problems;
– Dependent on staff for personal hygiene and bathing.
Review of the resident’s undated care plan, showed:
– The resident liked to be clean;
– Keep the resident’s hands and face clean throughout the day;
– Make sure the resident’s fingernails were cut and clean underneath them.
Observation on 1/8/19 at 12:21 P.M. showed the resident sat in the assist dining room,
eating his/her lunch and picked up food that had spilled off the plate unto the table.
His/her right middle, ring and little fingernails had a dark brown substance underneath
his/her fingernails.
Observation on 1/9/19 at 8:47 A.M., showed the resident sat in his/her room in a
wheelchair. A dark brown substance partially filled the underneath side of the right
middle, ring and little fingernails.
During an interview on 1/14/19 at 10:45 A.M., CNA B said:
– He/she cleaned the resident’s fingernails when he/she gave showers;
– He/she clipped and cleaned residents’ fingernails whenever they needed done, if they
were not diabetics.
During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses said:
– When staff removed a brief soiled with feces or urine, they should provide complete
perineal care;
– Staff should always provide good, complete perineal care, front and back;
– If the resident was incontinent in bed, staff should clean between the resident’s legs,
down the backs of the legs and up the resident’s back.
– Staff should shave resident’s facial hair whenever needed, but at least on their shower
days.
– Staff should keep nails clean as needed and on shower days, some of the residents use
their fingers to eat, staff should make sure fingernails were clean.
F 0686

Level of harm – 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 ensure staff
followed the pressure ulcer, wound care treatment, and change of a resident’s condition
policies and procedures for one resident (Resident #38) of 14 sampled residents. Staff
failed to ensure the resident had a pressure relieving cushion for his/her wheelchair and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Actual harm

Residents Affected – Few

(continued… from page 9)
failed to notify the physician, in a timely manner, of a change in the resident’s pressure
ulcer. The facility census was 38.
Record review of the facility’s Care and Prevention of Pressure Ulcers (PU) Policy and
Procedure, dated (MONTH) 2006, showed:
– Purpose- to prevent and treat further breakdown of pressure ulcers;
– Equipment included a pressure reducing chair pad;
– Guidelines included to use pressure-reducing devices to relieve pressure.
Review of the facility’s Wound Care and Treatment Policy and Procedure, dated (MONTH)
2006, showed:
– The care plan should reflect the current status of the PU, appropriate goals, and
approaches;
– Positioning and pressure reduction included wheelchair position: pressure-reduction
cushion.
Review of the facility’s undated, Change in a Resident’s Condition or Status Policy and
Procedure, showed:
– Policy statement: The facility shall promptly notify the resident’s attending physician
of changes in the resident’s condition and/or status;
– Policy interpretation and implementation – The nurse supervisor will notify the
resident’s attending physician when there is a need to alter the resident’s treatment
significantly and when it is deemed necessary or appropriate in the best interest of the
resident.
Review of Resident #38’s quarterly Minimum Data Sets (MDS), a federally mandated
assessment completed by facility staff, dated 12/11/18, showed:
– Staff scored the resident as 00 (severely cognitively impaired), out of a possible 15,
for the brief interview for mental status;
– Dependent on two or more staff for bed mobility and transfers;
– Wheelchair for mobility;
– One Stage III PU (Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon, or muscle is not exposed. Slough (yellow, tan, gray, green, brown or tan dead
tissue) may be present but does not obscure the depth of tissue loss. (MONTH) include
undermining (destruction of tissue extending under the skin edges so the PU is larger at
the base) or tunneling (passageway of tissue destruction under the skin that has an
opening at the skin level at the edge of the PU).
– [DIAGNOSES REDACTED].
Review of the resident’s undated current care plan, showed:
– Coccyx (the tailbone) PU;
– Pressure reducing mattress and needed staff to help him/her position side to side every
two hours. The resident would argue about turning side to side, as he/she just wanted to
lay on his/her left side.
– Dependent for transfers with mechanical lift (a device to transfer non weight bearing
residents) and did not want to get out of bed.
– admitted to hospice services for end stage [MEDICAL CONDITION] on 1/2/19.
– The approaches did not include a pressure-relieving cushion for the Broda chair (a
tilt-in-space wheelchair).
During an interview on 01/09/19 at 2:36 P.M., Family member (FM) A said:
– The resident developed a PU about two months ago;
– FM A felt the facility did not put preventative measures in place to prevent the PU.
During an interview on 1/10/19, at 9:50 A.M., Registered Nurse (RN) A said the facility
did not have a wound nurse. Licensed Practical Nurse (LPN) A measured the PUs weekly and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Actual harm

Residents Affected – Few

(continued… from page 10)
documented assessments in the wound book.
During an interview on 1/11/19, at 11:04 A.M., LPN A, said:
– The resident had a previous PU, which healed on 10/1/18;
– He/She first documented the resident’s new PU on 11/16/18, and it measured 2.1
centimeters (cm) by 0.5 cm;
– LPN A said the PU got worse very rapidly and the next week, on 11/21/18, it measured 3.5
cm by 1.0 cm with a depth of 0.3 cm. He/She sent a fax to the physician for orders, but
did not receive a response from the physician by the time the resident went to the
hospital;
– The PU measured 3.0 cm x 1.0 cm when the resident returned from the hospital on [DATE],
with orders for Santyl (an ointment to remove dead tissue) topical ointment to the coccyx
PU covered with border dressing and [MEDICATION NAME] (an antibiotic to treat an
infection) daily;
– On 12/5/18, LPN A sent a fax to the physician because the PU contained a bloody sack.
The physician said the order for [MEDICATION NAME] daily was an error and increased the
[MEDICATION NAME] to three times a day.
Review of Physician B’s telephone orders showed:
– 11/29/18, Santyl topical ointment to coccyx PU with [MEDICATION NAME] (a highly
absorbent foam dressing to absorb drainage), change daily. Low air loss mattress.
Reposition side to side every two hours and use pressure relieving cushion when up in
chair;
– 11/30/18, [MEDICATION NAME] 300 milligrams (mg) twice a day for 10 days for PU.
Review of LPN A’s fax to Physician B, dated 12/5/18, showed:
– Started Santyl to PU on 11/29/18, upon return from hospital;
– On [MEDICATION NAME] 300 mg daily for ten days;
– PU not improving, bleeding daily, thick blood/pus like sack protruding from PU and does
not move with cleansing;
– LPN A asked if staff could try something else;
– The bottom of the fax had a physician’s orders [REDACTED].M.
Review of Physician B’s telephone orders showed:
– 12/6/18, clarification give [MEDICATION NAME] 300 mg three times a day until 12/10/18.
Resident to see Physician B in wound clinic at 11:00 A.M., on 12/11/18;
– 12/11/18, discontinue current PU treatment, new PU treatment to pack coccyx PU with
[MEDICATION NAME] gauze (a gauze dressing used for infected wounds that may have a
build-up of dead tissue) daily for three days, cover with [MEDICATION NAME], then switch
to plain gauze in PU daily, and return to wound clinic in one month.
During an interview on 1/11/19, at 11:04 A.M., LPN A, said:
– On 12/10/18, the PU measured 3.3 cm by 0.8 cm;
– On 12/11/18, the resident went to the wound clinic and after [MEDICATION NAME] the PU,
it measured 2.0 cm by 0.5 cm and for a while the PU looked great although the tunneling
never got better and he/she still had a lot of drainage. RN A entered the wound clinic
orders and there was a mix-up in wound clinic orders. The wound clinic wanted Santyl on
the wound bed, but that did not get written in the order;
– On 12/19/18, the PU measured 2.0 cm x 0.4 cm. Physician B made rounds and LPN A told
Physician B the PU looked pretty nasty. Physician B [MEDICATION NAME](an antibiotic to
treat the infection) and [MEDICATION NAME] (an antibiotic to treat the infection) for
seven days and asked if staff used the Santyl. LPN B told Physician B about the mix-up
with the wound clinic orders. Physician B ordered the Santyl and staff started using the
Santyl on 12/19/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Actual harm

Residents Affected – Few

(continued… from page 11)
Review of Physician B’s progress notes, dated 12/19/18, showed:
– The resident had malodorous drainage from the PU area.
– Physician B’s assessment/plan showed the resident had an infected PU and orders for
[MEDICATION NAME] 100 mg twice a day [MEDICATION NAME] mg twice a day.
Review of Physician B’s telephone orders showed:
– 12/19/18, [MEDICATION NAME] (an antibiotic to treat infection) 100 mg twice a day for
seven days [MEDICATION NAME](antibiotic to treat infection) 500 mg twice a day for seven
days for PU. Discontinue current PU treatment. New orders to cleanse wound and pack with
plain packing gauze, apply Santyl to PU bed, cut [MEDICATION NAME] to wound size, place in
PU bed, and cover with dressing, daily and as needed.
Review of the resident’s vital sign flow sheet, dated (MONTH) (YEAR), showed:
– Staff documented the resident was on antibiotics for the PU from 12/20/18 through
12/27/18.
– No documentation of antibiotics from 12/27/18 through 12/30/19.
Review of the physician’s telephone orders, showed:
– 12/30/18, send the resident to the emergency room for blood sugar of 524.
– 12/31/18, readmit the resident under Physician B’s services, resume medications as
ordered, resume care and treatment.
During an interview on 1/11/19, at 11:04 A.M., and 1/14/19 at 1:20 P.M., LPN A, said
– On 12/26/18, the PU measured 2.0 cm by 0.5 cm with a 5.0 cm tunnel.
– On 1/2/19, the PU measured 2.0 cm by 0.8 cm with a 7 cm tunnel.
– He/she did not see the PU between last Tuesday 1/2/19, and today, 1/11/19.
– Last Tuesday, 1/2/19, the PU had nasty drainage, but did not have the necrotic (dead
tissue) area around the PU.
– He/she and RN A covered the day shift every week and did the resident’s PU dressing.
– LPN A said about 75% of the time when he/she did the PU dressing changes the resident
had thick brownish drainage. He/she said that drainage either saturated the dressing or
flowed from the PU during the dressing change. He/she said the resident had the drainage
since returning from the hospital in late (MONTH) (YEAR).
– He/she had not contacted the physician about the odorous drainage.
Review of the resident’s vital sign flow sheet, showed:
– No documentation of antibiotics from 12/31/18 through 1/11/2019.
During an interview and observation on 1/10/19, at 9:50 A.M., RN A did and said:
– RN A and a certified nurse aide (CNA) positioned the resident on the left side.
– When RN A removed the PU dressing and packing, a foul odor and a large amount of thick
tan drainage flowed from the open coccyx PU onto the incontinent pad.
– RN A gently pressed on the PU and more thick tan drainage flowed from the PU followed by
pink-tinged drainage.
– RN A applied Santyl to the approximately 16 inch long piece of gauze, packed the gauze
into the open PU, applied a piece of [MEDICATION NAME] over the upper edge of the PU,
covered the PU with a thick dressing, and secured it with tape.
– RN A said the resident was on antibiotics before going to the hospital, but was not on
any antibiotics when he/she returned from the hospital.
– RN A said he/she mentioned to the other nurses that the physician needed to be notified
of the drainage.
– RN A said if staff sent a fax to Physician B it would be under the fax tab in the chart.
– He/she did not contact the physician about the PU drainage since the resident returned
from the hospital.
– He/she said the resident went on hospice a few days ago.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Actual harm

Residents Affected – Few

(continued… from page 12)
Record review of the faxes in the resident’s chart showed:
– No fax to a physician regarding the resident’s PU drainage since returning from the
hospital.
Observations showed:
– On 1/10/19, at 10:50 A.M., the resident sat in the Broda chair. The Broda chair had a
thin, approximately one-half inch, pad covering the straps that made up the back and seat
of the chair. The chair did not have the physician’s orders [REDACTED].
– On 1/10/19, at 12:15 P.M., the resident sat upright in the Broda chair at a dining room
table, with no pressure relieving cushion in the chair.
– On 1/10/19, at 1:30 P.M., the resident slept in the on his/her back in the slightly
reclined Broda chair. The Broda chair had the thin pad covering the seat and back straps,
but did not have the physician ordered pressure relieving cushion in the chair.
– On 1/10/19, at 3:34 P.M., the resident remained in the slightly reclined Broda chair in
his/her room, without the physician’s orders [REDACTED].
During an interview on 1/15/19, at 8:45 A.M., Certified Occupational Therapy Assistant
(COTA) A said:
– Therapy put the resident in a tilt in space wheelchair with the facility’s best cushion.
– Therapy staff were in the process of trying to get a ROHO cushion (an adjustable
pressure relief cushion with soft flexible air cells), but the resident went on hospice,
so he/she would not qualify for a specialty cushion.
During an interview on 1/10/19, at 3:34 P.M., RN A said he/she called Physician B about
the PU drainage and received orders for Bactrim (an antibiotic to treat the infection) and
to obtain a culture (a test to identify the type of bacteria) of the PU.
Observation and interview 1/11/19 at 9:50 A.M., provided the following information:
– LPN A and RN A positioned the resident on his/her left side.
– A very foul smelling brownish bloody drainage saturated the resident’s compound PU
dressing.
– A purplish, black three-pointed star-shaped area surrounded the open PU.
– LPN A said the PU measured 3.5 cm by 1.3 cm with a 5.3 cm tunnel at five o’clock. LPN A
said the PU and the purplish black area measured 5 cm by 5.3 cm.
– LPN A obtained a culture of the pressure ulcer.
– RN A said he/she always gently pressed on the resident’s pressure ulcer and usually
there was drainage from the PU.
During interviews on 1/14/19, at 10:30 A.M., and 2:30 P.M., the Interim Director of
Nursing (IDON) said:
– When she started working at the facility in (MONTH) (YEAR), the resident walked to the
dining room.
– She was not aware the resident recently went on hospice.
– The facility did not have a wound nurse, so the DON would be responsible to get a
pressure-relieving cushion for the resident’s Broda chair.
– She did not know the resident did not have a pressure relieving cushion in his/her Broda
chair.
During an interview on 1/11/19 at 2:30 P.M., the Administrator said:
– She expected staff to follow physician’s orders [REDACTED].
– Staff should notify the physician of a change in a resident’s condition.
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to ensure
resident environment remained free of accident hazards, when they failed to follow
manufacturer’s guidelines during mechanical lift transfers for Resident #16. Additionally,
the facility failed to transfer residents in a safe manner, when staff did not use proper
techniques to reduce the possibility of accidents and injuries during the use of a gait
belt transfer for Resident #6 and #20. The facility also failed to ensure safe water
temperatures for residents, staff and visitors, when water temperatures in the facility
rose above 120 degrees Fahrenheit (F). The facility census was 38.
1. Review of the manufacturer’s guideline for the mechanical lift showed:
– Invacare does not recommend locking the rear casters of the patient lift when lifting an
individual.
– Doing so could cause the lift to tip and endanger the patient and assistants.
– Invacare DOES recommend that the rear castors be left unlocked during lifting procedures
to allow the lift to stabilize itself when the patient is initially being lifted from a
stationary object.
– The legs of the lift must be in the maximum open position for optimum stability and
safety.
– If it is necessary to close the legs of the lift to maneuver the lift under the bed,
close the legs of the lift only as long as it takes to position the lift. Once the legs of
the lift are no longer under the bed, return the legs of the lift to the maximum open
position.
Review of the facility’s policy for Invacare Reliant Hoyer Lift, revised 9/23/16, showed:
– Lifting Procedure: Spread the wheel base of the lift.
– Warning: Invacare owner’s manual does NOT recommend locking the rear castors of the lift
when lifting an individual. Doing so could cause the lift to tip and endanger the patient
and assistants.
– Invacare does recommend that the rear casters be left unlocked during lifting procedures
to allow the lift to stabilize itself.
Review of Resident #16’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/19/18, showed:
– Both short and long term memory problems;
– Dependent on staff for transfers.
Review of the resident’s undated care plan, showed two staff should transfer the resident
with a mechanical lift.
Observation and interview on 1/9/19 at 8:41 A.M., showed the resident seated in a
wheelchair in his/her room. Certified Nurse Aide (CNA) B and CNA C transferred the
resident onto the shower chair.
– CNA C spread the legs of the lift around the resident’s wheel chair and locked the back
castors;
– Staff attached the lift sling to the lift and CNA C raised the resident from the
wheelchair with the castors locked;
– CNA C unlocked the castors, pulled the lift away from the wheel chair, closed the legs
of the lift and pushed it across at least five tiles to the resident’s bed;
– CNA C left the legs of the lift closed and lowered the resident on to the bed.
– After staff undressed the resident and placed a bath sheet over the resident, CNA C
placed the lift back under the bed with the legs closed, attached the sling to the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
mechanical lift, then lifted the resident from the bed.
– The legs of the mechanical lift remained closed while CNA C raised the resident from the
bed, left the legs closed and pulled the mechanical lift from under the bed and turned the
lift towards the shower chair;
– CNA C lowered the resident onto the shower chair.
Observation on 1/9/19 at 9:40 A.M., showed CNA B and CNA C used the mechanical lift to
transfer the resident from his/her shower chair back to bed.
– CNA B opened the lift around the shower chair, locked the castors and attached the loops
of the sling to the mechanical lift;
– CNA B raised the mechanical lift and the resident from the shower chair, unlocked the
castors and backed the lift away from the shower chair, closed the legs of the lift and
pushed the lift over to the resident’s bed;
– CNA B locked the castors and lowered the resident on to bed.
During an interview on 1/9/19 at 10:45 A.M., CNA C said he/she should close the legs of
the lift when moving the resident and open the legs to position around the wheelchair.
He/she did not know if the castors should be locked at any time.
During an interview on 1/9/19 at 11:10 A.M., CNA B said he/she locked the castors, so the
lift would not tip. The legs of the lift should be closed when moving the resident.
2. Review of the facility’s, undated, policy for Gait Belt Use showed:
– Assist the resident at the waist rather than pulling his/her arms or shoulders;
– Make sure the gait belt is never next to bare skin.
Review of Resident #20’s MDS dated [DATE], showed:
– Some difficulty making decisions;
– Required extensive assist with transfers.
Observation on 1/10/19 at 1:28 P.M., showed CNA D transferred the resident from his/her
wheelchair to his/her low bed in the following way:
– Loosely placed a gait belt around the resident’s waist;
– Placed a forearm on each side of the resident under the resident’s arms and grabbed the
gait belt;
– As the CNA lifted, turned and lowered the resident from the wheelchair to the low bed,
the gait belt and resident’s shirt raised at least eight inches around the resident’s
abdomen, back and sides, The CNA’s forearms raised under the resident’s armpits and raised
the resident’s shoulders;
– The resident did not assist with the pivot transfer.
During an interview on 1/10/19 at 2:01 P.M., CNA D said:
– He/she put the gait belt on the resident around the waist and loose enough he/she could
place both hands under the gait belt;
– When the gait belt rose, he/she should stop, reposition and tighten the gait belt;
– The resident did not help with the transfer, because he/she was paralyzed on the left
side.
During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses (IDON) said:
– She expected staff to place the gait belt snugly around the resident’s waist, tight
enough it would not slide up on the resident;
– If the gait belt slid up, staff should stop, reposition the gait belt and tighten it
more;
– Staff should never place their arms under the resident’s arms and should not place the
gait belt on bare skin.
3. Review of the facility’s, undated, policy for Gait Belt Use showed:
– Assist the resident at the waist rather than pulling his/her arms or shoulders;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
– Make sure the gait belt is never next to bare skin.
Review of Resident #6’s MDS, dated [DATE], showed:
– Able to make daily decisions:
– Dependent on staff for transfers.
Observation and interview on 1/11/19 at 9:58 A.M., showed CNA B and CNA D assisted the
resident to transfer from his/her bed to a wheelchair. CNA B said staff used a pivot disc
with the resident, because the resident’s left foot did not work. Both staff assisted the
resident to sit up on the side of the bed, the resident wore a hospital gown that was open
in the back. CNA B placed the gait belt on the resident and tightened it around the
resident’s waist. The gait belt laid against the resident’s bare back. Both staff placed
their forearms under the resident’s arms and grabbed the gait belt at the resident’s back.
When staff transferred the resident, both their forearms raised under the resident’s
armpits as the gait belt rose. CNA D said he/she should not have had the gait belt on the
resident’s bare skin.
During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses (IDON) said:
– She expected staff to place the gait belt snugly around the resident’s waist, tight
enough it would not slide up on the resident;
– If the gait belt slid up, staff should stop, reposition the gait belt and tighten it
more;
– Staff should never place their arms under the resident’s arms and should not place the
gait belt on bare skin.
4. Review of the facility’s Preventive Maintenance Checklist and Inspections showed staff
was to conduct weekly random room checks, per wing, for proper hot water temperatures. The
water temperatures should be between 105 and 120 degrees Fahrenheit (F) per regulations.
Observation on 1/8/19 at 4:30 P.M., showed resident room [ROOM NUMBER]’s hot water
temperature at 121.7 degrees F.
Observation, interview and record review on 1/8/19 at 5:30 P.M., showed:
– The Administrator checked water temperatures that showed, resident room [ROOM NUMBER]’s
water temperature were 123.4 F and the front entry women’s restroom water temperature was
122.5 F. She also found resident room [ROOM NUMBER]’s water temperature at 123.4 F.
– The Administrator checked the hot water heater and it showed the temperature set at
120.2 F.
– Review of the Facility Water Temperature Log, showed staff last checked facility water
temperatures on 12/7/18.
– The Administrator said water temperature checks should be conducted weekly. The former
Maintenance Supervisor (MS) was responsible to conduct water temperature checks. She
temporarily took on the MS responsibilities. She forgot to conduct weekly checks of water
temperatures. The temperature in resident rooms 214, 219 and the front women’s restroom
was too high and could potentially burn someone.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided appropriate catheter (a sterile tube inserted into the bladder to drain urine)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
care and catheter bag and tubing placement, to prevent urinary tract infections for one
resident (Resident #20). The facility census was 38.
Review of the facility’s procedure from the 2001 Nurse Assistant in a Long Term Care
Facility for Steps for Giving Peri Care with Catheter, showed:
– Check the catheter and drainage bag for leaks, kinks, level of bag, color and character
of urine; ensure that it is securely attached to the bed;
– Separate all perineal folds and provide peri care;
– Clean around the insertion site of the catheter;
– With a clean cloth wash the catheter tubing from the insertion site outward at least
four inches. Do not pull the catheter tubing.
1. Review of Resident #20’s medical record showed a laboratory report dated 8/27/18, that
showed many bacteria consistent with a urinary tract infection [MEDICAL CONDITION].
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/9/18, showed:
– Some difficulty with decision making skills;
– Required extensive assist with toilet use and personal hygiene;
– Suprapubic catheter (type of urinary catheter that empties the bladder through an
incision in the abdomen instead of a tube inserted in the urethra);
– Occasionally incontinent of urine and frequently incontinent of bowel.
Review of the resident’s undated care plan, showed:
– The resident needed two staff to assist with toilet use;
– The resident could be incontinent of the bladder even though he/she had a catheter;
– The resident needed catheter care done every shift;
– The resident takes medication for bladder spasms, but can still urinate through the
urethra;
– Assess for signs and symptoms of a UTI.
Observation and interview on 1/8/19 at 9:54 A.M., showed the resident sat in a wheelchair
in his/her room and watched television. The catheter tubing, with yellow brownish colored
urine, lay on the floor under the wheelchair. The resident said he/she had frequent UTIs
and bladder spasms. His/her physician recently injected [MEDICATION NAME] to help with the
urine leaking from the urethra, but he/she did not know if it worked, because he/she still
had a lot of bladder spasms. Night shift staff often forgot to empty his/her urinary
drainage bag.
Observation on 1/8/19 at 12:20 P.M., showed the resident in the main assist dining room in
his/her wheelchair. Both the dignity bag that contained the urinary drainage bag and the
drainage tubing lay on the floor.
Observation on 1/10/19 at 8:51 A.M., showed the resident in the main assist dining room in
his/her wheelchair. Both the dignity bag that contained the urinary drainage bag and the
drainage tubing lay on the floor.
Observation on 1/10/19 at 1:28 P.M., showed Certified Nurse Aides (CNA) A and D
transferred the resident from his/her wheelchair to bed and to provide catheter care.
While the resident sat in his/her wheelchair, CNA D hung the urinary drainage bag on
his/her waist pocket which was as high as the resident’s chest, then transferred the
resident into a low bed. CNA A told CNA D he/she needed to keep the drainage bag below the
resident’s bladder. CNA D used an alcohol wipe and cleaned the resident’s abdominal
insertion site around the tubing. With the same alcohol wipe, CNA D wiped down the
catheter tubing. The resident did not wear a leg strap to help secure the catheter tubing
in place.
During an interview on 1/10/19 at 2:00 P.M., CNA D said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
– The resident should have had a STAT lock or leg strap to secure the tubing, so it did
not get pulled;
– He/she should clean around the site in the resident’s belly, then wipe down the catheter
tubing;
– He/she should use an alcohol wipe to clean around the insertion site and down the
catheter tubing. He/she should not have used the same alcohol wipe for both areas.
Observation on 1/14/19 at 10:25 A.M., showed the resident sat in his/her wheelchair in the
hallway outside his/her room. The catheter tubing and the dignity bag that contained the
urinary drainage bag dragged on the floor. The resident propelled down the hallway towards
the assist dining room. Nursing staff were in the hallway as the resident wheeled by them.

During an interview on 1/14/19 at 12:53 P.M., the interim Director of Nursing said:
– All residents with a catheter, even a suprapubic catheter, should wear a leg strap;
– Neither the catheter tubing, urinary drainage bag nor the dignity bag should ever touch
the floor;
– Staff should use a clean wipe or clean washcloth to clean the insertion site and another
clean wipe or cloth to wipe down the tubing;
– Staff should maintain the drainage bag below the resident’s bladder.

F 0710

Level of harm – Immediate jeopardy

Residents Affected – Few

Obtain a doctor’s order to admit a resident and ensure the resident is under a doctor’s
care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
nursing staff had access to the facility’s anticoagulant (medication that makes it harder
for blood clots to form) policy and failed to ensure staff followed up with one resident’s
(Residents #19) physician in the absence of laboratory orders to monitor the effect of the
resident’s anticoagulation medication. The physician failed to order routine [MEDICATION
NAME] time (PT, a blood test to measure how long it takes blood to clot) and international
normalized ratio (INR, a standardized measure of the clotting ability of blood, used to
monitor the risk of bleeding when taking anticoagulation medication) tests for the
resident. Staff continued to administer the anticoagulant medication in the absence of
orders to monitor the effect of the medication. These failures placed the resident at risk
for significant adverse side effects including the risk of serious injury or death, such
as [MEDICAL CONDITION] or stroke and resulted in a PT flagged as high at 67.3 seconds and
an INR flagged as critically high at 6.2. The facility identified four residents on
anticoagulation medication that required routine orders for laboratory monitoring. The
facility census was 38.
1. Record review of the facility’s undated policy titled automatic stop orders showed:
– Anticoagulants – orders for an anticoagulant must also have an order for [REDACTED].
During an interview and observation on 1/14/19, at 8:50 A.M., the Administrator said:
– She could not find the anticoagulant policy in the nurses’ policy and procedure (P/P)
book.
– She opened a thick three ring binder she identified as the facility’s operating P/P
manual and turned to a policy titled automatic stop orders.
– She said the policy was not in the nurses’ P/P book.
– Whenever she found a nursing P/P in the operating manual, she made a photocopy for the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0710

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 18)
nurses’ P/P book.
– She said she would put a copy of the policy in the nurses’ P/P book.
Review of Resident #19’s care plan, dated 7/19/18, showed:
– The resident was at risk for bleeding or bruising because of an anticoagulant medication
to treat his/her risk of blood clots.
– The goal was to be free from complications from unusual bleeding.
– Interventions – [MEDICATION NAME] to prevent blood clots, PT/INR labs as ordered, help
the resident avoid sudden bumps or jarring to prevent bruising, report new areas of
bruising to the charge nurse, immediately report to the charge nurse any bleeding from the
nose or gums, rust or amber colored urine, dark black, tarry stools, pale and clammy skin,
or any weakness. If the resident reported any rectal bleeding, notify the charge nurse
immediately.
Review of Physician A’s order report, dated 8/28/18 through 9/28/18, showed:
– The resident’s [DIAGNOSES REDACTED].
During an interview on 1/11/19, at 11:15 A.M., Physician A said:
– Initially, the resident was on an anticoagulant that did not require lab monitoring.
– When the resident’s insurance would not pay for that mediation, he/she switched the
resident to [MEDICATION NAME] (an anticoagulant that required routine laboratory
monitoring).
– Physician A said he/she did not pick- up on the fact that the resident did not have an
order for [REDACTED].>- Physician A said he/she just missed it, but expected that
probably the pharmacy consultant should have caught the fact that the resident did not
have a monthly PT/INR lab order.
– Physician A said the resident should have a monthly PT/INR lab order.
During an interview on 1/15/19, at 10:40 A.M., Registered Nurse (RN) A said:
– The facility switched from Pharmacy A to Pharmacy B in (MONTH) (YEAR).
During an interview on 1/14/19, at 9:20 A.M., Pharmacy B’s consulting pharmacist said:
– He/she did the facility’s medication consults every month, made medication
recommendations, and was a second or third set of eyes, but their pharmacy’s computer
system did not interact with the facility’s electronic medical records (EMR).
– Since, the pharmacy’s computer system did not have access to the facility’s EMR
physician’s orders [REDACTED].
– Usually, the current month’s POS were not on the chart when he/she did the review.
– Whenever he/she saw a [MEDICATION NAME] order, he/she checked for an INR. He/she checked
the most recent INR to see that it was in a reasonable range and if not, he/she checked to
see that staff notified the physician.
– Sometimes, lab results were not in the chart. If labs were not in the charts, then
he/she did not see them and did not know about them.
– He/she was not saying a resident might not fall through the cracks, but typically,
he/she checked for the INR.
– If a resident was on [MEDICATION NAME], he/she checked to ensure the resident was not on
aspirin or any blood thinner. If the resident was on [MEDICATION NAME] and aspirin or
[MEDICATION NAME] he/she made a recommendation to the physician about the aspirin or
[MEDICATION NAME].
Record review of faxes staff sent to Physician A, dated 10/10/18, and 10/11/18, showed:
– 10/10/18, the insurance would not pay for the resident’s current anticoagulant.
– 10/11/18, the resident wanted to stay on an anticoagulant and was aware he/she would be
back on [MEDICATION NAME] and have blood drawn for PT/INR.
Review of Physician A’s telephone orders (TO) showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0710

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 19)
– An order, dated 10/11/18, for [MEDICATION NAME] 2 milligram (mg) tablet, daily at 5:00
P.M. and a PT/INR one week from the start date of [MEDICATION NAME].
– An order, dated 10/24/18, to recheck the PT/INR on Friday 10/26/18.
Review of the resident’s Medication Administration Record [REDACTED]
– Staff initialed the MAR indicated [REDACTED].
Record review of the resident’s laboratory test results, dated 10/19/18, showed:
– PT of 26.3 seconds and an INR of 2.6;
– A handwritten notation that the resident was on [MEDICATION NAME] 2 mg daily;
– A physician’s orders [REDACTED].
Record review of the resident’s laboratory test results, dated 10/26/18, showed:
– PT of 24.8 seconds and an INR of 2.5;
– A handwritten notation showed faxed 10/26/18.
Review of the nurses’ notes showed:
– 10/24/18 – new order to recheck PT/INR on Friday, 10/26/18.
– From 10/26/18 until 1/9/19, no staff documentation of contacting the physician about the
resident’s 10/26/18, PT/INR results and no reference of any new PT/INR order.
During an interview on 1/14/19, at 11:30 A.M., Laboratory A’s Client Service
Representative said:
– His/her records showed 10/26/18, was the resident’s most recent PT/INR.
– Laboratory B took over the long-term care accounts.
During an interview on 1/14/19, at 11:13 AM, Laboratory B’s Customer Service
Representative said:
– They took over the facility’s lab testing account in (MONTH) (YEAR).
– They did not do any lab tests for the resident in (MONTH) (YEAR).
– The first lab they did for the resident was on 1/10/19.
During an interview on 1/11/19, at 3:23 P.M. RN A said:
– Staff just did not follow up with Physician A about the 10/26/18, PT/INR results.
– Even when Physician A was out of town, he/she called every day to check on the
residents. Physician A gave staff a cell number to make sure staff could contact him/her.
– Usually when staff contacted Physician A with the PT/INR results, he/she gave the order
for the next PT/INR.
– Physician A always responded to a fax or telephone call.
Review of the resident’s November, (YEAR) and (MONTH) (YEAR), POS showed:
– [MEDICATION NAME] 2 mg daily at 5:00 P.M.
– No PT/INR lab orders to monitor the effect of the [MEDICATION NAME].
Record review of the resident’s MAR, dated (MONTH) (YEAR) and (MONTH) (YEAR), showed:
– In (MONTH) (YEAR), staff initialed the MAR indicated [REDACTED]. Staff documented the
[MEDICATION NAME] was not available on seven of the 30 days.
– In (MONTH) (YEAR), staff initialed the MAR indicated [REDACTED].
Review of Pharmacy B’s drug regimen reviews, dated 10/18/18, 11/20/18, and 12/18/18
showed:
– No recommendations related to [MEDICATION NAME] or for laboratory tests to monitor the
effect of the [MEDICATION NAME].
Review of the resident’s quarterly Minimum Data Sets (MDS), a federally mandated
assessment completed by facility staff, dated 1/6/19, showed:
– Staff scored the resident as 14, out of a possible 15 (cognitively intact), for the
brief interview for mental status (BIMS).
Review of the resident’s POS for (MONTH) 2019, showed:
– [MEDICATION NAME] 2 mg daily at 5:00 P.M.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0710

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 20)
– No order for PT/INR to monitor the effect of the [MEDICATION NAME].
Record review of the resident’s MAR, dated (MONTH) 2019, showed:
– Staff initialed the MAR indicated [REDACTED].
Observation and interview on 1/8/19, at 9:17 A.M., showed:
– The resident had a large purple bruise on the back of his/her right hand.
– The resident was not sure how he/she got the bruise, but said he/she bruised really,
easily.
– He/she had a bruised toe and was not sure how that happened.
During an interview and record review on 1/9/19, at 11:20 A.M., the Interim Director of
Nursing (IDON):
– Handed the surveyor the PT/INR, dated 10/26/18, and said this is the resident’s most
recent PT/INR.
– Said she just had staff contact the physician and received orders for a PT/INR and a
routine monthly PT/INR.
Review of a fax to Physician A, dated 1/9/19, showed:
– The resident had bruising of arms and a bloody nose. The resident was concerned that
his/her INR was high. The resident has not had a PT/INR done since 10/26/18, and is on
[MEDICATION NAME] 2 mg daily.
– A notation on the bottom of the fax showed order received.
During an interview on 1/14/19, at 9:30 A.M., and 1/15/19 at 3:12 P.M., Licensed Practical
Nurse (LPN) A said:
– No one told him/her to check residents’ orders to see if they had lab orders when on an
anticoagulant.
– He/she did not know anything about a policy stating a resident with an order for
[REDACTED].
During an interview on 1/14/19, at 10:30 A.M., the IDON said:
– She worked at the facility for about 3 months last year and then came back in (MONTH)
(YEAR), as the MDS coordinator.
– About the middle of (MONTH) (YEAR), she became the IDON along with being the MDS
coordinator.
– She did not know anything about the automatic stop date policy.
– The IDON said she had never seen that policy and was never told that a nurse should
check to see that there were routine labs ordered when a resident was on [MEDICATION
NAME].
– Usually, physicians gave orders to check the PT/INR for residents on [MEDICATION NAME]
and then gave the next lab order when staff sent them the results.
During an interview on 1/14/19, at 10:50 A.M., RN A said:
– He/she did not know anything about an automatic stop date policy that required routine
labs for any resident on [MEDICATION NAME].
– He/she was not told that nurses should check that residents on [MEDICATION NAME] had a
routine PT/INR order.
During an interview on 1/14/19, at 1:20 P.M., LPN A said:
– After staff send a fax to a physician, they put the fax on a clipboard until the
physician responded.
– Physician A usually called the staff with orders when he/she received the fax.
– Even when Physician A was out of town he/she called the facility every day.
Review of RN A’s nurse’s notes, dated 1/9/18 and 1/10/19, showed:
– 1/9/19, at 11:00 A.M., fax sent to Physician A regarding a lapse in the resident PT/INR
lab work, resident bruising easily, and resident had bloody nose.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0710

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 21)
-1/9/19 at 12:21 P.M., call received from Physician A with orders to draw PT/INR tomorrow
and monthly.
– 1/9/19 at 12:30 P.M., informed resident of orders.
During an interview on 1/11/19, at 3:35 P.M., RN A said about 5:00 P.M., last evening the
lab staff called with the resident’s critical lab value. He/she called Physician A, who
gave orders to hold the [MEDICATION NAME] from last night until Tuesday and then repeat
the PT/INR on Tuesday.
Record review of the resident’s laboratory test, dated 1/10/19, showed:
– PT flagged as high at 67.3 seconds with an INR flagged as a critical high at 6.2.
Review of RN A’s nurse’s notes, dated 1/9/18 and 1/10/19, showed:
– 1/10/19 at 4:00 P.M., received call from lab with critical values of PT 67.3 and INR of
6.2
– 1/10/19, at 4:10 P.M., called Physician A and received orders to hold [MEDICATION NAME]
until Tuesday and recheck PT/INR on Tuesday.
During an interview on 1/11/19, at 2:14 P.M., the resident said:
– A couple of days ago, he/she had a bloody nose. His/her nose just started bleeding, but
then stopped.
– The resident said when he/she coughed this morning there was blood in the tissue. He/she
had the nurse check and the nurse said it was blood.
During an interview on 1/11/19, at 3:23 P.M. RN A said:
-The resident coughed up some dark blood this morning, but not much, just like two or
three strands of blood.
– RN A said the blood was not bright red, it was dark blood.
– RN A told the resident that since his/her PT/INR was so high that his/her gums would
probably bleed if he/she brushed his/her teeth.
– He/she did not assess the resident, because it was just a small amount of blood.
During an interview on 1/11/19 at 2:30 P.M., the Administrator said:
– Physician A usually called staff in response to a fax.
– She expected staff to follow up with a physician, by the next day, if the physician did
not respond to a fax.
– She expected the nurses to review the POS monthly to ensure any resident on an
anticoagulant that required monitoring had routine lab orders.
Note: At the time of the survey, the violation was determined to be at the immediate and
serious jeopardy level J. Based on observation, record review, and interview completed
during the onsite visit, it was determined the facility had implemented corrective action
to address and lower the violation at this time. During the onsite visit, the facility
staff immediately began in-servicing all nurses, prior to the start of their shift, that
all residents with orders for [MEDICATION NAME]/[MEDICATION NAME] must have orders for a
routine PT/INR monitoring on their POS and in the lab draw computer system. On 1/14/19,
the DON added the PT/INR orders to the resident’s POS. The Administrator, DON, or designee
will train all newly hired nurses, during their initial orientation that all
anticoagulants requiring lab monitoring are to have an order for [REDACTED]. All new
admissions and re-admissions orders will be reviewed within 24 hours of admission to
ensure the POS reflected the order for lab monitoring. The DON created an anticoagulation
therapy tracking log. The DON, Administrator, or designee will monitor all residents on
anticoagulants requiring lab monitoring weekly with the anticoagulation therapy log for 90
days to ensure that the appropriate labs orders are on the POS and are being followed.
After those 90 days, the DON, Administrator, or designee will monitor anticoagulants
monthly to ensure that appropriate labs are put on the POS and are being followed. All
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0710

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 22)
above corrective actions will be discussed and addressed at the next all staff in-service
along with annual state survey findings, and in the next quarterly QAA meeting, scheduled
for 1/23/19. A final revisit will be conducted to determine if the facility is in
substantial compliance with participation requirements.
At the time of the exit, the severity level was lowered to a D level. This statement does
not denote that the facility has complied with State law (Section 198.026.1 RSMo)
requiring that prompt remedial action be taken to address a Class I violation
F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation, interview, and record review, the facility failed to post the nurse
staffing data in a prominent place readily accessible to residents and visitors on a daily
basis at the beginning of each shift. The facility census was 38.
1. Observations on all days of the survey, 1/8/19, 1/9/19, 1/10/19, 1/11/19 and 1/14/18,
showed incomplete nurse staffing data forms posted on a door behind the nurse’s station on
the 200 hall which was not easily accessible to all residents and visitors. Each day staff
did not completely fill out the form, in some cases leaving entire sections blank. There
was no nurse staffing data form posted on the Special Care Unit or on the 100 hall in the
front of the building.
Observation and interview on 1/14/19 at 1:47 P.M., showed Licensed Practical Nurse (LPN) A
retrieved a clipboard from a door behind the nurse’s station. Review of the form showed
staff had only documented the date as 1/14/19 and a census number of 38. He/she said there
was only one staffing sheet for the entire building and it was posted on the door behind
the 200 hall nurse’s station.
During an interview on 1/14/19 at 2:10 P.M., the Interim Director of Nursing said she
expected the nursing staff to entirely complete the Daily Staffing Form on each shift. She
did not realize the forms needed to be posted and easily accessible for all residents in
the facility.
During and interview, the Administrator said the facility did not have a policy for
Posting Direct Care Daily Staffing Numbers.

F 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 observation, interview and record review, the facility failed to provide
activities for residents on the Special Care Unit (SCU). The facility failed to provide
meaningful activities identified of interest to one sampled resident (Resident #13) when
staff did not implement activities for the resident in accordance with the comprehensive
assessment and care plan. The facility census was 38.
Review of the undated facility SCU pamphlet showed:
– The facility policy was to admit only those individual who’s physical and psycho-social
needs can be met by the facility. An individual must have the [DIAGNOSES REDACTED].
– The SCU has planned activities daily. The activities are based on past life enjoyment,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Some

(continued… from page 23)
and so all activities provide meaning for the residents.
– Wandering is a part of this disease and that is okay in the SCU.
Review of the facility Resident Activities policy dated 3/2012 showed:
– The Activities Services of each facility will plan, organize and carry out a program of
activities to meet individual resident needs. The program is designed to give resident
entertainment, communication, exercise, relaxation and an opportunity to express their
creative talent. Through the activities, residents can fulfill basic psychological and
social needs.
– All staff are responsible for assisting residents to activities of their choice.
– An activity program is planned for each resident as part of their total resident care by
the Activity director (AD). Residents shall be encouraged to participate in activities of
choice. An individualized program will be implemented for residents unable to participate
in or attend activities.
1. Review of Resident #13’s quarterly review Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/16/18, showed:
– Minimal difficulty hearing.
– Speaks clearly.
– Responds adequately to simple direct communication only.
– Moderately impaired vision.
– Severely impaired skills for daily decision making.
– [DIAGNOSES REDACTED].
Review of the residents undated care plan showed:
– He/she was a retired farmer and tractors were his/her [MEDICATION NAME].
– He/she had impaired vision due to [MEDICATION NAME] degeneration in his/her left eye.
He/she needed large print to read.
– He/she had impaired thinking and recall and was at risk for impaired communication
because of his/her Alzheimer’s dementia and being hard of hearing.
– Staff to ask the resident about preferences throughout the day. Staff to remember he/she
was forgetful and needed frequent cues and reminders.
– He/she was at risk for social isolation because of his/her poor vision, agitation and
being recently widowed. Staff to check with the resident daily about activities. He/she
needed staff supervision to get to and from activities. He/she liked to stay in bed
between meals and needed staff to provide a lot of encouragement for him/her to
participate in activities. It was okay for the resident to sit in the common sitting area
to watch television and visit with staff and peers. He/she liked to do simple trivia, to
tell stories and reminisce. He/she was interested and collected tractors. He/she used to
like to play bingo, checkers, dominoes, poker, solitaire and horseshoes. He/she liked to
listen to country music. He/she liked to watch old television shows and movies, especially
westerns.
Observations of the resident on 1/8/19, showed:
– At 10:15 A.M., the resident lay in bed.
– At 12:02 P.M., resident sleeping in bed with food tray positioned on a bedside table
next to him/her. Staff woke resident up and verbally encouraged him/her to eat. The
resident sat up at bedside began eating and the staff left the residents room.
During an interview on 1/8/19 at 1:30 P.M., Certified Nurse Aide (CNA) D and CNA I said
during the day shift, the resident normally slept a majority of the time.
Observation on 1/8/19 at 5:32 P.M., showed the resident lay in bed.
Observation of the resident on 1/9/19 at 8:20 A.M., showed the resident lay in bed with
food tray partially eaten on a bedside table next to him/her.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Some

(continued… from page 24)
During an interview on 1/9/19 at 9:46 A.M., the resident’s family members (FM) B and FM C
said staff do not interact with the resident. They leave him/her in bed all the time and
do not try to engage him in anything. It is hard for him/her to participate if staff do
not engage or encourage him/her to get involved. There is no quality of life for the
resident due to lack of staff attention. The resident spends his/her days in bed and eats
at bedside. Staff never turn the television on for the resident or visit with him/her. The
resident needed activities for stimulation. The family provided a CD music player with
country music CD’s in the resident’s room. The family has never observed staff set up the
CD player for the resident to hear the music. The resident’s life consisted of him/her
eating, staring at the wall and no one interacting with him/her.
Observations of the resident on 1/9/19, showed:
– At 10:48 A.M., the resident was lay in bed.
– At 5:25 P.M. the resident lay in bed.
Observation on 1/10/19 at 5:50 A.M., showed the resident lay in bed with water and
crackers at bedside. The resident sat up, said he/she would eat breakfast and then laid
back down.
In an interview on 1/10/19 at 5:52 A.M., CNA K said during the night shift, the resident
normally got up every two hours for only two to five minutes to get snacks, drinks and use
the toilet then lays back down in bed.
Observation on 1/10/19 at 5:58 A.M., showed the resident lay in bed.
In an interview on 1/10/19 at 1:53 P.M.:
– Certified Med Tech (CMT) C said during the day shift the resident remained in bed the
majority of the time. The resident got up a couple times a day for about four minutes to
wonder up the corridor, to get a sandwich and look for his/her spouse. Staff assisted the
resident up and down the corridor. The resident’s favorite activity was to eat and sleep.
– CNA L said the resident roams, but due to the resident’s poor vision and being hard of
hearing he/she is not able to see or hear what is showing on the television. Staff are not
able to visit with the resident one on one in his/her room due to the care needs of the
other residents on the SCU.
During an interview on 1/10/19 at 2:30 P.M., CNA F said four months ago, he/she began
working on the SCU during the facility evening shift. The resident normally only got up
and walked 10 to 15 minutes during the eight-hour shift. Staff assisted the resident to
toilet, to get a snack and to set up his/her food tray at bedside for supper. The resident
did not like group activities. The resident did not see well enough to do puzzles. The
resident enjoyed visiting, but staff were not always able to offer the resident activities
due to other resident behaviors. He/she thought the resident needed more activities that
would encourage him/her to get up out of bed and give the resident a better quality of
life.
In an interview on 1/10/19 at 2:58 P.M., CNA H said the resident refuses to come to the
SCU common area for supper stating he/she does not know anybody and he/she misses his/her
spouse.
In an interview on 1/10/19 at 3:12 P.M., the Interim Director of Nursing (IDON) said in
the past three months during her daily visiting on the SCU, she has only seen the resident
out of bed twice. Even when she administers the resident his/her medications the resident
sits at bedside and lays back down.
In an interview on 1/11/19 at 5:00 A.M., CNA M said he/she normally worked the SCU night
shift. The resident’s activities during the night shift, consisted of sleeping, eating
snacks, drinking soda and coming out to the corridor to get assistance to the toilet. The
total time the resident is up is sporadic, but is approximately two to three hours. No
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Some

(continued… from page 25)
activities are provided to the resident during the night shift. The resident just stayed
in his room, drank soda and ate snacks. The resident rarely walked the corridor but did
sometimes just to have something to do. The resident stayed to him/herself.
In an interview on 1/11/19 at 9:20 A.M., Social Services (SS) said Resident #13 was just
existing on the unit. The resident had no quality of life. The resident preferred to stay
in his/her room. Staff were not able to provide one on one activity for the resident as
they had to meet other resident care needs.
2. Review of the facility SCU activity calendar showed on 1/9/19 at 10:00 A.M., Sit
Dancing was scheduled.
Observation on 1/9/19 at 10:00 A.M. showed staff did not offer SCU residents Sit Dancing.
3. In an interview on 1/10/19 at 1:53 P.M., CMT C and CNA L said there were not many
activities on the SCU. They offer residents coloring, but the residents do not like it.
They did not have activities specifically for men. They painted female residents nails.
Two weeks ago, they complained to the AD and the SS that they did not have enough
materials or creative activities to provide the SCU residents. The SCU was only staffed
with a CNA and CMT who stayed on the unit. The CMT tried to assist the CNA with
activities, but the SCU was hectic due to some residents who are aggressive, while others
are wandering with other residents being a potential fall risk. With all the residents
having different needs at the same time, they were not able to keep the residents
occupied. They did not have the correct activities and activity materials to keep the
residents engaged and occupied. The AD told them funding for activities was limited.
In an interview on 1/11/19 at 5:00 A.M., CNA M said he/she normally worked the SCU night
shift. No activities were provided on the SCU during the night shift. He/she attempted to
come up with stuff to occupy residents who are up in the common area during the shift.
He/she was unaware of activity care plans for the SCU residents and had not used them.
In an interview on 1/11/19 at 9:20 A.M., the SS said for the last couple of months she was
aware that SCU activities are not stimulating enough for the residents. Staff are
concerned about the activity needs of the residents. SCU activity schedule was separate
from the rest of the facility. The SCU is assigned two staff. In order for the two staff
to manage resident care needs, they are not able to provide the residents with stimulating
activities. More needed to be done to keep the residents on the unit occupied with
appropriate activities. The facility needed more activity resources. The staff needed
training on providing activities for the needs of residents with dementia diagnoses. The
AD was kept busy with other facility services and not able to provide the SCU activities.
In an interview on 1/11/19 at 12:00 P.M., the AD said she had many responsibilities in
providing facility services. She was not able to spend much time on the SCU for
activities. The two staff assigned on the unit were to provide the activities, but were
kept too busy with the care needs of the residents preventing them from providing
activities. The SCU should have staff assigned to specifically provide for the activity
needs of the residents.
In an interview on 1/11/19 at 12:10 P.M. and 1/14/19 at 2:25 P.M., the administrator
said:
– If staff say they are not able to provide activities for the SCU residents, then the
facility system should be changed to ensure staff provided quality activities for the
residents.
– If the facility improved on providing SCU residents with activities that kept residents
interested it could correlate in less resident behavior problems that are due to resident
boredom.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 – Some

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to implement
procedures to ensure staff discarded discontinued medications and medication of deceased
residents. The facility census was 38.
1. Review of the undated facility policy titled Destroying Drugs did not show the time
limit the facility allowed discontinued medication and medication of deceased residents to
remain in the facility.
Observation on [DATE] at 12:07 P.M., in the medication room showed:
– Multiple medication cards containing discontinued medication for current residents and
medications of deceased residents;
– Several of the medications had been discontinued for over one month.
During an interview on [DATE] at 11:47 P.M. Licensed Practical Nurse (LPN) A said:
-The facility used to destroy medication in house with the previous pharmacy;
-They had not destroyed any medication since switching to the new pharmacy a couple months
ago, staff have been too busy.
During an interview on [DATE] at 12:07 P.M., Registered Nurse (RN) A said:
– Some of the medication had been in the medication room awhile, because they were not
sure if the current pharmacy takes back medication;
– He/she or another nurse would call the pharmacy to check, but he/she was not aware if
anyone had called;
– He/she was not sure how long the facility could keep discontinued medication or
medication of deceased residents.
During an interview on [DATE] at 11:25 P.M. Interim Director of Nursing (IDON) said:
– She was not sure what the facility process is for medication disposal;
– She had not disposed of any medication since becoming the IDON.
During an interview on [DATE] at 2:32 P.M. the IDON said:
– She expected discontinued medication and medication of deceased residents to be disposed
of in one month.

F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary needs.

Based on observation, record review and interview, the facility failed to consider the
preference of one sampled resident (Resident #238) when they did not assess the resident
to ensure they provided a nourishing, well-balanced diet that meets residents’ daily
nutritional and special dietary needs. The facility census was 38.
1. Review of the resident’s undated care plan showed:
– The resident did not have teeth and did not wear dentures;
– The resident had difficulty chewing and swallowing from dementia and not having
dentures;
– The care plan did not address chopping the resident’s meat.
During an interview on 1/08/19 at 02:19 PM Resident #238 said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
-He/she did not wear his/her dentures and has requested staff to meat chop his/her meat,
but they did not.
Observation on 1/09/19 at 08:34 AM showed:
-The resident ate breakfast, pancakes, oatmeal and sausage;
-The sausage was not chopped.
During an interview on 1/11/19 at 09:06 AM the Director of Nursing said the resident had
never mentioned wanting his/her food chopped.
During an interview on 1/10/19 at 2:08 P.M. Cook A said the speech therapist would send a
communication log regarding resident’s mechanical diets. He/she was not aware of any for
the resident.
During an interview on 1/11/19 at 09:51 AM the Dietary Manager said:
-The resident had not asked her to have his/her meat chopped;
– She completed food assessments on all new admissions to determine residents’
preferences;
-She was unable to find an assessment completed for the resident.
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to obtain the Registered
Dietitian’s (RD) weekly menu approval and did not have a substitution menu. The facility
census was 38.
1. Review of the facility Winter (YEAR)-2019 Week 2 menu and special diet spreadsheets
showed the bottom left portion section had Menus Approved By that was not signed.
In an interview on 1/10/19 at 8:55 A.M., the Dietary Manager (DM) said the RD did not sign
off approval of the facility regular menu and special diet menu. They did not have a RD
approved alternate menu.
In an interview on 1/10/19 at 3:30 P.M., the Administrator said the DM should have and did
not follow her expectations by getting the RD approval of the facility menu and special
diet spreadsheets. The facility did not have an alternate menu. The residents were to have
an RD approved alternate menu to choose substitutions to the regular menu item.

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, interview and record review, the facility failed to provide for food
safety and sanitation in the kitchen, when staff served residents non-pasteurized eggs,
did not properly store food or use proper hand-washing for food service. This had the
potential to affect all of the facility residents. The facility census was 38.
1. Review of the facility Receiving and Storage of Food policy dated 4/2011, showed staff
were to keep all foods in clean, undamaged wrappers or packages.
2. Observation and interview on 1/10/19 at 7:50 A.M., showed the Dietary manager (DM)
cooked two over-easy and six hard fried non-pasteurized eggs in a skillet. The DM said

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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 28)
Resident #7 ate two eggs cooked over-easy daily. The DM then covered the eggs with foil
and sat them on top of the oven. The DM said sometimes she cooked over-easy eggs for
Resident #21. She was unaware if the eggs were pasteurized or not.
In an interview on 1/10/19 at 8:00 A.M., the Administrator said she would check egg
invoices to see what type of eggs staff used in the kitchen.
During interview and record review on 1/10/19 at 11:09 A.M. and 3:30 P.M. and 1/11/19 at
10:44 A.M., the administrator showed the facility food order invoice had large Grade A
eggs. The Administrator said the eggs were not pasteurized. Over the last six months, the
DM was in charge of the kitchen. Since this morning’s breakfast, she found that the DM did
not know she was not to serve residents non-pasteurized eggs. The DM told the
administrator, she served residents soft eggs, fried eggs and egg sandwiches daily. The
Administrator instructed the DM she was only allowed to serve residents pasteurized eggs.
The facility did not have a policy on the use of non-pasteurized eggs. She expected
kitchen staff to serve only eggs that are pasteurized to residents for resident safety.
Non-pasteurized eggs had the potential to cause Salmonella poisoning.
3. Observation and interview 1/08/19 at 9:11 A.M., of the kitchen walk in refrigerator
showed:
– A container marked chicken casserole dated 12/26.
– A substance wrapped in undated foil marked ham slices positioned above dishes of
strawberry shortcake and apple sauce, that dripped with liquid when lifted. – An undated
container of what the DM said appeared to be spinach.
– Uncovered cheese slices.
– A plastic bag of undated hot dogs.
– Three unlabeled squeeze bottles appearing to contain salad dressing.
– Two undated squeeze bottles of barbeque sauce.
– Two undated loosely covered pies, with one of the pies partially eaten.
– Undated coleslaw.
– The DM said staff were to store meat/meat products on trays to prevent cross
contamination of other foods. Staff were to store foods that were not in the original
packaging in a labeled, dated, sealed plastic bag. Staff was to discard all food that was
unsealed from original packaging after three days. Staff should have labeled the opened
coleslaw to show the third day after they opened it. When staff put the sauces and
dressings in the squeeze bottles they should have labeled the bottles showing contents and
discard date.
Observation on 1/08/19 at 11:03 A.M., showed an undated squeeze bottle of barbeque sauce
in the special care unit refrigerator.
4. Observations on 1/10/19 at 8:37 A.M., showed the DM:
– Placed uncovered bread directly on the counter top to prepare toast.
– Used gloved hands to pick up bacon, toast, biscuits, ladles, push food carts in the
kitchen and out into the dining room without washing her hands between touching food
products, ladles and carts.
In an interview on 1/10/19 at 9:17 A.M., the DM said for kitchen sanitation;
– All kitchen staff were to wash their hands between food contact, between tasks, when
they touched something and when they leave the kitchen.
– During today’s breakfast preparation, she should have used utensils instead of her hands
to pick up food. She should have used a cutting board instead of the counter surface to
make toast. She should have washed her hands before leaving the kitchen.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265729

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

01/15/2019

NAME OF PROVIDER OF SUPPLIER

DAVIESS COUNTY NURSING AND REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

1337 WEST GRAND
GALLATIN, MO 64640

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide care in
a manner to prevent infection or the possibility of infection, when staff failed to
administer the Two-Step [MEDICATION NAME] (TB) test appropriately, read, and document the
results of the test in a timely manner for two residents (Residents #22 and #13). The
facility census was 38.
The facility did not provide a Two-Step TB testing policy for residents.
1. Review of Resident #13’s Minimum Data Set (MDS), a federally mandated assessment
records, showed:
– Admission MDS dated [DATE];
– Discharge Tracking Record dated 1/13/17;
– A second Admission MDS dated [DATE] with an admission date of [DATE].
Review of the facility’s Two Step TB test tracking system showed:
– Step one administered 4/4 (no year documented);
– Staff indicated they read the test on 4/6 and added the word neg, no year and no
induration, (a palpable, raised, hardened area or swelling, in millimeters) documented;
– Step two administered 4/20 (no year indicated);
– Staff indicated they read the test on 4/22 and added the word neg, no year and no
induration in millimeters documented.
2. Review of Resident #22’s Two Step TB tracking system showed:
– Staff documented administering the TB test on 11/8/18;
– Staff did not document when results were read.
During an interview on 1/14/19 at 12:53 P.M., the Interim Director of Nurses (IDON) said:
– She had only stepped into the IDON position a couple weeks earlier;
– The first step of the TB test should be administered upon initial admission and the
second step 14 days later, after that an annual test should be administered or an
assessment completed;
– Staff should read and record results within 72 hours;
– Results should be documented accurately with millimeters of induration to show a
negative test result.

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