Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview, and record review, the facility failed to provide a
resident or family group with a designated staff person responsible for setting up
meetings, notifying residents of meetings, providing assistance and responding to written
requests from the group meeting, and to act promptly upon grievances and recommendations
from the group. This had the potential to affect all the residents. The facility census
was 37.
Review of the facility’s Resident Rights Policy, dated (MONTH) (YEAR), showed:
– The resident has a right to form or participate in a resident group to discuss issues
and concerns about the nursing home’s policies and operations.
– Most homes have such groups, often called resident councils.
– The facility must give you meeting space and must listen to and act upon grievances and
recommendations of the group.
Review of the facility’s Supporting the Right of Residents to Voice Grievances, undated,
showed:
– The resident, their legal representative, and family have the right to express a
grievance or complaint about the care and services provided by the community.
– Each grievance or complaint is to be handled with respect and will receive a response.
– Residents and families are encouraged to bring concerns about the operation of the
household to the household learning circle so all residents have an opportunity to discuss
the issue and formulate a recommendation to the household team or neighborhood council.
– Recommendations or concerns discussed in a learning circle related to community policies
and procedures will be forwarded in writing to the administrator.
– Residents and their families may also report a complaint or grievance in writing to any
team member in the household or community. The written complaint will be forwarded to the
individual responsible for the area of service related to the complaint and/or the
community mentor.
– The household coordinator can decide to attempt to resolve the complaint, include the
issue in the next learning circle or consult with the administrator and ask for advice on
how to resolve the issue. Suggestions could also be sought from other households within
the community.
1. During the entrance conference on 12/3/18, at 9:24 A.M., the administrator said:
– There is no resident council president.
– The facility calls their resident council, community circles.
– The community circles are held regularly on each household and are facilitated by the
household coordinators.
During an interview on 12/4/18, at 10:00 A.M., the admission coordinator (AC) said:
– The community circles have not met since he/she was hired.
– He/she has not seen any community circle minutes.
During an interview on 12/4/18, at 10:03 A.M., the household coordinator (HC C) said:
– The community circles have not met since he/she was hired in (MONTH) (YEAR).
– He/she has not seen any community circle minutes.
During an interview on 12/4/18, at 10:05 A.M., the clinical coordinator (CC A) said:
– The community circles have not met since he/she was hired in (MONTH) (YEAR).
– He/she does not know who is responsible for the community circles or what the process is
for the community circles.
– He/she has not seen any community circle minutes.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 1)
During a group interview on 12/4/18, at 10:15 A.M., the seven residents in attendance
said:
– There is no resident council/community circles that meet on their households.
– Did not receive information about their resident rights and grievance process.
– They did not know how or who to file a grievance with; thinks it might be the house
supervisor.
– Residents did not know who their house supervisor was on their neighborhood.
– Residents voiced they did not receive an orientation about their neighborhood, rooms,
features of their room, and would liked to have been informed of which facility staff to
go to for various issues and concerns.
During an interview on 12/4/18, at 11:00 A.M., the Director of Nursing (DON) and the
administrator said:
– The community circles have not had meetings since the opening of the facility in (MONTH)
(YEAR).
– Staff should assist the residents in having a regular community circle with minutes and
follow up with responses from concerns.
– Concerns and issues should be addressed with the household coordinator, DON, and the
administrator as needed.
– Staff should provide upon admission information that includes their rights and the
grievance procedures.

F 0575

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Post a list of names, addresses, and telephone numbers of all pertinent State agencies
and advocacy groups and a statement that the resident may file a complaint with the State
Survey Agency.

Based on observations and interviews, the facility failed to ensure they posted in a
conspicuous location and available for residents and visitors a list of names, addresses
(mailing and email), and telephone numbers of all pertinent State agencies and advocacy
groups, such as the State Survey Agency, the State licensure office, adult protective
services the State Long-Term Care Ombudsman program, the protection and advocacy network,
home and community based service programs, and the Medicaid Fraud Control Unit; as well as
a statement that the resident may file a complaint with the State Survey Agency concerning
any suspected violation of state or federal nursing facility regulation, including but not
limited to resident abuse, neglect, exploitation, misappropriation of resident property in
the facility, and non-compliance with the advanced directives requirements and requests
for information regarding returning to the community. The census was 37.
Review of the Examination of Survey Results policy, dated (MONTH) 2007, showed a listing
of federal, state and local agencies responsible for the enforcement of rules and
regualtions govering the facility is posted at the main entrance and at each nurses’
station and/or other designated areas. The list includes the names, addresses, telephone
numbers and contact persons (where available) for:
– State survey office;
– State/local ombudsman’s office;
– State/local legal services office;
– Federal, state and local offices of the Departement of Human Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0575

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 2)
1. Observations on all days of the survey, 12/3/18, 12/4/18, 12/10/18 through 12/13/18, on
all households showed no required postings.
Observation 12/12/18, at 12:41 P.M., showed the required postings located on the first
floor of the facility which only housed offices and physical therapy. Inside the main
entrance of the facility was the elevator which lead to the households. A receptionist’s
desk was located just beyond the elevator. Behind the receptionist’s desk, hanging on the
wall to the right of the receptionist hung four 8 X 10 inch frames with the required
postings in the frames. The surveyor had to walk behind the receptionist’s desk to read
the postings. In the location these frames were posted, any residents or families would
have had to walk through the front door, past the elevator, past the receptionist and turn
back to the right in almost a 180 degree manner to see the frames.
During an interview on 12/12/18, at 3:30 P.M., the administrator said the required
information was not posted on the households as it was not considered aesthetically
pleasing and did not match the themes. He did not believe many residents or families had
walked past the receptionist’s desk and turned back to the right enough to see the
required postings where they are located.

F 0577

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation and interviews, the facility failed to post the most recent survey
results available for residents and families to examine. The facility census was 37.
1. During a group interview on 12/4/18, at 10:06 A.M., residents who attended said they
did not know where survey results were posted.
Observations on all days of the survey, 12/3/18, 12/4/18, 12/10/18 through 12/13/18,
showed no survey results posted on any household in the facility.
During an interview on 12/12/18, at 3:00 P.M., the administrator said they did not have
the survey results posted on the household. This was not considered aesthetically
pleasing.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interviews and record review, the facility failed to check the Nurse Aide (NA)
Registry for federal indicators (individuals with federal indicators cannot work in a
certified Medicare/Medicaid long term care facility) which affected seven of 11 sampled
and newly hire employees; failed to request the Employee Disqualification List Registry
(EDL, a listing of individuals disqualified from working in a certified home) which
affected one newly hired employee; and failed to obtain the Social Security (SS) Number
and did not record a date of hire for one newly hired employee. The facility census was
37.
1. Personnel records for Culinary Staff (CS) A showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
– Hire date 2/5/18.
– No NA registry check.
2. Personnel records for Occupational Therapist (OT) A showed:
– No hire date.
– No SS number.
– No NA registry check.
3. Personnel records for Registered Nurse (RN) A showed:
– Hire date 2/12/18.
– No NA registry check.
4. Personnel records for Licensed Practical Nurse (LPN) A showed:
– No NA registry check.
5. Personnel records for Homemaker (HM) A showed:
– No NA registry check.
6. Personnel records for RN B showed:
– No NA registry check.
7. Personnel records for LPN B showed:
– No NA registry check.
– No EDL check.
8. During an interview on 12/13/18 at 2:00 P.M., the Business Office Manager (BOM) said:
– She was responsible for obtaining the CBC, EDL, and NA Registry information for the
personell files of new hires.
– She did not know she needed to obtain the NA Registry information for all new hires; she
thought she was to obtain only for CNAs.
-She did not know why the date of hire, SS number, TB results and NA Registry was not in
OT A’s personnel file.
– She did not now why the EDL check, and NA Registry information was not in LPN B’s
personnel file.

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to follow their
policy to maintain documentation and complete a thorough investigation of two falls which
affected one on 12 sampled residents (Resident #23). The facility census was 37.
1. Review of the facility’s Resident Rights policy dated April, (YEAR) showed:
– Nursing homes must protect and promote the rights of each resident.
– Residents have the right to be free from abuse and neglect.
– The nursing home must investigate and report all suspected violations and any injuries
of unknown origin.
Review of the facility’s Managing Falls and Fall Risk policy dated December, 2007 showed:
– Staff will identify interventions related to the resident’s specific risks and causes to
try to prevent the resident from falling and try to minimize complications from falling.
– Staff, with input from the attending physician, will identify interventions to reduce
the risk of falls.
– If underlying causes cannot be readily identified or corrected, staff will try various
interventions based on assessment of the nature or category of falling, until falling is

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
reduced or stopped, or until the reason for the continuation of the falling is identified
as unavoidable.
– Staff will monitor and document each resident’s response to interventions intended to
reduce falling or the risks of falling.
– If interventions have been successful in preventing falling, staff will continue the
interventions or reconsider whether these measures are still needed if a problem that
required the intervention is resolved.
– If the resident continues to fall, staff will re-evaluate the situation and whether it
is appropriate to continue or change the interventions.
– Staff and/or physician will document the basis for conclusions that specific
irreversible risk factors exist that continue to present a risk for falling or injury due
to falls.
2. Review of Resident #23’s Fall Risk assessment dated [DATE] showed:
– No falls within the previous six months.
Review of the admission Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, dated 10/26/18 showed:
– [DIAGNOSES REDACTED].
– No falls.
– Occasional incontinence of bowel and bladder.
Review of the physician’s orders [REDACTED].
– [MEDICATION NAME] (to treat high blood pressure) 25 milligrams (mg) every six hours,
discontinued 11/22/18.
– 11/22/18: [MEDICATION NAME] 12.5 mg every six hours.
– 11/16/18: [MEDICATION NAME] 15 mg at bedtime for depression.
-11/23/18: [MEDICATION NAME] delayed release, 60 mg daily for [MEDICAL CONDITION].
– 11/7/18: [MEDICATION NAME]/[MEDICATION NAME], (Schedule II, a high potential for abuse
or addiction), 10/325 mg one tablet every eight hours for pain.
– 11/7/18: [MEDICATION NAME] 80 mg at bedtime for [MEDICAL CONDITION].
– 11/16/18: [MEDICATION NAME] 40 mg daily with breakfast for major [MEDICAL CONDITION],
discontinued 12/5/18.
– 10/17/18: [DIAGNOSES REDACTED] management. If blood sugar (BS) less than (<) 70 and
no symptoms, provide food/fluid rapidly absorbed glucose (sugar) source; if BS < 70 and
with symptoms, provide rapidly absorbed form of glucose or 15 grams (gm) glucose gel,
recheck BS after 15 minutes; if BS < 70 and unresponsive, apply glucose gel to the
[MEDICATION NAME] tissue (inside cheek/mouth) or administer injection of [MEDICATION NAME]
as needed (PRN).3
Review of the 14 day MDS dated [DATE] showed:
– Short- and long-term memory problems.
– Severely impaired cognition, not able to make decisions.
– Supervision of one staff for bed mobility and transfers.
– Locomotion on and off the unit occurred only once and with the assist of one staff.
– Not steady, but able to stabilize without staff assistance moving from seated to
standing position and moving on and off toilet.
– Not steady, only able to stabilize with staff assistance for walking, turning around,
and moving from bed to chair or wheelchair.
– No functional impairment.
– Walker.
– No falls.
– Antidepressants used in last five days.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– Antipsychotics used in last three days.
– Opioids used in last 7 days.
– [DIAGNOSES REDACTED]. The main symptom of this condition is feeling dizzy or faint when
you stand), and anorexia.
Review of a Nursing Progress Note dated 11/26/18 at 7:34 P.M., showed:
– Licensed Practical Nurse (LPN) F recorded that an aide notified him/her that the
resident complained about a fall.
– LPN F found the resident lying in bed and the resident said he/she did not feel well.
– LPN F asked why he/she did not feel well and the resident confirmed a fall in his/her
room approximately 30 minutes prior.
– The resident denied hitting his/her head, was alert, and the night nurse, Registered
Nurse (RN) C agreed to address the fall incident.
Review of BP readings from 11/26/18 through 11/27/18 showed:
– 11/26/18 at 7:00 P.M. – BP 100/46.
– 11/26/18 at 8:50 P.M. – BP 100/46.
– 11/27/18 at 6:13 A.M. – BP 117/79.
– 11/27/18 at 11:42 A.M. – BP 93/44.
– 11/27/18 at 11:54 P.M. – BP110/72.
Review of a Nursing Progress Note dated 11/27/18 at 1:03 A.M. showed:
– RN C recorded that he initial assessment started at 7:00 P.M. with ongoing observation.
– LPN F informed RNC that the resident stated he/she fell at 6:20 P.M. beside the door in
his/her room.
– Resident was alert, oriented, denied discomfort, denied hitting his/her head, stated
he/she leaned against the wall and slid down and was able to get up on his/her own without
difficulty.
– Resident stated he did not use his/her walker and felt dizzy at the time of the fall.
– No further dizziness reported, blood pressure (BP) 100/46, [MEDICATION NAME] (BP
medication) held at 6:00 P.M due to low BP.
– Resident reminded to use walker and stated he/she did not think he/she needed the walker
but would use it now.
– RN C did not record that the physician or family were notified of the fall or of the low
BP.
Review of Nurse Practitioner (NP) A’s progress note dated 11/27/18 at 9:00 A.M. showed:
– Vital signs (BP, heart rate, respirations, and temperature) reviewed.
– No assessment of fall or cause of fall.
Review of a Nursing Progress Note dated 11/29/18 at 4:31 A.M. showed:
– LPN G recorded that a staff reported to him/her at 4:00 A.M. that the resident felt
dizzy when he/she tried to stand and fell back onto his/her bed.
– Assessment completed, no injury observed, BP 93/68, heart rate 84, resident complained
of feeling wiped out.
– Resident instructed that this feeling might be related to a low BP, head of bed raised,
encouraged to drink more fluids.
– BP 30 minutes later 98/66, heart rate 84.
– Resident educated to use call light for assistance and continue to drink water.
– Would report to oncoming shift.
– LPN G did not record that the physician or family were notified of the fall onto the bed
and the low BP.
Review of BP readings from 11/28 showed:
– 11/28/18 at 7:53 A.M. – BP 114/70.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
Review of the Medical Record showed not Nursing Progress Note related to the fall on
11/30/18 or 12/1/18.
Review of Physician B’s Progress Note dated 12/5/18 showed:
– No documentation of falls on 11/26/18 and 11/29/18.
Review of the care plan updated 12/5/18 showed:
– At risk for falls.
– Assume a standing position slowly.
– Keep environment free of clutter.
– Toilet assist frequently.
– Proper footwear.
– Call light in reach at all times.
– Bed in lowest position.
During an interview on 12/10/18 at 11:26 A.M., the Director of Nursing (DON) said:
– There should be an investigation on the falls related to the resident.
– She would look for the investigation.
During an interview on 12/13/18 at 1:30 P.M., the DON said:
– Any nurse who finds a resident had fallen was responsible for initiating the Fall
Incident Report and the Root Fall Analyses.
– The falls are discussed in morning meetings to attempt to discover the root cause of the
fall.
– Care plans are updated with fall information at time of morning meetings.
– Falls are when a resident goes from an upright position to an unexpected sitting or
lying position.
– Falling back on the bed would be considered a fall.
– No fall investigations were found for Resident #23
– Fall investigations should have been done for each fall.
– The resident’s care plan should have been updated in the morning meeting when the falls
were discussed.
– The physician and family member should have been notified of each fall.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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, the facility failed to ensure staff
developed and updated a care plan consistent with resident’s specific conditions and needs
which affected two of 12 sampled residents (Resident #7 and #23). Staff failed to care
plan interventions for falls, orthostatic [MEDICAL CONDITION], and contact precautions
related to a [MEDICAL CONDITION] (MRSA) in a surgical wound to the buttock of Resident
#23. The facility census was 37.
1. Review of the facility’s Comprehensive Person Centered Care Plans policy dated
December, (YEAR) showed:
– A comprehensive, person centered care plan included measurable objectives and timetables
to meet the resident’s physical, psychosocial and functional needs will be developed and
implemented for each resident.
– The interdisciplinary team (IDT), the resident, and his/her family or legal

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Some

(continued… from page 7)
representative develops and implements a comprehensive, person-centered care plan for each
resident.
– The interventions are derived from a thorough analysis of the information gathered as
part of the comprehensive assessment.
– The comprehensive person centered care plan will include measureable objectives and
timeframes; will describe services that are to be furnished to attain or maintain the
resident’s highest practicable physical, mental, and psychosocial well-being.
– In corporate identified problem areas.
– Incorporate risk factors associated with identified problems.
– Reflect goals, timetables, and objectives in measurable outcomes.
– Aid in preventing or reducing decline in the resident’s functional status and/or
functional levels.
– Enhance optional functioning of the resident by focusing on a rehabilitative program.
– Reflect on currently recognized standards of practice for problem areas and conditions.
– Areas of concern that are identified during the resident assessment will be evaluated
before interventions are added to the care plan.
– Assessments of residents are ongoing and care plans are revised as information about the
resident and the resident’s condition changes.
– The IDT must review and update the care plan when there has been a significant change in
the resident’s condition, when the desired outcome is not met, when the resident was
readmitted to facility from the hospital, and at least quarterly in conjunction with the
required quarterly Minimum Data Set (MDS, a federally mandated assessment instrument
completed by facility staff) assessment.
2. Review of Resident #23’s 14 day MDS dated [DATE] showed:
– Short- and long-term memory problems.
– Severely impaired cognition, not able to make decisions.
– Supervision of one staff for bed mobility and transfers.
– Locomotion on and off the unit occurred only once and with the assist of one staff.
– Not steady, but able to stabilize without staff assistance moving from seated to
standing position and moving on and off toilet.
– Not steady, only able to stabilize with staff assistance for walking, turning around,
and moving from bed to chair or wheelchair.
– No functional impairment.
– Walker.
– No falls.
– Antidepressants used in last five days.
– Antipsychotics used in last three days.
– Opioids used in last 7 days.
– [DIAGNOSES REDACTED]. The main symptom of this condition is feeling dizzy or faint when
you stand), and anorexia.
Review of a Nursing Progress Note dated 11/26/18 at 7:34 P.M., showed:
– Licensed Practical Nurse (LPN) F recorded that an aide notified him/her that the
resident complained about a fall.
– LPN F found the resident lying in bed and the resident said he/she did not feel well.
– LPN F asked why he/she did not feel well and the resident confirmed a fall in his/her
room approximately 30 minutes prior.
– The resident denied hitting his/her head, was alert, and the night nurse, Registered
Nurse (RN) C agreed to address the fall incident.
Review of BP readings from 11/26/18 through 11/27/18 showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Some

(continued… from page 8)
– 11/26/18 at 7:00 P.M. – BP 100/46.
– 11/26/18 at 8:50 P.M. – BP 100/46.
– 11/27/18 at 6:13 A.M. – BP 117/79.
– 11/27/18 at 11:42 A.M. – BP 93/44.
– 11/27/18 at 11:54 P.M. – BP110/72.
Review of a Nursing Progress Note dated 11/271/8 at 1:03 A.M. showed:
– RN C recorded that he initial assessment started at 7:00 P.M. with ongoing observation.
– LPN F informed RNC that the resident stated he/she fell at 6:20 P.M. beside the door in
his/her room.
– Resident was alert, oriented, denied discomfort, denied hitting his/her head, stated
he/she leaned against the wall and slid down and was able to get up on his/her own without
difficulty.
– Resident stated he did not use his/her walker and felt dizzy at the time of the fall.
– No further dizziness reported, blood pressure (BP) 100/46, [MEDICATION NAME] (BP
medication) held at 6:00 P.M due to low BP.
– Resident reminded to use walker and stated he/she did not think he/she needed the walker
but would use it now.
– RN C did not record that the physician or family were notified of the fall or of the low
BP.
Review of Nurse Practitioner (NP) A’s progress note dated 11/27/18 at 9:00 A.M. showed:
– Vital signs (BP, heart rate, respirations, and temperature) reviewed.
– No assessment of fall or cause of fall.
Review of a Nursing Progress Note dated 11/29/18 at 4:31 A.M. showed:
– LPN G recorded that a staff reported to him/her at 4:00 A.M. that the resident felt
dizzy when he/she tried to stand and fell back onto his/her bed.
– Assessment completed, no injury observed, BP 93/68, heart rate 84, resident complained
of feeling wiped out.
– Resident instructed that this feeling might be related to a low BP, head of bed raised,
encouraged to drink more fluids.
– BP 30 minutes later 98/66, heart rate 84.
– Resident educated to use call light for assistance and continue to drink water.
– Would report to oncoming shift.
– LPN G did not record that the physician or family were notified of the fall onto the bed
and the low BP.
Review of BP readings from 11/28 showed:
– 11/28/18 at 7:53 A.M. – BP 114/70.
Review of the Medical Record showed not Nursing Progress Note related to the fall on
11/30/18 or 12/1/18.
Review of Physician B’s Progress Note dated 12/5/18 showed:
– No documentation of falls on 11/26/18 and 11/29/18.
Review of the care plan updated 12/5/18 showed:
– At risk for falls.
– Assume a standing position slowly.
– Keep environment free of clutter.
– Toilet assist frequently.
– Proper footwear.
– Call light in reach at all times.
– Bed in lowest position.
– Did not include assessment and treatment for [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Some

(continued… from page 9)
3. Review of Resident #23’s Nursing Progress note dated 11/5/18 at 1:40 P.M. showed:
– Staff called hospital and found resident admitted to the hospital with [REDACTED].
Review of the final Wound Culture and Sensitivity (C&S, a test to determine bacteria
causing a wound infection and the antibiotic to treat the infection) report dated 11/7/18
showed:
– Buttock wound.
– Heavy growth [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium that causes
infections in different parts of the body; tougher to treat than most strains of
staphylococcus aureus (staph) because it’s resistant to some commonly used antibiotics).
Review of a Nursing Progress note dated 11/7/18 at 1:20 P.M showed:
– Resident readmitted to the facility at 1:00 P.M. due to wound and wound treatment.
– Dressing to right buttock.
Review of a Nursing Progress note dated 11/9/18 at 6:41 A.M. showed:
– Receiving antibiotics to treat wound.
Review of a Nursing Progress note dated 11/4/18 at 3:21 P.M. showed:
– Copious amounts of green drainage from buttock wound.
Review of a history and physical written by Physician B dated 11/9/18 showed:
– Resident readmitted to hospital (11/5/18) due to [MEDICAL CONDITION] and found to have
an abscess on his/her buttock which required incision and drainage.
– C & S [MEDICAL CONDITION].
– Initially administered intravenous antibiotics.
– Transitioned to [MEDICATION NAME] (an antibiotic).
Review of the physician’s orders [REDACTED].
– [MEDICATION NAME] (an antibiotic to [MEDICAL CONDITION]) tablet, 100 milligram (mg)
twice daily (BID) for treatment of [REDACTED].
Review of a Nursing Progress note dated 11/11/18 at 10:26 P.M. showed:
– Contact Precautions in place due [MEDICAL CONDITION] in wound.
Review of the care plan dated 11/13/18 showed:
– Skin impairment.
– Use principles of infection control and Universal/Standard Precautions.
– Did not address Contact Precautions related [MEDICAL CONDITION].
Review of the 14 day Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, dated 11/19/18 showed:
– Short- and long-term memory problems.
– Severely impaired cognition.
– [DIAGNOSES REDACTED].
Review of the care plan updated 12/5/18 showed:
– Did not include a care plan for contact precautions related to [MEDICAL CONDITION]
infection of a surgical wound to the resident’s buttock.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interviews, the facility failed to ensure staff followed
professional standards of care when when staff transcribed medications orders in such a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
way as to not allow staff to accurately document the actual amount of narcotic pain
medications they administered, failed to ensure staff charted each medication they
administered in the medications administration record (MAR), failed to ensure they
administer all medications as ordered by the physician and failed to ensure the person who
administered the medication documented in the electronic (e) MAR, which affected one of 12
sampled residents (Resident #13). The facility’s census was 37.
Review of the Administering Medications policy, revised (MONTH) 2012, showed:
– Medications must be administered in accordance with the orders, including any required
timeframes;
– If a dosage is believed to be inappropriate or excessive for a resident, the person
preparing or administering the medication shall contact the resident’s Attending Physician
or the facility’s Medical Director to discuss the concerns;
– For residents not in their rooms or otherwise unavailable to receive medication on the
pass, the MAR may be flagged; after completing the medication pass, the nurse or designee
will return to the missed resident to administer the medication;
– If a drug is withheld, refused, or given at a time other than the scheduled time, the
individual administering the medication will update the eMAR;
– The individual administering the medication must document medication given in the eMAR.
Review of Resident #13’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– [MEDICATION NAME] (over the counter pain reliever) 500 milligrams (mg), 2 tablets to
equal 1,000 mg, orally every 8 hours;
– [MEDICATION NAME] (a narcotic pain reliever used to treat severe pain) patch, 25
micrograms/hour (mcg/hr), every 72 hours; order in effect 11/4/18 – 11/11/18;
– [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 75 mcg, 1 capsule before
breakfast; – [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 50 mg, 1 capsule every
evening;
– [MEDICATION NAME] (a narcotic pain reliever) 5 mg, 1 – 3 tablets every 3 hours PRN (as
needed) for pain.
Review of the resident’s eMAR, dated 11/10/18 through 12/10/18, showed:
– [MEDICATION NAME] 500 mg; start date 11/5/18; on 11/6/18; staff documented the 12:00
A.M. dose as not administered: Comment: Agency;
– No staff documented they gave the 12:00 A.M. dose on 11/7/18, 11/8/18, 11/9/18, 11/25/18
and 11/30/18; and no staff documented the 8:00 A.M. dose on 11/9/18, 11/23/18 and
11/30/18;
– [MEDICATION NAME] 75 mcg; give before breakfast; order date 11/2/18;
– Staff did not document they gave the medication on 11/3/18 through 11/10/18, 11/12/18,
11/16/18, 11/20/18, 11/26/18 and 11/30/18; Staff did not document a reason on these dates
for not administering;
– [MEDICATION NAME] 50 mg, every evening, ordered on [DATE];
– Staff documented on 11/5/18 through 11/8/18, staff documented the medication was charted
late; Comment: Agency.
Review of the eMAR, dated 11/10/18 through 12/10/18, showed:
– [MEDICATION NAME] 5 mg, take 1-3 tablets by mouth, every 3 hours PRN; start date
11/5/18;
– Staff documented they administered the medication almost on schedule but the
documentation did not document how many tablets staff administered at any given time
throughout the day.
Review of the eMAR, dated 11/10/18 through 12/10/18, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
– [MEDICATION NAME], 25 mcg/hr, every 72 hours; start date 11/4/18 through 11/11/18;
Administered on 11/4/18, 11/7/18, and 11/10/18
– [MEDICATION NAME], 12 mcg/hr, one time; order date of 11/13/18; administered on
11/13/18;
– [MEDICATION NAME], 25 mcg/hr, one time; ordered 11/18/18; documented as administered on
11/18/18;
– [MEDICATION NAME], 25 mcg/hr, every 72 hours; ordered 11/21/18 through 11/30/18; staff
documented they administered the first dose on 11/24/18;
– Staff applied a patch on 11/18/18 when ordered and did not reapply a new patch until
11/24/18, 144 hours after the one ordered on [DATE].
During an interview and record review on 12/12/18, at 5:06 P.M., Licensed Practical Nurse
(LPN) C said:
– Staff can document how many tablets they give if it is an open-ended order with multiple
choices. They have an option to go in and add how many pills they give.
– Review of the eMAR showed once cannot see how many pills staff administered by looking
at the eMAR.
– If there are three different options, staff should enter three separate orders when they
transcribe the order and nurses should document on the appropriate order to indicate how
many they gave.
– Not all agency staff had access to document in the facility’s eMAR.
During an interview on 12/13/18, at 1:30 P.M., the Director of Nursing (DON) said:
– Staff should chart when the medication is administered; if it is not on the MAR, it
means it is not given;
– The night shift supervisor is supposed to check orders every night.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to provide an
ongoing activity program based on the residents’ comprehensive assessments and preferences
of each resident. The facility did not have a designated activity staff to assist in
providing activities, did not post any group activities and did not let residents know
when any impromptu activities occurred. This affected all residents of the facility. The
facility had a census of 37.
Review of the facility’s Resident Rights, Your Rights and Protections as a Resident,
provided in each resident’s admission packet, dated 4/13/18, showed:
– Participate in Activities: You have the right to participate in an activities program
designed to meet your needs and the needs of the other residents.
Review of the Activity Evaluation policy, revised May, 2013, showed in order to promote
the physical, mental and psychosocial well-being of residents, an activity evaluation is
conducted and maintained for each resident. The policy listed the following for
implementation:
– Within 14 days of a resident’s admission to the facility, an activity evaluation will be
conducted to help develop a plan that reflects the choices and interests of the resident;
– The evaluation will be conducted by household staff who will evaluate related factors
such as functional level, cognition and medical conditions that may affect participation.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 12)
The resident’s lifelong interest, spirituality, life roles, goals, strengths, needs and
activity pursuit patterns and preferences will be included in the evaluation;
– Nursing staff will communicate with a resident’s physician to discuss and address
medical conditions or medications that may affect the resident’s participation in
activities;
– The activity evaluation is used to develop an individual activities care plan that will
allow the resident to participate in activities of his/her choice and interests;
– Each resident’s activities care plan shall relate to his/her comprehensive assessment
and should reflect his/her individual needs;
– The completed evaluation will be a part of the resident’s medical record and shall be
updated as necessary, but at least annually;
– The policy did not indicate the facility would have a qualified activity person to
oversee this process.
Review of the Programming for Residents with Cognitive Impairments and Other Special Needs
policy, reviewed (MONTH) 2006, showed activity programs are provided for the maintenance
and enhancement of each resident’s quality of life while promoting physical, cognitive and
emotional health. The facility will offer meaningful programs for residents with cognitive
impairments that use reality and sensory awareness techniques. The policy indicated it
should be implemented as follows:
– The interdisciplinary team (IDT) identifies each resident’s physical, emotional, or
mental challenges and needs during the assessment process;
– Residents with special needs are discussed with the IDT during care planning;
– The Activity Department coordinates care planning with nursing and other members of the
IDT to develop an effective approach to meeting special activity needs;
– Activity staff observes each resident to identify those residents who might benefit from
a Reality and Sensory Awareness Program; observation is made during the initial
assessment, change of condition review and in the course of group or individual activities
and may include the resident’s level of orientation to time, place and/or person.
1. Observation on 12/3/18, between 9:00 A.M. and 5:00 P.M., showed no activities provided
and no activities scheduled.
Observation on 12/4/18 between 7:20 A.M. and 5:15 P.M., showed one floor played an
impromptu game of bingo. No other activities were available or scheduled. No activities
were noted on the other two floors where residents resided.
During an interview on 12/4/18 at 2:38 P.M., Certified Nurse Aide (CNA) D said they do not
do activities but they need to be done. Residents sit in their rooms all day; they are
really sad. They do bingo once in a great while. Residents really need something to do.
They get depressed then do not want to go eat or receive care. He/she wished they we could
do activities, but they are told this is not a nursing home. And instead that this is
their home so they can do what they please. He/she still thinks the facility needs to
provide activities for the residents.
2. During the group interview on 12/4/18, at 2:43 P.M., all of the residents said or
agreed:
– They wanted and needed activities.
– All they had to do was watch TV or stare out the window.
– They would like music, games, crafts, bingo and card games.
– They need someone to get the activities started.
– They needed supplies to do activities.
– They would like to have a calendar of activities/events to follow.
During an interview on 12/4/18, at 3:55 P.M., the homemakers’ supervisor said the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 13)
homemakers prepare meals, make sure all residents have food to eat, and are happy with the
food served. The homemakers’ kitchens are like home; staff will provide residents
something to eat at any time of the day or night. The homemakers prepare some foods from
scratch, cook breakfast to order; finish the meals brought down from the main kitchen and
prepare sandwiches, bake cookies and cinnamon rolls. The homemakers are also to provide
activities but he/she had only one seen staff play bingo. He/she was new to the position
as were most of the staff so they were still trying to figure out how to be a short order
cook, keep the kitchen and dining rooms neat and clean and have time to do activities with
the residents. To her knowledge, there is no activity scheduled and staff were not trained
in appropriate activities for the residents.
Observations on 12/11/18, starting at 11:00 A.M., showed on all households, no residents
out of their rooms. TVs played in the living area of each household but no residents sat
in the area. On the 2nd and 3rd floors no chalk board to indicate the day of the week or
any planned activities for the day.
Observation on 12/11/18, at 11:37 A.M., on the 4th floor showed a blackboard outside the
kitchen door. The board had the following information written on it:
– The correct date;
– 1:30 P.M. Popcorn and movie;
– Weather for the day indicated a temperature of 36 degrees and cloudy with snow; actual
weather for the day was sunny with a high of 51 degrees
– 23 days until Christmas.
Observation on 12/11/18, at 2:30 P.M., showed no residents watching a movie on the 4th
floor, no popcorn had been popped.
Observations on all days of the survey, 12/3/18, 12/4/18, 12/10/18 through 12/13/18,
showed no activity calendars in resident rooms and no activity calendar posted for
residents to refer to for scheduled activities.
3. Review of Resident #17’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/25/18, showed the resident had
the following activity preferences:
– Very important to keep up with news, do his/her favorite activity, and participate in
religious services;
– Somewhat important to do things with groups of people and go outside to get fresh air
when the weather was good.
Review of the resident’s care plan, dated 11/9/18, showed no interventions or approaches
for activities.
During an interview on 12/4/18 at 9:17 A.M., Resident #17 said the facility has only had
two activities since he/she came to the facility in September. They played bingo once and
a church group singing Christmas Songs came last evening. He/she transferred from another
facility to be closer to family. He/she was used to having activities to do all the times.
It was depressing with nothing to do all day.
4. Review of Resident #9’s care plan dated 9/25/18 showed:
– Preferred activities that identify with prior lifestyle.
– Will express satisfaction with daily routine and leisure activities through next review
dates.
– Allow resident to express feelings and desires.
– Encourage the resident to become more involved with activities within the facility.
– Provide materials of interest.
-Provide setting in which activities are preferred.
During an interview on 12/3/18, at 11:16 A.M., Resident #9 said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 14)
– The facility did not have any activities for residents.
– The facility provided one activity of bingo on Halloween and that is all he/she
participated in during his/her stay at the facility.
5. Review of Resident #1’s admission Minimum Data Set (MDS), a federally mandated
assessment completed by staff dated 4/27/18, showed:
– Somewhat important to have books, newspapers and magazines to read; to do things with
groups of people, to do favorite activities; very important to keep up with the news, to
go outside to get fresh air when the weather is good, and to participate in religious
services.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– A Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate
cognitive impairment;
– Little interest or pleasure in doing things; feeling down and depressed several days;
feeling tired or having little energy nearly every day.
Review of the resident’s care plan, dated 11/19/18, showed:
– Will participate in senior exercise program two to three times a week;
– Will maintain current functional status through next review date;
– Encourage to participate in senior exercise program.
Review of the resident’s medical record showed no activity evaluation, and no activity
assessments.
During an interview on 12/3/18, at 10:58 A.M., Resident #1 said there are no activities at
the facility. He/she cannot maneuver the television remote to watch TV on his/her own.
Observation of the resident on 12/11/18 through 12/13/18, at various times during the day
showed he/she sat alone in his/her room with no TV or radio on. No books or magazines
available to him/her.
6. During an interview on 12/12/18 at 3:21 P.M. Household Coordinator (HC) B said:
– HCs are considered the AD.
– He/she did not activities with residents.
– The Homemakers could provide bingo, painting, decorating cookies, singing, watching
movies, puzzles, or cards.
– There was no activity calendar.
– There were only random activities provided.
– No resident knows when activities are provided or what will be provided.
During an interview on 12/13/18 at 1:30 P.M., the Director of Nursing (DON) and the
administrator said:
– Household staff provided activities.
– The facility did not have a qualified Activity Director (AD).
– The Unit Coordinator was responsible to update the activity care plans.
– The Aurora hall had exercise activities that some of the other residents on other halls
can attend.
– No staff invited or took residents to the exercise class, the residents go and attend
only if they want to attend.

F 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure the activities program is directed by a qualified professional.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 15)
Based on observation, record review and interviews, the facility failed to employ a
qualified activity professional to oversee the activity program for the facility. The
facility employed three household coordinators for each floor, but none of the three had
been through an approved activity program. The facility census was 37.
1. Review of the facility’s Resident Rights, Your Rights and Protections as a Resident,
provided in each resident’s admission packet, dated 4/13/18, showed:
– Participate in Activities: You have the right to participate in an activities program
designed to meet your needs and the needs of the other residents.
Review of the Activity Evaluation policy, revised May, 2013, showed in order to promote
the physical, mental and psychosocial well-being of residents, an activity evaluation is
conducted and maintained for each resident. The policy listed the following for
implementation:
– Within 14 days of a resident’s admission to the facility, an activity evaluation will be
conducted to help develop a plan that reflects the choices and interests of the resident;
– The evaluation will be conducted by household staff who will evaluate related factors
such as functional level, cognition and medical conditions that may affect participation.
The resident’s lifelong interest, spirituality, life roles, goals, strengths, needs and
activity pursuit patterns and preferences will be included in the evaluation;
– Nursing staff will communicate with a resident’s physician to discuss and address
medical conditions or medications that may affect the resident’s participation in
activities;
– The activity evaluation is used to develop an individual activities care plan that will
allow the resident to participate in activities of his/her choice and interests;
– Each resident’s activities care plan shall relate to his/her comprehensive assessment
and should reflect his/her individual needs;
– The completed evaluation will be a part of the resident’s medical record and shall be
updated as necessary, but at least annually;
– The policy did not indicate the facility would have a qualified activity person to
oversee this process.
Review of the Programming for Residents with Cognitive Impairments and Other Special Needs
policy, reviewed (MONTH) 2006, showed activity programs are provided for the maintenance
and enhancement of each resident’s quality of life while promoting physical, cognitive and
emotional health. The facility will offer meaningful programs for residents with cognitive
impairments that use reality and sensory awareness techniques. The policy indicated it
should be implemented as follows:
– The interdisciplinary team (IDT) identifies each resident’s physical, emotional, or
mental challenges and needs during the assessment process;
– Residents with special needs are discussed with the IDT during care planning;
– The Activity Department coordinates care planning with nursing and other members of the
IDT to develop an effective approach to meeting special activity needs;
– Activity staff observes each resident to identify those residents who might benefit from
a Reality and Sensory Awareness Program; observation is made during the initial
assessment, change of condition review and in the course of group or individual activities
and may include the resident’s level of orientation to time, place and/or person.
Review of the list of current employees with their job titles, provided by the facility,
showed no staff designated as the activity staff.
Observations on all days of the survey, 12/3/18, 12/4/18, 12/10/18 through 12/13/18,
showed no activity calendars in resident rooms and no activity calendar posted for
residents to refer to for scheduled activities.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 16)
During an interview on 12/3/18, at 10:58 A.M., Resident #1 said there are no activities at
the facility.
During a resident group interview on 12/4/18, at 10:06 A.M., seven residents said:
– They would like to have activities;
– There are no activities in their household;
– Most of the time they are looking at the TV or out the window;
– Would like music programs, games, crafts, bingo or card games;
– Need someone to get them started with activities.
– Need supplies to do activities.
– Would like to have a calendar of activities/events to follow.
During an interview on 12/11/18, at 10:11 A.M., Clinical Coordinator (CC) A said:
– Right now the activity’s budget mixed in with the raw foods budget.
– There is no designated activity person that she was aware of.
– The Registered Dietitian (RD) is supposed to be doing it but she is already doing too
much;
– Homemaker (HM) A sometimes will play Bingo with the residents in his/her household on
his/her own time, but that is never scheduled and only on the 4th floor.
– Eventually the Household Coordinators (HC) will be doing staffing for each household to
free the current staffing coordinator up to move into activities.
During an interview on 12/12/18 at 3:21 P.M., Household Coordinator (HC) B said:
– HCs are considered the AD.
– He/she did not activities with residents.
– The Homemakers could provide Bingo, painting, decorating cookies, singing, watching
movies, puzzles, or cards.
– There was no activity calendar.
– There were only random activities provided.
– No resident knows when activities are provided or what will be provided.
During an interview on 12/13/18, at 1:30 P.M., the administrator and the Director of
Nursing (DON) said:
– Each household should function on it’s own, with its own staff, including activities.
– The homemakers should be providing activities, but did not believe they had been through
any approved class.
– Any household staff provided activities.
– The facility did not have a qualified Activity Director (AD).
– The Unit Coordinator was responsible to update the activity care plans.
– The Aurora hall had exercise activities that some of the other residents on other halls
can attend.
– No staff invited or took residents to the exercise class, the residents go and attend
only if they want to attend.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based observation, record review and interviews, the facility failed to ensure they
staffed a qualified restorative aide (RA) who provided active range of motion (AROM) and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
passive range of motion (PROM) for one of 12 sampled residents, who had been discharged
from occupational therapy with orders for a restorative nursing program (RNP) and failed
develop a plan of care with measurable goals and outcomes. This had the potential to
affect all residents with orders for a RNP. The facility census was 37.
Review of the Restorative Nursing Services policy, revised (MONTH) (YEAR), showed
residents will receive restorative nursing care as needed to help promote optimal safety
and independence. The policy directed staff on the following interpretations and
implementation procedures:
– Consists of nursing interventions that may or may note be accompanied by formalized
rehabilitation services (e.g. physical, occupational or speech therapies);
– Residents may be started on a RNP upon admission, during the course of stay or when
discharged from rehabilitative care;
– Restorative goals and objectives are individualized and resident-centered, and are
outlined in the resident’s plan of care;
– The resident or representative will be included in determining goals and the plan of
care;
– Restorative goals may include, but are not limited to supporting and assisting the
resident in: adjusting or adapting to changing abilities; developing, maintaining or
strengthening his/her physiological and psychological resources; maintaining his/her
dignity, independence and self-esteem; and participating in the development and
implementation of his/her plan of care.
Review of certificates provided by the facility for Contracted RA showed the following:
– Certificate of completion of the Corrective Exercise Specialist course on 1/15/15;
– Certificate of completion of the Certified Personal Trainer course on 4/10/17;
– Certificate of completion of the 200-hour LifePower Yoga Teacher Training on 12/3/17;
– Did not provide a certificate of completion of the RA nursing course.
The facility did not provide a copy of the contract signed by the facility and Contracted
RA, with expectations for documentation, care planning, developing goals for providing a
RNP for residents who are discharged from physical, occupational and speech therapies.
Review of Resident #’1’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/27/18, showed the resident received
physical therapy (PT) two days and occupational therapy (OT) three days out of the
previous seven days.
Review of the resident’s care plan addressing pain, dated 6/21/18, showed the resident has
complaints of chronic pain related to [MEDICAL CONDITION] arthritis, especially in
shoulders. Interventions and approaches included:
– Acknowledge that his/her pain is unique and believable;
– Ask about past effective and ineffective pain relief measures;
– Evaluate effectiveness of pain management interventions;
– Handle gently, using extra caution with joints, especially shoulders;
– Monitor and record any complaints of pain;
– Support join areas with transfers/movement;
– The resident’s care plan did not include any information regarding splint or brace use
or any RNP.
Review of the OT discharge summary, dated 6/28/18, showed:
– Dates of service: 4/19/18 through 6/28/18;
– Prognosis to maintain current level of function (CLOF) = Excellent with consistent staff
support; Excellent with participation in RNP;
– Discharge recommendations: 24 hour care, functional maintenance program (FMP)/RNP with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
splint/brace;
– FMP/RNP: to facilitate maintaining current level of performance and in order to prevent
decline, development of and instruction in the following RNPs has been completed with the
interdisciplinary team (IDT): ROM (active) and transfers, orthotic wear schedule.
Review of the resident’s quarterly MDS, dated [DATE], showed the resident was discharged
from PT and OT on 6/28/18. The MDS did not reflect any RA services in the previous seven
days.
Review of the resident’s care plan, dated 7/24/18, showed a problem of activities of daily
living (ADL) functional/rehabilitation potential, ability to move in bed, transfer, dress,
eat, toilet, and maintain personal hygiene and bathe has deteriorated related to a humerus
fracture. Interventions and approaches included:
– Provide feeding assistance; Use adaptive equipment at mealtimes;
– Do not rush, allow extra time to complete ADLs;
– Follow OT/PT/ST recommendations;
– No specific plan of care related to the discharge instructions given when the resident
discharged from OT in June, (YEAR).
Review of resident’s care plan, dated 9/13/18, showed a problem of activities. The plan
listed one approach of participation in senior exercise program, two to three times a
week, with general flow sheet.
Review of the resident’s quarterly MDS, dated [DATE], showed staff did not indicate the
resident had been receiving any type of rehabilitative services, such as PT, OT or RNP, in
the previous seven days.
Review of the OT therapy discharge summary, dated 10/23/18, showed:
– Dates of service: 9/18/18 through 10/23/18;
– Prognosis to maintain CLOF = Excellent with consistent staff support;
– Discharge Recommendations: Home exercise program and 24 hour care; adaptive feeding
equipment and ROM program with exercises specialist;
– RNP/FMP: to facilitate patient maintaining current level of performance and in order to
prevent decline; development of and instruction in the following RNPs has been completed
with the IDT: eating/self-feeding, AROM and PROM.
Observation and interview on 12/3/18, at 3:15 P.M., showed and the resident said he/she
could not use the TV remote to change the channels on his/her TV due to his/her hands. No
splints visible in his/her room at this time.
Review of the physician’s orders [REDACTED].
– 9/17/18: OT for eval and treat for [MEDICAL CONDITION] arthritis;
– 11/5/18: PT eval and treat; under Medicare Part B;
– No orders for a RNP.
Observation and interview on 12/12/18, at 11:08 A.M., showed the resident sat in his/her
room, no splints on his/her hands or visible in his/her room. The resident said he/she
does have a girl who comes to get him/her for exercise two or three times a week. A small
calendar hung beside the resident’s wheelchair with CRA’s name written on it three days a
week.
Review of the resident’s medical records on 12/12/18, showed no documentation of any RNP.
During an interview on 12/12/18, 11:23 A.M., the administrator and the Director of Nursing
(DON) said they employed no certified nurse aides (CNA) who were certified as RA but do
contract with the gym, and have personal trainers who do RA with residents who have
orders. They did not know where those notes would be, but will check.
During an interview on 12/12/18, at 3:09 P.M., the DON said CRA does come over to do RA
with residents. She is a personal trainer but did not know what her credentials are. She
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
is actually an employee of the gym next door, not the facility. She cannot document in
their system to show what services she is working on with the residents on her caseload.
The DON said If it is not documented, it did not happen. She did not know who was on CRA’s
case load currently.
During an interview on 12/13/18, at 1:30 P.M., the DON said:
– Some residents buy their own membership to the gym next door;
– No one comes to get residents to go to those classes at the gym;
– The clinical coordinators are to monitor to ensure RA is done and it should be
monitored;
– The IDT talks about RA in the morning stand up meeting; therapy goes to
clinical/households to discuss RA;
– She was unsure if they had a policy to spell this out;
– The RA program for each resident should be individualized, documented and monitored.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
used proper techniques and follow facility policy to reduce the possibility of accidents
and injury during a gait belt transfer (a device to help with transferring) for one out of
12 sampled residents (Resident #7). The facility census was 37.
Review of the facility’s Safe Lifting and Movement of Residents, revised (MONTH) (YEAR),
showed:
– The facility uses the appropriate techniques and devices to lift and move residents in
order to protect the safety and well being of staff and residents.
– Nursing staff, in conjunction with the rehabilitation staff, shall assess individual
residents’ needs for transfer assistance on an ongoing basis.
– Staff responsible for direct resident care will be trained in the use of manual
(gait/transfer belts).
– Safe lifting and movement of residents is part of an overall facility employee health
and safety program.
Review of Resident #7’s admission Minimum Data Set (a federally mandated assessment
instrument) completed by facility staff, dated 10/25/18, showed:
– Severely cognitive impaired.
– Extensive assist of two staff for transfers.
– Not steady, only able to stabilize with staff when move from a seated to standing
position and from moving off and on the toilet.
– Walking did not occur.
– [DIAGNOSES REDACTED].
Review of the care plan, revised 11/30/18, showed:
– Problem: Activities of daily living (ADL) functional/rehabilitation potential.
– Approach: do not rush the resident; allow for plenty of time to complete ADLs; report
any further deterioration in status to the physician; monitor for presence of
pain/intolerance during self care; provide adequate rest periods between activities.
– Problem: Falls; History of falls related to weakness and lack of safety awareness.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
– Approaches: encourage resident to assume a standing position; encourage to use
environmental devices; give verbal reminders not to ambulate/transfer without assistance;
keep be in low positioning with brakes locked at all times; provide proper, well
maintained footwear; monitor for cues that resident has to use the bathroom.
Review of the care plan does not address how the resident transfers.
Observation on 12/3/18, at 11:38 A.M., showed:
– Certified Nurse Aide (CNA) B and CNA C assisted the resident from the wheelchair to the
commode to provide pericare.
– CNA C applied a taunt gait belt to the resident abdomen.
– CNA B and CNA C lifted the resident with the gait belt, the resident provided minimal
assistance in the transfer.
– The gait belt slid up under the residents armpits and his/her shoulders went in an
upward motion.
– The resident pivoted one step, legs buckled, and then unable to assist in the transfer.
– Both CNA’s pulled the resident by the gait belt up under his/her arms to pull to the
commode.
– The resident was unable to stand from the commode.
– CNA C pulled the resident up by his/her gait belt that slid up under his/her armpits
while CNA B provided pericare.
– CNA C and CNA B used the gait belt up under the residents arm to transfer back to the
wheelchair.
– The residents legs buckled and the CNA’s dragged the resident to his/her wheelchair.
– The resident was unable to bear weight and assist with the transfer back to the
wheelchair.
During an interview on 12/3/18, at 12:15 A.M., CNA B said:
– He/she know how to care for the residents based on verbal report before the shift and
was told the resident was a two person gait belt transfer.
– The resident was unable to bear weight and should be a Hoyer lift to be safe.
– Gait belts should be tight over the abdomen and should not slide under the arm pits and
make the residents shoulders go up.
– Staff should let the charge nurse know when a resident is having difficulty
transferring.
During an interview on 12/3/18, at 12:18 A.M., CNA A said:
– The resident was tired today and had difficulty bearing weight and transferring.
– Gait belts should be tight on the residents abdomen and not move during the transfer.
– Residents should not be dragged during a gait belt transfer.
During an interview on 12/13/18, at 1:30 P.M., the Director of Nursing (DON) said:
– Staff should apply gait belts snuggly around the abdomen.
– Gait belts should stay in place and not slide under the residents armpits.
– During a gait belt transfer, the resident shoulders should not raise from the gait belt
under their armpits.
– Staff should inform the charge nurse if a resident is having difficulty transferring.
– Staff should not drag a resident during a gait belt transfer.
– The care plan should state how a resident is transferred.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough food/fluids to maintain a resident’s health.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interviews, the facility failed to follow their policy to
monitor resident weights in order to ensure residents maintained their usual body weight
or a desirable body weight when staff did not weigh one resident for an extended period
and did not reweigh residents when they received a weight outside the normal range for
these residents. The affected three (?) of 12 sampled residents (Residents #1, #16 and
#23). The facility had a census of 37 at the time of the survey.
Review of the Weight Assessment and Intervention policy, revised (MONTH) 2008, showed the
multidisciplinary team (MDT) will strive to prevent, monitor and intervene for undesirable
weight loss. The policy directed staff to do the following:
– Nursing staff will measure resident weights on admission and weekly for two weeks
thereafter. If no weight concerns are noted at this point, weights will be measured
monthly;
– Weights will be recorded in the individual’s medical record;
– Any weight change of 5% or more since the last weight assessment will be retaken the
next day for confirmation. If the weight is verified, nursing will immediately notify the
dietitian in writing, verbal notification must be confirmed in writing;
– The dietitian will review weight records monthly to follow individual weights trends
over time. Negative trends will be evaluated by the treatment team whether or not the
criteria for significant weight change has been sent.
1. Review of Resident #1’s nutritional assessment, dated 4/25/18, showed:
– No diagnoses that would cause a major fluctuation in weight such as [MEDICAL CONDITION]
or [MEDICAL CONDITION];
– Usual body weight 145-155 lbs;
– No swallowing disorders;
– No nutritional problems.
Review of Resident #1’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument, completed by staff, date 7/13/18, showed:
– Total dependence on staff for activities of daily living such as dressing, moving in and
out of his/her room, bed mobility and transfers; limited assistance from staff for eating;
– Weight 150 pounds (lbs).
Review of the resident’s weights in the electronic medical record from admission showed:
– 7/13/18:150.2 lbs;
– 7/22/18 at 12:38 P.M.: 154.8 lbs;
– 7/22/18 at 4:04 P.M.: 189.8 lbs; no reweight after staff obtained a weight of 189.8 lbs.
Review of the resident’s medical records showed no dietitian’s note after the weight of
189.8 lbs and no notes from a MDT meeting regarding the resident’s weight variance.
Review of the resident’s quarterly MDS, dated [DATE], showed a weight of 152 lbs.
Review of the resident’s weights in the electronic medical records showed:
– 9/30/18: 152 lbs;
– 10/7/18: 148.6 lbs;
– 10/14/18: 148.8 lbs;
– 10/21/18: 145.3 lbs;
– 10/28/18: 144.4 lbs;
– 11/4/18: 152.2 lbs;
– 11/11/18: 184.2 lbs;
– 11/18/18: 148.2 lbs.
Review of the resident’s medical records showed no dietitian’s note after the jump in
weight to 184.2 lbs and the drop to 148.2 lbs the following week.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
2. Review of Resident #16’s registered dietician note, dated 5/31/18, showed:
– admitted to hospice and appetite is poor.
– Consumes 26-45% of accepted meals.
– Recent weight 135.6 pounds (lbs).
– Refused weekly weight.
– Will monitor weight and plan of care.
Review of Resident #16’s quarterly MDS, dated [DATE], showed:
– Moderate cognitive impairment.
– On a therapeutic diet.
– Extensive assist of one staff for eating.
– Diagnoses included [MEDICAL CONDITION].
– Weight is blank.
Review of the resident’s weights on the medical record showed:
– 5/12/18: 135.6 lbs
– (MONTH) (YEAR): No weights
– (MONTH) (YEAR): No weights
– (MONTH) (YEAR): No weights
– (MONTH) (YEAR): No weights
– (MONTH) (YEAR): No weights
– 11/11/18: 170.4 lbs
– 11/19/18: 105.4 lbs
– 12/02/18: 114.4 lbs
– 12/9/18: 168.8 lbs
Review of the registered dietician notes, dated 11/19/18, showed:
– Quarterly MDS completed.
– No weights on record and request staff for monthly weights to monitor nutritional
status.
3. Review of Resident #23’s 14 day MDS dated [DATE] showed:
– Short- and long-term memory loss.
– Severely cognitively impaired.
– Independent with eating.
– Insulin six days.
– No mechanically altered or diabetic diet.
– No weight gain or loss noted.
– Weight 162 pounds (lbs).
– Diagnoses included: Anorexia and diabetes.
Review of the resident’s weights on 12/13/18 showed:
– 10/9/18: 164 lbs.
– 10/28/18: 209 lbs.
– 11/4/18: 171.4 lbs.
– Current weight 12/9/18: 151 lbs.
4. During an interview with on 12/12/18, at 3:21 P.M., the registered dietician (RD),
said:
– Staff should weigh residents according to the physician orders.
– Staff should weigh residents at least monthly.
– There is no one person designated to weigh the residents.
– Staff should reweigh a resident if there is a large weight variance, notify the charge
nurse, the physician, and then notify him/her.
During an interview on 12/13/18 at 1:30 P.M., the Director of Nursing (DON) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
– No one staff member was assigned to weigh residents on the units; any staff can weigh
the residents.
– Certified Nurse’s Aides or anyone can weigh the residents.
– The weights should be recorded on the Medication Administration Record (MAR).
– Residents should be weighed at least monthly or as often as ordered.
– The nurse should look at the MAR and tell a staff member to weigh the resident if
needed.
– The Dietician should pull all the weights and bring to the weekly meeting to discuss
weight loss and interventions to be put in place.
– Staff identify those residents with weight loss at the weekly meeting and we make
changes or put interventions in place.
– The Dietician should assess weight on admission to facility, at least quarterly or more
often depending on weight loss.
– Staff should reweigh a resident if the weight fluctuates greatly.
– The facility scale may need to be recalibrated.
– The physician should be notified of significant weight fluctuations, changes in weight,
or refusal for weights to be obtained.

F 0711

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
had the physicians to review orders monthly and obtain a signed physician’s orders
[REDACTED].#10, #13, and #23); and failed to reconcile new medication orders when a
resident returned from the hospital which affected on resident (Resident #14). The
facility census was 37.
1. Review of the facility’s Reconciliation of Medications on Admission policy dated July,
(YEAR) showed:
– Purpose: To Ensure medication safety by accurately accounting for the resident’s
medications, routes, and dosages upon admission or readmission to the facility.
– Gather information needed to reconcile the medication list: Approved medication
reconciliation form, discharge summary from referring facility, admission order sheet, all
prescriptions and supplement information obtained from the resident/family during the
medication history, and most recent Medication Administration Record [REDACTED].
– Medication reconciliation is the process of comparing pre-discharge medications to
post-discharge medications by creating an accurate list of both prescription and over the
counter medications that includes the drug name, dosage, frequency, route, and indication
for use for the purpose of preventing unintended changes or omissions at transition points
of care.
– Medication reconciliation reduces medication errors and enhances resident safety by
ensuring that the medications the resident needs and has been taking continue to be
administered without interruption, in the correct dosages and routes, during the
admission/transfer process.
– Medication reconciliation helps to ensure that all medications, routes, and dosages on

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0711

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
the list are appropriate for the resident and his/her condition, and do not interact in a
negative way with other medications/supplements on the list.
– Medication reconciliation helps to ensure that medications, routes, and dosages have
been accurately communicated to the attending physician and care team.
– If there is a discrepancy or conflict in medications, dose, route, or frequency,
determine the most appropriate action to resolve the discrepancy such as: Contact nurse
from referring facility, contact the physician from the referring facility, discuss with
the family, contact the resident’s primary physician or attending physician.
Review of the facility’s Administering Medications policy dated December, 2012 showed:
– Medications shall be administered in a safe and timely manner and as prescribed.
– Medications must be administered in accordance with the orders, including any required
time frame.
2. Review of Resident #10’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/7/18 showed:
– Short- and long-term memory problems.
– Moderately impaired cognition, supervision needed for making decisions.
– [DIAGNOSES REDACTED].
Review of the physician’s orders [REDACTED].
– No signed order for [MEDICATION NAME] 125 mcg, daily at noon.
– Start date 11/28/18.
– End date- Open ended.
Review of the Medication Administration Record [REDACTED]
– Staff administered and/or attempted to administer the [MEDICATION NAME] on days 12/1/18
through 12/9/18.
3. Review of Resident # 23’s 14 day assessment dated [DATE] showed:
– Short- and long-term memory problems.
– Severely cognitively impaired.
– [DIAGNOSES REDACTED].
– Antidepressants five of last seven days.
– Antipsychotics three of the last seven days.
Review of the POS [REDACTED]
– No signed orders by the physician for the following medications: [REDACTED]
– Start date- 11/7/18- [MEDICATION NAME] tablet (for nausea) 4 milligrams (mg), every six
hours PRN, end date open ended.
– Start date- 11/7/18- [MEDICATION NAME]/[MEDICATION NAME] 10/325 mg, one tablet every
eight hours for pain, end date open ended
– Start date 11/7/18- Pantoprazole (for gastric reflux) 40 mg daily, end date open ended.
– Start date 11/7/18- [MEDICATION NAME] (to lower cholesterol) 80 mg at bedtime, end date
open ended.
– Start date 11/7/18- Occupational Therapy (OT) evaluation and treat as indicated, end
date open ended.
Review of the MAR for 12/1/18 through 12/13/18 showed:
– Staff administered the medications 12/1/18 through 12/13/18.
4. Review of Resident #14’s quarterly MDS dated [DATE] showed:
– A Brief Interview for Mental Status score of 13 which indicated that he/she made his/her
own decisions.
– Shortness of breath with sitting and exertion.
– Diuretics (rids body of excess fluid buildup) in last seven days.
– Anticoagulants (blood thinner) in last six days.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0711

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
– [DIAGNOSES REDACTED].
Review of the hospital discharge medication record dated 12/3/18 showed:
– New medication: [MEDICATION NAME] (blood pressure medication) 2.5 mg daily.
– New medication: [MEDICATION NAME] (blood pressure medication) 25 mg daily.
– New medication: [MEDICATION NAME] sulfate (MS) concentrate 20 mg/ milliliter (ml),
administer 0.25 ml every four hours as needed (PRN).
– New medication: [MEDICATION NAME] 10 mg, four tablets once a day for four days, three
tablets daily for four days, two tablets daily for four days, then one tablet daily for
four days, the discontinue.
– Continued previously ordered medications included: [MEDICATION NAME] (pain and fever
medication) 325 mg, two tablets every four hours as needed (PRN).
– Continued: [MEDICATION NAME] diskus (to treat asthma) 250/50 mg, inhale twice (BID)
daily;
– Continued: Aspirin (blood thinner) 81 mg daily.
– Continued: [MEDICATION NAME] (to treat constipation) 10 mg rectal suppository daily PRN.
– Continued: [MEDICATION NAME] (to treat asthma) 0.5 mg-2.5 mg/3 ml inhale 3 ml four times
(QID) per day.
– Continued: [MEDICATION NAME] (to treat sinus congestion) 50 mcg/inhale nasal spray, one
spray BID.
– Continued: [MEDICATION NAME] (diuretic) 80 mg daily.
– Continued: [MEDICATION NAME] (used to treat pain or [MEDICAL CONDITION]) 100 mg daily at
noon.
– Continued: [MEDICATION NAME] (cold and flu medication) 600 mg, one every 12 hours.
– Continued: [MEDICATION NAME][MEDICATION NAME](used to treat nausea and vomiting) four
mg, one tablet every six hours PRN.
– Continued: Potassium chloride (a supplement) 20 milliequivilents (meq), one tablet BID.
– Continued: Senna (stool softener) 8.6 mg, two tabs daily.
– Continued: [MEDICATION NAME] (a diuretic and blood pressure medication) 25 mg, one
tablet daily.
– Continued: Tamsulosin (treatment of [REDACTED].
– Discontinue: [MEDICATION NAME] (blood pressure medication) 25 mg, ½ tab BID,
– Discontinue: MS concentrate 20 mg/5 ml, five mg every four hours PRN.
Review of the physician’s history and physical dated 12/7/18 showed:
– Medications reviewed.
– Assessment and plan: Increased [MEDICATION NAME] to BID x three days, adding [MEDICATION
NAME] ([MEDICATION NAME], a diuretic, signed by physician) every morning; continue BB (no
name of medication given), [MEDICATION NAME] (signed), [MEDICATION NAME] (signed),
[MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME], not signed),
Senna (not signed), [MEDICATION NAME] (not signed) and [MEDICATION NAME] (not signed and
two different orders).
Review of the facility POS dated 12/13/18 showed:
– [MEDICATION NAME] 10 mg suppository, ordered 11/7/18, one daily PRN, not signed by the
attending physician.
– [MEDICATION NAME] capsule 100 mg daily, not signed by the attending physician and not
included in the hospital discharge orders.
– [MEDICATION NAME] capsule 100 mg, two capsules BID, not signed by the attending
physician and a different dose from the hospital discharge order; ordered 11/7/18 with an
open ended discontinue date.
– Senna 8.6 mg, two tabs daily, ordered 11/7/18, not signed by the attending physician.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0711

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
– Potassium chloride 20 meq, one tablet BID, ordered 11/19/18, not signed by the attending
physician.
– [MEDICATION NAME]/[MEDICATION NAME] (to treat asthma) solution per a nebulizer (machine
used to inhale the medication), ordered 12/3/18, 0.5-3 mg, one vial QID; not included on
hospital discharge orders and not signed by the attending physician.
– [MEDICATION NAME] tablet, one tablet every 12 hours, not signed by the attending
physician.
– [MEDICATION NAME] (used to treat gastric reflux) 40 mg one tablet daily, ordered
12/13/18 and not signed by the attending physician.
Review of the MAR indicated [REDACTED]
– Staff administered the medications to the resident.
5. Review of Resident #13’s electronic medical records on 12/10/18, showed:
– Green checkmarks down the side of the e-POS to indicate the orders that had been signed
off on;
– Red Xs were next to three orders on the POS;
– [MEDICATION NAME] (used for constipation), 100 mg, one tablet, twice a day; ordered on
[DATE];
– [MEDICATION NAME] SR (used to treat anxiety) sustained-release 12 hour, 150 mg, by mouth
daily; ordered on [DATE];
– [MEDICATION NAME] D (used to treat seasonal allergy), extended release 12 hour, [PHONE
NUMBER] mg tablet, one tablet at bedtime;
– All three medications were ordered by the same physician, who was not the resident’s
attending physician.
6. During an interview on 12/13/18, at 8:45 A.M., the Admissions Coordinator (AC) said:
– She usually put new orders into the computer when a resident was admitted or readmitted
.
– Nurses also put in orders when a resident was readmitted .
– Anytime a resident returns from the hospital the orders should be entered and dated the
date of return and signed by the staff who entered the orders.
During an interview on 12/13/18 at 1:30 P.M., the Director of Nursing (DON) said:
– All POS medications should be signed by the physician.
– Telephone orders should be signed by the physician within 24 to 48 hours after the nurse
received the order.
– Readmit orders should be entered into the computer when the resident returns to the
facility.
– The Admissions Coordinator (AC) was responsible for monitoring return/discharge orders
into the computer.
– LPN C was the nurse who worked when Resident #14 returned on 12/3/18 and should have
entered all discharge orders into the computer upon the resident’s arrival to the
facility.
– LPN C said he/she thought he/she only needed to enter the medications that were changed
for Resident #14 and did not realize all medications needed to be entered to show new
orders after discharge from the hospital.
– All previous orders prior to hospitalization are always discontinued and the new
discharge orders need to be entered and considered the newest orders to follow.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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

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 record review and interviews, the facility failed to assure they followed their
policy to act on any irregularities noted by the pharmacist during the monthly Medication
Regimen Review (MRR), which affected one of 12 sampled residents (Resident #1). The
facility census was 37.
Review of the facility’s Medication Regimen Review, revised (MONTH) 2007, showed:
– The consultant pharmacist shall review the medication regimen of each resident at least
monthly.
– The primary purpose of this review is to help the facility maintain each resident’s
highest practicable level of functioning by helping them utilize medications appropriately
and prevent or minimize adverse consequences related to medication therapy to the extent
possible.
– The consultant pharmacist will document his/her findings and recommendations on the
monthly drug/medication regimen review report and will provide the Director of Nursing
(DON) and medical director with a signed, dated copy of the report, listing the
irregularities found and recommendations for their solutions.
– The consultant pharmacist will provide a written report to physicians for each resident
with an identified irregularity.
– Copies of drug/medication regimen review reports, including physician responses, will be
maintained as part of the permanent medical record.
– The facility shall include a review of key issues related to medications and medication
irregularities in its quality assurance (QA) program.
1. Review of Resident #1’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/27/18, showed:
– Little interest or pleasure in doing things, feeling down, depressed or hopeless several
days; feeling tired or having little energy nearly every day;
– Took antianxiety, antidepressants and opiods seven out of seven days.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Little interest or pleasure in doing things, feeling down, depressed or hopeless several
days; feeling tired or having little energy nearly every day;
– Took antianxiety, antidepressants and opiods seven out of seven days;
– Did not indicate if a GDR had been attempted as of 7/13/18.
Review of the resident’s care plan showed a problem of [MEDICAL CONDITION] drug use with
start date of 7/27/18. The plan showed the following:
– At risk for adverse consequences related to receiving antianxiety and antidepressant
medication;
– Assess if behavioral/mood symptoms present a danger;
– Attempt non-pharmacological interventions;
– Monitor for effectiveness;
– Monitor mood;
– Pharmacy consultant review every month.
Review of the Medication Regimen Review (MRR) Active Recommendations Lacking a Final
Response, dated 8/13/18, showed:
– Resident is receiving one or more psychopharmacological agents. In order to continually
evaluate the need of this therapy, please document behaviors at least daily. Routed to:
Nursing;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 28)
– Has an order for [REDACTED]. The typical application is 2 to 4 grams and the maximum
total body dose of 1% gel should not exceed 32 grams per day. Please clarify this order to
ensure proper administration; routed to: physician;
– Recommendation status: No Response.
Review of the MRR, dated 9/27/18, showed:
– Recently started on [MEDICATION NAME] (an antidepressant, sometimes used as an appetite
stimulant and [MEDICAL CONDITION], but never used to treat [MEDICAL CONDITION] arthritis).
Please correct the indication associated with this order;
– Please discontinue as needed (PRN) [MEDICATION NAME] (an [MEDICATION NAME]) due to
non-use.
– Resident is receiving one or more psychopharmacological agents. In order to continually
evaluate the need of this therapy, please document behaviors at least daily. Routed to:
Nursing;
– Has an order for [REDACTED]. The typical application is 2 to 4 grams and the maximum
total body dose of 1% gel should not exceed 32 grams per day. Please clarify this order to
ensure proper administration; routed to: physician;
– Recommendation status: No Response.
Review of the Medication Regimen Review (MRR) Active Recommendations Lacking a Final
Response, dated 10/19/18, showed:
– Recently started on [MEDICATION NAME] (an antidepressant, sometimes used as an appetite
stimulant and [MEDICAL CONDITION], but never used to treat [MEDICAL CONDITION] arthritis).
Please correct the indication associated with this order;
– Please discontinue as needed (PRN) [MEDICATION NAME] (an [MEDICATION NAME]) due to
non-use.
– Resident is receiving one or more psychopharmacological agents. In order to continually
evaluate the need of this therapy, please document behaviors at least daily. Routed to:
Nursing;
– Has an order for [REDACTED]. The typical application is 2 to 4 grams and the maximum
total body dose of 1% gel should not exceed 32 grams per day. Please clarify this order to
ensure proper administration; routed to: physician;
– Recommendation status: No Response.
Review of the resident’s current physician’s orders [REDACTED].
– [MEDICAL CONDITION] arthritis listed as his/her first diagnosis;
– Order date: 11/28/18: Chart behaviors every shift;
– Order date: 4/18/18: [MEDICATION NAME], 25 mg, orally PRN;
– Order date: 4/18/18: [MEDICATION NAME] gel, 1%, 1% topically, four times a day; did not
indicate a dosage for administration;
– Order date: 8/30/18: [MEDICATION NAME], 7.5 mg orally; at bedtime; Diagnosis:
[REDACTED].
During an interview on 12/10/18, at 5:06 P.M., the Director of Nursing (DON) said:
– There is no process in place to ensure medication review are given to the physician and
followed up on.
– Staff should review the Consultant Pharmacist’s Medication Regimen Review monthly, make
appropriate changes, and follow up to make sure they are addressed.
– Staff should give the physicians the Attending Physician/Prescriber Sheet to receive
recommendations and orders within a few days of the physician receiving them.
Review of the resident’s medical record on 12/12/18, showed no behaviors charted for the
resident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the failed failed to ensure one of 12
sampled residents (Resident #1) who used psychotic and [MEDICAL CONDITION] drugs received
a gradual dose reduction (GDR) in an effort to discontinue these medications. The facility
also failed to ensure as needed (PRN) orders for psychotic and [MEDICAL CONDITION] and
drugs were limited to 14 days which affected three of 12 sampled residents (Resident #5,
#16 and #22) and had the potential to affect all residents who received psychoactive
medications. The facility census was 37.
Review of the facility’s Tapering Medications and GDR Reduction Policy, revised (MONTH)
2007, showed:
– All medications shall be considered for possible tapering. Tapering that is applicable
to antipsychotic medications shall be referred to as a gradual dose reduction.
– Residents who use antipsychotic drugs shall receive gradual dose reductions and
behavioral interventions, unless clinically contraindicated, in an effort to discontinue
these drugs.
– Periodically, the staff and practitioner will review the continued relevance of each
resident’s medications.
– Within the first year after a resident is admitted on an antipsychotic medication or
after the resident has been started on an antipsychotic medication, the staff and
practitioner shall attempt a GDR, in two separate quarters (with at least one month
between the attempts), unless clinically contraindicated. After the first year, the
facility shall attempt a GDR at least annually, unless clinically contraindicated.
– Attempting tapering of sedatives and hypnotics shall be considered as a way to
demonstrate whether the resident is benefiting from a medication or might benefit form a
lower or less frequent dose.
Review of the facility’s Medication Regimen Review, revised (MONTH) 2007, showed:
– The consultant pharmacist shall review the medication regimen of each resident at least
monthly.
– The primary purpose of this review is to help the facility maintain each resident’s
highest practicable level of functioning by helping them utilize medications appropriately
and prevent or minimize adverse consequences related to medication therapy to the extent
possible.
– The consultant pharmacist will document his/her findings and recommendations on the
monthly drug/medication regimen review report and will provide the Director of Nursing
(DON) and medical director with a signed, dated copy of the report, listing the
irregularities found and recommendations for their solutions.
– The consultant pharmacist will provide a written report to physicians for each resident
with an identified irregularity.
– Copies of drug/medication regimen review reports, including physician responses, will be
maintained as part of the permanent medical record.
– The facility shall include a review of key issues related to medications and medication
irregularities in its quality assurance (QA) program.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
1. Review of Resident #1’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/27/18, showed:
– Little interest or pleasure in doing things, feeling down, depressed or hopeless several
days; feeling tired or having little energy nearly every day;
– Took antianxiety, antidepressants and opiods seven out of seven days.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Little interest or pleasure in doing things, feeling down, depressed or hopeless several
days; feeling tired or having little energy nearly every day;
– Took antianxiety, antidepressants and opiods seven out of seven days;
– Did not indicate if a GDR had been attempted as of 7/13/18.
Review of the resident’s care plan showed a problem of [MEDICAL CONDITION] drug use with
start date of 7/27/18. The plan showed the following:
– At risk for adverse consequences related to receving antianxiety and antidepressent
medication;
– Assess if behavioral/mood symptoms present a danger;
– Attempt non-pharmacological interventions;
– Monitor for effectiveness;
– Monitor mood;
– Pharmacy consultant review every month.
Review of the Consultant Pharmacist’s Medication Regimen Review (MRR) sheet, dated
8/13/18, showed the pharmacist indicated the resident is on low-dose [MEDICATION NAME]
(used to treat anxiety) 0.25 milligrams (mg) nightly. During the first year in which the
resident is admitted on a psychopharmacological medications or after the facility has
initiated such a medications, the facility should attempt to taper the medication during
at least two separate quarters (with at least one month between attempts), unless
clinically contraindicated. Please consider a trial discontinuation of the medication or
document clinical rationale below (including risk/benefit) for continuing current dose.
Review of the Note to Attending Physician/Prescriber, dated 8/13/18, showed the pharmacist
indicated the same information as in the MRR. The resident’s physician had not indicated a
response to the pharmacist’s recommendations.
Review of the MRR Active Recommendations Lacking a Final Response sheet, dated 9/27/18,
showed the pharmacist indicated the resident is on low-dose [MEDICATION NAME] (used to
treat anxiety) 0.25 milligrams (mg) nightly. During the first year in which the resident
is admitted on a psychopharmacological medications or after the facility has initiated
such a medications, the facility should attempt to taper the medication during at least
two separate quarters (with at least one month between attempts), unless clinically
contraindicated. Please consider a trial discontinuation of the medication or document
clinical rationale below (including risk/benefit) for continuing current dose. Routed to:
physician.
Review of the Medical Director Report of Irregularities sheet, dated 11/16/18, showed the
pharmacist indicated the resident is on low-dose [MEDICATION NAME] (used to treat anxiety)
0.25 milligrams (mg) nightly. During the first year in which the resident is admitted on a
psychopharmacological medications or after the facility has initiated such a medications,
the facility should attempt to taper the medication during at least two separate quarters
(with at least one month between attempts), unless clinically contraindicated. Please
consider a trial discontinuation of the medication or document clinical rationale below
(including risk/benefit) for continuing current dose.
Review of the Note to Attending Physician/Prescriber, dated 11/16/18, showed the
pharmacist indicated the same information as above. The resident’s physician had not
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
indicated a response to the pharmacist’s recommendations.
Review of the resident’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– [MEDICATION NAME], 0.25 mg, orally, twice a day (BID) at 6:00 A.M. and 6:00 P.M.;
– Order date of 4/18/18, with no end date.
Review of the resident’s medical record on 12/12/18, showed no documentation from the
resident’s physician to indicate why he/she did not respond to the GDR recommendations in
August, (MONTH) and November, (YEAR), made by the pharmacist.
2. Review of Resident #5’s MRR sheet, dated 11/1/18 through 11/16/18, showed:
– 11/16/18: Beginning (MONTH) 28th, (YEAR) PRN orders for antipsychotic drugs are limited
to 14 days. This resident currently has an active order for PRN [MEDICATION NAME] (an
antipsychotic to treat mental/mood disorders). If you feel it is appropriate for the PRN
order to be renewed every 14 days, please ensure proper documentation exists in the
resident’s medical record and face to face visit is performed in order to renew the order
every 14 days. Alternatively, would you like to discontinue this resident’s PRN
[MEDICATION NAME]?
Review of the Note to Attending Physician/Prescriber Sheet, dated 11/16/18, showed:
– Beginning (MONTH) 28th, (YEAR) PRN orders for antipsychotic drugs are limited to 14
days. This resident currently has an active order for PRN [MEDICATION NAME]. If you feel
it is appropriate for the PRN order to be renewed every 14 days, please ensure proper
documentation exists in the resident’s medical record and a face to face visit is
performed in order to renew the order every 14 days. Alternatively, would you like to
discontinue this resident’s PRN [MEDICATION NAME]?
Review of the POS [REDACTED]
– [MEDICATION NAME] 2 mg/milliliter (ml) liquid administer 0.5 ml every four hours PRN for
nausea.
– Start date: 10/22/18
– End date: open ended.
– [MEDICATION NAME] (an antianxiety, Schedule IV medication low potential for abuse and
affects the central nervous system) 2 mg/ml administer 0.25 ml sublingual (SL, under the
tongue) PRN every four hours for anxiety disorder.
– Start date: 10/22/18
– End date: open ended.
Review of the resident’s care plan, revised 12/4/18,showed:
– Problem: [MEDICAL CONDITION] drug use.
– Receives antianxiety medication related to anxiety.
– Approaches: Monitor behavior and mood symptoms; establish a baseline functional status
prior to initiating the medication; monitor for effectiveness and adverse consequences;
document behavior and mood.
Review of the resident’s medical record showed no Attending Physician/Prescriber sheets
completed.
2. Review of Resident #16’s POS, dated 11/10/18 through 12/10/18, showed:
– [MEDICATION NAME] 2 mg/ml administer 0.25 ml PRN every four hours for anxiety with a
[DIAGNOSES REDACTED].
– Start date: 10/24/18
– End date: open ended.
Review of the care plan, revised 12/4/18, showed:
– Problem: [MEDICAL CONDITION] drug use.
– Receives antidepressant medication for treatment of [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
– Approaches; monitor residents mood and behavior; pharmacy consultant review; document
resident’s mood; assess/record effectiveness of medication; and establish a baseline
functional status prior to initiating the medication.
Review of the resident’s medical record showed no Attending Physician/Prescriber sheets
completed.
3. Review of Resident #22’s Medical Director Report of Irregularities dated 11/1/18
through 11/16/18 showed:
– Addressed to Physician A.
– The resident currently has an active order for PRN Ambien. If you feel it is appropriate
for the PRN order to be extended beyond 14 days, please ensure proper documentation exists
in the resident’s medical record and indicate the duration for the PRN order.
Alternatively, would you like to discontinue the resident’s Ambien?
– Note written to physician.
Review of the MRR Sheet dated 11/1/18 through 11/16/18 showed:
– 11/16/18: The resident currently has an active order for PRN Ambien. If you feel it is
appropriate for the PRN order to be extended beyond 14 days, please ensure proper
documentation exists in the resident’s medical record and indicate the duration for the
PRN order. Alternatively, would you like to discontinue the resident’s Ambien?
– 11/16/18: Beginning (MONTH) 28th, (YEAR), PRN orders for antipsychotic drugs are limited
to 14 days. This resident currently has an active order for PRN [MEDICATION NAME]
([MEDICATION NAME]). If you feel it is appropriate for the PRN order to be renewed every
14 days, please ensure proper documentation exists in the resident’s medical record and a
face-to-face visit is performed in order to renew the order every 14 days. Alternatively,
would you like to discontinue this resident’s PRN [MEDICATION NAME]?
– Note written to physician.
Review of the POS [REDACTED]
– [MEDICATION NAME] (an antianxiety, Schedule IV medication low potential for abuse and
affects the central nervous system) 0.25 ml sublingual (SL, under the tongue) as needed
(PRN) every four hours for agitation/restlessness/anxiety.
– Start date: 11/10/10
– End date: Open ended.
– [MEDICATION NAME] (an antipsychotic to treat mental/mood disorders) 0.5 mg, one tablet
every six hours PRN.
– Start date: 10/26/18.
– End date: 11/20/18, D/C (discontinue) date.
-[MEDICATION NAME](Schedule IV, hypnotic for [MEDICAL CONDITION]) five mg tablet,
administer 2.5 mg at bedtime.
– Start date: 10/29/18.
– End date: 11/29/18, D/C date.
Review of the care plan dated 11/14/18 showed:
– Problem: [MEDICAL CONDITION] drug use.
– Received hypnotic medications related to [MEDICAL CONDITION] (sleeplessness).
– Goal: Would not exhibit signs of drug related sedation, low blood pressure, or
[MEDICATION NAME] (how the nerves affect body movement) symptoms.
– Approaches: Assess for underlying condition/cause requiring hypnotic.
– Assess/record effectiveness of the drug treatment, monitor and report signs of sedation,
low blood pressure, or [MEDICATION NAME] symptoms.
– Attempt non-pharmacological (non-medication) interventions.
– Quantitatively and objectively document the resident’s mood/behavior.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
– Problem: [MEDICAL CONDITION] drug use.
– At risk for adverse consequences related to receiving antipsychotic medication for
treatment of [REDACTED].
– Goal: Would not exhibit signs of drug related side effects or adverse drug reaction
through next review dated.
– Approaches: Assess if behavioral symptoms present a danger to the resident and/or others
and intervene as necessary.
– Assess functional status prior to initiation of drug use to serve as baseline.
– Assess/record effectiveness of drug treatment, monitor and report signs of sedation,
[MEDICATION NAME] and other symptoms.
– Monitor for signs of extrapyramidal symptoms: [DIAGNOSES REDACTED] (continuous spasms
and muscle contractions), akathisia (motor restlessness), Parkinsonism (characteristic
symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive
dyskinesia (irregular, jerky movements).
– Monitor resident’s behavior and response to medication.
– Quantitatively and objectively document the resident’s behavior.
– Attempt non-pharmacological interventions.
– Problem: [MEDICAL CONDITION] drug use.
– Received antidepressant medication related to depression.
– Goal: Would not exhibit signs of drug related sedation, low blood pressure, or
[MEDICATION NAME] symptoms through the next review.
– Approaches: Assess resident’s functional status prior to initiation of drug use to serve
as a baseline.
– Assess/record effectiveness of drug treatment, monitor and report sign of sedation,
[MEDICAL CONDITION], or [MEDICATION NAME] symptoms.
– Drug reduction as recommended by pharmacist.
– Monitor resident’s mood and response to medication.
– Pharmacy consultant review.
Review of the Note to Attending Physician/Prescriber dated 11/16/18 showed:
– Beginning (MONTH) 28th, (YEAR), PRN orders for antipsychotic drugs are limited to 14
days. This resident currently has an active order for PRN [MEDICATION NAME] ([MEDICATION
NAME]). If you feel it is appropriate for the PRN order to be renewed every 14 days,
please ensure proper documentation exists in the resident’s medical record and a
face-to-face visit is performed in order to renew the order every 14 days. Alternatively,
would you like to discontinue this resident’s PRN [MEDICATION NAME]?
– Physician A did not sign, did not mark agree or disagree, or give a reason to continue
[MEDICATION NAME] to discontinue the medication.
Review of the Note to the Attending Physician/Prescriber dated 11/16/18 showed:
– The resident currently has an active order for PRN Ambien. If you feel it is appropriate
for the PRN order to be extended beyond 14 days, please ensure proper documentation exists
in the resident’s medical record and indicate the duration for the PRN order.
Alternatively, would you like to discontinue the resident’s Ambien?
– Physician A did not sign, did not mark agree or disagree, or give a reason to continue
[MEDICATION NAME] to discontinue the medication.
Review of the MRR Active Recommendations Lacking a Final Response sheet dated 11/16/18
showed:
– Recommendation: [MEDICATION NAME] is considered an antipsychotic, although it can be
used to treat nausea and vomiting. Therefore, according to Federal requirements, a PRN
order for [MEDICATION NAME] is limited to 14 days. A new PRN order cannot be renewed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
unless the attending or prescribing practitioner first evaluates the resident to determine
if entering a new order for the PRN medication is appropriate. If you feel it is
appropriate for the PRN order to be extended beyond 14 days, please ensure proper
documentation exists in the resident’s medical record and indicate the duration for the
PRN order. Alternatively, would you like to discontinue this resident’s PRN [MEDICATION
NAME]?
– Routed to the physician.
– Recommendation Status: No response.
Review of the significant change in condition MDS dated [DATE] showed:
– A Brief Interview for Mental Status (BIMS) score of nine, which indicated supervision
needed for decision making.
– Mood score of eight which indicated poor concentration, poor appetite, complaints of
tiredness, and trouble falling and staying asleep.
– No behaviors.
– Antidepressants in last seven days.
– Antipsychotics in last four days.
– Antipsychotics given on and as needed (PRN) basis.
– No GDR attempted.
– GDR not documented by the physician.
– Medication follow-up not assessed/no information.
– Hospice.
– [DIAGNOSES REDACTED].
Review of the Care Area Assessment Summary (CAAS, determines areas of care to be care
planned) dated 11/19/18 showed:
– Resident took antipsychotic and antidepressant medications.
– Unnecessary drug evaluation: No excessive dose or duration, no inadequate monitoring of
effectiveness or adverse consequences, and no inadequate or inappropriate indications for
use.
– Antidepressants: Increased risk for falls.
– Antipsychotics: Increased risk for falls.
– Overall status change for relationship to psychotic drug use: No major difference in
A.M./P.M. performance, no decline in cognition/communication, no decline in mood, not
decline in behavior, and no decline in activities of daily living (ADL).
– Analysis: Resident reassessed for significant change due to going on hospice services.
History [MEDICAL CONDITION] of the lung with metastasis to the brain. Other comorbidities
included high blood pressure, [MEDICAL CONDITION], and gastric reflux disease. Alert,
confusion at times but able to voice needs. On antidepressants for a [DIAGNOSES REDACTED].
[MEDICATION NAME] PRN and used during look back period with no side effects noted. No GDR
noted, nursing to contact the physician for orders. Staff to observe for any side effects
and report.
Review of the resident’s medical record on 12/13/18 showed:
– No Consultant Pharmacist’s Medication Regimen Review Sheet for [MEDICATION NAME] PRN.
– No Consultant Pharmacist’s Medication Regimen Review Active Recommendations Lacking
Final Response sheet for [MEDICATION NAME] PRN.
– No Note to the Attending Physician/Prescriber sheet for [MEDICATION NAME] PRN.
4. During an interview on 12/10/18, at 5:06 P.M., the Director of Nursing (DON) said:
– GDR’s have not been completed since (MONTH) (YEAR) due to short staffing.
– There is no process in place to ensure medication review and GDR’s are given to the
physician and followed up on.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
– Staff should review the Consultant Pharmacist’s Medication Regimen Review monthly, make
appropriate changes, and follow up to make sure they are addressed.
– Staff should give the physicians the Attending Physician/Prescriber Sheet to receive
recommendations and orders within a few days of the physician receiving them.

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided a safe and effective medication administration system that was free of
significant medication errors which affected two of 12 sampled residents (Resident #9 and
#10) when they did not administer physician ordered medications because the contracted
pharmacy did not provide the medication in a timely manner and as ordered and administered
a medication that was discontinued by the attending physician. The facility census was 37.
1. Review of the facility’s Administering Medications policy dated December, 2012 showed:
– Medications shall be administered in a safe and timely manner and as prescribed.
– Medications must be administered in accordance with the orders, including any required
time frame.
Review of the Pharmacy Services Overview policy dated April, 2007 showed:
– The facility shall accurately and safely provide or obtain pharmacy services including
the provision of routine and emergency medications and biologicals, and the services of a
licensed pharmacist.
– The licensed pharmacist shall collaborate with the facility leadership and staff to
coordinate pharmacy services within the facility and to guide the development and
implementation of pharmacy services procedures.
– The facility shall contract with a licensed pharmacist to help it obtain and maintain
timely and appropriate pharmacy services that support residents’ needs, are consistent
with current standards of practice, and meet state and federal requirements.
– This includes collaborating with the facility and Medical Director to develop,
implement, evaluate, and revise the procedures for the provision of all aspects of
pharmacy services including ordering, delivery and acceptance, storage, distribution,
preparation, dispensing, administration, disposal, documentation, and reconciliation of
all medications and biologicals in the facility.
– Help the facility develop mechanisms to communicate, address, and resolve issues related
to pharmacy services.
– Help the facility assure that medications are requested, received, and administered in a
timely manner as ordered by authorize prescribers.
– Recommend the types of medication delivery system to standardize packaging, such as
bottles, bubble packs, tear strips, in an effort to minimize medication errors.
2. Review of Resident # 9’s physician’s orders [REDACTED].
– Ordered 9/10/18: [MEDICATION NAME] with sugar powder in packet, 4 grams (gm), one packet
daily for diarrhea.
– [MEDICATION NAME] (Vitamin B12) solution, 1,000 micrograms (mcg)/milliliter (ml),
administer 1,000 mcg/1ml daily one Tuesday every two weeks intramuscularly (IM, inject
into muscle).
– [MEDICATION NAME] (An [MEDICATION NAME] used to treat severe allergic reactions)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
injectable, 50 mg IM every day PRN (as needed) for rash, allergy).
Medication Administration Record (MAR) dated 9/9/18 through 9/30/18 showed:
– Administer medications as ordered, evaluate/record/report effectiveness and any adverse
side effects daily, charted daily as done.
– [MEDICATION NAME] four gm packet with sugar given daily during the month of September,
(YEAR).
– [MEDICATION NAME] given IM on Tuesday, 9/11/18.
– [MEDICATION NAME] not given on Tuesday, 9/25/18; reason charted- Pharmacy called and
medication ordered.
– [MEDICATION NAME] injection given on 9/16/18, 9/18/18, and 9/22/18 for itching and
hives.
Review of the POS dated 10/10/18 through 11/10/18 showed:
– Ordered 9/10/18: [MEDICATION NAME] with sugar powder in packet, 4 gm, one packet daily
for diarrhea.
– [MEDICATION NAME] solution, 1,000 mcg/ml, administer 1,000 mcg/1ml daily one Tuesday
every two weeks intramuscularly.
– [MEDICATION NAME] injectable, 50 mg IM every day PRN for rash, allergy.
Review of the MAR dated 10/1/18 through 10/31/18 showed:
– Administer medications as ordered, evaluate/record/report effectiveness and any adverse
side effects daily, charted daily as done.
– [MEDICATION NAME] four gm packet with sugar given daily during the month of October,
(YEAR).
-[MEDICATION NAME] given IM on Tuesday, 10/9/18.
– [MEDICATION NAME] charted as given IM on Tuesday, 10/23/18 but staff gave the injection
on 10/24/18 because the medication was not in the facility on the due date of Tuesday,
10/23/18; staff had to wait for pharmacy to deliver the medication in order to be able to
administer the late dose.
– [MEDICATION NAME] injection given on 10/4/18 and 10/5/18 for headache and itching.
Review of the MAR dated 11/1/18 through 11/30/18 showed:
– Administer medications as ordered, evaluate/record/report effectiveness and any adverse
side effects daily, charted daily as done.
– [MEDICATION NAME] four gm packet with sugar given daily from 11/1/18 through 11/18/18.
The resident refused the medication from 11/19/18 through 11/30/18, no reason charted.
– [MEDICATION NAME] given IM on Tuesday, 11/6/18.
– [MEDICATION NAME] not given on Tuesday, 11/20/18, no reason charted.
– [MEDICATION NAME] injection, none give during the month of November, (YEAR).
Review of the 60 day Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, dated 11/6/18 showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions.
– Independent in all activities of daily living (ADLs).
– One injection in the last seven days.
– Weight: 426 pounds.
– [DIAGNOSES REDACTED].
– The MDS did not include a [DIAGNOSES REDACTED]. Symptoms can vary from person to person
but usually develop slowly over time. However, sometimes symptoms occur suddenly and cause
a life-threatening condition called acute [MEDICAL CONDITION], also known as an acute
adrenal crisis or Addisonian crisis).
Review of the POS dated 11/10/18 through 12/10/18 showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
– Ordered 9/10/18: [MEDICATION NAME] with sugar powder in packet, 4 gm, one packet daily
for diarrhea.
– [MEDICATION NAME] solution, 1,000 mcg/ml, administer 1,000 mcg/1ml daily one Tuesday
every two weeks intramuscularly.
– [MEDICATION NAME] injectable, 50 mg IM every day PRN.
Review of the MAR dated 12/1/18 through 12/10/18 showed:
– Administer medications as ordered, evaluate/record/report effectiveness and any adverse
side effects daily, charted daily as done.
– [MEDICATION NAME] four gm packet with sugar not given 12/1/18 through 12/10/18 due to
the resident refused the medication, reason given by resident was that he/she did not need
the medication.
– [MEDICATION NAME] not given on scheduled day of 12/4/18, no reason charted.
– [MEDICATION NAME] injection, none given 12/1/18 through 12/101/8.
During an observation of a medication pass and interview on 12/4/18 at 10:39 A.M.,
Licensed Practical Nurse (LPN) D and Resident #9 did and said:
– LPN D entered to administer medications to the resident.
– No [MEDICATION NAME] injectable was in the resident’s locked medication cabinet.
– LPN D said the pharmacy should send medications on the evening/night shift and the
evening/night shift staff should place in the resident’s locked cabinet.
– LPN D said he/she had to call for a dose of the [MEDICATION NAME] the last time the
injection was due, the week of 11/20/18, because the pharmacy did not send.
– The MAR showed the [MEDICATION NAME] had not been given since 11/6/18.
– He/she said he/she knew he/she called the pharmacy to have the dose for week of 11/20/18
to be delivered.
– Another nurse should have given the dose, but it was not charted if it was given.
– LPN D called the pharmacy to obtain a dose of the [MEDICATION NAME] for today’s
(12/4/18) dose.
– The pharmacy said it would be delivered later on 12/4/18.
– LPN D said medications were usually delivered on the evening/night shift sometimes as
late as 9:00 P.M.
– LPN D asked the pharmacy why they did not deliver the [MEDICATION NAME] because it was
ordered to be given on Tuesdays, every two weeks.
– The pharmacy said they cannot send unless staff called in order every two weeks even
though they had the original order.
– LPN D said he/she did not understand why they could not supply if the pharmacy already
had the order.
– LPN D said a note needed to be placed into the computer to tell all nurses that the
[MEDICATION NAME] should be ordered on Sundays for delivery on Monday in order to
give the dose on the scheduled day of Tuesday, every two weeks.
– LPN D attempted to administer [MEDICATION NAME] powder, four gm to the
resident but the resident refused the medication.
– The resident said the pharmacy did not send four gm packets to the facility
anymore, they sent a tub of the medicated powder and the medication did not have
a measuring device to measure the correct dose.
– The resident said one nurse poured out an amount to give him/her but she refused
because there was no way for the nurse to know if it was the correct dose of four
gm.
– The resident said no staff attempted to get the packets of medication or a
measuring device.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
– LPN D said he/she did not know why there was no measuring device to measure
the powdered medication.
– The resident reported the facility did not provide the injectable [MEDICATION NAME] for
him/her and he/she did not know why.
– The resident said his/her family member bought a bottle of injectable [MEDICATION NAME]
and provided the medication to the facility.
– LPN D said the resident provided his/her own [MEDICATION NAME] because the pharmacy
would not send the medication but he/she did not know why.
During an interview on 12/13/18 at 1:30 P.M., the Director of Nursing (DON) said:
– The Admission Coordinator (AC) entered medications into the computer and sent
the orders to the contracted pharmacy upon admission.
– The ordered medications should be received on the day of admission.
– Medications are delivered anytime during the day and even later at night.
– She did not know why the medication would not be in the facility if it was on
the original POS.
– All scheduled medications should be delivered and be available for
administration.
– The PRN ordered [MEDICATION NAME] should be sent by the pharmacy and the resident
should not have to buy the medication at an outside pharmacy for the facility to
use for administration.
– Staff should notify the DON and the pharmacy to obtain a measuring device to
measure the [MEDICATION NAME] powder for correct administration.
– She did not know why the pharmacy did not send the four gm packets as ordered
or why they did not provide a measuring device for the tub of [MEDICATION NAME]
powder.
3. Review of Resident #10’s telephone order sheet dated 10/26/18 showed:
– Discontinue [MEDICATION NAME].
Review of the quarterly MDS dated [DATE] showed:
– Short- and long-term memory problems.
– Moderately impaired cognition, supervision needed for making decisions.
– [DIAGNOSES REDACTED].
Review of the MAR dated 11/1/18 through 11/30/18 showed:
– [MEDICATION NAME] 125 mcg daily at noon.
– Administered or attempted administration daily at noon from 11/1/18 through 11/29/18.
– Staff administered a dose of [MEDICATION NAME] on 11/1/18, 11/4/18, 11/5/18, 11/6/18,
11/7/18, 11/9/18, 11/10/18, 11/12/18, 11/15/18, 11/16/18, 11/20/18, 11/21/18, 11/24/18,
and 11/28/18.
Review of the POS dated 11/10/18 through 12/10/18 showed:
– [MEDICATION NAME] 125 mcg, one tablet at noon for [MEDICAL CONDITION].
– Start date 6/27/18.
– D/C date 11/10/18
Review of the MAR dated 12/1/18 through 12/10/18 showed:
– [MEDICATION NAME] 125 mcg, on tablet at noon.
– Staff administered [MEDICATION NAME] on 12/1/18, 12/4/18, and 12/5/28.
During an interview n 12/11/18 at 2:39 P.M. the DON said:
– The physician discontinued the [MEDICATION NAME] on 10/26/18 but staff did not
discontinue it on the POS and MAR and continued to give the [MEDICATION NAME].
During an interview on 12/13/18 at 1:30 P.M., the DON said:
– The [MEDICATION NAME] was discontinued on 10/26/18 but was given through 12/13/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
– She expected medications that were discontinued to be stopped as ordered.
– The nurse who took the order should have discontinued the medications when the order was
received.

F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Employ sufficient staff with the appropriate competencies and skills sets to carry out
the functions of the food and nutrition service, including a qualified dietician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interviews, the facility failed to ensure their
qualified registered dietitian (RD) had adequate time to complete those functions of food
and nutrition services, which included assessing the nutritional needs of residents,
developing and evaluating regular and therapeutic diets, including texture of foods and
liquids, to meet the specialized needs of residents; developing and implementing person
centered education programs involving food and nutrition services for all facility staff;
and food preparation, service and storage. This affected two of 12 sampled residents
(Residents #1 and #13). The facility’s census was 37.
Review of the Nutritional Assessment policy, dated September, 2011, showed a nutritional
assessment, including current nutritional status and risk factors for impaired nutrition,
shall be conducted for each resident. The policy directed, in part, the following
procedures:
– The RD, in conjunction with the nursing staff and healthcare practitioners, will conduct
a nutritional assessment for each resident upon admission (within current initial
assessment timeframes) and as indicated by a change in condition that places the resident
at risk for impaired nutrition;
– The assessment will be conducted by the multi-disciplinary team (MDT, which includes the
RD, nursing consultant pharmacist and the resident’s physician) and shall identify at
least the following components;
– For the Dietitian: An estimate of calorie, protein, nutrient and fluid needs; whether
the resident’s current intake is adequate to meet his/her nutritional needs; and special
food formulations.
Review of the Weight Assessment and Intervention policy, dated (MONTH) 2008, showed the
MDT will strive to prevent, monitor and intervene for undesirable weight loss for our
residents. The policy directed, in part, the following procedures:
– The nursing staff will measure resident weights on admission and weekly for two weeks
thereafter. If no weight concerns are noted at that point, weights will be measured
monthly thereafter;
– Any weight change of 5% or more since the last weight assessment will be taken the next
day for confirmation. If the weight is verified, nursing will immediately notify the RD in
writing. Verbal notification must be confirmed in writing;
– The RD will review weight records monthly to follow individual weight trends over time.
Negative trends will be evaluated by the treatment team whether or not the criteria for
significant weight change as been met;
– Care planning for weight loss or impaired nutrition will be a MDT effort and will
include the physician, nursing staff, the RD, the consultant pharmacist and the
resident/legal surrogate;
– The RD will discuss undesired weight gains with the resident and/or family;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 40)
– If a resident declines to participate in a weight loss goal, the RD will document the
resident’s wishes, and those wishes will be respected.
1. Review of Resident #1’s medical record showed one nutritional assessment completed upon
the resident’s admission. The assessment was dated 4/25/18. No other nutritional
assessments found in the medical records.
2. Review of Resident #13’s medical record showed no admission nutritional assessment. The
resident was admitted on [DATE].
3. During an interview on 12/11/18, at 10:11 A.M., Clinical Coordinator (CC) A said the RD
is responsible for grievances, social services and is the household coordinator for the
4th floor. She is also responsible for activities but is already doing too much and cannot
possible do all that is required as well as RD duties.
During an interview on 12/12/18, at 3:21 P.M., the RD said she works as the RD PRN, but
was promoted to the household coordinator/social services. She is responsible for
admissions/discharges for her floor, care planning, several sections of the MDS,
scheduling physicians’ appointment, transportation, and ordering medline supplies for all
three floors. She is supposed to do full nutritional assessments on new admissions within
seven days of admit, with a significant change in condition, as well as quarterly
assessments. She is supposed to follow up on weights with a weight variance report from
the MDS, but this has just started. Staff should be contacting her when they chose to
substitute items that are on the planned menu, but they do not. She is considered the
activity director but has done no activities because of all the other issues. She began
working in (MONTH) as the household coordinator and has been unable to get all of the
dietary duties done with all of the social service issues she has to deal with.
During an interview on 12/13/18, at 1:30 P.M., the Director of Nursing (DON) said:
– The RD monitors weekly weights and brings them to the weekly meeting.
– RD assessments should be done on admission, quarterly, and with a weight variance.
– These assessments should be found in the residents’ progress notes.
– The Dietician should pull all the weights and bring to the weekly meeting to discuss
weight loss and interventions to be put in place.
– Staff identify those residents with weight loss at the weekly meeting and we make
changes or put interventions in place.
– The Dietician should assess weight on admission to facility, at least quarterly or more
often depending on weight loss.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation, record review and interview, the facility failed to consult with the
Registered Dietitian before making substitutions to the planned menu to ensure the
substitutions were nutritionally adequate. This practice affected all residents who
received food from the facility’s kitchen. The census was 37.
Review of the facility’s Substitutions policy, dated April, 2007, showed:
– Food substitutes will be made as appropriate and as necessary;
– The food services manager (FSM), in conjunction with the Clinical (Registered) Dietitian
(RD), may make food substitutions as appropriate or necessary;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
– The food services shift supervisor on duty will make substitutions only when
unavoidable;
– The FSM will maintain an exchange list identifying the seven exchanges of food groups.
When in doubt about an appropriate substitution, the FSM will consult with the RD prior to
making a substitution.
– Residents’ likes and dislikes will be considered when making substitutions;
– All substitutions are noted on the menu and filed in accordance with the established
dietary policies; notations of substitutions must include the reason for the substitute;
– The FSM will review the substitutions regularly to avoid recurrences when possible.
Review of the menus for breakfast on 12/11/18, showed staff should prepare eggs, bacon and
toast for the residents. The menu did not indicate any approved substitutions by the FSM
or the RD.
Observation of the breakfast meal on 12/11/18 on the 3rd and 4th floors showed:
– Staff on the 4th floor prepared toast and sausage links for the residents;
– Staff on the 3rd floor prepared English muffins, bacon and grapes for the residents.
– Neither floor prepared any type of eggs for the residents.
During an interview on 12/11/18, at 9:24 A.M., Homemaker (HM) A said the main kitchen
sends food over for lunch and dinner, but they fix whatever they want for breakfast. She
did not talk with anyone when they didn’t follow what the menus said for breakfast.
During an interview on 12/11/18, at 11:45 A.M., HM C said they fix whatever they want to
fix for the morning meal. Most residents don’t come out for breakfast early so they just
fix it as they see the residents.
During an interview on 12/12/18, at 3:21 P.M., the RD said:
– No one clears substitutions through her, but they should;
– She did not talk to the FSM regarding issues in the kitchen.
– Homemakers should follow the menus for all three meals, unless they discuss it with her.

F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Have a plan that describes the process for conducting QAPI and QAA activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to provide
documentation that the Quality Assessment and Assurance (QAA) committee met on a quarterly
basis and the appropriate attendees; failed to identify, develop, implement, monitor, and
evaluate system problems. This had the potential to affect all residents. The facility
census was 37.
Review of the facility’s Quality Assurance and Performance Improvement (QAPI) Committee,
dated (MONTH) (YEAR), showed:
– The facility shall establish and maintain a QAPI committee that overseas the
implementation of the QAPI program.
– Goals: establish, maintain and oversea facility systems and processes to support the
delivery of quality of care and services; promote the consistent use of facility systems
and processes during provision of care and services; help identify actual and potential
negative outcomes relative to resident care and resolve them appropriately; support the
use of root cause analysis to help identify where patterns of negative outcomes point to
underlying systematic problems; coordinate the development, implementation, monitoring,
and evaluation of performance improvement projects to achieve specific goals, and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 42)
coordinate and facilitate communication regarding the delivery of quality resident care
within and among departments and services, and between facility staff, residents, and
family members.
– The following individuals will serve on the committee: administrator, Director of
Nursing (DON), medical director, dietary representative, pharmacy representative,
household coordinators, certified nursing staff representative, social service
representative, activities representative, environmental services representative,
infection control representative, rehabilitation/restorative services representative,
staff development representative, safety representative, and medical records
representative.
– The committee will meet monthly.
– The committee shall maintain minutes of all regular and special meetings that include at
least the following information: date, time, name of committee members present and absent,
summary of the reports and finds, summary of any approaches and action plans to be
implemented, conclusions and recommendations from the committee, and time the meeting
adjourned.
– The committee shall track the progress of any active plans of correction.
– The committee shall advice the administration of the need for policy or procedural
changes and as appropriate monitor to ensure that such changes are implemented.
– The committee shall help various departments/committees/disciplines/individuals develop
and implement plans of correction and monitoring approaches. These plans and approaches
should include specific time frames for implementation and follow-up.
During an interview on 12/12/18 at 3:14 P.M., the DON said:
– The QAPI committee met (MONTH) (YEAR) and (MONTH) (YEAR).
– She stated there is no documentation from the meetings or signature sheet of who
attended.
– She stated the census has been low and there has not been many issues, concerns, or
identified areas that needed to be addressed.
– She stated there is no documentation of an issue they had identified from start to
finish.
During an interview on 12/13/18, at 10:00 A.M., the administrator and DON said:
– The QAPI committee meets monthly with the the following invited: administrator,
pharmacist, DON, chief medical officer (CMO), medical director, psychiatrist, household
and clinical coordinators, nurse practitioner.
– There is no signature sheet of attendees for the meetings.
– Administrator stated the committee has not found very many fundamental problems and have
been discussing the change over of the company with the hospital and why they are tracking
information.
– DON stated they had identified in (MONTH) a wound issue and got a contract with a wound
physician; she stated there is no documentation of wound issues.
– DON stated call lights, [MEDICAL CONDITION] medications, and immunizations have been
issues they have discussed at their meetings but have no documentation.
– DON stated the committee should be identifying, developing, implementing, monitoring,
evaluating, and documenting issues and care areas to provide quality of care.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided care in a manner to prevent infection or the spread of infection when they did
not follow their policy for transmission based precautions which affected one of 12
sampled residents (Resident #23). Staff also failed to ensure they conducted a complete
Two-Step Purified Protein Derivative (PPD) [MEDICAL CONDITION] (TB) skin test on five
sampled residents (Residents #1, #5, #7, #8 and #13). This had the potential to affect all
residents of the facility. The facility census was 37.
1. Review of the facility’s Isolation-Initiating Transmission-Based Precautions policy
dated January, 2012 showed:
– Transmission-Based Precautions will be initiated when there is reason to believe that a
resident has a communicable infectious disease. Transmission-Based Precautions may include
Contact Precautions, Droplet Precautions or Airborne Precautions.
– The facility shall make every effort to use the least restrictive approach to managing
individuals with potentially communicable infections.
– Transmission-Based Precautions shall only be used when the spread of infection cannot be
reasonably prevented by less restrictive measures.
– If a resident is suspected of or identified as having a communicable infectious disease,
the charge nurse or nursing supervisor shall notify the infection the attending physician
for appropriate Transmission-Based Precautions.
– Transmission-Based Precautions will remain in effect until the physician discontinues
them, which should occur after pertinent criteria for discontinuation are met.
– When Transmission-Based Precautions are implemented, staff shall ensure that protective
equipment (gowns, gloves, masks, etc.) is maintained near the resident’s room so that
everyone entering the room can have access to what they need.
– Post an appropriate notice near the resident’s door and on the chart so that all
personnel will be aware of the precautions.
– Ensure that the appropriate linen barrel/hamper and waste containers with appropriate
liners are placed in or near the resident’s room.
– Place necessary equipment and supplies in the room that will be needed during the
isolation period.
– Explain to the resident/family the reason for the precautions.
– Contact Precautions- Potential exposure to microorganisms through direct contact with
the resident, or indirect contact with belongings/environment.
– Ensure all environmental surfaces are washed at least daily and as needed.
– Use Standard-Precautions (the minimum infection prevention practices that should be used
in the care of all patients all of the time
Standard precautions include: hand hygiene, use of personal protective equipment (e.g.,
gloves, gowns, masks), safe injection practices, safe handling of potentially contaminated
equipment or surfaces in the patient environment, and respiratory hygiene/cough
etiquette).
2. Review of a Nursing Progress note regarding Resident #23’s dated 11/11/18 at 10:26 P.M.
showed:
– Contact Precautions in place due [MEDICAL CONDITION] in wound.
Review of the care plan developed for Resident #23 dated 11/13/18 showed:
– Skin impairment.
– Use principles of infection control and Universal/Standard Precautions.
– Did not address Contact Precautions related [MEDICAL CONDITION].
Review of the 14 day Minimum Data Set (MDS), a federally mandated assessment instrument
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 44)
completed by facility staff, dated 11/19/18 showed:
– Short- and long-term memory problems.
– Severely impaired cognition.
– [DIAGNOSES REDACTED].
During an interview on 12/04/18 at 1:20 PM, Certified Nurse Aide (CNA) D said he/she puts
on gloves and gowns when going into an isolated residents room. When they finish giving
care they put the cloth items in the red bag and use disinfectant wipes to wipe down the
room, they take the red bags to laundry. She learned what to do from his/her CNA classes.
No one at the facility gave him/her instructions on how to care for residents on
isolation.
During an interview on 12/3/18 at 1:30 P.M. the Director of Nursing (DON) said:
– The resident was on Contact/Transmission Based Precautions [MEDICAL CONDITION] in
his/her urine.
During an interview on 12/4/18 at 1:30 PM, CNA F said staff clean resident bathrooms,
provide resident care, do laundry and even go get snacks from the kitchen. If a resident
is on isolation, they put the resident’s clothing in an isolation bag and their personals
in a blue linen bag.
During an observation and interview on 12/4/18 at 3:45 P.M., Licensed Practical Nurse
(LPN) D and LPN E did and said:
– Changed the resident’s wound dressing to the right buttock;
– A pair of underwear soiled with urine and wound drainage lay on a cloth covered
chair/twin sleeper beside the resident’s bed.
– A dietary tray, washable dishes and utensils sat on the cloth covered chair beside the
soiled underwear.
– No red barrels or hampers were in the resident’s room for collection of soiled linen and
trash.
– LPN E pulled a red trash bag from the small trash can and placed soiled dressings and
equipment from the wound care procedure into the bag and sat the bag on the floor in the
bathroom.
– LPN E pulled a red trash bag from the small trash can and placed linens soiled with
wound drainage into the red bag and sat the bag on the floor in the bathroom.
– LPN E said he/she did not know what the facility policy was related to
Contact/Transmission Based Precautions.
– LPN E said there should be red barrels or hampers in the room for soiled linens and
trash because the wound [MEDICAL CONDITION] and the resident was on Contact/Transmission
Based Precautions.
– He/she needed to obtain the barrels/hampers for the isolation room.
– The isolation cart outside the room was a bedside table taken from an empty room and had
no wheels; an isolation cart should have wheels.
– Both LPNs washed their hands and LPN E removed the trash and linen bags from the
resident’s room.
– LPN E did not realize the underwear was soiled with urine and wound drainage.
– LPN E returned and took the dietary tray out of the room and gave to the tray to
Homemaker (HM) B.
– HM B took the tray into the dishwashing room of the fourth floor community’s kitchen and
did not wear gloves.
During an interview on 12/4/18 at 4:00 P.M., HM B said:
– Staff did not tell him/her that the resident [MEDICAL CONDITION].
– The resident should receive his/her meals on disposable dishes and tray.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 45)
– HM B placed the soiled dishes in the dishwasher with other dishes to be washed.
– The soiled dishes from the resident should not be washed with other dishes because of
[MEDICAL CONDITION].
During an interview on 12/4/18 at 4:30 P.M. the DON said:
– Urine and wound soiled underwear should not be placed on the cloth covered chair.
– The cloth covered chairs should be removed from resident rooms; there was no way to
clean the chairs.
– Barrels or hampers should be placed in the resident’s room with red bags to collect
soiled linen.
– Barrels or hampers should be place in the resident’s room with yellow bag to collect
trash.
– The Contact/Transmission Based Precautions cart was a bedside table from an empty room
without wheels and staff should use the carts with wheels purchased by the facility.
– The facility did not use paper/disposable dishes/cutlery.
– The resident’s dishes could be washed in the dishwasher with other dishes in the
community’s kitchen.
– She did not realize the wound cultured [MEDICAL CONDITION], she though it was in the
urine.
Observation on 12/10/18, 12/11/18, 12/12/18 and 12/13/18 showed:
– The Contact/Transmission Based Precaution cart was a bedside table with no wheels.
During an interview on 12/13/18 at 1:30 P.M. the DON said:
– Red bags and barrels/hampers should be in rooms where Contact/Transmission Based
Precautions were ordered for trash and linen.
– The Nursing Staff Clinical Coordinators should monitor residents on Contact/Transmission
Based Precautions.
– The cloth covered chairs could be cleaned with a cleaning gun and a chemical cleaner,
but she did not know if the cleaner [MEDICAL CONDITION].
– The Contact/Transmission Based Precaution carts should have wheels.
3. Review of the facility’s [MEDICAL CONDITION] Infection Control Program Policy, revised
(MONTH) 2012, showed:
– The facility recognizes that [MEDICAL CONDITION] (TB) (infectious bacterial disease that
affects the lungs) transmission has been identified as a risk in healthcare settings. To
prevent nosocomial transmission of TB, the facility has instituted a TB infection control
program.
– Assignment of responsibility for the oversight of TB infection control to the infection
control committee.
– Facility designee to oversee the TB program is blank in the policy.
– An annual TB risk assessment (TBRA) and TB risk classification based on the information
obtained from the TBRA.
– The medical director, Director of Nursing (DON), and Infection Preventionist will review
the TB infection control program annually with the infection control committee.
– The infection control committee will present any recommendations to the facility’s
quality assurance committee.
– The inservice coordinator will provide annual staff education regarding TB recognition
and prevention.
4. Review of Resident #5’s medical record showed the resident admitted on [DATE] with a TB
1st step administered 11/28/18 and not read 42-78 hours. No documentation of a TB 2nd step
administered or read.
5. Review of Resident #8’s medical record showed no documentation of TB 1st and 2nd step
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 – Many

(continued… from page 46)
administered since his/her admission on 10/30/18.
6 . Review of Resident #7’s medical record showed TB 1st step administered 10/18/18 and
read on 10/21/18 with a negative 0 millimeter (mm). TB 2nd step administered 11/1/18 and
not read 42-78 hours since his/her admission on 10/18/18.
7. Review of Resident #13’s preventive health care records, located in the facility’s
electronic medical record showed:
– Staff documented they administered the TB test Step 1 on 11/2/18; staff did not indicate
in the record that they read the test;
– No documentation that the second step had been administered or read.
Review of the resident’s medication administration record (MAR) for 11/2/18 through
11/30/18, showed:
– Read TB test and document results in preventive health care; once a day every 14 days;
start/end dates: 11/5/18-11/17/18;
– Two Step PPD – Step 2 completed with 14 days of step 1; once a day every 14 days;
start/end dates: 11/2/18-11/17/18;
– On Friday, 11/16/18, staff charted at 11:46 P.M., they did not administer the second
step due to the item being unavailable.
Review of a packing slip from the pharmacy showed they delivered two boxes of [MEDICATION
NAME] injection on 11/29/18, at 8:15 P.M.
8. Review of Resident #1’s preventive health care records, showed:
– Staff documented they administered the 1st step of his/her TB test on 4/18/18, but did
not document they read the test;
– Staff documented they administered the 2nd step of his/her TB test on 5/2/18, but did
not document they read the test.
During an interview on 12/13/18 at 1:30 P.M., the DON said:
– Staff should perform the initial TB 1st step upon admission and read 42-78 hours later.
Then a TB 2nd step should be completed 14 days later.
– Staff should put the TB 1st and 2nd step in the physician orders [REDACTED].
– Staff should document on the MAR and under the preventive care tab in Matrix when
completed.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to implement,
follow, and monitor a facility-wide antibiotic stewardship program. The facility had 24
residents on antibiotics from 11/1/18 to 12/12/18. This deficient practice had the
potential to affect all residents in the facility. The facility census was 37.
Review of the facility’s Antibiotic Stewardship – Orders for Antibiotics, revised (MONTH)
(YEAR), showed:
– Antibiotics will be prescribed and administered to residents under the guidance of the
facility’s antibiotic stewardship program and in conjunction with the facility’s general
policy for medication utilization and prescribing.
– Appropriate indications for use of antibiotics include criteria met for clinical
definition of active infection or [MEDICAL CONDITION]; and pathogen susceptibility, based

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

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 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 47)
on culture and sensitivity (C&S), to antimicrobial (or therapy begun while culture is
pending).
– Use of an antibiotic based on clinical criteria of [MEDICAL CONDITION] may be
appropriate. The staff and practitioner will document the specific criteria that support
the suspicion in the resident’s clinical record.
– When a C&S is ordered, it will be completed and lab results and the current clinic
situation will be communicated to the prescriber as soon as possible to determine if
antibiotic therapy should be started, continued, modified, and discontinued.
Review of the facility’s Infection Prevention and Control Program, revised (MONTH) (YEAR),
showed:
– The infection prevention and control program is facility-wide effort involving all
disciplines and individuals and is an integral part of the quality assurance and
performance improvement program.
– The elements of the infection prevention and control program consists of
coordination/oversight, polices/procedures, surveillance, data analysis, antibiotic
stewardship, outbreak management, prevention of infection, and employee health and safety.

– The infection prevention and control committee is responsible for reviewing and
providing feedback on the overall program which include whether physician management of
infections is optimal; whether antibiotics usage pattern need to be changed; whether
information about culture results or antibiotic resistance is transmitted accurately and
in a timely fashion; where there is appropriate follow-up of acute infections.
– Antibiotic stewardship – culture reports, sensitivity data, and antibiotic usage reviews
are included in surveillance activities; medical criteria and standardized definitions of
infections are used to help recognize and manage infections; and antibiotic usage is
evaluated and practitioners are provided feedback on reviews.
During antibiotic stewardship record review and interview with the DON on 12/12/18, at
2:00 P.M. showed:
– Resident antibiotic surveillance spreadsheet dated (MONTH) (YEAR) showed 10 residents on
antibiotics; one resident who did not meet McGeers criteria (infection surveillance for
long term care).
– Resident antibiotic surveillance spreadsheet dated 10/18/18 showed 14 residents on
antibiotics; 7 residents who did not meet the McGeers criteria.
– No antibiotic surveillance for (MONTH) or (MONTH) (YEAR).
– DON stated the antibiotic surveillance should be completed immediately upon the resident
being prescribed antibiotics and monthly.
– DON stated the facility should be monitoring antibiotics as the residents are currently
being prescribed rather than tracking the usage after the antibiotics are completed to be
able to address any concerns.
– DON notified the pharmacy to find out how many residents are currently on antibiotics;
24 residents on antibiotics from 11/1/18 to 12/12/18.
– Antibiotic usage/monitoring is discussed during morning meetings and during quality
assurance meetings.
– DON currently does not have any antibiotic surveillance and unsure which and how many
residents are currently on antibiotics.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation, interview, and record review, the facility failed to ensure all
residents were offered the influenza and pneumococcal vaccines in a timely manner. This
affected 8 of 12 sample residents (Resident #5, #6, #7, #8, and #16). The facility census
was 37.
Review of the facility’s Influenza Vaccine Policy, revised (MONTH) (YEAR), showed:
– All residents who have no medical contraindications to the vaccine will be offered the
influenza vaccine annually to encourage and promote benefits associated with vaccinations
against influenza.
– Between (MONTH) 1st and (MONTH) 31st each year, the influenza vaccine shall be offered
to residents, unless the vaccine is medically contraindicated or the resident has already
been immunized.
– Prior to the vaccination, the resident or resident representative will be provided
information and education regarding the benefits and potential side effects of the
influenza vaccine. Provision of such education shall be documented in the resident’s
medical record.
– A resident’s refusal of the vaccine shall be documented on the Informed Consent for
Influenza Vaccine and placed in the resident’s medical record.
– The infection preventionist will maintain surveillance data on influenza vaccine
coverage and reported rates of influenza among residents and staff.
– Residents may obtain their influenza vaccines from their personal physicians.
Documentation of previous vaccinations should be provided to the facility.
Review of the facility’s Pneumococcal Vaccine Policy, revised (MONTH) (YEAR), showed:
– All residents will be offered pneumococcal vaccines to aid in prevention
pneumonia/pneumococcal infections.
– Prior to or upon admission, residents will be assessed for eligibility to receive the
pneumococcal vaccine series, and will be offered the vaccine series within thirty days of
admission to the facility unless medically contraindicated or the resident has already
been vaccinated.
– Assessments of pneumococcal vaccination status will be conducted within five working
days of the resident’s admission if not conducted prior to admission.
– Before receiving a pneumococcal vaccine, the resident or resident representative shall
receive information and education regarding the benefits and potential side effects of the
pneumococcal vaccine. Provision of such education shall be documented in the resident’s
medical record.
– If the resident refuses, appropriate entries will be documented in each resident’s
medical record indicating the date of the refusal of the pneumococcal vaccine.
1. Review of Resident #5’s medical record showed no consent or refusal for influenza and
pneumococcal vaccine since his/her admission on 10/22/18.
2. Review of Resident #6’s medical record showed no consent or refusal for influenza and
pneumococcal vaccine since his/her admission on 10/29/18.
3. Review of Resident #8 ‘s medical record showed no documentation of resident receiving
the influenza and pneumococcal vaccine prior to admission on 10/30/18.
4. Review of Resident #7’s medical recorded showed no documentation of resident refusing
the influenza and pneumococcal vaccine since his/her admission on 10/18/18.
5. Review of Resident #16’s medical record showed no consent or refusal for influenza and
pneumococcal vaccine since his/her admission on 5/8/18.
6. During an interview on 12/13/18, at 1:30 P.M., the Director of Nursing (DON) said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265867

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

NAME OF PROVIDER OF SUPPLIER

NORTERRE

STREET ADDRESS, CITY, STATE, ZIP

2555 NORTERRE CIRCLE
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 49)
– Staff should offer residents the pneumococcal vaccination upon admission.
– Staff should document on the residents chart when administering the pneumococcal vaccine
and document if they refuse.
– Staff should go over the risks and benefits with residents prior to administering the
influenza and pneumococcal vaccination.
– Staff should offer, administer, and document influenza vaccinations during the months of
(MONTH) through (MONTH) as well as refusals.
– The facility did not administer any or offer them since they received the influenza
vaccines the second week in October.