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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on observation and interview, the facility failed to notify residents of the
availability and location of the most recent survey results and did not post the most
recent survey results in an accessible location to the residents. This practice affected
three residents (Residents #4, #43, and #61) outside of the 18 sampled residents and had
the potential to affect all residents. The facility’s census was 77.
Observation of the facility’s survey results located in the front lobby on 3/18/19 at 2:00
P.M. showed the survey results of the years (YEAR), (YEAR) and (YEAR). The most recent
survey results of (YEAR) were not available.
During a Resident Council interview on 3/19/19 at 1:54 P.M., Residents #4, #43, and #61
collectively said they were not aware of the survey results availability.
During an interview on 3/22/19 at 1:41 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff), Coordinator said she would
expect the current survey results to be available to residents and to the public. The
(YEAR) results had not been in the binder, but that had been corrected.

F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to send a copy of the notice of
transfer to a representative of the Office of the State Long-Term Care Ombudsman (an
advocate source for residents in the nursing home) for one resident (Resident #42) and
failed to provide written notification of a transfer to the hospital to the resident’s
representative for one resident (Resident #174) out of 18 sampled residents. The
facility’s census was 77.
1. Record review of Resident #42’s medical record showed the resident was transferred to
the hospital on [DATE] and readmitted on [DATE].
During an interview on 3/21/19 at 3:08 PM, the Ombudsman representative said they did not
receive any notifications of hospitalization s for the month of (MONTH) 2019.
During an interview on 3/22/19 at 1:41 P.M., the Administrator said she would expect a
list of transfers and discharges to be sent to the Ombudsman each month. She said the
admissions coordinator sends a list at the end of each month.
2. Record review of Resident #174’s medical record showed the resident transferred to the
hospital on [DATE]. The record did not contain documentation of written notification of
transfer to the resident or resident representative.
During an interview on 3/20/19 at 11:17 A.M., the Social Worker said the facility sends
the notice of transfer to the responsible party. The facility failed to send the notice
for this resident because the nurse that sent the resident out to the hospital only works
one time a month. The nurse didn’t know he/she was supposed to send it.
The facility did not provide a policy for notification of an unplanned transfer to a
hospital.

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

F 0624

Level of harm – Potential for minimal harm

Residents Affected – Many

Prepare residents for a safe transfer or discharge from the nursing home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide and document
sufficient preparation and orientation to residents to ensure safe and orderly transfer
from the facility in a manner that the resident can understand for two residents (Resident
#42 and #174) out of 18 sampled residents. The facility’s census was 77.
1. Record review of Resident #42’s medical record showed no documentation of preparation
or orientation of the resident for transfer to the hospital on [DATE].
2. Record review of Resident #174’s medical record showed no documentation of preparation
or orientation of the resident for transfer to the hospital on [DATE].
3. During an interview on 3/22/19 at 1:40 P.M., the Director of Nursing (DON) said they
would expect the resident to be oriented and prepared for a transfer, especially if they
were alert. They usually give a lot of reassurance before they are transferred but need to
document it.
4. The facility did not provide a policy for orientation for transfer.

F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and/or
resident’s representative of their bed hold policy at the time of transfer to the hospital
for three residents (Resident #42, #57, and #174) out of 18 sampled residents. The
facility’s census was 77.
1. Record review of Resident #42’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– The medical record did not contain documentation of a letter which notified the resident
and/or the resident’s representative of the facility bed hold policy.
2. Record review of Resident #57’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted on [DATE];
– The medical record did not contain documentation of a letter which notified the resident
and/or the resident’s representative of the facility bed hold policy.
3. Record review of Resident #174’s medical record showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE];
– The medical record did not contain documentation of a letter which notified the resident
and/or the resident’s representative of the facility bed hold policy.
4. During an interview on 3/20/19 at 11:17 A.M., the Social Worker said the facility does
not send the bed hold policy with each transfer because it is provided when the resident
is admitted .
5. Record review of the facility’s undated policy, titled Bed Hold Policy, showed it is

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 2)
the policy of this facility to notify the Resident/Responsible Party of the bed hold
policy. This notification shall be given on admission to the facility, at the time of
transfer to the hospital, and at the time of non-covered therapeutic leave.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure an admission, a
quarterly, and an annual Minimum Data Set, (MDS, a federally mandated assessment to be
completed by the facility staff), had been completed in a timely manner, for two residents
(Resident #23 and #26) out of 18 sampled residents and five residents, (Resident #6, #18,
#19, #38, and #67) outside the sample. The facility’s census was 77.
1. Record review of Resident #6’s medical record showed:
– admitted on [DATE];
– No admission assessment;
– A quarterly assessment on 10/05/18;
– An annual assessment, in process, dated 1/03/19.
2. Record review of Resident #18’s medical records showed:
– admitted [DATE];
– No admission assessment;
– An annual assessment on 10/25/18;
– A quarterly, in process, on 1/23/19.
3. Record review of Resident #19’s medical record showed:
– admitted [DATE];
– A quarterly assessment on 10/31/18;
– An annual, in process, on 1/25/19.
4. Record review of Resident #38’s medical records showed:
– admitted [DATE];
– An admission assessment on 11/01/18;
– A quarterly, in process, on 1/30/19.
5. Record review of Resident #67’s medical record showed:
– admitted on [DATE];
– A discharge on 7/28/18;
– No re-entry assessment;
– A discharge assessment on 9/20/18;
– A re-entry on 9/22/18;
– A discharge on 9/25/18;
– An entry tracking on 9/26/18;
– A quarterly assessment on 10/10/18;
– A quarterly, in process, on 1/08/19.
6. Record review of Resident #23’s medical record showed:
– admitted on [DATE];
– An admission assessment on 10/23/18;
– A quarterly, in process, on 1/20/19.
7. Record review of Resident #26’s medical record 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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
– admitted [DATE];
– A discharge assessment on 6/03/18;
– A discharge assessment on 7/18/18;
– A discharge assessment on 8/22/18;
– A quarterly assessment on 10/15/18;
– A quarterly assessment, in process, on 1/09/19.
8. During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they fell behind
and there were concerns with missing assessments. Some assessments were not finished and
the ones showing in process, were not transmitted. They are aware of the problem and are
working on it.
9. Record review of the facility’s policy titled, MDS Completion and Submission
Timeframes, revised, (MONTH) 2011, showed the facility will conduct and submit resident
assessments in accordance with current federal and state submission timeframes. The
Assessment Coordinator or designee shall be responsible for ensuring that the resident
assessments are submitted to The Centers for Medicare and Medicaid Services (CMS) Quality
Improvement and Evaluation System (QIES) Assessment Submission and Processing System
(ASAP), in accordance with the [MEDICATION NAME] federal and state guidelines.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a significant change
assessment for one resident (Resident #28) out of 18 sampled residents. The facility’s
census was 77.
Record review of Resident #28’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s care plan, updated 1/10/19, showed the resident admitted
to hospice care on 12/29/18 with a [DIAGNOSES REDACTED].
Record review showed an annual Minimum Data Set (MDS, a federally mandated assessment
instrument completed by facility staff), dated 11/20/18, completed for the resident.
The facility failed to complete a significant change MDS assessment within 14 days of the
resident’s election of the hospice benefit on 12/29/18.
During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they fell a little
behind. There were concerns with missing assessments and knows there were some that were
not finished.
Record review of the facility’s policy titled, MDS Completion and Submission Timeframes,
revised,January 2011, showed the facility will conduct and submit resident assessments in
accordance with the current federal and state submission timeframes. The Assessment
Coordinator or designee shall be responsible for ensuring that the resident assessments
are submitted to The Centers for Medicare and Medicaid Services (CMS) Quality Improvement
and Evaluation System (QIES) Assessment Submission and Processing System (ASAP), in
accordance with the federal and state guidelines.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assure that each resident’s assessment is updated at least once every 3 months.

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure they assessed the
residents using the quarterly Minimum Data Set (MDS, a federally mandated assessment to be
completed by the facility staff), no less frequently than once every three months and had
been completed in a timely manner for two residents (Resident #23 and #26) out of 18
sampled residents and five residents (Resident #6, #18, #19, #38 and #67) outside the
sample. The facility’s census was 77.
1. Record review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the staff
are directed as follows:
– The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA)
non-comprehensive assessment for a resident that must be completed at least every 92 days
following the previous OBRA assessment of any type. It is used to track a resident’s
status between comprehensive assessments to ensure critical indicators of gradual change
in a resident’s status are monitored. Such, not all MDS items appear on the quarterly
assessment. The Assessment Reference Date (ARD) must be not more than 2 days after the ARD
of the most recent OBRA assessment of any type;
– Assessment Completion refers to the date that all information needed has been collected
and recorded for a particular assessment type and staff have signed and dated that the
assessment is complete;
– For required Comprehensive assessments, assessment completion is defined as completion
of the Care Area Assessment (CAA) process in addition to the MDS items, meaning that the
registered nurse (RN) assessment coordinator has signed and dated both the MDS (item
Z0500) and the CAA (s) (item V0200B) completion attestations. Since a Comprehensive
assessment includes completion of both the MDS and the CAA process, the assessment timing
requirements for a comprehensive assessment apply to both the completion of the MDS and
the CAA process;
– Assessment Completion date for quarterly MDS assessments is the ARD plus 14 calendar
days;
– Transmission Date for quarterly MDS assessments, the Completion date plus 14 calendar
days.
Record review of the facility’s policy titled, MDS Completion and Submission Timeframes,
revised,January 2011, showed the facility will conduct and submit resident assessments in
accordance with the current federal and state submission timeframes. The Assessment
Coordinator or designee shall be responsible for ensuring that the resident assessments
are submitted to The Centers for Medicare and Medicaid Services (CMS) Quality Improvement
and Evaluation System (QIES) Assessment Submission and Processing System (ASAP), in
accordance with the federal and state guidelines.
2. Record review of Resident #6’s medical record showed:
– admitted [DATE];
– No admission assessment completed;
– No quarterly assessments completed until 10/05/18, five days late ;
– No quarterly assessment completed for (MONTH) (YEAR).
3. Record review of Resident #18’s medical record showed:
– admitted [DATE];
– No admission assessment completed;
– No quarterly assessments completed until 10/25/18, 36 days late.
4. Record review of Resident #19’s medical record showed:
– admitted [DATE];
– No quarterly assessment until 10/31/18, 276 days late.
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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
5. Record review of Resident #38’s medical record showed:
– admitted [DATE];
– No quarterly assessments completed in (YEAR);
– An admission assessment was not completed until 11/01/18, six months late.
6. Record review of Resident #67’s medical record showed:
– admitted on [DATE];
– No quarterly assessment completed for (MONTH) (YEAR);
– No quarterly assessment completed for (MONTH) (YEAR).
7. Record review of Resident #23’s medical record showed:
– admitted on [DATE];
– An admission assessment completed on 10/23/18, four months late;
– No quarterly assessments completed until 1/8/19, six months late.
8. Record review of Resident #26’s medical record showed:
– admitted [DATE];
– No quarterly assessments completed until 10/15/18.
9. During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they had fell a
little behind and there were concerns with missing assessments. Some of them were not
finished and the ones that showed in process were not transmitted. We are aware of the
problem and have a process in place.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete and electronically
transmit, annual and quarterly Minimum Data Sets (MDS, a federally mandated assessment to
be completed by facility staff), in a timely manner and in accordance to guidelines for
two residents (Resident #23 and #26) out of 18 sampled residents and five residents
(Resident #6, #18, #19, #38 and #67) outside the sample. The facility’s census was 77.
1. During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they have fell
behind and there was some that had not been finished. The ones showing in process were not
transmitted. The MDS Coordinator said he/she called the Quality Improvement Program for
Missouri (QIPMO), about the previous Coordinator not doing any of the MDSs accurately.
He/she was instructed to start with annual assessments for each resident to start the
processes for the MDSs to get on a quarterly schedule.
2. Record review of Resident #6’s medical record showed:
– An admission date of [DATE];
– No admission assessment completed;
– An annual assessment, in process, dated 1/3/19 but not transmitted.
3. Record review of Resident #18’s medical record showed:
– An admission date of [DATE];
– No admission assessment completed;
– A quarterly assessment, in process, dated 1/23/19 but not transmitted.
4. Record review of Resident #19’s medical record showed:
– An admission date of [DATE];
– An annual assessment, in process, dated 1/25/19 but not transmitted.
5. Record review of Resident #38’s medical record 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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
– An admission date of [DATE];
– An admission assessment on 11/1/18, six months late;
– A quarterly assessment, in process, dated 1/30/19 but not transmitted.
6. Record review of Resident #67’s medical record showed:
– An admission date of [DATE];
– A quarterly assessment, in process, dated 1/08/19 but not transmitted.
7. Record review of Resident #23’s medical record showed:
– An admission date of [DATE];
– An admission assessment on 10/23/18, four months late;
– A quarterly assessment, in process, dated 1/20/19 but not transmitted.
8. Record review of Resident #26’s medical record showed:
– An admission date of [DATE];
– A quarterly assessment, in process, dated 1/9/19 but not transmitted.
9. Record review of the policy titled, MDS Completion and Submission Timeframes, revised
(MONTH) 2011, showed the facility will conduct and submit resident assessments in
accordance with current federal and state submission timeframes. The Assessment
Coordinator or designee shall be responsible for ensuring that the resident assessments
are submitted to The Centers for Medicare and Medicaid Services (CMS) Quality Improvement
and Evaluation System (QUIES) Assessment Submission and Processing System (ASAP), in
accordance with the current federal and state guidelines.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document a complete and
accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the
facility) for three residents (Residents #11, #35, and #45) out of 18 sampled residents
and one resident (Resident #28) outside of the sample. The facility’s census was 77.
1. Record review of Resident #11’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of the resident’s significant change MDS, dated [DATE], showed section J1400
was checked ‘no’ for prognosis less than six months.
2. Observation on 3/18/19 at 12:30 P.M., of Resident #35 showed the resident to have
missing and broken front teeth.
Record review of the significant change MDS, dated [DATE], section L0200 showed ‘none’ for
missing or broken teeth.
Record review of the resident’s nurse progress notes, dated 1/1/19 through 2/25/19, showed
the resident fell on [DATE] with a laceration to left eye lid and abrasion to cheek bone.
On 1/3/19 the resident had a swollen left hand and an x-ray was obtained. The result of
x-ray showed displaced thumb.
Record review of the resident’s quarterly MDS, dated [DATE], section J1900 showed was
checked for ‘2 or more falls without injury’.
Record review of the resident’s medical chart showed the resident admitted to Hospice care
on 11/23/18.
Record review of the resident’s quarterly MDS, dated [DATE], section J1400 checked ‘no’
for prognosis less than six months.
3. Record review of Resident # 45’s admission MDS, dated [DATE], showed section M0210, the
resident did not have any pressure ulcers on admission.

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
Record review of the resident’s baseline care plan, dated 12/13/18, showed pressure ulcers
marked under Disease/Illness Management. The body image documentation showed areas of
pressure injury.
During an interview on 3/21/19 at 9:50 A.M., Registered Nurse (RN) A said the resident had
pressure ulcers on buttocks and left ankle. He/she said the pressure ulcers resolved on
3/3/19 and 3/5/19.
During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they have fell
behind and there was some that had not been finished. The MDS Coordinator said he/she
called the Quality Improvement Program for Missouri (QIPMO), about the previous
Coordinator not doing any of the MDSs accurately. He/she was instructed to start with
annual assessments for each resident to start the processes for the MDSs to get on a
quarterly schedule.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan within 48 hours of admission that included the minimum healthcare
information necessary to properly care for the immediate needs for four residents
(Resident #23, #33, #41, and #173) and failed to provide a copy of the baseline care plan
to two resident’s representatives (Resident #57 and #174) out of 18 sampled residents. The
facility’s census was 77.
1. Record review of Resident #23’s (MONTH) 2019 Physician order [REDACTED].
– admission date of [DATE];
– [DIAGNOSES REDACTED].
Record review showed the resident’s medical record did not contain a baseline care plan.
During an interview on 3/21/19 at 3:40 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) Coordinator said the resident
did not have a baseline care plan.
2. Record review of Resident #33’s POS, dated 2/21/19 through 3/21/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
Record review showed the resident’s medical record did not contain a baseline care plan.
During an interview on 3/22/19 at 11:00 A.M., the Director of Nursing (DON) said the
resident did not have a baseline care plan.
3. Record review of Resident #41’s baseline care plan, dated 2/21/18, showed:
– admission date of [DATE];
– No code status (the level of medical interventions a patient wishes to have started if
their heart or breathing stops).
4. Record review of Resident #57’s POS, dated 2/18/19 through 3/18/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Resident not own responsible party.
Record review of resident’s baseline care plan showed a copy was given to the resident but
not the resident’s representative.

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
4. Record review of Resident #173’s POS, dated 2/20/19 – 3/20/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Resident is his/her own responsible party.
Record review showed the resident’s medical record did not contain a baseline care plan.
During an interview on 03/18/19 at 12:17 P.M., the resident said he/she did not understand
what a care plan was. The resident said he/she didn’t know what the surveyor was talking
about.
During an interview on 3/19/19 at 3:04 P.M., the DON and MDS Coordinator said they agree
there is no baseline care plan located in the chart. The comprehensive care plans have not
been completed yet. The policy is for the floor nurse to do the baseline care plan and put
it in the chart within 48 hours of admission, this one was not done.
5. Record review of Resident #174’s POS, dated 1/23/19 – 2/23/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Resident’s responsible party is his/her family member.
Record review showed the resident’s medical record did not contain a baseline care plan.
During a telephone interview on 3/20/19 at 10:51 A.M., the resident’s responsible party
said the facility did not go over a care plan with him/her when the resident was admitted
. He/she was not provided a copy of the baseline care plan.
During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said the nurses are
suppose to complete a baseline care plan within 48 hours of admission and put it in the
chart.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to implement an individualized
comprehensive care plan for five residents (Resident #11, #35, #42, #56, and #174) out of
18 sampled residents and one resident (Resident #9) outside the sample. The facility’s
census was 77.
1. Record review of Resident #9’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– [MEDICATION NAME] (an antipsychotic to treat certain types of mental disorders) 100
milligram/milliliter (mg/ml) 1 ml intramuscular once a day every 29 days;
– [MEDICATION NAME] 50 mg/ml, 1 ml intramuscular once a day every 29 days.
Record review of the resident’s care plan showed no care plan for antipsychotic drugs.
2. Record review of Resident #11’s (MONTH) 2019 POS, showed:
– [DIAGNOSES REDACTED].
– Do Not Resuscitate (DNR)-Hospice (a type of care focused on the terminally ill or
seriously ill patient’s pain and symptoms, with the prognosis of death/dying in less than
six months).
Record review on 3/20/19 at 2:25 P.M., of the resident’s care plan showed:
– Full code status (all resuscitative and aggressive curative treatment are provided);
– No care plan for hospice.

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
3. Record review of Resident #35’s (MONTH) 2019 POS, showed displaced fracture of base of
first metacarpal bone (the first bone proximal to the thumb), left hand (broken thumb on
left hand).
Record review of the resident’s nurse progress note, dated 1/3/19, showed:
– Resident hand very swollen, bruised across top hand and around thumb;
– X-ray result of acute mildly displaced [MEDICAL CONDITION] of the first metacarpal.
Record review of the resident’s care plan showed the care plan updated on 3/12/19 (two
months late) for hand injury.
Observation of the resident on 3/18/19 at 12:30 P.M. showed the resident to have missing
and broken front teeth.
Record review of the resident’s care plan showed no dental care plan.
4. During an interview on 3/18/19 at 3:01 P.M., Resident #42 said he/she has had diarrhea
for several weeks.
During an interview on 3/21/19 at 11:00 A.M., Licensed Practical Nurse (LPN) B said the
resident has had diarrhea since his/her colonoscopy on 2/28/19. LPN B checked the
Medication Administration Record [REDACTED].
During an interview on 3/21/19 at 11:10 A.M., the resident said he/she has diarrhea a lot.
The resident said his/her bowel movements are liquid and does not have an odor. The
resident said he/she did not know the facility had medication for diarrhea.
During an interview on 3/22/19 at 1:41 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) Coordinator said she would
expect the care plan to include all areas of care/needs. She said if it is a current
problem, then it should be on the care plan.
Record review of the resident’s POS, dated 3/1/19 to 3/31/19, showed:
– [DIAGNOSES REDACTED].
– [MEDICATION NAME] A-D 1 mg/7.5 ml oral every 4 hours-prn (as needed), for diarrhea;
– Milk of Magnesia (constipation medication) 400 mg/5 ml 30 ml oral once a day-prn.
Record review of the resident’s care plan showed no plan for medical condition
constipation/diarrhea.
5. Record review of Resident #56’s POS, dated 2/18/19 -3/18/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Orders for [MEDICATION NAME] (a blood thinner).
Record review of the resident’s comprehensive care plan did not include
anticoagulant(prevent blood clots, blood thinner) therapy.
6. Record review of Resident #174’s POS, dated 1/23/19 – 2/23/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Resident’s responsible party as the family member.
Record review of the resident’s medical chart showed no comprehensive care plan.
During an interview on 03/19/19 at 3:11 P.M., the Director of Nursing (DON) and the
MDS/Care Plan Coordinator agreed that the comprehensive care plan is not available in the
medical record (chart) and the POS is not the correct date for this resident. The MDS
Coordinator said she had finished the comprehensive care plan for this resident but failed
to print it and put it in the chart. She said no one would have access to it.
7. During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said she would expect
any areas of concern on the baseline care plan to be carried over to the comprehensive
care plan if needed.
8. Record review of the facility’s policy titled Care Plans–Comprehensive, revised 10/10,
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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
showed:
– An individualized comprehensive care plan that includes measurable objectives and
timetables to meet the resident’s medical, nursing, mental and psychological needs is
developed for each resident;
– Identifying problem areas and their causes, and developing interventions that are
targeted and meaningful to the resident are interdisciplinary processes that require
careful data gathering, proper sequencing of events and complex clinical decision making;
– Assessments of residents are ongoing and care plans are revised as information about the
resident and resident’s condition change.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to revise and update
comprehensive care plans with specific interventions to meet the individual needs of three
residents (Resident #11, #26, and #33) out of 18 sampled residents. The facility’s census
was 77.
1. Record review of Resident #11’s significant change Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) dated 3/2/19 showed the
resident was placed on hospice (a type of care focused on the terminally ill or seriously
ill patient’s pain and symptoms, with the prognosis of death/dying in less than six
months).
Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of the resident’s care plan on 3/20/19 at 2:25 P.M. showed:
– Full code status (all resuscitative and aggressive curative treatment are provided);
– Hospice was not care planned.
Record review showed the facility provided a new copy of the resident’s updated care plan,
last revised 3/21/19 at 8:13 A.M., showed:
– DNR status;
– Crown Hospice is following the resident for hospice care.
2. Record review of Resident #26’s (MONTH) 2019 POS, showed:
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s nurse’s notes, dated 10/27/18 through 3/6/19, showed:
– On 10/27/18, the resident found on hands and knees at bed side. He/she was up in
wheelchair on fall mat. No apparent injuries noted;
– On 12/19/18 at 3:45 A.M., the resident up in wheelchair in dining room. He/she quickly
decided to stand up and attempted to walk. He/she fell to left knee, striking the chair.
Has small abrasion to left knee;
– On 12/19/18 at 8:45 P.M., Aide on hall reported the resident on floor. Aide informed
nurse when he/she returned from getting ice for hall, he/she found resident lying on right
side in lunch/television room. Upon nurse’s arrival to hall, resident was up in a sitting
position. No one witnessed the fall and no injury noted;
– On 2/11/19, the resident found sitting on bottom next to empty bed in room. Denied

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
pain/injury, unable to tell what happened. Roommate sleeping, no witnesses to
possible/assumed fall;
– On 2/26/19, the resident sitting up on floor next to bed, no injury noted at this time;
– On 3/6/19, the resident found on floor in room, denies any pain or discomfort, no
apparent injuries noted.
Record review of the resident’s physical therapy notes, dated 3/13/19, showed the resident
to be full weight bearing with a front wheeled walker for assistance in mobility.
Record review showed the facility provided a new copy of the resident’s updated care plan,
last revised 3/21/19, showed:
– Resident will get out of merry walker (a walker and chair combination designed to allow
the user the ability to move more freely) without assistance;
– Resident on a mechanical soft diet with nectar thick liquids;
– Did not reflect order for super cereal and house supplement or weekly weights;
– No new fall interventions since 7/17/17.
During an interview on 3/21/19 at 11:46 AM, Certified Nurse Aide (CNA) H said the resident
used to have a merry walker, but doesn’t use it anymore as far as he/she knows. CNA H
don’t know how long it has been since the resident used it. CNA H said I’ve only been back
here for a few weeks. The resident is working with therapy and using a wheeled walker.
3. Record review of Resident #33’s POS, dated 2/21/19 through 3/21/19, showed:
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Registered Dietitian’s (RD) progress notes, dated 2/26/19
through 3/21/19, showed:
– On 2/26/19, the resident now with open areas to buttocks per nurse. Nurse reports
initially with one area and now with two. Current diet order is mechanical soft with
nectar thick liquids and is with 2/21/19 order for yogurt three times daily (TID) with
meals while on antibiotics. Has B complex vitamin in place and [MEDICATION NAME]. Will
recommend addition of multivitamin. Will also recommend start of house supplement 90
milliliters (ml) TID to better assist with meeting increased nutritional needs for wound
healing. Goal is for adequate intake to promote wound healing and weight stability. RD
will continue to monitor weight, report of wound healing, and follow up as needed;
– On 3/21/19, the resident continues with increased nutritional needs related to wound
healing, with multiple wounds noted to buttocks, and per nurse this date, wound progress
without change. Continues with B complex vitamin place and [MEDICATION NAME]. Will
recommend follow up with previous RD recommendation to add multivitamin and start of house
supplement of 90 ml TID to better assist with meeting increased nutritional needs for
wound healing.
Record review of the resident’s Weekly Wound Tracking Report, dated 2/17/19 through
3/16/19, showed:
– On 2/17/19, left ischium two centimeters (cm) by two cm by 0.1 cm;
– On 2/23/19, left proximal 0.7 cm by 0.5 cm by 0.1 cm and left distal 1.3 cm by 1.5 cm by
0.1 cm;
– On 3/16/19, left proximal 0.4 cm by 0.3 cm by 0.1 cm and left distal 1.4 cm by 1.3 cm by
0.1 cm.
Record review of the resident’s care plan, last revised 1/10/19, did not address pressure
ulcers.
4. During an interview on 3/22/19 at 1:41 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff), Coordinator said she would
expect care plans to be updated quarterly, annually, with a significant change or with any
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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
change. If there were a fall or injury, the care plan should be updated. The care plans
have not been updated like they should be because we have focused on MDS.

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 interview and record review, the facility failed to follow physician’s orders for
three residents (Resident #26, #33, and #42) out of 18 sampled residents. The facility’s
census was 77.
1. Record review of Resident #26’s (MONTH) and (MONTH) 2019 Physician’s Order Sheet (POS),
showed an order for [REDACTED].
Record review of the resident’s weights showed:
– On 2/1/19, 175.0 lbs;
– On 3/4/19, 164 lbs;
– On 3/13/19, 175.0 lbs.
During an interview on 3/22/19 at 1:41 P.M., the Director of Nursing (DON) said she would
expect a resident with an order for [REDACTED].
2. Record review of Resident #33’s Registered Dietitian’s (RD) progress notes, dated
2/26/19 through 3/21/19, showed:
– On 2/26/19, the resident now with open areas to buttocks per nurse. Nurse reports
initially with one area and now with two. Current diet order is mechanical soft (a diet
that involves only foods that are physically soft, with the goal of reducing or
eliminating the need to chew the food) with nectar thick liquids (liquids which coats a
spoon and easier to swallow when the person has swallowing difficulty or chokes on regular
liquids) and is with 2/21/19 order for yogurt three times daily (TID) with meals while on
antibiotics. Has B complex vitamin in place and [MEDICATION NAME]. Will recommend addition
of multivitamin. Will also recommend start of house supplement (a weight loss supplement
with added calories to aid in nutrition) 90 milliliters (ml) TID to better assist with
meeting increased nutritional needs for wound healing. Goal is for adequate intake to
promote wound healing and weight stability. RD will continue to monitor weight, report of
wound healing, and follow up as needed;
– On 3/21/19, the resident continues with increased nutritional needs related to wound
healing, with multiple wounds noted to buttocks, and per nurse this date, wound progress
without change. Continues with B complex vitamin place and [MEDICATION NAME]. Will
recommend follow up with previous RD recommendation to add multivitamin and start of house
supplement of 90 ml TID to better assist with meeting increased nutritional needs for
wound healing.
Record review of the resident’s POS, dated 2/21/19 through 3/21/19, showed no order for
multivitamin or house supplement.
During an interview on 3/22/19 on 1:41 P.M., the DON said the dietitian puts
recommendations on a spread sheet and the DON prints them out. The nurse sends them to the
physician and we wait on the response to come back.
Record review of the facility’s policy, titled Registered Dietitian Protocol, dated
10/1/17, showed once the facility receives recommendations from the RD, nursing will
contact physician and follow associated physician orders.
3. During an interview on 3/18/19 at 3:01 P.M., Resident #42 said he/she has had diarrhea

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 13)
for several weeks.
During an interview on 3/21/19 at 11:00 A.M., Licensed Practical Nurse (LPN) B said the
resident has had diarrhea since his/her colonoscopy on 2/28/19. LPN B checked his/her
Medication Administration Record [REDACTED].
During an interview on 3/21/19 at 11:10 A.M., the resident said he/she still has diarrhea
a lot. The resident said the bowel movements are liquid and does not have an odor. The
resident said he/she did not know there was medication he/she could take for diarrhea.
Record review of the resident’s POS, dated 3/1/19 to 3/31/19, showed:
– [DIAGNOSES REDACTED].
– [MEDICATION NAME] A-D (to treat diarrhea) liquid, 1 mg(milligram)/7.5 ml (milliliter),
amount 7.5 ml oral every four hours-prn (as needed).
During an interview on 3/22/19 at 1:41 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) Coordinator said if the nurse
knows a resident has diarrhea and the resident has an order for [REDACTED].

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 record review, the facility failed to complete a comprehensive
discharge summary for one resident (Resident #58) out of one closed record review. The
facility’s census was 77.
Record review of Resident #58’s medical record showed:
– No recapitulation of the resident’s stay including diagnoses, course of
illness/treatment or therapy, and pertinent lab, radiology, and consultation reports;
– No reconciliation of all pre-discharge medications with the resident’s post-discharge
medications;
– No post-discharge plan of care developed to assist the resident to adjust to his/her
living environment.
During an interview on 3/22/19 at 1:40 P.M., the Regional Director of Clinical Operations
said the recapitulation is on our discharge summary and each discipline would offer input
for a planned discharge. If there is an unplanned discharge, that may not happen because
we don’t have enough time.
Record review of the facility’s undated policy, titled Discharge Summary and Plan Policy,
showed:
– When the facility anticipates a resident’s discharge to a private residence or another
nursing care facility (I.e., skilled, intermediate care, residential care facility (RCF),
etc.), a discharge summary and post-discharge plan will be developed which will assist the
resident to adjust to his or her new living environment;
– The discharge summary will include a recapitulation of the resident’s stay at this
facility and a final summary of the resident’s status at the time of the discharge in
accordance with established regulations governing release of resident information and as
permitted by the resident;
– The discharge summary will include a description of the resident’s;
– Medically defined condition and prior medical history;
– Medical status;
– Physical and mental functional status;

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
– Sensory and physical impairments;
– Nutritional status and requirements;
– Special treatments and procedures;
– Mental and psychosocial status;
– Discharge potential;
– Dental condition;
– Activities potential;
– Rehabilitation potential;
Cognitive status;
– Drug therapy;
– The post discharge plan will be developed by the Interdisciplinary Team (IDT) with the
assistance of the resident and his/her family and will contain, as a minimum;
– A description of the resident’s and family’s preferences for care;
– A description of how the resident and family will access such services;
– A description of how the care should be coordinated of continuing treatment involves
multiple caregivers;
– The identity of specific resident needs after discharge;
– A description of how the resident and family need to prepare for the holidays.

F 0711

Level of harm – Potential for minimal harm

Residents Affected – Many

Ensure the resident’s doctor reviews the resident’s care, writes, signs and dates
progress notes and orders, at each required visit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure physician orders
[REDACTED]. This affected 10 out of 18 sampled residents (Residents #8, #10, #11, #35,
#41, #42, #57, #71, #123, and #174) and one resident (Resident #9) outside the sample. The
facility’s census was 77.
1. Record review showed Resident #8’s primary care physician (Physician D) failed to sign
and date:
– The Physician order [REDACTED].
– POS signed 3/13/19.
2. Record review showed Resident #9’s primary care physician (Physician D) failed to sign
and date:
– POS dated 2/1/19 – 2/28/19 within one month;
– POS signed 3/13/19.
3. Record review showed Resident #10’s primary care physician (Physician C) failed to sign
and date:
– POS dated 2/01/19-2/28/19 within one month;
– POS signed 3/04/19.
4. Record review showed Resident #11’s primary care physician (Physician D) failed to sign
and date:
– POS dated 2/1/19 – 2/28/19 within one month;
– POS signed 3/12/19.
5. Record review showed Resident #35’s primary care physician (Physician D) failed to sign
and date:
– Telephone orders dated 12/10/18, 12/24/18, 12/28/18, 1/3/19, 1/7/19, 1/14/19 and
2/25/19;

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0711

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 15)
– No orders for Hospice treatment on POS dated 12/1/18 – 12/31/18, 1/1/19 – 1/31/19,
2/1/19 – 2/28/19 or 3/1/19 – 3/31/19;
Record review showed Physician D failed to sign and date the following POSs within one
month:
– POS dated 12/1/18 – 12/31/18;
– POS signed on 1/25/19;
– POS dated 2/1/19 – 2/28/19;
– POS signed 3/12/19.
Record review showed Physician E failed to sign the Hospice Treatment Plan dated 11/23/18.
6. Record review showed Resident #41’s primary care physician (Physician C) failed to sign
and date the POS dated 2/18/19 – 3/18/19.
7. Record review showed Resident #42’s primary care physician (Physician D) failed to sign
and date:
– POS dated 1/4/19 – 2/4/19;
– POS dated 2/1/19 – 2/28/19.
8. Record review showed Resident #57’s primary care physician (Physician C) failed to sign
and date the following POS within one month:
– POS dated 2/01/19- 2/28/19;
– POS signed 3/04/19.
9. Record review showed Resident #123’s primary care physician (Physician C) failed to
sign and date the following:
– POS dated 2/15/19 – 3/15/19;
– POS dated 3/15/19 – 3/31/19 not signed until 3/20/19.
10. Record review showed Resident #174’s primary care physician (Physician C) failed to
sign and date the following POS within one month:
– POS dated 2/21/19 – 2/23/19;
– Failed to provide orders for services dated 2/24/19 – 2/28/19.
During an interview on 3/22/19 at 1:40 P.M., the Director of Nursing said the physicians
sign the orders when they visit the facility for rounds. They round weekly or monthly,
they round when they want to, not on a particular day each week or month. The signed
orders are supposed to be in the medical record (chart). She would expect telephone orders
to be signed by the physician. The telephone orders are mailed or the physician signs them
when they come in. Orders should probably be signed weekly, the orders that are mailed may
take a little longer. If the provider is coming the next day we will put the order on
their board for signature. If we mail them, we send the original and they send back the
original. All orders should be dated when they are signed.

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation and interview, the facility failed to post the nurse staffing data in
a clear and readable format in a prominent place readily accessible to residents and
visitors on a daily basis at the beginning of each shift. The facility’s census was 77.
Observations on 3/19/19, 3/20/19, and 3/21/19 showed the facility did not post the nurse
staffing data in a prominent place.
During an interview on 3/22/19 at 1:40 P.M., the Administrator said the nurse staffing is

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 16)
supposed to be in the front lobby but they recently painted the lobby and had moved it to
the nurse office. They failed to put it back in the lobby, but it has been moved now.
Record review of the facility’s policy, titled Posted Nursing Staffing Policy, dated
12/1/18, showed this facility will post the nursing department actual staffing numbers in
a high-visibility common area.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to store all drugs
and biologicals in a safe and effective manner by monitoring refrigerator temperatures and
keeping with accepted professional standards for infection control in the medication
refrigerator. The facility’s census was 77.
Observation on 3/21/19 at 2:30 P.M., of the 300 hall medication refrigerator showed:
– The refrigerator contained the emergency medication locked box located in unlocked,
vacant nurses’ office;
– The padlock on refrigerator unlocked;
– No temperature logs.
Observation on 3/21/19 at 2:40 P.M., of the 200 hall medication refrigerator showed:
– The refrigerator located in unlocked, vacant nurses’ office;
– The padlock on refrigerator unlocked;
– The refrigerator contained:
– One brown bag which contained yogurt, cottage cheese, and almonds;
– One bottle of Magnesium [MEDICATION NAME] (for constipation);
– 30 [MEDICATION NAME] suppositories (to treat/prevent flare-ups of ulcerative [MEDICAL
CONDITION]);
– 14 Biscolax suppositories (for constipation);
– 12 Promethegan suppositories (anti-nausea/vomiting medication);
– One bottle of [MEDICATION NAME] (antibiotic);
– One locked emergency medication kit.
– The temperature log showed:
– No temperatures recorded for January, 2019 or February, 2019;
– No temperatures recorded for (MONTH) 1, 2, 3, 4, 5, 6, 7, 8, 10, 14, 15, 19, 20, or 21,
2019.
During an interview on 3/21/19 at 2:50 P.M., Certified Medication Technician (CMT) F said
there used to be a temperature log on the front of the refrigerator on the 300 hall but
he/she could not find it in the office. He/she thinks it is the nurse’s responsibility to
check the temperatures.
During an interview on 3/21/19 at 2:55 P.M., Registered Nurse (RN) A said he/she didn’t
see the temperature log today.
During an interview on 3/22/19 at 1:40 P.M., the Director of Nursing (DON) said the night
nurse, or anyone, is responsible for checking the medication refrigerator temperatures and
it should be checked every night. There should not be food in the medication refrigerator.
The refrigerators have locks on them and should be kept locked.
Record review of the facility’s policy, titled Medication Storage, dated copyright 2014,

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
showed:
– Medications housed on our premises are stored in the pharmacy and/or medication rooms
according to the manufacturer’s recommendations. All medications are stored in designated
areas which are sufficient to ensure proper sanitation, temperature, light, ventilation,
moisture control, segregation, and security;
– Temperatures are maintained within 35-45 degrees Fahrenheit. Charts are kept on each
refrigerator and temperature levels are recorded daily by the charge nurse or other
designee.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation, interview, and record review,the facility failed to maintain the
palatability of food by preparing and serving foods at the appropriate temperature for
four residents ( Resident #10, #23, #57 and #174) out of 18 sampled residents and one
resident (Resident #52) outside the sample. This practice potentially affected all
residents in the facility. The facility’s census was 77.
During an interview on 3/18/19 at 11:49 AM, the Administrator said they currently do not
have a dietary manager.
During an interview on 3/18/19 at 11:55 A.M., the Social Services Worker I said they
haven’t had a dietary manager for almost a month. Social Services Worker I said he/she
tries to help out wherever he/she can.
During an interview in the main dining room on 3/18/19 at 12:40 P.M., Resident #23, #57,
and #173 said the food was cold and not done.
An observation in the main dining room on 3/18/19 at 12:41 P.M. showed seven plates left
with more than 50% of uneaten food left on them.
Observation of a test tray on 3/18/19 at 12:54 P.M. showed:
– Unseasoned ground beef for a mechanical diet (easy to chew) due to no hamburger patties
left to be served/cooked, with a temperature of 127.3 degrees Fahrenheit (°F);
– The meat portion, hamburger patty, was substituted with the mechanical ground beef;
– Runny baked beans with a temperature of 118.7 °F;
– Unseasoned potato wedges not fully cooked, pale and firm in texture, with a temperature
of 99.5 °F.
During an interview on 3/18/19 at 1:04 P.M., Resident #10 said the fries (potato wedges)
need to be deep fried or cooked longer.
Observation on 3/18/19 at 1:05 P.M., of Resident #10’s meal tray showed the potato wedges
looked pale in color and firm in texture.
Record review on 3/19/19 at 11:36 A.M. of the facility’s Food Temperature Log, dated
3/17/19 through 3/23/19, showed no temperatures for breakfast or lunch meals on Monday
3/19/19.
During an interview on 3/19/19 at 10:00 A.M., Resident #52 said when he/she received
his/her lunch tray yesterday, it contained unseasoned ground meat for a mechanical diet
because they had run out of hamburger patties. The resident did not require a mechanical
diet.
During an interview on 3/19/19 at 11:36 A.M., Cook G said he/she takes and records the
temperatures in the kitchen before putting on the steam table and pointed out the food

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:

265704

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

03/22/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF PERRYVILLE, THE

STREET ADDRESS, CITY, STATE, ZIP

430 NORTH WEST STREET
PERRYVILLE, MO 63775

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
temperature log hanging on the wall in the kitchen.
During an interview on 3/22/19 at 1:41 P.M., the Administrator said she would expect food
to be served at acceptable temperature levels.
Record review of the facility’s policy, titled Monitoring Food Temperatures for Meal
Service, dated 2011, showed:
– Food temperatures will be monitored daily to prevent food borne illness and ensure foods
are served at palatable temperatures;
– Prior to serving a meal, food temperatures will be taken and documented for all hot and
cold foods to ensure proper serving temperatures. Any food item not found at the correct
holding/serving temperature will not be served, but will undergo the appropriate
corrective action.