Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, facility staff failed to provide a comfortable and
homelike environment for ten residents (#3, #25, #28, #29, #50, #52, #56, #60, #61, and
#65) when they did not repair broken storage drawers, for residents (#3, #25, #50, #52,
#56, #60, and #65) when they did not repair baseboards and holes in doors for residents
(#25, #28, #29, #50, #56, #60, and #61), and when they did not repair baseboards and holes
in walls in public areas. The facility census was 69.
1. Review of the facility’s policies showed staff did not provide a policy related to
providing a homelike environment for residents.
2. Observation on 08/27/18 at 10:13 A.M., showed broken storage drawers with holes and
peeling exteriors under the vanity sink in Resident #25’s room. Further observation showed
a hole in the wall next to the bathroom door.
Observation on 08/27/18 at 10:29 A.M., showed the baseboard peeled away from the wall near
Resident #29’s bed. Further observation showed broken storage drawers under Resident #29
and #56’s vanity sink. Additional observation showed a hole above the baseboard near the
residents’ bathroom door.
Observation on 08/29/18 at 11:29 A.M., showed broken storage drawers under Resident #65’s
vanity sink.
Observation on 08/29/18 at 11:31 A.M., showed broken storage drawers under Resident #52’s
vanity sink. Further observation showed one drawer missing.
Observation on 08/29/18 at 11:32 A.M., showed a hole in the wall near the baseboard across
from room [ROOM NUMBER]. Further observation showed the corner baseboard missing with
sheetrock and metal exposed near room [ROOM NUMBER].
Observation on 08/29/18 at 11:33 A.M., showed broken storage drawers under Resident #50’s
vanity sink. Further observation showed a broken baseboard near the bathroom door.
Observation on 08/29/18 at 11:36 A.M., showed small holes in Resident #60’s bathroom door.
Further observation showed broken storage drawers with cracked and peeling exteriors under
the vanity sink.
Observation on 08/29/18 at 11:37 A.M., showed a missing storage drawer under the vanity
sink in Resident #3’s room.
Observation on 08/29/18 at 11:38 A.M., showed the baseboard peeled away from the wall near
Resident #29’s bed. Further observation showed broken storage drawers under Resident #29
and #56’s vanity sink. Additional observation showed a hole above the baseboard near the
residents’ bathroom door.
Observation on 08/29/18 at 11:40 A.M., showed broken storage drawers with holes and
peeling exteriors under the vanity sink in Resident #25’s room. Further observation showed
a hole in the wall next to the bathroom door.
Observation on 08/29/18 at 12:02 P.M., showed a broken baseboard under the storage drawers
in Resident #28 and Resident #61’s room.
3. During an interview on 08/30/18 at 10:18 A.M., Maintenance said every morning he/she
checks the door and water temperatures and talks to staff to see if everything is in
working repair. He/She said staff can leave repair requests on his/her desk. He/She said
missing drawers are being worked on and are in the shop. He/She said some of the drawers
are off track and will not close because CNA’s will transport them from one room to
another and they are not interchangeable. He/She said most of the holes in walls, doors,
and drawers are caused by wheelchairs and to be repaired and painted. He/She said he/she
is currently working on the holes in the walls. He/She said he/she is trying to get them

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
to install a more durable wall material to prevent holes but it is expensive. He/She said
the missing baseboards and dented holes in walls are due to wheelchairs and he/she is
constantly working to repair them.
During an interview on 08/30/18 at 10:25 A.M., Certified Nursing Aide (CNA) I said staff
report needed repairs to maintenance verbally or via a note in writing. He/She said he/she
usually fixes minor issues the same day and more time consuming issues he/she will repair
as soon as possible.
During an interview on 08/30/18 at 10:54 A.M., Licensed Practical Nurse (LPN) B said
he/she notifies maintenance verbally if he/she needs something to be repaired. He/She said
maintenance usually fixes things as soon as he/she can. He/She said he/she is not aware of
any non-repaired issues. He/She said he/she has not noticed any missing drawers or holes
in the walls because it is not his/her job. He/She said housekeeping and maintenance are
responsible for making sure resident rooms do not need any repairs.
During an interview on 08/30/18 at 1:02 P.M., the Director of Nursing (DON) said staff
should inform maintenance verbally or in a note if they notice something that needs
repaired. He/She said the administrator should monitor to make sure things are repaired.
He/She said maintenance said he/she had ordered new drawers. He/She said he/she is unsure
how long ago it was. He/She said he/she has noticed areas in the building that need to be
repaired. He/She said maintenance is repairing stuff as requested.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to develop
measurable goals and interventions for individualized, comprehensive care plans to address
the physical, mental and psychosocial needs of 8 out of 17 sampled residents. Staff failed
to develop a comprehensive care plan within seven days of completing the comprehensive
Minimum Data Set (MDS), a federally mandated assessment for two residents (Resident #5, #
69), failed to develop and implement interventions to address pain for one resident
(Resident #11), the use of side rails/grab bars for one resident (Resident #17), and
respiratory care for four residents (Resident #8, #28, 29, and #41). The facility census
was 69.
1. Review of the facility’s policy on Care Planning, dated (MONTH) (YEAR), showed staff
are directed:
-The facility Care Planning/ Interdisciplinary Team (IDT) is responsible for the
development of an individualized comprehensive care plan for each resident;
-A comprehensive care plan for each resident is to be developed within seven (7) days of
the completion of the resident assessment (MDS);
-The care plan is based on the resident’s comprehensive assessment and is developed by a
Care Planning/IDT which includes, but is not limited to the following personnel: attending
physician, dietary manager, social services worker, activities director, therapists,
consultants (as appropriate), Director of Nursing (DON), charge nurse responsible for
resident care, others as appropriate or necessary to meet the needs of the resident;
-The resident, the resident’s family and/ or legal representative guardian or surrogate
are encouraged to participate in the development of and revisions to the resident’s care
plan.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 2)
2. Review of Resident #5’s comprehensive Minimum Data Set (MDS), a federally mandated
assessment, dated 5/12/18, showed staff assessed the resident as follows:
-Moderately impaired cognition;
-No mood symptoms;
-No behaviors or rejection of care;
-Received antipsychotic and antidepressant medications for seven days during the review
period.
Review of the resident’s care plan, dated 7/18/18, showed staff did not develop the
comprehensive care plan within seven days of completion of the comprehensive MDS. Staff
documented the following to address the dementia care needs of the resident:
-Assist of 1 with bathing, dressing, toileting, and personal hygiene. Keep all personal
items in reach, provide non-distracting environment for grooming/personal hygiene;
-Assess/record effectiveness of drug treatment. monitor and report signs of sedation,
[MEDICATION NAME] and extrapyramidal symptoms;
-Administer meds crushed, will not take in multiple attempts due to dementia.
3. Review of Resident #8’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively intact;
-Poor appetite on several days;
-No behaviors or rejection of care;
-Oxygen therapy.
Review of the resident’s care plan, dated 7/24/18, showed staff did not address the
resident’s oxygen use or tubing changes.
Review of the resident’s physician’s orders [REDACTED]. Further review showed staff are
directed to change oxygen tubing monthly.
4. Review of Resident #11’s face sheet showed he/she admitted to facility on 11/22/17,
with [DIAGNOSES REDACTED].
Review of the resident’s admission pain assessment, completed by staff on 11/23/17, showed
staff documented the following:
-Vocal complaints of pain, rated as severe;
-Pain in legs;
-Almost constantly, on scale 6 out of 10;
-Pain limited daily activities over the past 5 days;
-Pain comes and goes;
-Measures previously used to alleviate pain: [MEDICATION NAME], rest, relaxation
techniques;
-Initiate plan of care.
Review of the resident’s baseline care plan, signed completed by staff on 11/23/17, showed
pain was not identified as an area of concern.
Review of the resident’s comprehensive care plan, dated 11/23/17, showed staff did not
document any directions or interventions to address the resident’s pain.
Review of the resident’s admission MDS, dated [DATE], showed staff documented resident was
admitted [DATE], and assessed the resident as follows:
-Not on a scheduled pain medication regimen;
-Received as needed (PRN) pain medications;
-Did not receive non-medication intervention for pain;
-Vocal complaints of pain (that hurts, ouch, stop);
-Indicators of pain or possible pain observed daily.
Further review of the resident’s records, showed staff did not develop and implement
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 3)
interventions to address the resident’s pain until 4/9/18. Staff were directed:
-Problem: Resident has chronic complaints of pain and history of opioid abuse per
guardian;
-Goal: Pain will be monitored and treated within parameters set by guardian and physician;
-Interventions: Update guardian on pain complaints, follow up with pain specialist. Make
guardian aware of pain specialist prior to visit.
During an interview on 8/27/18 at 11:56 A.M., the resident said he/she has pain on a scale
of 7 out of 10 to his/her lower back, but had not asked staff at this time for pain
medication.
During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said if a
resident complains of pain on admission, he/she expects staff to document care plan
interventions for the pain, and staff should always attempt non-pharmacological
interventions for pain.
5. Review of Resident #17’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively intact;
-Required extensive assistance of two or more staff with bed mobility, dressing, and
toileting;
-Use of walker and wheelchair.
Review of the resident’s care plan, last updated 8/16/18, showed staff are directed to do
the following:
-Assist the resident with activities of daily living (ADLs) with three staff for pericare,
bed mobility, and dressing;
-Stand by assist with two staff with walker for transfers.
Further review showed staff did not develop and implement measurable goals and
interventions to address the resident’s use of side rails or grab bars.
Observation on 8/27/18 at 11:27 A.M., showed the resident in his/her bed with a half side
rail in the raised position on the left and right side at the head of his/her bed.
Observation on 8/28/18 at 11:32 A.M., showed the resident in his/her bed with a half side
rail in the raised position on the left and right side at the head of his/her bed.
Observation on 8/29/18 at 11:19 A.M., showed the resident in his/her bed with a half side
rail in the raised position on the left and right side at the head of his/her bed.
6. Review of Resident #28’s comprehensive admission MDS, dated [DATE], showed staff
assessed the resident as follows:
-Cognitively intact;
-No mood;
-No behaviors or rejection of care;
-Oxygen therapy.
Review of the resident’s care plan, dated 4/12/18, showed staff did not address when to
administer oxygen or the flow rate ordered for the resident. Further review showed staff
are directed to change the resident’s oxygen tubing weekly.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as follows:
-Cognitively intact;
-No mood;
-No behaviors or rejection of care;
-Oxygen therapy.
Review of the resident’s POS, dated 08/01/18, showed staff are directed to administer 2
liters of oxygen per minute per nasal cannula at night and PRN for shortness of breath.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 4)
Further review showed staff are directed to change oxygen tubing monthly.
Observation on 08/27/18 at 10:22 A.M., showed the resident’s oxygen tubing dated 08/07/18.

Staff did not change the resident’s oxygen tubing weekly, as directed by the physician’s
orders [REDACTED].
Observation on 08/28/18 at 10:46 A.M. showed the resident’s oxygen tubing dated 08/07/18.
Staff did not change the resident’s oxygen tubing weekly, as directed by the physician’s
orders [REDACTED].
Observation on 08/29/18 at 12:04 P.M., showed the resident’s oxygen tubing dated 08/07/18.

Staff did not change the resident’s oxygen tubing weekly, as directed by the physician’s
orders [REDACTED].
7. Review of Resident #29’s comprehensive admission MDS, dated [DATE], showed staff
assessed the resident as follows:
-Cognitively intact;
-No mood;
-No behaviors or rejection of care;
-Oxygen therapy.
Review of the resident’s POS, dated 08/01/18, showed staff are directed to administer 2-5
liters of oxygen per minute per nasal cannula continuous for shortness of breath. Further
review showed staff are directed to change oxygen tubing monthly.
Review of the resident’s care plan, dated 08/29/18, showed staff did not address the
resident’s oxygen use or tubing changes.
Observation on 08/27/18 at 10:29 A.M., showed the resident’s oxygen tubing dated 07/27/18.

Observation on 08/28/18 at 12:48 P.M. showed the resident’s oxygen tubing dated 07/27/18.
Observation on 08/29/18 at 12:00 P.M., showed the resident’s oxygen tubing dated 07/27/18.

8. Review of Resident #41’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-No mood;
-No behaviors or rejection of care;
-Extensive assistance of one or more staff for bed mobility;
-Oxygen therapy.
Review of the resident’s POS, dated 08/01/18, showed staff are directed to administer 3
liters of oxygen per minute per nasal cannula continuous for [MEDICAL CONDITIONS]. Further
review showed staff are directed to change oxygen tubing weekly. Additional review showed
staff are directed to allow the resident use of bedrails for repositioning and safety.
Review of the resident’s care plan, dated 08/29/18, showed staff are directed to
administer 2 liters of oxygen to the resident. Further review showed staff did not address
the use of bedrails, did not indicate the correct amount of oxygen to administer per the
physician’s orders [REDACTED].
Observation on 08/27/18 at 10:39 A.M., showed the resident in bed with half rails on each
side. Further observation showed the resident on oxygen via nasal cannula set at 2 liters.
Additional review showed the oxygen tubing undated.
Observation on 08/29/18 at 12:11 P.M., showed the resident sit in his/her wheelchair in
the dining room. Further observation showed the resident on oxygen via nasal cannula set
at 2 liters. Additional review showed the oxygen tubing undated.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 5)
Observation on 08/29/18 at 2:12 P.M. showed the resident in bed with half rails on each
side. Further observation showed resident on oxygen via nasal cannula set at 2 liters.
Additional review showed the oxygen tubing was not dated.
9. Review of Resident #69’s significant change MDS, dated [DATE], showed staff assessed
the resident as follows:
-Severe cognitive impairment;
-No impairments to upper or lower extremities;
-No behavior or rejection of care;
-Limited assist of one with dressing, and toileting, and set-up help with eating;
-Extensive assist of one with personal hygiene.
Review of the resident’s comprehensive care plan, dated 8/29/18, showed staff are
directed:
-Assist of one with all ADLs except resident is able to feed self;
-Offer turning and peri care frequently throughout shift
-Check for incontinence in morning, before and after meals, at bed time, and frequently
throughout shift;
-Offer to perform personal hygiene, (washing face, combing hair, dressing) every morning.
Staff did not develop the comprehensive care plan within seven days of completion of the
comprehensive MDS.
During an interview on 8/27/18 at 2:45 P.M., Certified Nursing Assistant (CNA) N said the
resident became incontinent of bowel and bladder about 2 weeks ago, has gotten weaker, and
needs more assistance from staff with his/her ADLs.
10. During an interview on 8/30/18 at 10:32 A.M., CNA D said staff use information from
each resident’s care plan to provide care for the resident. He/She said residents’ care
plans are located in their charts, and in the wall kiosks.
11. During an interview on 8/30/18 at 10:54 A.M., Licensed Practical Nurse (LPN) B said
the MDS coordinator creates care plans and they should be created to meet the residents
needs and staff should follow the care plans and interventions.
12. During an interview on 8/30/18 at 11:21 A.M., the MDS Coordinator said he/she creates
the care plans based on the residents care area assessment off the MDS and through
interviews from residents and family members, and the care plan should accurately reflect
the resident.
13. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said the
MDS Coordinator creates the care plans and they should reflect the residents. The DON said
things like side rail use, Activities of Daily living, dementia, weight loss, pain, and
oxygen use should be on the care plan. The DON said he/she expects staff to follow the
care plans and interventions.

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 observation, interview, and record review facility staff failed to update the
plan of care with change in resident’s needs for four residents (Residents #25, #62, #73,
and #122) regarding falls, changes in limitations of range of motion, and wounds. Facility
census was 69.
1. Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 6)
assessment, dated 03/20/18, showed facility staff assessed the resident as follows:
-Severe cognitive impairment;
-Required total dependence of one or more staff for eating, toileting, and personal
hygiene;
-Required extensive assistance of two or more staff for bed mobility and transfers;
-Required extensive assistance of one staff for dressing;
-No falls during lookback period.
Review of the resident’s care plan, last updated 03/23/18, showed facility staff are
directed to do the following:
-Assist to bed when tired/sleeping;
-Apply foot buddy for leg support;
-Provide individualized toileting interventions based on needs and patterns.
Review of the resident’s comprehensive significant change MDS, dated [DATE], showed
facility staff assessed the resident as follows:
-Severe cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility;
-Required extensive assistance of one staff for transfers, dressing, eating, toileting,
and personal hygiene;
-No falls during lookback period.
Review of the resident’s internal incident report, dated 08/23/18, showed staff documented
the resident fell on [DATE] and staff are following up on it through interdisciplinary
team meetings.
Review of the resident’s nurses’ notes, dated 08/23/18 showed staff documented they
conducted neurological checks and the resident denied pain.
Further review of the resident’s care plan, last updated 03/23/18, showed staff did not
update the resident’s care plan with fall interventions following the fall with injury on
08/23/18.
2. Review of Resident #62’s MDS, dated [DATE], showed facility staff assessed the resident
as follows:
-Sever cognitive impairment;
-Required total assistance of two or more staff for bed mobility, transfer, dressing; and
toileting;
-Required total assistance of one staff for eating, personal hygiene, and bathing;
-Limited range of motion in both upper and lower extremities.
Review of the resident’s Monthly Summary, dated 8/1/18, showed staff documented the
resident had limitations of range of motion in both upper and lower extremities.
Review of the resident’s care plan, last updated 8/9/18, showed facility staff are
directed to do the following:
-Use appropriate staff member for activities of daily living,
-Toilet and reposition before and after meals, at bed time and as needed;
-Bilateral lower extremities impaired;
-Assess lower extremities every day for skin condition;
-Maintain upright position in wheelchair.
Further review of the resident’s care plan, last updated 8/9/18, showed staff did not
update the resident’s care plan with the limitation in range of motion limitation in upper
extremities.
Observation on 8/27/18 at 11:49 A.M., showed the resident’s hands in a fist.
Observation on 8/28/18 at 10:36 A.M., showed the resident in bed with both his/her hands
in a fist.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 7)
Observation on 8/28/18 at 2:15 P.M., showed the resident in his/her wheelchair with
his/her hands in a fist.
Observation on 8/30/18 at 10:26 A.M., showed the resident in his/her bed with his/her
hands in a fist.
3. Review of Resident #73’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Severe cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility, transfers, and
toileting;
-Required extensive assistance of one staff for dressing and personal hygiene;
-One fall with no injury after admission;
-No weight loss of 5% or more in the last 6 months.
Review of the resident’s care plan, last updated 02/06/18, showed facility staff are
directed to do the following:
-Two staff present for transfers, personal hygiene, and toileting;
-Provide appropriate fitting wheelchair;
-Assess pain;
-Provide special boots to be worn;
-Proper catheter placement;
-Monitor diabetes;
-Monthly weights;
-Report weight gain or loss;
-Provide alternates for food dislikes;
-Offer snacks.
Review of the resident’s quarterly MDS, dated [DATE], showed facility staff assessed the
resident as follows:
-Severe cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility, transfers, and
toileting;
-Required extensive assistance of one staff for dressing and personal hygiene;
-One fall with no injury after admission;
-No weight loss of 5% or more in the last 6 months.
Review of the resident’s notes, dated 05/21/2018, showed the Registered Dietician
documented the resident’s weight increase by 11% in 180 days from 207.2 to 229.4. He/She
recommended no changes.
Review of the resident’s nurses’ notes, dated 05/22/18, showed staff documented the
resident was in his/her wheelchair in the dining room after lunch when he/she reached for
something on the ground and fell on to the floor. Staff noted the resident did not hit
his/her head, denies pain, and had no visible injuries.
Further review of the resident’s care plan, last updated 02/06/18, showed facility staff
did not update the care plan with the fall, review of current fall interventions or new
fall interventions. Additional review showed staff did not update the care plan with the
weight gain or add any weight monitoring.
4. Review of Resident #122’s face sheet, showed the resident was admitted on [DATE].
Review of the resident’s Admission assessment, dated 8/16/18, showed facility staff
assessed the resident’s skin as buttocks and buttocks cleft red, irritated, and fragile.
Skin is intact.
Review of the resident’s skin assessments, dated 8/17/18, showed staff documented the
resident had an excoriated area to coccyx.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 8)
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Cognitively intact;
-Required extensive assistance of two or more staff for bed mobility and transfers;
-Required extensive assistance of one staff member for dressing and bathing;
-No pressure ulcers;
-No skin issues.
Review of the resident’s Nurses Notes, dated 8/27/18, showed facility staff documented
wound one to right buttock measures 2.6 cm x 3.0 cm x 0.1 cm onset on 8/16/18 upon
admission to facility with denudation and excoriation (reddened skin). Wound two to left
buttock measuring 1.5 cm x 1.5 cm x 0.1 cm with onset on 8/16/18 of excoriation. Both
wounds were cleaned with wound cleanser and applied barrier (cream used to provide a
barrier from being wet) cream twice and day and as needed for soiling. Measurements were
completed 8/23/18.
Review of the resident’s care plan, last updated 8/27/18, showed the resident was at risk
for pressure ulcers and staff were directed to do the following:
-Consider speciality bed;
-Elevate heels off bed or use heel protectors;
-Position with pillows to elevate pressure points off bed;
-Skin assessments and inspection every shift with close attention to heels by Certified
Nurse Assistant (CNA) and weekly by nurses;
-Do frequent small shift of body weight, turn and reposition frequently throughout shift
and as needed.
Further review of the resident’s care plan showed staff did not update the care plan to
address the open areas on the resident’s buttocks.
Observation on 8/23/18 at 1:55 P.M., showed Licensed Practical Nurse (LPN) J entered the
resident’s room. Observation showed the resident had an open area on the right buttock and
three open areas on the resident’s left buttock. LPN J said he/she is not sure how the are
categorized, but the wounds are open and have serosanguineous drainage (clear, thin,
watery drainage) and the wound bed is red and raw.
Observation on 8/29/18 at 11:52 A.M., showed the Assistant Director of Nursing (ADON)
entered the residents room. Observation showed the ADON rolled the resident to the left.
Observation showed the resident had an open area on the right buttock and three open areas
on the left buttock. The ADON said the resident’s bottom has denuded skin. The ADON said
the resident’s had one open area on the right bottom that measured 2.3 centimeter (cm) x
2.5 cm x 0.1 cm. The ADON said the wound has was 70 percent (%) [MEDICATION NAME] tissue
(thin tissue that cover all exposed surface of body) and 30% granulation tissues (new
connective tissue in the surface of the wound). ADON said the resident’s left buttock
wound measured 1.6 cm x 1 cm x 0.1 cm with 10% granulation tissue and 90% [MEDICATION
NAME] tissue with two satiate open area that are less than 1 cm one is 5% granulation and
95% [MEDICATION NAME] tissues.
5. During an interview on 8/30/18 at 10:54 A.M., LPN B said the MDS coordinator and nurses
can update resident’s care plans. Care plans should be updated with any change of
condition such as falls, personal preference, weight loss, new skin issues or wounds.
6. During an interview on 8/30/18 at 11:21 A.M., the MDS Coordinator said he/she updates
care plans as well as nurses. The MDS coordinator said care plans should be updated with
any change in condition, activity of daily living changes, weight loss, falls,
antibiotics, hospitzation, and new skin issues or wounds. The MDS Coordinator said he/she
gets the information by staff passing the word along, reviewing charts quarterly, and
weekly risk meetings.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 9)
7. During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said nurses
and the MDS coordinator can update care plans. The DON said falls, open areas, and
limitations in range of motion should be updated in the residents’ care plans. The DON
said Resident’s #25’s fall should be on the care plan within the first 24 hours. The DON
said he/she updated Resident’s #122 care plan with a fall on 8/29/18. The DON said wounds
should be updated on the residents care plan. The DON said Resident’s #73’s fall should
have been updated on the care plan.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide an
ongoing program of activities designed to meet the resident’s interests for four sampled
residents (Residents #11, #25, #29, #33), failed to conduct scheduled daily activities on
the locked unit, and failed to provide weekend and evening activities for all residents.
The facility census was 69.
1. Review of the facility’s policy on Activities dated (MONTH) 2012, showed the following:
-The activities services of each facility will plan, organize, and carry out a program of
activities to meet individual resident needs;
-The Activity Director (AD) will develop a monthly activity calendar based on the
resident’s needs and interests;
-The calendar should include a wide variety of activities to meet all aspects of daily
living;
-The activity calendar should list time of activity, and include evening and weekend
activities based on resident’s interests.
2. Review of the Activity calendar dated (MONTH) (YEAR) showed the following:
-Saturday 6/2/18: Readings at 10:00 A.M., and Front Porch Pickers at 2:00 P.M.;
-Sunday 6/3/18: Nail care at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 6/9/18: Reminisce DVD (no time scheduled), and Balloon swat at 3:00 P.M.;
-Sunday 6/10/18: Nail care at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 6/16/18: Guess the opposite (no time scheduled), and Balloon swat at 3:00 P.M.;
-Sunday 6/17/18: Nail care at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 6/23/18: Name that tune (no time scheduled), and Balloon swat at 3:00 P.M.;
-Sunday 6/24/18: Nail care at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 6/30/18: Sing along with aides (no time scheduled), and Balloon swat at 3:00
P.M.;
-Staff did not schedule any activities after 3:00 P.M., for the entire month of June.
3. Review of the Activity calendar, dated (MONTH) (YEAR), showed the following:
-Sunday 7/1/18: Movie of choice at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 7/7/18: Friends and coffee at 7:00 A.M., Find it pictures at 8:00 A.M., and
Front Porch Pickers at 2:00 P.M.;
-Sunday 7/8/18: Move of choice at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 7/14/18: Puzzles, word finds, and cards (no time scheduled);
-Sunday 7/15/18: Movie of choice at 10:00 A.M., and Church at 2:30 P.M.;
-Saturday 7/21/18: Get out visit with a friend (no time scheduled), and Dominoes at 1:30
P.M.;
-Sunday 7/22/18: Movie of choice at 10:00 A.M., and Church at 2:30 P.M.;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-Saturday 7/28/18: Word finds, read a good book, and cards with friends (no time
scheduled);
-Sunday 7/29/18: Movie of choice at 10:00 A.M., and Church at 2:30 P.M.;
-Staff did not schedule any activities after 3:30 P.M., for the entire month of July.
4. Review of the Activity calendar, dated (MONTH) (YEAR), showed the following:
-Saturday 8/4/18: Music and relaxation at 7:00 A.M., Movie and popcorn at 10:00 A.M., and
Front Porch Pickers at 2:00 P.M.;
-Sunday 8/5/18: Visit with others (no time scheduled), and Church at 2:30 P.M.;
-Saturday 8/11/18: Cards with friends, puzzles, and music (no time scheduled);
-Sunday 8/12/18: Talk with a veteran (no time scheduled), and Church at 2:30 P.M.;
-Saturday 8/18/18: Puzzle, music, cards, and board games (no time scheduled);
-Sunday 8/19/18: Reminisce with friends about school (no time scheduled), and Church at
2:30 P.M.;
-Saturday 8/25/18: Puzzles, cards, sewing (no time scheduled);
-Sunday 8/26/18: Sing old songs (no time scheduled), and Church at 2:30 P.M.
-Staff only scheduled two evening activities for the entire month of (MONTH) (8/17/18 and
8/28/18).
5. Review of Resident #11’s admission Minimum Data Set (MDS), a federally mandated
assessment, dated 12/1/17 showed staff assessed the resident with moderate cognitive
impairment, required extensive assist of one staff with locomotion on and off unit, and
prefers to spend time away from nursing home.
Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff did
not document the resident participated in any activities. Staff documented the resident
likes to stay in his/her room, is very talkative, loves his/her coffee, and likes bingo,
which is the only game he/she will come out to play.
Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff
documented the resident attended the following activities:
-7/3/18: Bingo and popcorn;
-7/6/18: Enjoyed ice cream that was brought to him/her;
-7/11/18: Came to the band in the North dining room;
-7/23/18: Enjoyed the children reading to him/her;
-7/26/18: Went to Country Store for the first time.
Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff
documented the resident attended the following activities:
-8/3/18: Talked with him/her about raising children;
-8/18/18: Enjoyed ice cream and two cups of coffee;
-8/20/18: Bingo and popcorn;
-8/26/18: Visited with peers outside, watched Cardinals baseball game on TV;
-8/29/18: Visited with peers outside.
Review of the resident’s care plan last updated 8/28/18, showed staff are directed:
-Resident will not leave facility without presence of staff or family member;
-Provide supervision with transfers, independent with all other ADLs;
-Uses wheelchair for locomotion, may need assistance for long distances;
-Ensure resident is aware of activities, allowed to decorate room, and voice feelings to
staff.
Review of the resident’s activities assessment dated [DATE] showed staff documented:
-Prefers his/her own room for independent leisure;
-Prefers music, watching TV, people watch, and bingo;
-Will play bingo twice a week, rest of time spent in room.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
During an interview on 8/27/18 at 11:56 A.M., the resident said he/she likes to play
Bingo, but staff doesn’t offer it that often. He/She said there is not much to do on the
weekends either, and he/she would love if staff offered even Bingo on the weekends,
because he/she would participate.
6. Review of Resident #25’s quarterly MDS, dated [DATE], showed facility staff assessed
the resident as follows:
-Severe cognitive impairment;
-Required extensive assistance of two or more staff for bed mobility, transfers, and
toileting;
-Required extensive assistance of one staff for eating, dressing, and personal hygiene.
Review of the resident’s activity participation log, dated 06/2018, showed staff did not
document the resident attended any facility activities.
Review of the resident’s activity participation log, dated 07/2018, showed staff
documented the resident attended the following activities:
-7/09/18 reading with kids;
-7/11/18 watched a band;
-7/16/18 reading with kids;
-7/24/18 tell a joke day;
-7/27/18 watched a band.
Review of the resident’s activity participation log, dated 08/2018, showed staff
documented the resident attended the following activities;
-8/04/18 listened to music;
-8/08/18 watched a band;
-8/14/18 listened to the piano;
-8/28/18 supper with youth group.
Review of the resident’s comprehensive significant change MDS, dated [DATE], showed
facility staff assessed the resident as follows:
-Severe cognitive impairment;
-Customary routine activities include: receiving shower, snacks between meals, listening
to music, being around animals, doing group activities, and participating in favorite
activities;
-Required extensive assistance of two or more staff for bed mobility;
-Required extensive assistance of one staff for transfers, dressing, eating, toileting,
and personal hygiene.
Review of the resident’s care plan, last updated 08/29/18, showed staff are directed to
provide a setting in which activities are preferred: by the nurse’s station or in the
dining room so the resident can people watch.
Review of the resident’s activity assessment, dated 08/29/18, showed staff assessed the
resident as:
-Alertness varies by day;
-Prefers his/her own room or activity room;
-Prefers one on one activities and independent leisure;
-Likes to nap frequently, people watch, and reminisce;
-Interested in music, watching television, and talking.
Observation on 08/27/18 at 2:36 P.M., showed the resident lie in bed and appear to sleep.
Further observation showed the light off, the television was not on, and no music was
played.
Observation on 08/28/18 at 10:41 A.M., showed the resident lie in bed and appear to sleep.
Further observation showed the light off, the television was not on, and no music was
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
played.
Observation on 08/28/18 at 12:57 P.M., showed the resident sit in his/her wheelchair in
his/her room. Further observation showed the light off, the television was not on, and no
music was played.
7. Review of Resident #29’s comprehensive admission MDS, dated [DATE], showed facility
staff assessed the resident as follows:
-Cognitively intact;
-Activity preferences include music and spiritual service;
-Required extensive assistance of two or more staff for bed mobility and transfers;
-Required extensive assistance of one staff for dressing, toileting, and personal hygiene.
Review of the resident’s care plan, last updated 08/29/18, showed staff are directed to
provide the resident with activities that identify with the resident’s prior lifestyle,
such as drinking beer as ordered once or twice per week.
Review of the resident’s activity participation log, dated 08/2018, showed staff
documented the resident attended the following activities;
-8/08/18 hospice came in and shaved the resident;
-8/16/18 family came to visit;
-8/20/18 had coffee and looked at the menu;
-8/23/18 came out for both meals;
-8/27/18 family came to visit;
-8/28/18 enjoyed music at dinner.
Review of the resident’s complete medical record showed staff did not complete an activity
assessment for the resident and did not complete activity logs for 06/2018 or 07/2018.
Observation on 08/27/18 at 10:29 A.M., showed the resident laid in bed and appear to
sleep.
Observation on 08/28/18 at 12:48 P.M., showed the resident laid in bed and appear to
sleep.
Observation on 08/29/18 at 2:11 P.M., showed the resident laid in bed and appear to sleep.

8. Review of Resident #33’s significant change MDS, dated [DATE], showed staff assessed
the resident with mild cognitive impairment, prefers to have books, newspapers and
magazines to read, and to do his/her favorite activities.
Review of the resident’s activity participation log, dated (MONTH) (YEAR), showed staff
did not document the resident participated in any activities. Staff documented the
resident likes soda, watching the ballgame and movies in his/her room, likes outdoor time
(smoking), and bingo is the only game he/she will come out to play.
Review of the resident’s quarterly MDS dated [DATE], showed staff assessed the resident as
cognitively intact, required supervision with transfer, independent with locomotion on
unit, and required assist of one staff with locomotion off unit via wheelchair.
Review of the resident’s activity participation log, dated (MONTH) (YEAR), showed staff
documented the resident attended the following activities:
-7/4/18: Celebrated 4th of (MONTH) with resident, special meal and outdoor time;
-7/9/18: Enjoyed bingo and the kids;
-7/11/18: Enjoyed the band in the North dining room;
-7/16/18: Enjoyed the kids reading to him/her;
-7/27/18: Enjoyed the band.
Review of the resident’s activity participation log dated (MONTH) (YEAR), showed staff
documented the resident attended the following activities:
-8/18/18: Resident was excited about meatloaf for lunch;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-8/20/18: Enjoyed popcorn for afternoon snack;
-8/21/18: Visited with staff;
-8/22/18: Visited with peers outside;
-8/26/18: Visited with peers outside;
-8/29/18: Visited with peers outside.
Review of the resident’s care plan, last updated 8/28/18, showed staff are directed to
offer assist of one with transfers, and encourage small group programs.
During an interview on 8/30/18 at 10:20 A.M., the resident said he/she loves to play
bingo, but they only have it sometimes twice a week. He/She said it would be nice to have
bingo on the weekends sometimes to at least give the residents something to do because the
weekends are boring. The resident said he/she did not even care if he/she won or not,
because it’s just a game.
9. Review of the White Board on the unit, showed the following scheduled activities for
Monday 8/27/18:
-11:15 A.M.: Roll of the dice;
-1:15 P.M.: Crafts for September;
-2:00 P.M.: Bingo.
Observation on 8/27/18 at 11:38 A.M., showed a total of nine residents in the TV/lobby
area. Further observation showed there was no staff-led activity in progress.
Observation on 8/27/18 at 2:30 P.M., showed a total of six residents in the TV/lobby area.
Further observation showed there was no staff-led activity in progress.
Observation and interview on 8/27/18 at 2:38 P.M., showed Resident #11 sat in his/her room
in the wheelchair. The resident said staff did not offer him/her to play Bingo today.
During an interview on 8/27/18 at 2:30 P.M., Certified Nursing Assistant (CNA) O said
according to the board, Bingo was scheduled for 2:00 P.M., but it looks like they didn’t
do it back here today.
10. Review of the White Board on the unit, showed the following scheduled activities for
Tuesday 8/28/18:
-2:00 P.M.: Board game (Sorry)
-3:00 P.M.: Baking.
Observation on 8/28/18 at 2:08 P.M., showed there was no staff-led activity in progress.
Observation on 8/28/18 at 2:20 P.M., showed a total of six residents sat in the TV/lobby
area. Further observation showed there was no staff-led activity in progress.
11. Review of the White Board on the unit, showed the following scheduled activities for
Wednesday 8/29/18:
-11:15 A.M.: Roll the dice;
-2:00 P.M.: Mid-week social drink a beer & painting.
During an interview on 8/29/18 at 12:02 P.M., Resident #11 said he/she did not play any
Bingo this week, and did not do a roll the dice activity today either. He/She said staff
usually has activities scheduled on the board, but often cancels the activities, so
residents only end up doing something about twice a week back in the locked unit.
Observation and interview on 8/29/18 at 12:09 P.M., showed Resident #71 sat in a chair in
his/her room. The resident said staff did not do a roll the dice activity today. He/She
said there is not usually any activities on the weekends. He/She said sometimes they have
church, but that doesn’t interest him/her. He/She would enjoy bowling/fishing or something
like that because he/she is from the country.
12. During an interview on 8/29/18 at 2:40 P.M., the AD said he/she had to cancel the beer
and painting activity today because the administrative staff said they did not have the
time to get the supplies for the activity, and he/she was busy with a transport errand, so
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
he/she did not get to go shopping for supplies either. He/She said the Roll the dice
activity was not held in the morning either, because he/she had to go on a transport. The
AD said most of the activities are held in the front of the building (North side), but
staff will assist a few residents from the locked unit to scheduled activities. The AD
said if he/she has a free moment he/she will go to the unit and play balloons with the
residents and they love it. He/She said on weekends when he/she is not at work, the
residents do open activities (puzzles, crafts, etc.), and pretty much what the residents
want to do. He/She said the CNAs will conduct activities like popcorn and a movie as well
when he/she is not there.
During an interview on 8/30/18 at 10:25 A.M., CNA D said he/she works every other weekend.
The CNA said staff conducts activities on the weekends, based on the calendar (dice, board
games, movie), and every once in a while bingo, if the AD has the supplies left out.
He/She said there are at least seven residents that play bingo regularly, but thinks it’s
only done once a week on the unit. He/She said sometimes staff takes some of the residents
on the unit to the front for activities.
During an interview on 08/30/18 at 10:25 A.M., CNA I said all staff are technically
responsible for doing activities with residents but there is an activities person. He/She
said the activities person works day shift five days a week and sometimes on the weekends.
He/She said the activities person selects a staff member to help deliver activities when
he/she is not here. He/She said sometimes family members volunteer to help with
activities. He/She said they try to make sure the more dependent residents have music
playing or television on in their rooms.
During an interview on 8/30/18 at 10:49 A.M., Licensed Practical Nurse (LPN) C said on
Sundays, activities typically include church, puzzles, and sometimes staff paint
residents’ nails. On Saturdays, they usually have movie and popcorn, ball/balloon swat,
cards, and sometimes music. He/She thinks bingo is held twice a week back in the unit. The
LPN said activities are not usually canceled without a replacement, but the mid-week
social and beer activity is not usually held for residents on the locked unit, even if
they have an order for [REDACTED].>During an interview on 08/30/18 at 10:54 A.M., LPN B
said the AD is responsible for doing activities with residents. He/She said on evenings
and weekends the CNAs help with activities. He/She said all staff are responsible for
inviting residents to activities and all residents should be invited to all activities.
He/She said Resident #62 participates in balloon swat and other physical games and
Resident #25 sleeps a lot but he/she is rarely in his/her room because he/she is usually
sitting at the nurses’ station so they can talk to him/her.

F 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure the activities program is directed by a qualified professional.

Based on record review and staff interviews, facility staff failed to ensure the
activities program was directed by a qualified professional. This had the potential to
affect all residents in the facility. The facility census was 69.
1. Review of the facility’s Activities policy, dated (MONTH) 2012, showed the Activity
Director (AD) provides a key role in enhancing the quality of a resident’s daily life.
2. During an interview on 8/29/18 at 1:36 P.M., Licensed Practical Nurse (LPN) C said
Certified Nursing Assistant (CNA) H is the Activities Director (AD). The LPN said the AD
just started about a month or so prior.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
During an interview on 8/29/18 at 2:40 P.M., CNA H said he/she was the AD/CNA and
transport person when needed. He/She has not received any formal or online training, and
has been the AD since (MONTH) (YEAR). He/She said he/she thinks the Administrator was
working on getting him/her to complete a week-long training, but did not know when. He/She
said he/she assisted the previous AD with activities about three days per week.
During an interview on 8/29/18 at 4:48 P.M., the Administrator said the facility currently
does not have an AD until CNA H is trained. He/She said CNA H is an activities aide at
this time, and has not completed any formal/online training. The Administrator said there
are plans for CNA H to attend a one-week training, but he/she did not have a date planned
as yet.

F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the
director of nurses on a full time basis.

Based on interview and record review, facility staff failed to provide the services of a
Registered Nurse (RN), for at least eight (8) consecutive hours per day, seven days a
week. The facility census was 69.
Review of the facility’s Licensed Nurses staffing schedule, dated (MONTH) (YEAR), showed
staff did not document an RN was scheduled to work on Sunday 7/15/18.
Review of the facility’s RN staff time sheets, dated 7/1/18 through 7/31/18, showed
facility staff did not provide the services of an RN on the following dates:
-Saturday 7/7/18;
-Sunday 7/15/18;
-Saturday 7/28/18
Review of the facility’s RN staff time sheets, dated 8/1/18 through 8/30/18, showed the
total hours worked between the three staff RNs on the following dates:
-Saturday 8/4/18, 6.53 hours;
-Sunday 8/5/18, 5.57 hours;
-Sunday 8/12/18, 1.83 hours;
-Sunday 8/19/18, 0 hours;
-Saturday 8/26/18, 4.17 hours (14 hours apart);
During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said he/she
only works Monday through Friday each week. The DON said the Assistant Director of Nursing
(ADON) and RN A provide RN coverage on Saturdays and Sundays. He/She was not aware that an
RN did not work on 7/7/18, 7/15/18, 7/28/18, and 8/19/18. The DON said there should always
be an RN in the building for at least eight consecutive hours seven days per week. He/She
expects staff to notify him/her if the RN had called-in for the day, or had to leave for
an emergency, because there has to be an RN there for at least 8 hours.
During an interview on 8/30/18 at 2:08 P.M., the Administrator said the DON, ADON and RN A
are the only RNs on staff at this time. The Administrator said he/she expects the RNs to
provide at least 8 hours of coverage each day, including the weekends. He/She expects the
RN to notify him/her if he/she had to leave before the end of the shift so a replacement
could be arranged.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 – Minimal harm or potential for actual harm

Residents Affected – Few

Post nurse staffing information every day.

Based on observation, interview and record review, facility staff failed to post the
required nurse staffing information daily, and failed to ensure the nurse staff posting
contained accurate information when posted. The facility census was 69.
Review of the licensed nurses staff schedule dated (MONTH) (YEAR), showed day shift is
defined as 6 A.M. to 2 P.M., evening shift 2 P.M. to 10 P.M., and night shift 10 P.M. to 6
A.M. Further review showed on 8/26/18, staff documented the following:
-Day shift: One Registered Nurse (RN) scheduled to work eight hours total;
-Evening shift: Two Licensed Practical Nurse (LPN): scheduled to work eight hours total.
Review of the nurse staff posting dated 8/26/18, showed it did not contain the total
number of licensed and unlicensed staff directly responsible for resident care. Further
review showed staff documented the following:
-Day shift RN: 16 hours total;
-Evening shift LPN: 12 hours total.
Staff did not post an accurate and complete nurse staff posting.
Observation and review on 8/27/18 at 3:45 P.M., showed the facility’s nurse staff posting
on the wall outside the Social Services Director (SSD) office, did not contain the total
number of licensed and unlicensed staff directly responsible for resident care.
Observation and review on 8/28/18 at 10:02 A.M., showed the facility’s nurse staff posting
on the wall outside the SSD office, dated 8/27/18, did not contain an accurate date, or
the total number of licensed and unlicensed staff directly responsible for resident care.
Staff did not post an accurate and current nurse staff posting.
Observation and review on 8/29/18 at 11:47 A.M., showed the facility’s nurse staff posting
on the wall outside the SSD office, dated 8/27/18, did not contain an accurate date,
census, or the total number of licensed and unlicensed staff directly responsible for
resident care. Staff did not post an accurate and current nurse staff posting.
Observation and review on 8/30/18 at 11:16 A.M., showed the facility’s nurse staff posting
on the wall outside the SSD office, did not contain the total number of licensed and
unlicensed staff directly responsible for resident care.
During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said he/she
thinks the Administrator completes the nurse staff posting, with information from the
staffing book/schedule. The DON said he/she was not sure who updates the staff posting on
the weekends. The posting should include the census, date, facility name, total number and
total hours worked by each category of licensed/unlicensed staff. The DON said the staff
posting should be updated every day, and was not sure why not it was not updated 8/28/18
and 8/29/18.
During an interview on 8/30/18 at 2:08 P.M., the Administrator said he/she usually
completes the nurse staff posting, and the weekend manager is responsible to complete on
the weekends when he/she is not there. The Administrator said the posting should include
the facility name date, census, total hours for licensed and unlicensed staff, and should
probably include the number of each category of staff. He/She said the staff posting
should be updated daily, and was not sure why it was not updated on 8/28/18 and 8/29/18.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, licensed facility staff failed to
ensure controlled medications were properly stored, failed to routinely conduct a physical
inventory of controlled medications, failed to record the number of narcotic cards at the
beginning and end of each shift, and failed to ensure change of shift sheets for
controlled medications were routinely signed by each on-coming and off-going staff.
Additionally, facility staff failed to properly document the as needed (PRN)
administration of a controlled medication for one randomly observed resident (Resident
#58). The facility census was 69.
1. Review of the facility’s policy on Controlled Substance Storage, revised (MONTH) 2011,
showed staff are directed:
-Medications included in the Drug Enforcement Administration (DEA) classification as
controlled substances are subject to special handling, storage, disposal and recordkeeping
in the facility in accordance with federal, state, and other applicable laws and
regulations;
-The Director of Nursing in collaboration with the consultant pharmacist, maintains the
facility’s compliance with federal and state laws and regulations in handling of
controlled substances;
-Schedule II-V medications and other medications subject to abuse or diversion are stored
in a permanently affixed, (double-locked) compartment separate from all other medications,
or per state regulations;
-Controlled substances that require refrigeration are stored within a locked box within
the refrigerator. The box must be attached to the inside of the refrigerator;
-At each shift change, or when keys are transferred, a physical inventory of all
controlled substances, including refrigerated items is conducted by two licensed nurses
and is documented;
-The consultant pharmacist or designee routinely monitors controlled substance storage
records (such as change of shift sheets, individual controlled substance accountability
sheets, delivery confirmation sheets) and expiration dates, during routine medication
storage inspections.
2. Review of the facility’s Narcotics Shift Change sheet, showed staff are directed to
document the facility name, hall, date, shift, time, nurse/CMT leaving duty, nurse/CMT
arriving, number of cards at start, number of cards added or subtracted, and number of
cards remaining.
3. Review of the North side Narcotics Shift Change sheet for (MONTH) (YEAR) showed the
following:
-8/1/18: on-coming nurse (2pm to 10pm) and off-going nurse (10pm to 6am) did not sign;
-8/2/18: on-coming nurse (6am to 2pm) and off-going nurse (2pm to 10pm) did not sign;
-8/3/18: on-coming nurse (6am to 2pm) and off-going nurse (10pm to 6am) did not sign;
-8/4/18: on-coming nurse (6am to 2pm), off-going nurse (2pm to 10pm), on-coming nurse (2pm
to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/5/18: on-coming nurse (6am to 2pm), off-going nurse (2pm to 10pm), on-coming nurse (2pm
to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/6/18: on-coming nurse (6am to 2pm), and off-going nurse (2pm to 10pm) did not sign;
-8/8/18: on-coming nurse (6am to 2pm), and off-going nurse (2pm to 10pm) did not sign;
-8/10/18: on-coming nurse (6am to 2pm), and off-going nurse (2pm to 10pm) did not sign;
-8/11/18: on-coming nurse (10pm to 6am), and off-going nurse (10pm to 6am) did not sign;
-8/12/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/13/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-8/14/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/15/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/16/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/18/18: on-coming nurse (6am to 2pm) did not sign.
Staff did not document the number of narcotic cards and bottles remaining at the end of
each shift/day for the entire month of August, as directed by the form.
4. Review of the South side Narcotics Shift Change sheet for (MONTH) (YEAR) showed the
following:
-8/2/18: on-coming nurse (10pm to 6am) did not sign;
-8/3/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/5/18: on-coming nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/7/18: on-coming nurse (10pm to 6am) did not sign;
-8/8/18: off-going nurse (10pm to 6am) did not sign;
-8/9/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), on-coming nurse (2pm
to 10pm), off-going nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/10/18: on-coming nurse (2pm to 10pm), off-going nurse (2pm to 10pm), and off-going
nurse (10pm to 6am) did not sign;
-8/13/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), on-coming nurse (2pm
to 10pm), off-going nurse (2pm to 10pm), and off-going nurse (10pm to 6am) did not sign;
-8/18/18: on-coming nurse (2pm to 10pm), off-going nurse (2pm to 10pm), and off-going
nurse (10pm to 6am) did not sign;
-8/19/18: on-coming nurse (6am to 2pm) and off-going nurse (2pm to 10pm) did not sign;
-8/20/18: on-coming nurse (2pm to 10pm) and off-going nurse (2pm to 10pm) did not sign;
-8/21/18: on-coming nurse (2pm to 7:30pm) and off-going nurse (7:30pm to 6am) did not
sign;
-8/23/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), and on-coming nurse
(2pm to 10pm) did not sign;
-8/27/18: staff did not sign the sheet for any shift that day;
-8/28/18: on-coming nurse (6am to 2pm), off-going nurse (6am to 2pm), on-coming nurse (2pm
to 10pm), and off-going nurse (2pm to 10pm) did not sign.
Staff did not document the number of narcotic cards and bottles remaining at the end of
each shift/day for 27 out of 28 days reviewed, as directed by the form.
5. Review of Resident #58’s individual controlled substance accountability sheets, showed
staff documented a remaining quantity of 3.5 ml (milliliters) of [MEDICATION NAME] (a
schedule IV controlled medication).
Review of the resident’s electronic Medication Administration Record [REDACTED]. Further
review of the narcotic count sheet showed staff documented they administered 0.5 ml of the
medication to the resident on 8/17/18, 8/18/18, 8/19/18, 8/20/18, 8/24/18, 8/26/18, and
8/27/18. Staff failed to properly document the time and reason for administration of a
controlled medication to a resident for seven days.
6. Observation on 8/27/18 at 9:43 A.M., showed the North Medication storage room unlocked,
and unattended. Further observation showed the refrigerator inside the med room also
unlocked, unattended, and contained:
-an opened bottle of [MEDICATION NAME] 2 milligrams/ milliliters (mg/ml), labeled for
Resident #12;
-an unopened bottle of [MEDICATION NAME] 2 mg/ml, labeled EKIT (emergency kit).
7. During an interview on 8/27/18 at 10:16 A.M., Licensed Practical Nurse (LPN) B said
nurses are expected to reconcile the amount remaining on each card with the individual
resident’s controlled medication record, and sign the on-coming and off-going spots on the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
narcotic count sheets in the book. The LPN said staff are expected to lock the medication
room at all times when unattended.
During an interview on 8/28/18 at 11:21 A.M., LPN C nurses are expected to physically
check the quantity of medication left in the bottles and verify with the written amount
documented on the individual resident’s controlled medication record sheet, but the nurses
don’t always do it. The LPN said he/she did not physically check the amount of medication
in the bottles stored in the refrigerator at the beginning of his/her shift. He/She said
sometimes it is hard to get the off-going night nurse to come and perform the count with
the on-coming nurse.
During an interview on 8/30/18 at 10:42 A.M., LPN C said staff are expected to always
store narcotic medications under double-lock when not being accessed.
During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said he/she
expects staff to store narcotic medications (controlled substances) behind two locks.
He/She said oncoming and off-going nurses and CMTs are expected to count every container
of narcotics each shift, and document the quantities of each. The DON said staff should at
a minimum sign the narcotic count sheet at each shift change, but should also document the
total number of cards/bottles of narcotic medications in the cart and/ or refrigerator.
He/she said staff are expected to physically verify the amount of narcotic liquid
medication left inside the bottle with the actual amount documented on the sheet. The DON
said he/she also expects staff to document administration of PRN narcotics on the
resident’s eMAR, and not just on paper. Additionally, he/she expects the nurse/CMT to
document a corresponding note with a reason for the administration of the PRN medication.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to follow their Medication
Regimen Review (MRR) process to identify irregularities and minimize or prevent adverse
consequences for three of five residents (Resident’s #5, #12, and #43) reviewed for
unnecessary medications. The facility census was 69.
1. Review of the facility’s policy on Medication Regimen Review (MRR), revised (MONTH)
2011, showed the following:
-The consultant pharmacist reviews the medication regimen of each resident at least
monthly;
-In performing MRRs, the consultant pharmacist incorporates federally mandated standards
of care, in addition to other applicable professional standards;
-The consultant pharmacist identifies irregularities through a variety of sources
including Medication Administration Records (MARs), prescriber’s orders, progress notes of
prescriber/nurses/consultants, the Resident Assessment Instrument (RAI), laboratory and
diagnostic test results, behavior monitoring, information, facility staff, attending
physician, and from interviewing/assessing/observing the resident. The consultant
pharmacist’s evaluation includes, but is not limited to reviewing and/ or evaluating the
following:
*A written diagnosis, indication, or documented objective findings support each
medication order;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
*As needed (PRN) orders include indications for use;
*Indications for use and therapeutic goals are consistent with current medical literature
and clinical practice guidelines;
*The prescribed dose is appropriate to the resident’s clinical status;
*The duration of therapy is indicated and is appropriate for the resident;
-Resident-specific irregularities and/or clinically significant risks resulting from or
associated with medications are documented and reported to the Director of Nursing (DON),
and/or prescriber as appropriate;
-Recommendation are acted upon and documented by the facility staff and or the prescriber:
*Physician accepts and acts upon suggestion or rejects and provides an explanation for
disagreeing;
*If there is potential for serious harm and the attending physician does not concur, or
the attending physician refuses to document an explanation for disagreeing, the Director
of Nursing and the consultant pharmacist contact the medical director.
2. Review of Resident #5’s annual Minimum Data Set (MDS), a federally mandated assessment
tool, dated 5/12/18, showed staff assessed the resident as follows:
-[DIAGNOSES REDACTED].
-Moderate impaired cognition;
-No mood symptoms;
-No behaviors or rejection of care;
-Received antipsychotic medications for 7 days;
-Received antidepressant medications for 7 days;
-Antipsychotics were received on a routine basis only;
Review of the resident’s care plan last updated 8/29/18, showed staff are directed:
-Resident receives [MEDICAL CONDITION] medication related to [DIAGNOSES REDACTED].
-Assess/record effectiveness of drug treatment, monitor and report signs of sedation,
[MEDICATION NAME] and extrapyramidal symptoms (EPS);
-Follow Gradual Dose Reductions (GDR) with physician and pharmacy consult;
-Monitor For behaviors every shift. (Listed in eMAR Behavior Monitoring).
Review of the monthly MRR documented by the Consultant Pharmacist, showed he/she
documented the following:
-2/28/18 MRR-complete
-3/31/18 MRR-complete
-4/30/18 MRR-complete
-5/25/18 MRR-no recommendations
-6/28/18 MRR-complete
-7/31/18 MRR-no recommendations
Review of the resident’s physician’s orders [REDACTED].
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] (an antipsychotic medication) 2.5 mg twice daily (BID) for anxiety
disorder, begin 1/30/18.
The Consultant Pharmacist failed to recognize and notify facility staff and the physician,
of the use of an antipsychotic medication for an inappropriate [DIAGNOSES REDACTED].
3. Review of Resident #12’s MDS, dated [DATE] showed facility staff assessed the resident
as follows:
-Severe cognitive impairment;
-Required total assistance of one staff for bed mobility, transfers, dressing, eating,
toileting, personal hygiene, and bathing;
-7 days of antipsychotic medication;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
-7 days of antidepressants medications.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s MRR, dated 7/31/18, showed the consultant pharmacist documented
[MEDICATION NAME] 0.25 mL hours as needed for anxiety CMS requires that all PRN
psychoactive medication orders are to be written for no more than 14 days. If PRN
psychoactive are deemed necessary beyond this time, the prescribing practitioner must
document a clinical rationale and specify the duration of use.
Further review of the resident’s MRR, dated 7/31/18 showed the physician did not check
agree, disagree, or other and documented This is for comfort care. The physician did not
specify a duration for use.
Review of the resident’s care plan, last updated 8/28/18, showed the resident’s is on
[MEDICAL CONDITION] medications and staff are directed to monitor for adverse effects and
behaviors every shift.
During an interview on 8/29/18 at 4:55 P.M., the Director of Nursing (DON) said the
physician documented for comfort care because the resident’s is hospice. The DON believes
the physician did not agree because of his/her statement. The DON said he/she does not
believe hospice patients should be included in the requiment.
During an interview on 8/30/18 at 10:45 A.M., Licensed Practical Nurse (LPN) B said PRN
[MEDICAL CONDITION] medication should only be ordered for 14 days and if they are ordered
for more than 14 days staff should call the physician and get clarification. LPN B said
he/she is not sure why the resident’s medication did not have a stop date.
4. Review of Resident #43’s annual MDS, dated [DATE], showed staff assessed the resident
as follows:
-[DIAGNOSES REDACTED].
-BIMS not assessed;
-No mood symptoms or depression;
-Rejection of care, and wandering that did not impact others;
-Received antipsychotic medications for 7 days;
-Received antidepressant medications for 7 days;
-Antipsychotics were received on a routine basis only;
-Last attempted GDR 9/22/17.
Review of the resident’s care plan, dated 7/9/18, showed staff are directed the resident
is at risk for falls due to use of [MEDICAL CONDITION] medications and self-ambulatory.
Further review of the care plan updated 7/26/18, showed staff are directed to follow GDR
by pharmacist review with physician orders, and monitor for behaviors and interventions
every shift.
Review of the Consultant Pharmacist’s Note to Attending Prescriber, dated 1/26/18, showed
he/she documented if clinically appropriate, please consider reducing the current
medication dose to [MEDICATION NAME] (an antipsychotic medication) 0.25 mg, take half
tablet BID. If a GDR is clinically contraindicated at this time, please document the
clinical rationale below. This must address the reason(s) why an attempted dose reduction
would likely impair the resident’s function, or cause psychiatric instability by
exacerbating an underlying medical or psychiatric disorder.
Further review of the resident’s record showed the physician did not document a response
to the Consultant Pharmacist’s recommendation. Additional review of the records showed
facility staff did not follow up on the recommendation, or contact the medical director
for direction.
Additional review of the monthly MRR documented by the Consultant Pharmacist, showed
he/she documented the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
-2/28/18 MRR-complete
-3/31/18 MRR-complete
-4/30/18 MRR-complete
-5/25/18 MRR-no recommendations
-6/28/18 MRR-complete
-7/31/18 MRR-no recommendations
Review of the POS [REDACTED].
The Consultant Pharmacist and facility staff did not follow up for six months, on a
previously recommended GDR for a resident prescribed a routine Antipsychotic medication.
5. During an interview on 8/29/18 at 1:12 P.M., the DON said if the Consultant Pharmacist
only documented MRR-complete, he/she did not have any additional documentation to
accompany that note.
During an interview on 8/29/18 at 4:55 P.M., the DON said the pharmacist reviews residents
medications and then he/she sends the recommendation to the DON who will send it to the
physician. The DON said he/she expects the physician to review and document agree/disagree
and if disagree a rational within 72 hours of receiving the pharmacy recommendation.
During an interview on 8/30/18 at 10:45 A.M., LPN B said pharmacist reviews the residents’
medications. The pharmacist send his/her recommendations to staff. LPN B said the nurse
sends the recommendation to the physician and the physician will sign if he/she agrees or
disagrees. He/She said if the physician disagrees there should be a rationale. The LPN
said if the physician does not respond or does not complete all required information staff
should call the physician for follow up and clarification.

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’s licensed staff failed
to ensure medications were monitored and stored in a safe and effective manner. Licensed
staff failed to discard expired medications and properly secure medications in one of one
sampled medication storage room. Staff also failed to remove and discard expired, and/ or
improperly labeled medications from two of three sampled medication carts. The facility
census was 69.
1. Review of the facility’s policy on Storage of Medications, dated (MONTH) 2012, showed
staff are directed:
-Medication rooms, carts, and medication supplies are locked when not attended by persons
with authorized access;
-All medications dispensed by the pharmacy are stored in the container with the pharmacy
label;
-Potentially harmful substances such as household poisons, cleaning supplies,
disinfectants are clearly identified and stored separately from floor stock medications
when not in the medication cart;
-Outdated, contaminated, or deteriorated medications and those in containers that are
cracked, soiled, or without secure closures are immediately removed from inventory,
disposed of according to procedures for medication disposal, and re-ordered from the
pharmacy;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 23)
-All expired medications will be removed from the active supply and destroyed in the
facility regardless of amount remaining. The medication will be destroyed in the usual
manner;
-When the original seal of a manufacturer’s container or vial is initially broken, the
container or vial will be dated:
**The nurse shall place a date opened sticker on the medication and enter the date opened
and the new date of expiration. The expiration date of the vial will be 30 days unless the
manufacturer recommends another date or regulations/guidelines require different dating;
2. Review of the facility’s policy on Storage of Medications, dated (MONTH) (YEAR), showed
staff are directed all medications for residents must be stored at or near the nurse’s
station in a locked cabinet, a locked medication room, or one or more locked medication
carts; and no discontinued, outdated, or deteriorated drugs or biologicals may be retained
for use.
3. Observation on 8/27/18 at 9:43 A.M., showed the North Medication storage room unlocked,
and unattended. Observation showed the cabinet above the sink unlocked and contained the
following:
-Two bags of 0.9% Sodium Chloride Injection 100 ml (medication administered
intravenously), expired 5/2018;
-Multiple cards with various pills for different residents, [MEDICATION NAME] vials
(inhaled medications), glucose gel (used to treat low blood sugar levels), 1 [MEDICATION
NAME] injection pen (used to treat severe low blood sugar levels) labeled EKIT (emergency
kit), Carbamezapine liquid (medication to treat [MEDICAL CONDITION] and [MEDICAL
CONDITION] disorder), labeled for Resident #62.
Further observation showed the refrigerator unlocked and contained multiple insulin pens
(used to treat elevated blood sugar levels) labeled for different residents, two vials of
pneumonia vaccine, two vials of [MEDICATION NAME] medication (used to test individuals for
[MEDICAL CONDITION]-a bacterial lung disease), two bottles of controlled medications,
among other medications.
Observation showed on top of the refrigerator a red bin labeled overflow with:
-Multiple oral medications to include [MEDICATION NAME] 2 milligrams (mg) (antipsychotic
medication), [MEDICATION NAME] 80 mg (used to treat heart rhythm problems), [MEDICATION
NAME] 25 mg (used to treat high blood pressure), [MEDICATION NAME] 20 mg (used to treat
fluid retention);
-A box with seven [MEDICATION NAME] injections (medication injected to prevent blood
clots) 30 mg/0.3 milliliters (ml), labeled for Resident #70, and another box with 10
injections for the same resident;
-A box with two [MEDICATION NAME] injections 40 mg/0.4 ml labeled for Resident #55.
Additional observation showed the following underneath the sink:
-A spray bottle of Springtime odor counteractant with a warning label to keep out of reach
of children;
-A plastic cottage cheese container, with a powdered substance inside, and a hand-written
label Thickener, dated 4/24/18;
-An opened metal container of Sysco Instant food thickener, dated 1/18.
During an interview on 8/27/18 at 10:16 A.M., Licensed Practical Nurse (LPN) B said staff
are expected to lock the medication room at all times when unattended, because there are
medications inside. The LPN said he/she had the keys for the medication room and did not
know why the room was left unlocked. The LPN said nurses are responsible to discard
expired medications and IV supplies, but do not have a specific schedule. He/She said the
Consultant Pharmacist also checks the med room for expired meds, but was not sure how
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

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 24)
often. He/She said staff just hadn’t tossed the expired IV meds as yet.
4. Observation on 8/27/18 at 10:25 A.M., showed the North Medication/Treatment Cart
contained the following:
-A Basaglar Kwikpen (medication to lower blood sugar levels), opened and undated, labeled
for Resident #26;
-A [MEDICATION NAME] (medication to lower blood sugar levels), opened and undated, labeled
for Resident #23;
-A [MEDICATION NAME] vial 100 units/ml, opened, and unlabeled with a resident name or the
date;
-A [MEDICATION NAME] vial (medication to lower blood sugar levels), 100 units/ml, opened
and undated, labeled for Resident #23;
-A [MEDICATION NAME] vial 100 units/ml, opened and undated, labeled for Resident #38;
During and interview on 8/27/18 at 10:32 A.M., LPN B said staff are expected to label
insulin pens and vials with the resident’s name, opened and expiration dates, and affix
the prescription label if available.
5. Observation on 8/28/18 at 10:51 A.M., showed the South Medication Cart contained the
following:
-A [MEDICATION NAME] labeled for Resident #71, expiration date 8/26/18;
-A [MEDICATION NAME] labeled for Resident #63, with an opened date of 7/23/18, another
opened date of 8/12/18, and an expiration date of 8/26/18.
During an interview on 8/28/18 at 10:59 A.M., LPN C said it was unclear when Resident
#63’s [MEDICATION NAME] was expired based on the two different opened dates documented by
staff. The LPN said nurses and Certified Medication Technician’s administer insulin to
residents at the facility, and they are expected to check the expiration dates on each
medication before they administer it to the resident.
6. During an interview on 8/30/18 at 10:42 A.M., LPN C said nurses on the day and evening
shift check for expired medications in the med rooms once a month, but with no set
schedule. He/She said the Consultant Pharmacist also checks the med rooms once a month for
expired medications. The LPN said chemicals should not be stored in the same compartment
with thickeners/food products.
During an interview on 8/30/18 at 1:03 P.M., the Director of Nursing (DON) said the med
room should be locked at all times when not accessed, and he/she expects staff to store
narcotic medications (controlled substances) behind two locks. The DON said the Consultant
Pharmacist checks the med rooms monthly for expired medications, and was at the facility
the last week of July. He/She said facility staff is ultimately responsible to check for
expired medications, and he/she missed the expired IV medications. He/She said thickener
(or other foods) should be stored in their original containers, and should not be stored
in the same compartment with chemicals inside the medication room.

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, facility staff failed to appropriately
wash hands and change gloves during care and treatments for four residents (Resident #7,
#12, #33, and #69), and failed to clean a wound during a treatment for one resident
(Resident #60) out of 17 sampled residents, to prevent the spread of bacteria. The
facility census was 69.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
1. According to the Infection Control Guidelines for Long Term Care Facilities (Section
3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because
micro-organisms adhere to the surface of a glove easier than to the skin of your hands.
*Hand washing remains the single most effective means of preventing disease transmission;
wash hands whenever they are soiled with body substance and when each resident’s care is
completed.
2. Review of the facility’s policy on handwashing, dated (MONTH) (YEAR), showed staff are
directed to perform handwashing to reduce transmissions of organisms from resident to
resident, nursing staff to resident, and resident to nursing staff.
3. Review of the facility’s policy on Gloves, dated (MONTH) (YEAR), showed staff are
directed:
-Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound
drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these
substances), and/ or persons with a rash;
-Change gloves between contacts with different residents or with different body sites of
the same resident.
4. Observation on 8/27/18 at 12:18 P.M., showed Certified Nurse Assistant (CNA) K and CNA
L entered Resident’s #7’s room. Observation showed CNA L washed his/her hands and applied
gloves and CNA K applied gloves. CNA K removed the resident’s soiled brief. CNA K provided
incontinence care to the resident and did not wash his/her hands or change his/her gloves.
CNA K applied the resident’s new brief and pants. CNA K touched the resident’s sheets,
pillows, clothes, and skin with his/her soiled gloves. CNA K removed his/her gloves and
washed his/her hands. CNA K did not wash hands and change gloves in a manner to prevent
the spread of bacteria.
5. Observation on 8/28/18 at 1:53 P.M., showed CNA E and CNA F entered Resident #69’s
room, washed hands and applied gloves. Observation showed the resident incontinent of
urine. CNA E turned the resident side to side, while CNA F provided incontinence care. CNA
E applied a cream to the resident’s buttocks and washed hands. CNA F continued to wear
his/her contaminated gloves, touched the resident’s clothing and placed a clean brief on
the resident before he/she washed hands. CNA F did not change gloves and wash/sanitize
hands in a manner to prevent the spread of bacteria.
6. Observation on 8/29/18 at 12:53 P.M., showed the Assistant Director of Nursing (ADON)
and CNA N entered Resident #33’s room, washed hands and applied gloves, and assisted the
resident to stand. Observation showed the resident incontinent of urine. CNA N provided
incontinence care to the resident, while the ADON applied a dressing to the resident’s
buttocks, and washed hands. CNA N continued to wear his/her contaminated gloves, placed
the clean brief on the resident, and assisted the resident back to the recliner, before
he/she washed hands. The CNA did not change gloves and wash/sanitize hands in a manner to
prevent the spread of bacteria.
During an interview on 8/30/18 at 10:32 A.M., CNA D said staff are expected to wash hands
when they enter a room, during and after perineal care, between glove changes, and before
they leave the room.
7. Review of Resident #12’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 5/26/18, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Required total assistance of one staff for bed mobility, transfers, dressing, eating,
toilet use, personal hygiene and bathing;
-Resident had a stage two pressure ulcer that originated in the facility on 3/12/18 with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
slough;
-Resident’s wound is worsening.
Review of the resident’s care plan, last updated on 8/22/18, showed the resident has a
pressure ulcer and staff are directed to do the following:
-Observe and report signs of infection;
-Assess and record the condition of the skin surrounding the pressure ulcer;
-Assess the pressure ulcer for location, stage, and size;
-Catheter placement to facilitate wound healing;
-Conduct a systematic skin inspection weekly;
-Keep bony prominence from direct contact with one another;
-Turn and reposition every two hours.
Review of the resident’s Physician order [REDACTED]. edges. Cover with bordered gauze an
change daily as needed.
Review of the resident’s wound company documentation, dated 8/16/18, showed the wound care
company documented wound continues to decline, significant odor this visit. Further review
showed the wound care company talked to hospice and the hospice director [MEDICATION
NAME](antibiotic) 250 milligrams (mg) twice a day for 14 days and [MEDICATION NAME]
(antibiotic) 500 mg three times a day for 14 days.
Observation on 8/29/18 at 2:16 P.M., showed the Assistant Director of Nursing (ADON)
entered Resident #12’s room and washed his/her hands and applied gloves. The ADON removed
the resident’s brief. Observation showed the resident with a small amount of bowel
movement on his/her bottom. Observation showed the ADON removed the resident’s dressing.
Observation showed moderate drainage on the soiled dressing. Observation showed the ADON
did not wash his/her hands and change gloves before he/she wiped the resident’s wound with
gauze. Observation showed the ADON washed his/her hands and changed his/her gloves and
applied the treatment and dressing. Observation showed the ADON wiped the bowel movement
from the resident’s bottom from his/her bottom toward the clean dressing. The ADON did not
clean the resident’s wound in a manner to prevent the spread of bacteria as directed and
did not clean the residents bottom in a manner to prevent wound contamination.
8. Review of Resident #60’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-Required extensive assistance of two or more staff for bed mobility, transfers, and
toilet use;
-Required extensive assistance of one or more staff for dressing and personal hygiene;
-Resident has a stage four pressure ulcer with slough that was present upon entry.
Review of the resident’s care plan, last updated on 8/29/18, showed the resident had a
pressure ulcer and staff are directed to do the following:
-Administer antibiotics as ordered;
-Administer vitamins, minerals, and antibiotics as needed;
-Assess the resident for pain related to pressure ulcer and treat pain as indicated;
-Conduct a systematic skin inspection daily by certified nurse aide (CNA), weekly by
nurse, and report signs of infection;
-Provide custom made electric wheelchair with pressure reduction seat;
-Provide air mattress on bed;
-Provide a regular diet and protein supplements as ordered;
-Float heels when in bed;
-Provide multi-podus boot to right foot;
-Foley catheter to aid in wound healing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265398

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

GAMMA ROAD LODGE

STREET ADDRESS, CITY, STATE, ZIP

250 E LOCUST
WELLSVILLE, MO 63384

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
-Keep skin clean and dry as possible to minimize skin exposure to moisture;
-Keep linens clean, dry, and wrinkle free;
-Toilet, turn and reposition as ordered;
-Treatment as ordered by wound care plus team;
-Use moisture barrier product to perineal area.
Review of the resident’s Physician order [REDACTED]. necrosis of bone. Further review
showed the resident’s physician ordered staff are directed to cleanse the coccyx wound
with wound cleanser (a solution used to clean wounds), apply skin prep (a protective film
or barrier) to surrounding area, apply santyl (enzyme used to help heal wounds by breaking
up and removing dead skin) and calcium alginate (absorbent dressing) to wound bed and
edges, cover with ABD pad (highly absorbent sterile dressing) secure with tape, and change
daily and as needed for soiling. Additional review showed the resident’s physician ordered
staff to cleanse the left buttocks wound with wound cleanser (a solution used to clean
wounds), apply skin prep (a protective film or barrier) to surrounding area, apply
hydrogel (highly absorbent gel used to promote wound healing) to wound bed and edges,
cover with ABD pad (highly absorbent sterile dressing) secure with tape, and change daily
and as needed for soiling.
Review of the resident’s wound company documentation, dated 8/23/18, showed the wound care
company documented coccyx wound unhealed, improved, with no signs of infection. Further
review showed the wound care company documented the left buttocks unhealed, unchanged,
with no signs of infection.
Observation on 8/27/18 at 3:27 P.M., showed Licensed Practical Nurse (LPN) M entered the
resident’s room. LPN M washed his/her hands and applied gloves. LPN G removed the
residents brief. Observation noted red drainage from the wound on the resident’s brief.
Further observation showed the resident did not have a dressing on his/her wound as
directed by physician’s orders [REDACTED]. Observation showed LPN M did not clean the
wound as directed before he/she applied the treatment and dressing to the resident’s
wound. LPN M removed his/her gloves and washed his/her hands. Observation showed LPN M did
not clean the residents wound in order to prevent the spread of bacteria as directed.
9. During an interview on 8/30/18 at 10:54 A.M., LPN B said staff should wash their hands
and change gloves when staff enter/exit a room, between dirty/clean tasks, between glove
changes, LPN B said staff should clean wounds with every treatment, change gloves between
clean and dirty tasks to prevent wound infections.
During an interview on 8/30/28 at the Director of Nursing (DON) said staff are expected to
wash or sanitize hands between dirty and clean procedures, between glove changes with care
or treatments. The DON said staff should clean the wound with each wound treatment to
prevent infections The DON said staff should clean any bowel movement from a resident’s
bottom prior to starting the wound treatment.