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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to protect one
resident’s (Resident #12) of twenty four sampled residents, dignity in a public area and
failed to create an environment that was respectful of the rights of six residents
(Resident #14, #69, #25, #62, #101 and #43) when staff did not assist Resident #12 with
provision of clothing that fit/repositioning of his/her clothing when the resident’s body
was exposed, including the resident’s peri-area, in the dining room and about the facility
hallways. The facility failed to treat resident (Resident # 39) with dignity and respect
by referring to the resident as being spoiled when the resident requested showers and the
bed made. The facility failed to ensure staff treated thirteen residents (Resident #1,
#12, #22, #27, #29, #39, #43, #69, #72, #95, #97, #101, and #111) of 24 sampled residents
and six additional residents (Resident #14, #25 #59, #62, #69 and #92) in a manner that
maintained their dignity when staff utilized paper plates and plastic silverware for meal
service. The facility census was 118.
1. Review of the Resident Rights Policy, dated as revised (MONTH) (YEAR), showed the
following:
-Employees shall treat all residents with kindness, respect, and dignity;
-Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the residents right to a dignified existence.
2. Review of Resident #12’s care plan, date initiated 6/17/15, showed the following:
-[DIAGNOSES REDACTED].
-Requires minimal assistance due to weakness for many activities of daily living (ADLs)
and/or requiring supervision for completion for some ADL’s.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment tool
required to be completed by facility staff, dated 3/15/19, showed the resident required
extensive assistance with dressing.
During an interview on 3/20/19 at 2:40 P.M. the resident said the following:
-His/Her pants were not on properly;
-His/Her pants would not stay up; the more he/she self-propelled the more they slipped
down;
-He/she had lost weight and his/her pants just would not stay up.
Observation of the lunch meal on 03/17/19 at 1:30 P.M. showed the following:
-The resident sat in the main dining room in a wheelchair with three resident tablemates;
-Thirty-six resident sat in the main dining room;
-The waistband of Resident #12’s pants was below the resident’s buttocks and the front
part of his/her pants pulled down, exposing his/her pubic hair;
-The resident wore neither underwear or incontinent briefs;
-The resident’s buttocks and peri-area were visible to any onlooker.
Observation of the supper meal on 03/17/19 at 6:05 P.M. showed the following:
-The resident sat in the main dining room in a wheelchair with three resident tablemates;
-The waistband of the resident’s pants was below the resident’s buttocks and the front
part of his/her pants pulled down, exposing his/her pubic hair;
-The resident wore neither underwear or incontinent briefs;
-The resident’s buttocks and peri-area were visible to any onlooker.
Observation of the breakfast meal on 03/18/19 at 8:24 A.M. showed the following:
-The resident sat in the main dining room in a wheelchair;
-The waistband of the resident’s pants was below the resident’s buttocks and the front

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
part of his/her pants pulled down, exposing his/her pubic hair;
-The resident wore neither underwear or incontinent briefs;
-The resident’s buttocks and peri-area were visible to any onlooker.
-The administrator delivered a breakfast tray to the resident’s three table mates
separately. The administrator did not assist the resident with proper positioning of
his/her clothing or cover the resident’s exposed body;
-Medical Records staff U delivered silverware to the residents at Resident #12’s table.
Medical Records staff U did not assist the resident with proper positioning of his/her
clothing or cover the resident’s exposed body;
-Certified Nurse Aide (CNA) V delivered Resident #12 his/her breakfast tray. CNA V did not
assist the resident with proper positioning of his/her clothing or cover the resident’s
exposed body.
Observation on 03/19/19 at 12:00 P.M. showed the following:
-The resident self-propelling in his/her wheelchair in the facility hallway;
-The waistband of the resident’s pants was below the resident’s buttocks and the front
part of his/her pants pulled down, exposing his/her pubic hair;
-The resident wore neither underwear or incontinent briefs;
-The resident’s buttocks and peri-area were visible to any onlooker.
-CNA J walked past the resident and spoke to him/her. CNA J did not assist the resident
with proper positioning of his/her clothing or cover the resident’s exposed body.
During an interview on 03/18/19 at 3:25 P.M., Resident #101 said the following:
-He/she had seen Resident #12 with his/her pants down, exposing his/her parts;
-Seeing this made his/her stomach roll, but he/she had gotten used to it.
During an interview on 03/18/19 at 3:26 P.M., Resident #43 said the following:
-He/she had seen Resident #12 with his/her pants down, exposing his/herself;
-He/she doesn’t like seeing this and it bothers him/her that Resident #12 is not covered
up or staff doesn’t help him/her.
During interview on 03/18/19 at 3:27 P.M., Resident #14 said the following:
-He/she has seen Resident #12 with his/her pants down, exposing his/herself;
-He/she loses his/her appetite when he/she sees it and wishes staff would address it
instead of ignoring it;
-Other residents call Resident #12 duck pants, because you can see his/her quack.
During an interview on 03/18/19 at 3:28 P.M., Resident #69 said the following:
-He/she had seen Resident #12 with his/her pants down in public areas of the facility;
-He/she thinks it’s inappropriate and doesn’t want to see it.
During an interview on 03/22/19 at 3:53 P.M., the Director of Nursing (DON) said resident
clothing should be adjusted to prevent exposure.
3. Observation on 3/17/19 at 1:15 P.M., showed dietary cook/aide CC portioning salad for
supper meal service in individual Styrofoam bowls.
Observation of the assisted dining room on 03/17/19 at 6:00 P.M. showed the following:
-Twenty-one residents with three staff assisting the residents with their evening meal;
-Staff served the residents’ evening meal consisting of pasta and red sauce, salad, bread
and yogurt on Styrofoam plates and bowls with plastic utensils. Staff served beverages in
Styrofoam cups.
Observation of the main dining room on 03/17/19 at 6:16 P.M. showed the following:
-Thirty-three residents present for the meal and four staff in and out of the dining room;
-Staff served the residents’ evening meal consisting of pasta and red sauce, salad, bread
and yogurt on Styrofoam plates and bowls with plastic utensils. Staff served beverages in
Styrofoam cups.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
3. Review of Resident #1’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/16/19 showed the following:
-Cognition moderately impaired;
-Independent with eating.
Observation on 3/17/19 at 6:10 P.M. showed the following:
-The resident sat in his/her room eating supper;
-The resident had plastic utensils to use to eat;
-Staff served the resident’s meal including fruit and lettuce salad served in a Styrofoam
bowl;
-Staff served the main entrée, pasta with sauce and garlic on a paper plate;
-Staff served the resident’s drinks in Styrofoam cups.
Observation on 3/21/19 at 10:55 A.M. showed the resident had a plastic spoon to eat
his/her cereal.
During an interview on 3/21/19 at 10:55 A.M., the resident said the following:
-He/she said he/she did not like lunch or dinner served on paper plates and did not like
plastic knives and forks;
-He/she said at different times staff provided plastic and paper products to eat with and
he/she did not know why;
-He/she had a plastic spoon for his/her cereal today.
4. Review of Resident #12’s MDS, dated [DATE], showed the following:
-BIMS of 15 indicating intact cognition;
-[DIAGNOSES REDACTED].
-Independent with eating, set up help only.
During an interview on 03/17/19 at 6:08 P.M. the resident said it was harder to eat the
meal from the Styrofoam and to use plastic silverware.
5. Review of Resident #14’s MDS, dated [DATE], showed the following:
-BIMS of 15;
-[DIAGNOSES REDACTED].
-Supervision with eating, set up help only.
During an interview on 3/18/19 at 2:50 P.M. the resident said he/she would rather eat from
real plates, using real silverware, instead of the Styrofoam and plastic.
6. Review of Resident #22’s MDS, dated [DATE], showed the following:
-BIMS of 14 (cognition intact);
-[DIAGNOSES REDACTED].
-Independent with eating, set up help only.
During an interview on 3/19/19 at 10:00 A.M., the resident said he/she did not like being
served his/her meals on Styrofoam and having to use plastic silverware; this made it
harder to eat the meal.
7. Review of Resident #25’s MDS, dated [DATE], showed the following:
-BIMS of 15;
-[DIAGNOSES REDACTED].
-Independent with eating, set up help only.
During an interview on 3/18/19 at 2:50 P.M. the resident said he/she does not like meals
being served on Styrofoam or having to use plastic utensils; this makes it harder to eat
the food.
8. Review of Resident #27’s annual MDS, dated [DATE], showed the following:
-The resident was cognitively intact for daily decision making;
-Independent with eating, set up help only.
Observation on 3/17/19 at 6:01 P.M., showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-The resident sat on the edge of his/her bed eating supper;
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
During an interview on 3/17/19 at 6:01 P.M. the resident said the following:
-He/she does not like eating from Styrofoam as it does not keep the food at a warm
temperature;
-The facility serves meals on Styrofoam regularly;
-There will be times when he/she will get either just a plastic spoon or plastic fork and
the entree may require a different utensil, such as staff may served soup and provide a
plastic fork to eat the soup.
9. Review of Resident #29’s Admission MDS, dated [DATE], showed the following:
-The resident was cognitively intact for daily decision making;
-[DIAGNOSES REDACTED].>-Required limited assist of one staff for eating.
Observation on 3/17/19 at 6:10 P.M., showed the following:
-The resident sat in the assisted dining room;
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
During an interview on 3/18/19 at 10:18 A.M., the resident’s family member said the
following:
-He/she did not like the resident being served his/her meal on Styrofoam;
-Styrofoam appears cheap and the plastic silverware breaks easily.
10. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following:
-The resident was cognitively intact for daily decision making;
-[DIAGNOSES REDACTED].>-Required set up assistance of staff for eating.
Observation on 3/17/19 at 6:15 P.M., showed the following:
-The resident sat in the main dining room;
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
During an interview on 3/17/19 at 6:18 P.M., the resident said the following:
-The facility did not have enough staff to do dishes and this is the reason they have to
eat on and Styrofoam plates and use plastic utensils;
-He/she did not like eating off of Styrofoam or using plastic utensils;
-The facility served on Styrofoam and used plastic utensils on a regular basis.
Observation on 3/18/19 at 10:49 A.M. showed the following:
-The resident’s hair was disheveled;
-The resident’s bed was soiled and unmade;
-A hamper full of clothes sat in the middle of the resident’s room behind his/her chair.
During an interview on 3/18/19 at 10:50 A.M. the resident said the following:
-Staff were supposed to give him/her a shower this morning;
-He/she liked to be showered early so he/she could be in clean clothes for the day;
-Staff were supposed to make and his/her bed as soon as he/she got out of bed but they
still had not changed the sheets and/or made the bed;
Observation and interview on 3/18/19 at 10:50 A.M. showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-The resident turned on his/her call light;
-CNA A entered the resident’s room;
-The resident told CNA A that he/she still had not been given a bath, staff had not picked
up his/her laundry for days, and staff still had not made his/her bed;
-CNA A told the resident that he/she was spoiled and that the CNA working his/her hall
would help him/her as soon as he/she could. He/she knew the resident liked things a
certain way and was spoiled, but all CNAs did things differently and that did not make
them wrong.
During an interview on 3/18/19 at 10:55 A.M. CNA A said he/she did not think there was
anything wrong with calling the resident spoiled.
During an interview on 3/18/19 at 10:56 A.M. the resident said he/she didn’t like the
staff calling him/her spoiled.
During an interview on 3/22/19 the DON said the following:
-She would not expect staff to call the resident spoiled;
-Staff should spoil all the residents.
During an interview on 4/4/19 at 12:50 P.M. the administrator if a resident was asking for
help and voicing concerns, it would not be appropriate for the staff member to call the
resident spoiled.
11. Review of Resident #59’s MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Independent with eating, set up help only.
Observation and interview on 03/20/19 at 8:30 A.M. showed the following:
-Resident #59 sat in the main dining room eating Rice Krispie cereal with a plastic fork;
-The resident said staff told him/her there were no spoons available;
-Two other unidentified residents were eating oatmeal and cream of wheat cereal with a
plastic fork.
During an interview on 03/17/19 at 6:05 P.M. the resident said he/she would never have
served meals on Styrofoam or used plastic silverware and he/she thought it was
disrespectful to the elderly.
12. Review of Resident #72’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Independent with eating, set up help only.
Observation on 3/17/19 at 6:05 P.M., showed the following:
-The resident sat on the edge of his/her bed;
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
During an interview on 3/17/19 at 6:05 P.M. the resident said the following:
-He/she did not like eating from Styrofoam. It felt cheap and did not keep the foods very
warm;
-Staff served meals on Styrofoam regularly with plastic silverware. Sometimes the plastic
silverware would break when trying to cut food.
13. Review of Resident #95’s admission MDS, a federally mandated assessment instrument
completed by facility staff, dated 3/4/19 showed the following:
-Cognition intact;
-Independent with eating.
Observation on 3/17/19 at 6:15 P.M. showed the following:
-The resident sat in a chair in his/her room eating supper;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
Observation on 3/21/19 at 9:54 A.M. showed the resident had a plastic spoon to eat his/her
breakfast.
During an interview on 3/21/19 at 9:54 A.M., the resident said the following:
-It bothers him/her to use plastic silverware;
-He/she can’t do anything with plastic silverware;
-It is usually the spoon that is plastic, but can be all plastic utensils at times;
-He/she had a plastic spoon at breakfast today;
-Have been served plastic utensils a lot lately.
14. Review of Resident #97’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Independent with eating, set up help only.
Observation on 3/17/19 at 6:30 P.M., showed the following:
-The resident sat in a straight back chair in the main dining room;
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
During an interview on 3/17/19 at 6:30 P.M. showed the following:
-He/she did not like to eat off of Styrofoam, it did not feel homelike;
-He/she said the facility served meals regularly on Styrofoam.
15. Review of Resident #111’s annual MDS, dated [DATE], showed the following:
-The resident was cognitively intact for daily decision making;
-[DIAGNOSES REDACTED].
-Required set up assistance of staff for eating.
Observation on 3/17/19 at 6:15 P.M., showed the following:
-The resident sat in the main dining room;
-Staff served the resident lettuce and fruit in Styrofoam bowls;
-Staff served the main entrée, pasta with sauce, and garlic bread on a Styrofoam plate;
-Staff provided plastic utensils for the resident to eat his/her meal;
-Staff served the resident drinks in Styrofoam cups.
During an interview on 3/17/19 at 6:18 P.M., the resident said the following:
-He/she did not like eating off of Styrofoam or using plastic utensils;
-The facility served on Styrofoam and used plastic utensils on a regular basis.
16. Review of Resident #62’s MDS, dated [DATE], showed the following:
-BIMS of 15;
-Independent with eating.
During an interview on 3/18/19 at 2:50 P.M. the resident said the plastic silverware was
flimsy and broke easily.
17. Review of Resident #43’s MDS, dated [DATE], showed the following:
-BIMS of 15;
-[DIAGNOSES REDACTED].
-Independent with eating, set up help only.
Resident #43 said plastic silverware frequently punctured through the Styrofoam plates.
18. Review of Resident #69’s MDS, dated [DATE], showed the following:
-BIMS of 15;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Independent with eating, set up help only.
During an interview on 3/18/19 at 2:50 P.M. the resident said he/she can’t cut meat with
plastic knives very well.
19. Review of Resident #92’s MDS, dated [DATE], showed the following:
-BIMS of 15;
-[DIAGNOSES REDACTED].
-Independent with eating.
During an interview on 3/18/19 at 2:50 P.M. the resident said it bothered him/her to eat
from Styrofoam all of the time.
20. Review of Resident #101’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-[DIAGNOSES REDACTED].
-Independent with eating, set up help only.
During an interview on 3/18/19 at 2:50 P.M. the resident said he/she would rather eat from
real plates, using real silverware, instead of the Styrofoam and plastic.
21. Interviews during the resident council meeting on 03/18/19 at 2:50 P.M. showed
residents said the following:
-Meals were frequently served on Styrofoam/paper products;
-Reasons given for the use of the Styrofoam/paper products vs. real dishes included the
facility being short staffed, not enough time for staff to wash real dishes and/or the
dishwasher was broken.
22. During interview on 3/18/19 at 12:40 P.M. dietary aide DD said sometimes he/she was
the only one staff working in the kitchen and could not get everything completed. They had
to serve off of Styrofoam plates and use disposable utensils and cups just to get the
residents served.
During an interview on 3/20/19 at 1:42 P.M. dietary aide CC said there wasn’t enough staff
to get everything done including dishes. They had to serve the residents on disposable
plates, silverware and cups because staff couldn’t get the dishes clean in time.
During interview on 3/22/19 at 3:53 P.M. the Director of Nursing said the following:
-Plastic and paper are appropriate to be served on if outside at a picnic;
-Residents should not have to eat cereals with a fork;
-Resident clothing should be adjusted to prevent exposure.
During an interview on 4/4/19 at 12:50 P.M. the administrator said she would expect staff
to adjust a resident’s clothing to cover the residents buttocks, hips, and perineal area.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

U4413
Class II*
Based on record review and interview, the facility failed to ensure each resident was
afforded the right to manage his/her financial affairs, when the facility failed to advise
residents of money held in the facility operating account that belonged to the resident.
The facility failed to deposit funds in excess of $100 in an interest bearing account that
was separate from any of the facility’s operating accounts, and credit all interest earned
on resident’s funds to that account. The deficient practice affected 13 residents

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
(Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13). The facility census
was 118.
1. Record review of the facility maintained Accounts Receivable A/R Aging Report for the
period 03/01/18 through 03/20/19, showed the following residents with personal funds held
in the facility operating account:
Resident Amount Held in Operating Account
#1 $ 23.00
#2 $ 2,363.12
#3 $ 11.00
#4 $ 2,691.76
#5 $ 1,002.51
#6 $ 84.11
#7 $ 1,312.60
#8 $ 3,276.16
#9 $ 2,565.86
#10 $ 1,648.02
#11 $ 2,481.20
#12 $ 2,527.60
#13 $ 5.60
Total $19,992.54
During an interview on 03/20/19 at 1:29 P.M., the Corporate Controller said he/she was
working on cleaning up the operating account.

F 0582

Level of harm – Potential for minimal harm

Residents Affected – Some

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to provide the resident or
resident representative with a Notice of Medicare Provider Non-Coverage (NOMNC) when all
covered Medicare services were ending for two residents (Resident #101 and #61), who
remained in the facility after Medicare services ended; and failed to provide evidence
staff notified the individuals of the discharge from Medicare services at least two days
in advance of services ending for one resident (Resident #39). The facility census was
118.
1. Review of the undated facility Policy for the NOMNC Centers for Medicare and Medicaid
Services (CMS)- When to Deliver the NOMNC showed the following:
-A Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively
referred to as plans) must deliver a completed copy of the NOMNC to
beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive
outpatient rehabilitation facility, and hospice services;
-The NOMNC must be delivered at least two calendar days before Medicare covered services
end of the second to last day of service if care is not being provided daily;
Plans only: In situations where the decision to terminate covered services is not
delegated to a provider by a health plan, but the provider is delivering the notice, the
health plan must provide the service termination date to the provider at least two
calendar days before Medicare covered services end;

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0582

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 8)
Providers must deliver the NOMNC:
-To all beneficiaries eligible for the expedited determination process per Chapter 4,
Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of
the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees
with the termination of services. Medicare providers are responsible for the delivery of
the NOMNC;
-The provider must ensure that the beneficiary or representative signs and dates the NOMNC
to demonstrate that the beneficiary or representative received the notice and understands
that the termination decision can be disputed.
2. Review of a Department of Health and Human Services, Centers for Medicare and Medicaid
Services form, dated 2/2017, titled Skilled Nursing Facility Beneficiary Protection
Notification Review, Beneficiary Liability Protection Notice Scenarios showed residents
having skilled benefit days remaining and are being discharged from Part A services and
will continue living in the facility should be issued a NOMNC.
3. Review of the facility policy Medicare Advance Beneficiary Notice (ABN), dated 4/23/12,
showed the following:
-Residents receiving Medicare covered services shall have advanced notice of when those
services will be ending and will be made aware of their appeal rights. Should residents
wish to continue receiving said services knowing that we believe services would not be
paid for by Medicare, they will be made aware of any charges or liability they would incur
for said services;
-Two days prior to Medicare A services or Medicare B services are expected to end, the
resident or responsible party is to be informed and the form CMS Notice of Medicare Non
Coverage shall be completed following form instructions. This form explains the notice and
the resident’s appeal rights. Should an appeal be made, facility will be contacted by the
CMS Quality Improvement Organization and complete form CMS -Detailed Explanation of Non
Coverage following form instructions. These forms are to be used for all Medicare Part A
and Medicare Part B;
-When the resident or responsible party wishes to continue receiving services the facility
believes will not be covered by Medicare, facility will issue the SNF-ABN liability notice
explaining what the charges will be. The liability notice for Medicare Part A is the
SNF-ABN form CMS- and the liability notice for Medicare Part B is form CMS-R-131
(03/2011);
-Social Services designee shall present notices and complete applicable forms. Verbal
notification is acceptable so long as Social Services then completes the written form,
signs indicating notice given verbally and insert form in the patient record, then proceed
to mail the form asking responsible party to sign and return to facility;
-Note: The NOMNC informs one that services are ending AND they have rights to appeal;
-When the Medicare Part A Skilled days are exhausted, the NOMNC form is not necessary
because they have used up their benefit, nothing to appeal;
-If the person is staying on at the nursing home after the Medicare covered stay, present
the liability notice SNF-ABN which informs them of the charges they will incur.
4. Review of Resident #39’s SNF Beneficiary Protection Notification Review showed the
resident’s last covered day of Medicare services was 12/24/18.
Review of the resident’s SNFABN showed the resident signed the form on 12/24/18 the day
services ended.
Review of the resident’s NOMNC showed the resident signed the form on 12/24/18 the day
services ended.
Review showed no evidence staff documented the resident had been notified prior to
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0582

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 9)
12/24/18.
5. Review of Resident #101’s SNF Beneficiary Protections Notification Review showed the
resident’s last covered day of Medicare services was blank.
Review of the resident’s SNFABN showed the resident’s last covered day of Medicare
services was 1/24/19.
Review of the resident’s medical record showed no evidence the facility provided the
resident with the NOMNC.
6. Review of Resident #61’s SNF Beneficiary Protection Notification Review showed the
resident’s last covered day of Medicare services was 2/15/19.
Review of the resident’s medical record showed no evidence the facility provided the
resident with the NOMNC.
7. During interview on 3/22/19 at 5:10 P.M. the administrator said the following:
-The Social Service Designee (SSD) was responsible for completing and issuing SNF
beneficiary notices upon discharge from Medicare Part A services;
-The facility did not currently have a SSD;
-She would expect a NOMNC to be issued 48 hours prior to the ending of services to the
resident or representative if services are ended, days are not exhausted and benefit days
remain.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a home
like environment for six residents (Resident #12, #39, #43, #53, #69,and #101) in a review
of 24 sampled residents and five additional residents (Resident #5, #14, #25, #28 and #62)
when the facility did not provide laundry services to provide clean clothing for the
residents or washcloths available for the staff to use to provide cares. The facility
failed to repair one sampled resident’s (Resident #46) and one additional resident’s
(Resident #58) wheelchairs. The facility census was 118.
1. Review of the facility policy Quality of Life, Homelike Environment last revised
(MONTH) (YEAR) showed the following:
– Residents are provided with a safe, clean comfortable and homelike environment and
encouraged to use their personal belongings to the extent possible;
-The facility staff and management shall maximize to the extent possible, the
characteristics of the facility that reflect a personalized, homelike setting;
– These characteristics include clean, sanitary and orderly environment and inviting
colors and décor.
2. Review of Resident #5’s care plan revised 12/31/18, showed the following:
-The resident had dementia, gets confused and needs direction;
-The resident will have all of his/her basic needs met by staff;
-Assist times one supervision with care needs and bathing; allow him/her to do as much for
him/herself with set up assistance as tolerated;
-Encourage the resident to perform or participate in ADL’s to extent possible;
-Extensive assistance with bathing;
-Staff may need to provide more ADL assistance in the mornings when the resident first

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
gets out of bed.
Observation on 3/19/19 at 6:06 A.M. showed the following:
-The resident lay in his/her bed;
-The inner canthus of the resident’s right eyes had dried yellow matter in the corner;
-CNA L assisted the resident with morning cares, dressed the resident and transferred
him/her to his/her wheelchair;
-CNA L took the resident out of the room and to the day area off of the nursing station;
-CNA L did not wash the resident’s face or hands when getting the resident up for the day.
3. Record review of Resident #28’s updated care plan, dated 1/4/19, showed the following:
-Resident is limited in ability for all ADL’s; he/she requires the assist of one staff for
all of his/her ADL’s;
-Requires extensive assistance with grooming;
-Requires extensive assistance with hygiene.
Observation on 3/19/19 at 5:52 A.M., showed the following:
-The resident lay in his/her bed;
-The corners of the resident’s mouth had dried white matter in the corners;
-The inner canthus of the resident’s eyes had dried yellow matter in the corners;
-CNA L assisted the resident with morning cares, dressed the resident and transferred
him/her to his/her wheelchair;
-CNA L took the resident to the day area off of the nursing station;
-CNA L did not wash the resident’s face or hands when getting the resident up for the day.
During an nterview on 3/19/19 at 6:10 A.M., CNA L said the following:
-He/she did not wash Resident #28 or #5’s face or hands because the facility did not have
washcloths available to complete this task;
-He/she had to step out of the room while providing cares to Resident #5 to try and find
him/her clean pants in the laundry;
-Clean laundry was hit and miss at the facility and a lot of times staff did not have the
clean laundry they needed unless they did it themselves;
-He/she would do laundry as time allowed just so he/she would have available items he/she
needed, but he/she had not been told it was his/her responsibility to do facility laundry;
-When providing peri-care, he/she had to use the disposable wipes because washcloths were
not available for use.
3. Review of Resident #12’s care plan revised 1/31/19, showed the following:
-Requires minimal assistance due to fluctuating weakness for many ADL’s and/or requiring
supervision for completion for ADL’s;
-Does need extensive assistance with bathing needs;
-Supervise to ensure personal hygiene is met;
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-BIMS of 15 indicating no cognitive impairment;
-Personal hygiene, including bathing, combing of hair and shaving, required limited
assistance; one person physical assist.
Observation on 3/17/19 at 12:58 P.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident was wearing a red baseball shirt and gray sweat pants.
Observation and interview on 3/18/19 at 9:25 A.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident wore the same red baseball shirt and gray sweat pants that he/she was noted
to be wearing on 3/17/19.
Observation and interview on 3/19/19 at 8:10 A.M. showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-The resident lay in bed in his/her room;
-The resident said he/she wanted to get up for breakfast but he/she did not have any clean
pants;
-He/she paid for the facility to do his/her laundry;
-Laundry service was horrible and sometimes he/she didn’t change his/her clothes to make
sure he/she had something to wear.
4. Review of Resident #14’s care plan revised 12/27/18, showed the following:
-The resident has an ADL self-care deficit and requires assistance with dressing and
hygiene;
-Extensive assistance with bathing needs;
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Requires extensive assistance of one staff for dressing;
-Requires limited assistance of one staff for personnel hygiene.
During interview on 3/18/19 at 4:00 P.M. the resident said the following:
-He/she paid for the facility to do his/her laundry;
-He/she had difficulty getting his/her laundry back after sending it to be cleaned;
-He/she frequently was without socks and/or underwear and it sometimes took two weeks to
get his/her laundry back.
5. Review of Resident #25’s care plan revised 12/24/18, showed the following:
-Required extensive assistance with bathing;
-Required limited assistance with dressing.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-BIMS of 15;
-Requires extensive assistance of one staff for dressing;
-Requires limited assistance of one staff for personnel hygiene.
During interview on 3/18/19 at 4:00 P.M. the resident said the following:
-He/she paid for the facility to do his/her laundry;
-He/she sometimes did not have his/her laundry returned for a couple of weeks and he/she
had to wear his/her clothes more than once, when they really needed to be cleaned.
7. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following:
-The resident was cognitively intact for daily decision making;
-Required extensive assistance of staff for dressing;
-Required limited assistance of one staff for transfers.
Observation on 3/18/19 at 10:49 A.M. showed the following:
-The resident’s bed was soiled and unmade;
-A hamper full of clothes sat in the middle of the resident’s room behind his/her chair;
-The resident turned on his/her call light;
-CNA A entered the resident’s room;
-The resident told CNA A that he/she still had not been given a bath, staff had not picked
up his/her laundry for days, and staff still had not made his/her bed.
During an interview on 3/18/19 at 10:55 A.M. CNA A said he/she always picked up his/her
resident’s laundry and took it to the laundry room but not all CNAs did this.
During interview on 3/18/19 at 10:50 A.M. and 3/21/19 at 10:40 A.M. the resident said
staff were supposed to make his/her bed as soon as he/she got out of bed but they still
had not changed the sheets and/or made the bed. He/she reported needing laundry done to
staff and they still have not done it. He/she was on his/her last pair of pants to wear.
Observation on 3/21/19 at 10:40 A.M. showed the resident’s full clothes hamper still sat
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
behind the resident’s chair.
8. Review of Resident #43’s care plan revised 1/15/19, showed the following:
-Assist time one staff with daily care;
-Required extensive assistance with dressing;
-Required limited assistance with grooming, requiring staff set up help only.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance of one staff for dressing;
-Was independent with set up assistance only for personal hygiene.
Observation and interview on 3/18/19 at 4:00 P.M. showed the following:
-The resident said he/she paid for the facility to do his/her laundry;
-He/she mostly went without socks;
-The resident was observed to be wearing black tennis shoes with no socks;
-Staff did not always have washcloths available to give to him/her to wash his/her face.
10. Record review of Resident #53’s quarterly MDS, dated [DATE], showed he/she required
limited assistance with personal hygiene.
Review of the resident’s care plan, dated 2/27/19, showed the following:
-Required limited assistance with ADL’s;
-Avoid doing things for the resident that he/she can do; assist as needed;
-Encourage to groom self with set up help (assistance required for completion);
-Encourage participation in ADL’s to the extent possible;
-Limited assistance with grooming (staff to provide set up at sink assist only when
resident is unable to perform);
-Give verbal reminders and cues while participating in ADL tasks.
During an interview on 03/17/19 at 1:05 P.M., the resident’s family member said the
following:
-He/she took the resident’s laundry home to wash because the facility seemed to lose
his/her items or it took the facility too long to do the resident’s laundry. He/she
thought it was due to a staffing issue and staff just didn’t have time to do laundry
regularly;
-He/she usually helped the resident shave and wash his/her face, but staff often tell
him/her they were out of washcloths.
11. Record review of Resident #62’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-The resident was independent and required no staff assistance with dressing or personal
hygiene.
Review of the resident’s care plan revised 1/25/19, showed the following:
-The resident was alert and oriented to person, place and time;
-The resident completed his/her own ADL’s.
During interview on 3/18/19 at 4:00 P.M. the resident said the following:
-Laundry services could use some improvement;
-He/she paid for the facility do to his/her laundry;
-Getting laundry back that had been sent to be cleaned sometimes took two weeks;
-He/she sometimes had to shower without washcloths because the facility did not have any
clean washcloths.
12. Review of Resident #69’s care plan revised 2/7/19, showed the following:
-Encourage the resident to groom self with staff set up help;
-Limited assistance with dressing and grooming.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-Cognitively intact;
-Extensive assistance of one staff with dressing;
-Limited assistance of one staff for personal hygiene.
During interview on 3/18/19 at 4:00 P.M. the resident said the following:
-He/she paid for the facility do to his/her laundry;
-Laundry was not always returned in a timely manner; it sometimes took two weeks to get
items back;
-Staff was often limited on the amount of washcloths they gave him/her to do his/her
bathing cares.
13. Review of Resident #101’s care plan revised 3/1/19, showed the following:
-Requires limited assistance for daily care;
-Can make needs known;
-Requires staff support for dressing and bathing.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required total dependence on staff for dressing;
-Extensive assistance of one staff for personal hygiene.
During interview on 3/18/19 at 4:00 P.M. the resident said the following:
-He/she paid for the facility do to his/her laundry;
-He/she did not always have clean laundry available because it took the laundry staff
weeks to get his/her clothes clean.
14. Record review of Resident #46’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Used wheelchair for mobility.
Observation and interview on 3/17/19 at 1:20 P.M., showed the following:
-The resident sat in his/her wheelchair, the armrest on the right of the wheelchair was
cracked and peeling;
-The resident said the armrest was rough and uncomfortable.
15. Record review of Resident #58’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment for daily decision making;
-Used wheelchair or walker for mobility.
Observation on 3/17/19 at 1:59 P.M., showed the resident sat in his/her wheelchair, the
armrests of the wheelchair were cracked and peeling and the handle from the left push bar
in the back of the wheelchair was missing.
During an interview on 3/19/19 at 10:40 A.M. CNA K said the following:
-He/she verbally reports to maintenance when he/she had issues with a resident’s
wheelchair;
-Wheelchairs are to be cleaned at least once weekly and if issues noted then he/she would
report.
During interview on 03/22/19 at 3:53 P.M. the director of nursing (DON) said the
following:
-Laundry turn around should be on the same day;
-There should be washcloths to wash resident faces;
-Wheelchairs should be clean and repaired;
-If a wheelchair needs repaired she would expect staff to report that to the maintenance
personnel.
During an interview on 4/1/19 at 2:23 P.M. and 4/4/19 at 12:50 P.M., the Administrator
said the following:
-CNAs are responsible for ensuring wheelchairs, including armrests are in good repair 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
reporting issues with the wheelchairs as they arise. CNA staff can report wheelchair
issues to the Unit Managers;
-The facility does not have a policy for resident/facility laundry turn around or
expectations.
-Laundry staff is responsible for resident and facility laundry. Laundry staff is
responsible for picking laundry up and returning it;
-Residents should get their laundry items returned within 48 hours, a week is too long;
-She would expect staff to have washcloths available to provide personal care to the
residents;
-She had no knowledge of laundry issues.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure two residents with a
mental disorder had a DA-124 Level I screen (used to evaluate for the presence of
psychiatric conditions to determine if a preadmission screening/resident review (PASARR)
level II screen is required) as required, for two residents (Resident #91 and Resident
#95) in a review of 24 sampled residents. The facility census was 118.
1. Record review of the Missouri Department of Health and Senior Services (DHSS) guide
titled, PASARR Desk Reference, dated 3/3/08, showed:
-The PASARR is a federally mandated screening process for any person for whom placement in
a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening
(completion of the DA124C form).
-A Level II assessment is completed on those persons identified at Level I who are known
or suspected to have a serious mental illness (such as [MEDICAL CONDITION], dementia,
[MEDICAL CONDITION], etc., MR or related MR condition to determine the need for
specialized service (completion of the DA124A/B form). The facility responsible for
completing the DA124A/B and/or DA124C forms is also responsible for submitting completed
form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care
Regulation, Central Office Medical Review Unit (COMRU);
-PASARR screening is required: To assure appropriate placement of persons known or
suspected of having a mental impairment;
-To assure that the individual needs of mentally impaired persons can be and are being met
in the appropriate placement environment;
-To be compliant with the OBRA/PASARR federal requirements, see 42 CFR 483.Subpart C; and
-To assure Title XIX funds are expended appropriately and in accordance with Legislative
intent.
2. Record review of resident #91’s face sheet showed his/her date of admission was
2/11/19.
Record review of the resident’s (MONTH) 2019 physician order [REDACTED].
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] (antipsychotic) 10 milligrams (mg) daily in the morning for bi-polar
(mental illness);
-[MEDICATION NAME] order changed on 2/28/19 to 5 mg daily for [MEDICAL CONDITION] (mental
illness);

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-[MEDICATION NAME] (antidepressant) 15 mg at bedtime for depression.
Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated
assessment tool required to be completed by facility staff, dated 2/18/19 showed the
following:
-[DIAGNOSES REDACTED].
-The resident was admitted to the facility from the hospital;
-The resident had received antipsychotic medications for the past seven days;
-The resident received antipsychotic medications on a routine basis;
-No documentation that a PASARR was completed for the resident.
Record review of the resident’s care plan, dated 2/22/19 showed the following:
-The resident was at risk for adverse reactions or complications from routine psychoactive
medication usage;
-Administer psychoactive medications as ordered by the physician;
-Monitor/document/report as needed any adverse reactions to psychoactive medication usage:
change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal
thoughts, withdrawal, and decline in activities of daily living (ADL) ability, etc.
Review of the resident’s medical record showed no PASARR screening (Level I or II).
3. Review of Resident #95’s face sheet, showed:
-admitted to the facility on [DATE], 1/30/19 and readmitted on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s admission MDS, dated [DATE], showed the following:
-The resident was cognitively intact;
-A PASARR was not completed for the resident;
-admitted from an acute hospital.
Record review of the resident’s care plan, dated 3/5/19, showed the following:
-Administer psychoactive medications as ordered by physician;
-Monitor/document/report as needed any adverse reactions to psychoactive medication usage:
change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal
thoughts, withdrawal, and decline in activities of daily living (ADL) ability, etc.
Record review of the resident’s medical record showed no PASARR screening (Level I or II).

During interview on 3/22/19 at 3:53 P.M. the director of nursing (DON) said level one
screenings should be completed upon entrance or admission to the facility.
During interview on 3/22/19 9:10 A.M. and 11:37 A.M. the administrator said she had no
more PASARRs. She gave the state agency (SA) survey team all the PASARRs she had found.
The former/previous social services employee left her office in a mess. She didn’t think
the residents needed a PASARR because they had not had a psychiatric stay in the past two
years.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to meet acceptable
professional standards of practice for three residents (Resident #29, #71 and #97) in 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
review of 24 sampled residents. Facility staff failed to follow physician’s orders
[REDACTED].#29 and #71), and failed to assess one resident (Resident #97) who was
undergoing both [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments for possible side
effects or complications. The facility census was 118.
1. During an interview on 4/4/19 at 12:50 P.M. the administrator said the following:
-She would expect staff to follow physician orders;
-She would expect the Director of Nursing (DON) set the expectations for documentation.
2. Review of Resident #29’s face sheet showed the resident was admitted to the facility on
[DATE] with [DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].>Review of the resident’s
Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to
be completed by facility staff, dated 1/7/19, showed the following:
-Cognitively intact for daily decision making;
-Had no rejection of care;
-Required limited assistance of one staff for eating;
-Weight was 163 pounds.
Review of the resident’s care plan, dated 1/13/19 showed the following:
-Problem: The resident requires extensive assist to full staff asssistance with ADL’s;
-Interventions: Eating: The resident can feed his/her self although at times, does not
complete meal therefore staff required. Limited assistance at meals. Eats in supervised
dining room except at lunch in which he/she eats in room with family member per family
member’s request;
-Problem: The resident has [MEDICAL CONDITION];
-Interventions: Monitor/document/report as needed any signs/symptoms of [MEDICAL
CONDITION]: weight gain unrelated to intake.
Review of the resident’s Weight Record, showed no documentation/evidence staff weight the
resident daily as ordered on [DATE], 1/23/19, 1/24/19, 2/3/19, and 2/22/19.
Review of the resident’s Physician Orders, dated 2/6/19, showed an order for [REDACTED].
Further review of the resident’s care plan, dated as initiated 2/27/19, showed the
following:
-Problem: The resident has experienced weight fluctuations placing him/her at risk for
nutritional deficit. The resident requires nutritional monitoring;
-Interventions: Daily weights as ordered. The resident to use plate with plate guard or
built up edges for all meals when available.
Further review of the resident’s Weight Record, showed no documentation/evidence staff
weight the resident daily as ordered on 3/2, 3/3, 3/4, 3/10, and 3/14/19.
Observation 3/17/19 at 6:10 P.M., showed the resident in the supervised dining room. Staff
served the resident’s meal on a Styrofoam plate with no plate guard and no built up edges
as physician ordered.
Observation on 3/18/19 at 9:31 A.M., showed the resident in the supervised dining room.
He/She ate his/her meal from a glass plate with no plate guard and no built up edges as
physician ordered.
Observation on 3/21/19 at 8:49 A.M., showed the resident in the supervised dining room.
He/She ate his/her meal off a glass plate with no plate guard and no built up edges as
physician ordered.
During an interview on 3/21/19 at 8:50 A.M., Certified Nurse Assistant (CNA) AA, said
he/she had never seen the resident with a plate guard or built up edges on the plate.
During an interview on 3/21/19 at 9:02 A.M., Unit Manager Licensed Practical Nurse (LPN)
W, said he/she was unaware if the resident had an order for [REDACTED].>During an
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
interview on 3/21/19 at 9:03 A.M., Unit Manager LPN NN, said dietary should put a plate
guard on or send a plate with built up edges if the physician ordered one.
During an interview on 3/21/19 at 8:51 A.M., the Occupational Therapist said the resident
should have a plate guard or built up edges on his/her plate if the physician ordered
this.
3. Review of Resident #71’s updated care plan, dated 2/8/19 showed the following:
-Dependent on staff for locomotion;
-Transfer with two staff;
-The resident will have his/her basic care needs met daily;
-At risk for pressure ulcers due to the need for extensive assistance with repositioning
and bed mobility;
-History of healed pressure injury (right and left heels);
-Administer treatments as ordered and monitor for effectiveness;
-Elevate bilateral heels as much as the resident will allow; the resident does not want to
wear any pressure boots; when applied, the resident will resist and kick off;
-Extensive assistance with repositioning or bed mobility; needs pressure relief when in
bed and wheelchair.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Extensive assistance of one staff for bed mobility;
-Total dependence of two staff for transfers;
-Extensive assistance of one staff for locomotion on and off the unit;
-Used wheelchair for mobility device;
-History of pressure ulcer/injury;
-Risk of pressure ulcer/injury;
-Pressure decreasing device for wheelchair and bed.
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Bilateral heels open to air with heel protectors every shift related to [MEDICAL
CONDITION] ([MEDICAL CONDITION] disorder of the central nervous system that affects
movement, often including tremors).
Observation on 03/17/19 at 2:45 P.M. showed the following:
-The resident lay in his/her bed;
-The resident did not have bilateral heel protectors on; there were none observed in the
resident room;
-The resident’s heels were not elevated off of the bed.
Observation on 03/18/19 at 10:00 A.M. showed the following:
-The resident lay in his/her bed;
-The resident did not have bilateral heel protectors on; there were none seen in the
resident room;
-The resident’s heels were not elevated off of the bed.
During interview on 03/18/19 at 10:00 A.M., LPN H said he/she did not know if the resident
was to be wearing heel protectors or have his/her feet elevated.
Observation on 03/19/19 at 10:26 A.M. showed the following:
-The resident lay in his/her bed;
-The resident did not have bilateral heel protectors on; there were none seen in the
resident room;
-The resident’s heels were not elevated off of the bed.
During interview on 03/19/19 at 10:26 A.M., CNA J said the following:
-He/she did not know where the resident’s heel protectors were;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-He/she had returned the resident to bed that morning and had not elevated his/her heels;
he/she did not know they needed to be.
4. Review of Resident #97’s quarterly MDS dated [DATE], showed the resident was cognitvely
intact for daily decision making;
Review of the resident’s physician progress notes [REDACTED].
-Recent PET scan (positron emission tomography is an imaging test that helps reveal how
your tissues and organs are functioning) showed a large mass in the superior segment of
the right lower lobe lung, most likely represents a [MEDICATION NAME] ([MEDICAL
CONDITION]). He/she was also noted to have a large soft tissue mass in the left proximal
posterior thigh which was even more metabolically active with a second nodule in the right
thigh. Possibly both could reflect metastatic (widespread) disease. The biospy showed
metastatic disease and is receiving infusion therapy.
Review of the resident’s physician progress notes [REDACTED]. His/her next scheduled
infusion is 2/27/19.
Review of the resident’s care plan, dated as reviewed 2/26/19, showed the following:
-Problem: The resident is at risk for pain or discomfort due to [DIAGNOSES
REDACTED].>-Interventions: Anticipate the resident’s need for pain relief and respond
immediately to any complaints of pain. Identify and record previous pain history and
management of that pain and impact on function. Monitor/document for side effects of pain
medication. Monitor/record pain characteristics. Monitor/record/report to nurse any
sign/symptoms of non-verbal pain;
-No documentation regarding the resident’s [MEDICAL CONDITION] and [MEDICAL CONDITION] in
the care plan or directions to monitor for potential complications from both.
Review of the resident’s medical record showed the following:
-No documentation/evidence the resident was going to [MEDICAL CONDITION] or [MEDICAL
CONDITION] therapy appointments;
-No documentation/evidence the resident was being assessed following the [MEDICAL
CONDITION] or [MEDICAL CONDITION] appointments.
During an interview on 3/17/19 at 2:00 P.M., the resident said he/she had been going out
for [MEDICAL CONDITION] appointments and [MEDICAL CONDITION].
During an interview on 3/20/19 at 12:10 P.M., Licensed Practical Nurse (LPN) M, said the
following:
-The resident goes out daily for [MEDICAL CONDITION] therapy;
-Staff should document in the medical record when the resident leaves and when he/she
returns;
-Staff should document in the medical record how the resident responded to [MEDICAL
CONDITION] or [MEDICAL CONDITION] and if he/she was having any side effects of the either.

Further review of the resident’s medical record, showed the following:
-No documentation/evidence the resident was going to [MEDICAL CONDITION] or [MEDICAL
CONDITION] therapy appointments;
-No documentation/evidence the resident was being assessed following the [MEDICAL
CONDITION] or [MEDICAL CONDITION] therapy appointments.
5. During an interview on 3/22/19 at 3:53 P.M., the Director of Nurses (DON) said the
following:
-She would expect staff to follow physician orders;
-She would expect staff to follow the resident care plans;
-She would expect staff to document after [MEDICAL CONDITION] and [MEDICAL CONDITION]
therapy any complications from either.

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to provide
necessary services to maintain good personal hygiene and prevent body odors for 13
residents (Resident #12, #22, #27, #29, #53, #57, #71, #72, #97, #99, #109, #110 and #111)
in a review of 24 sampled residents and four additional residents (Resident #5, #9, #28
and #38). Staff failed to provide showers, nail care, oral care, and grooming to include
shaving. The facility census was 118.
1. Review of the facility policy titled Brushing and Combing Hair, dated (MONTH) 2007,
showed the following:
-The purpose of the policy was to provide hair and scalp care;
-The resident’s hair should be brushed and combed every morning before breakfast and when
necessary throughout the day.
2. Review of the facility policy titled Shower/tub bath, dated (MONTH) 2010, showed the
purposes of this procedure was to promote cleanliness, provide comfort to the resident and
to observe the condition of the resident’s skin.
3. Review of the facility policy titled Mouth Care, dated (MONTH) 2010, showed the
following:
-The purpose of this procedure was to keep the resident’s lips and oral tissues moist, to
cleanse and freshen the resident’s mouth and to prevent infections of the mouth;
-Review the resident’s care plan to assess for any special needs of the resident.
4. Review of the facility policy titled Care of Fingernails/toenails, dated (MONTH) 2010,
showed the following:
-The purposes of this procedure are to clean the nail bed, to keep nails trimmed and to
prevent infections;
-Review the resident’s care plan to assess for any special needs of the resident;
-Nail care includes daily cleaning and regular trimming;
-Proper nail care aides in the prevention of skin problems around the nail bed;
-Unless otherwise permitted, do not trim the nails of diabetic residents or residents with
circulatory impairments;
-Trimmed smooth nails prevent the resident from accidentally scratching and injuring
his/her skin.
5. Record review of Resident #27’s Annual Minimum Data Set (MDS) a federally mandated
assessment instrument, completed by facility staff, dated 1/3/19, showed the following:
-Cognitively intact for daily decision making;
-No rejection of care;
-Required limited assistance of one staff for transfers, dressing, and toileting;
-Required physical help in part of bathing activity with assist of one staff;
-Had an indwelling catheter;
-Was always continent of bowel.
Review of the resident’s care plan, dated as revised 2/1/19, showed the following:
-Problem: The resident requires staff assistance with grooming and bathing;
-Approaches: Extensive assist with bathing needs especially with washing and drying of
lower body. Limited assist with toileting needs. Staff does have to assist with catheter

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
cares and emptying of catheter drainage bag. Set up at sink for the resident to self
perform own grooming needs.
Review of the facility shower assignment showed the resident was to get a shower on Monday
and Thursday day shift.
Observation and interview on 03/17/19 at 4:20 P.M., showed the resident complained that
he/she does not get showers. The resident’s hair was disheveled and greasy. The resident
had an area of dried blood on his/her lower right leg. The resident wore yellow hospital
gown. The resident had a brownish colored area to the foot of his/her bed on the sheets.
Observation and interview on 3/18/19 at 10:10 A.M., showed the resident was wearing the
same yellow gown as 3/17/19 and still the area of dried blood on his/her lower right leg
remained. The resident said he/she had not had a shower and had not had his/her sheets
changed. The resident’s hair was disheveled and greasy and he/she still had the brownish
colored area to the foot of his/her bed on the sheets.
Observation and interview on 3/19/19 at 10:49 A.M., showed the resident wore the same
yellow gown as 3/17/19 and still had an area of dried blood on his/her lower right leg.
The resident said he/she had not had a shower and had not had his/her sheets changed. The
resident’s hair was disheveled and greasy and he/she still had the brownish colored area
to the foot of his/her bed on the sheets. The resident resided in the room by him/herself
and upon entering the room, the room had a foul odor.
Observation and interview on 3/20/19 at 11:53 A.M., showed the resident wore the same
yellow gown as 3/17/19 and still had an area of dried blood on his/her lower right leg.
The resident said he/she had not had a shower and had not had his/her sheets changed. The
resident’s hair was disheveled and greasy and he/she still had the brownish colored area
to the foot of his/her bed on the sheets. The resident’s room had a foul odor.
Observation and interview on 3/21/19 at 9:07 A.M., showed the resident wore the same
yellow gown as on 3/17/19 and still had an area of dried blood on his/her lower right leg.
The resident said he/she had not had a shower and had not had his/her sheets changed. The
resident’s hair was disheveled and greasy and he/she still had the brownish colored area
to the foot of his/her bed on the sheets. The resident’s room had a foul odor.
6. Review of Resident #5’s care plan, revised 12/31/18, showed the following:
-The resident had dementia, gets confused and needs direction;
-The resident will have all of his/her basic needs met by staff;
-Assist times one supervision with care needs and bathing; allow him/her to do as much for
him/herself with set up assistance as tolerated;
-Encourage the resident to perform or participate in ADL’s to extent possible;
-Staff may need to provide more ADL assistance in the mornings when the resident first
gets out of bed.
Review of the resident’s quarterly MDS dated [DATE], showed the following:
-Brief interview for mental status (BIMS) of nine indicating some cognitive impairment
(BIMS scores range from 0-15, the higher the score, the lower the impairment to the
cognitive response);
-Personal hygiene, including washing and drying of the face and hands, required limited
assistance of one staff.
Observation on 3/19/19 at 6:06 A.M. showed the following:
-The resident lay in his/her bed;
-The inner canthus of the resident’s right eyes had dried yellow matter in the corner;
-Certified Nurse Aide (CNA) L assisted the resident with morning cares, dressed the
resident and transferred him/her to his/her wheelchair;
-CNA L took the resident out of the room and to the day area;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-CNA L did not wash the resident’s face or provide oral care before taking the resident
out of the room.
7. Record review of Resident #9’s Admission MDS dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Had no rejection of care;
-Required extensive assist of one staff for bed mobility, transfers, dressing, and
toileting;
-Required limited assist of one staff for personal hygiene;
-Required physical help of one staff for bathing;
-Was occasionally incontinent of urine;
-Was always continent of bowel.
Review of the resident’s care plan, dated as reviewed 3/11/19, showed the following:
-Problem: The resident requires limited to extensive assist with ADL’s;
-Interventions: The resident requires extensive assist from staff with showering two times
weekly and as necessary.
Review of the facility’s shower assignment sheet, showed the resident was to receive on
Tuesday and Friday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-On 1/30/19 there was no hot water, so shower was not given;
-Received a shower on 2/25/19, 3/2/19, and 3/8/19;
-No documentation to show showers were given or refused on other days.
Observation and interview on 3/18/19 at 4:12 P.M., showed the resident said he/she does
not get showers. He/she had not received a shower for over ten days. He/she would prefer
his/her family member be at the facility when he/she takes a shower and would prefer a
bench over the shower chair. The resident was in bed with only a brief on and covered in a
sheet. The resident’s hair was disheveled and greasy. The room had an unidentifiable odor.

8. Review of Resident #12’s updated care plan, dated 1/31/19, showed the following:
-Requires minimal assistance due to fluctuating weakness for many ADL’s and/or requiring
supervision for completion for ADL’s;
-Does need extensive assistance with bathing needs;
-Does refuse showers at times; approach at different times of day for showers;
-Supervise to ensure personal hygiene is met;
-Refuses to shave chin at times; continue to offer assistance in tasks until resident is
agreeable with completion.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-BIMS of 15 indicating intact cognition;
-Personal hygiene, including bathing, combing of hair and shaving, required limited
assistance; one person physical assist.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the following:
-The resident’s last documented shower was on 2/21/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 02/25/19, 02/28/19, 03/04/19, 03/07/19, 03/11/19, 03/14/19, 03/18/19 and
03/21/19.
Observation on 03/17/19 at 12:58 P.M. showed the following:

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt.
Observation on 3/18/19 at 9:25 A.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt.
Observation on 3/19/19 at 8:10 A.M. showed the following:
-The resident lay in bed in his/her room;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt.
Observation and interview on 3/22/19 at 10:05 A.M. showed the following:
-The resident sat in his/her wheelchair in the facility hallway;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt;
-The resident said he/she needed help shaving his/her facial hair and staff never assisted
him/her;
-He/she sometimes asked for supplies to shave and assistance, but staff never brought them
or offered to help;
-He/she likes to be clean shaven;
-Staff does not always help him/her with bathing;
-He/she used to go to the shower room and linen room on his/her own because he/she got
tired of waiting on staff to help, but he/she got in trouble with staff for doing that so
he/she doesn’t do it anymore;
-He/she does not even have a comb or wash clothes to clean up at the sink if he/she wanted
to.
9. Review of Resident #22’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance with personal hygiene, including shaving;
-Required physical help in part of bathing assistance.
Review of the resident’s care plan, revised 2/21/19, showed the following:
-Requires supervision to limited assistance at times with ADL’s;
-The resident will be appropriately assisted with ADL’s as needed;
-Allow the resident to do as much as possible for him/herself and offer assistance when
needed;
-Encourage the resident to allow staff to assist with hygiene and bathing; encourage staff
assist and completion of these tasks;
-Limited assistance with bathing;
-Set up and supervision for grooming needs to assure the resident is completing task.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the following:
-The resident’s last documented shower was on 2/21/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 02/25/19, 02/28/19, 03/04/19, 03/07/19, 03/11/19, 03/14/19, 03/18/19 and
03/21/19.
Observation on 03/17/19 at 12:02 P.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-The resident had unshaven facial hair resembling stubble.
Observation on 3/18/19 at 9:25 A.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 3/19/19 at 8:10 A.M. showed the following:
-The resident sat in a wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
Observation and interview on 3/22/19 at 10:15 A.M. showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble;
– He/she needed help shaving his/her facial hair and staff never assisted him/her;
-He/she sometimes asked for supplies to shave and assistance, but they never brought them
or offered to help;
-He/she likes to be clean shaven;
-Staff does not always help him/her with bathing because they are short staffed;
-It had been a long time since he/she had a shower and he/she felt dirty.
10. Record review of Resident #28’s annual MDS, dated [DATE], showed the following:
-BIMS of seven indicating severely impaired cognition;
-Personal hygiene, including washing and drying of the face and hands, required extensive
assistance.
Review of the resident’s care plan revised 1/4/19, showed the following:
-Resident is limited in ability for all ADL’s; he/she requires the assist of one staff for
all of his/her ADL’s;
-Requires extensive assistance with grooming;
-Requires extensive assistance with hygiene.
Observation on 3/19/19 at 5:52 A.M., showed the following:
-The resident lay in his/her bed;
-Dried white matter was present in the corners of the resident’s mouth;
-Dried yellow matter was present in the corners of the resident’s eyes;
-CNA L assisted the resident with morning cares, dressed the resident and transferred
him/her to his/her wheelchair;
-CNA L took the resident to the day area;
-CNA L did not wash the resident’s face or hands or provide oral care when getting the
resident up for the day.
11. Record review of Resident #29’s Admission MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-No rejection of care;
-Was dependent on one staff for dressing, toileting, and bathing;
-Required extensive assist of one staff for bed mobility, transfers, and personal hygiene;
-Always incontinent of bladder;
-Frequently incontinent of bowel.
Review of the resident’s care plan, dated 1/13/19, showed the following:
-Problem: The resident requires extensive to full staff assistance with ADL’s;
-Interventions: The resident is totally dependent on one staff to provide showers twice
weekly and as necessary.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-The resident received one shower on 3/7/19 (49 days);
-No documentation to show the resident had refused or received a shower for the other
days.
Observation and interview on 03/17/19 at 3:05 P.M., showed the resident’s family member
said the resident did not receive showers like he/she should. The resident had been at the
facility since 12/31/18 and as far as he/she knew had only received three showers. The
resident’s hair appeared greasy.
During an interview on 3/19/19 at 8:30 A.M., the resident’s family member said that the
resident did not receive his/her shower last night. Observation showed the resident’s hair
appeared greasy.
Observation on 3/22/19 at 10:53 A.M., showed a hand written sign on the resident’s door
that said, Shower time!
During an interview on 3/22/19 at 11:13 A.M., the resident’s family member said the
following: He/she put the sign on the resident’s door to remind staff to do the resident’s
shower. He/she was unsure if the resident received his/her shower the night before.
12. Review of Resident #38’s quarterly MDS, dated [DATE], showed the following:
-BIMS of 14;
-Personal hygiene, required extensive assistance of one staff;
-Bathing, was totally dependent on two or more staff.
Review of the resident’s care plan, revised 1/22/19, showed the following:
-Requires extensive assist to full assist with daily cares;
-Staff to assist to make sure basic care needs are met;
-Is incontinent of bladder with occasional incontinence of bowel.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the following:
-The resident received a shower on 2/07/19;
-No documentation the resident received a shower as scheduled on 02/11/19, 02/14/19,
02/18/19, 02/21/19, 02/25/19, 02/28/19, 03/04/19, 03/10/19, 03/11/19, 03/14/19 and
03/18/19.
Observation and interview on 03/17/19 at 2:45 P.M. showed the following:
-The resident lay in bed watching television;
-The resident said he/she had not had a shower for six weeks;
-The reason staff gives him/her for not getting his/her shower is that they are low on
staff; this includes no hair washing;
-His/her hair felt greasy;
-The resident’s hair appeared greasy;
-The resident ran his/her hands through his/her hair and it stood up on end.
13. Record review of Resident #53’s quarterly MDS, dated [DATE], showed the following:
-BIMS of 10;
-Personal hygiene, including shaving, required limited assistance.
Review of the resident’s care plan, dated 2/27/19, showed the following:
-Required limited assistance with ADL’s;
-Avoid doing things for the resident that he/she can do; assist as needed;
-Encourage to groom self with set up help (assistance required for completion);
-Encourage participation in ADL’s to the extent possible;
-Limited assistance with grooming (staff to provide set up at sink assist only when
resident is unable to perform);
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-Give verbal reminders and cues while participating in ADL tasks.
Record review of the facility’s shower assignment sheet showed the resident was to receive
his/her showers on Tuesday and Friday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the resident had received showers
as scheduled, but there was no documentation to support the resident had been shaved.
Observation and interview on 03/17/19 at 1:05 P.M., showed the following:
-The resident had a mustache and goatee; there was facial stubble on the resident’s
cheeks;
-The resident’s family member said staff frequently did not assist the resident with
shaving; he/she thought it was due to a staffing issue and they just didn’t have time;
he/she usually helped the resident shave as the resident would not want the facial
stubble.
14. Review of Resident #57’s care plan, dated 7/25/18, showed the following:
-Check frequently for wetness and change after incontinence occurs;
-Continent of bowel and bladder with occasional incontinence requiring pads/briefs;
-The resident often refuses showers. Does shave as needed. Staff is to encourage shower or
at minimal washing body at sink to prevent odor or complications from poor hygiene.
Review of the resident’s annual MDS, a federally mandated assessment instrument completed
by facility staff, dated 1/31/19, showed the following:
-Cognition moderately impaired;
-Had no rejection of care;
-Bathing somewhat important;
-Required extensive assistance of one staff for bathing;
-Frequently incontinent of urine.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-Refused a shower on 3/8/19;
-The resident received a shower on 3/14/19;
-There was no documentation the resident received a shower 1/17/19 through 3/13/19 (55
days).
Observation on 3/20/19 at 1:35 P.M., showed the resident walking the halls of the
facility. The resident’s hair was disheveled.
15. Record review of Resident #71’s care plan revised 1/16/19, showed the following:
-Dependent on staff for bathing;
-Extensive assistance with grooming needs; unable to complete tasks on own.
Record review of the resident’s MDS, dated [DATE], showed the following:
-BIMS of six indicating severely impaired cognition;
-Personal hygiene, including shaving, required extensive assistance and was a one person
physical assist;
-Total dependence on staff for bathing.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the resident had received showers
as scheduled, but there was no documentation to support the resident had been shaved.
Observation on 03/17/19 at 3:22 P.M. showed the following:
-The resident lay in bed on his/her left side;
-The resident had unshaven facial hair resembling stubble.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
Observation on 3/18/19 at 9:15 A.M. showed the following:
-The resident sat in his/her wheelchair in the assisted dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 3/19/19 at 11:02 A.M. showed the following:
-The resident lay in bed on his/her left side;
-The resident had unshaven facial hair resembling stubble.
16. Record review of Resident #72’s Admission MDS dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-No rejection of care;
-Required physical help in part of bathing activity of one staff;
-Required limited assistance of one staff for bed mobility, transfers, dressing, and
toileting;
-Required supervision with set-up help for personal hygiene;
-Was continent of bowel and bladder.
Review of the resident’s care plan, dated 12/2/18, showed the following:
-Problem: The resident requires limited to extensive assist with ADL’s due to recent
hospitalization and increased weakness;
-Interventions: Provide shower/bath two times a week and as needed (extensive assist).
Limited assist with grooming.
Record review of the facility’s shower assignment sheet showed the resident was to receive
his/her showers on Monday and Thursday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-The resident refused to shower on 2/11/19, 2/14/19, and 2/21/19;
-The resident received one shower on 2/25/19 (40 days);
-The resident refused to shower on 3/7/19 and 3/14/19;
-No documentation the resident received a shower from 2/25/19 to 3/22/19 (25 days).
Observation and interview on 03/17/19 at 2:21 P.M., showed resident said that he/she does
not get showers like he/she would like. The resident was unshaven and hair appeared
disheveled and greasy, he/she said that he/she would like to be shaved daily.
Observation and interview on 3/19/19 at 7:24 A.M., showed the resident wearing the same
clothes as he/she had on 3/18/19. He/she had slept in his/her clothes. The resident said
that he/she did not receive a shower last night 3/18/19. The resident was still unshaven
and his/her hair was disheveled and greasy.
Observation and interview on 3/21/19 at 8:42 A.M., showed the resident in the same clothes
he/she wore on 3/20/19. The resident said that he/she had still not received a shower.
He/she was shaven, but his/her hair was disheveled and greasy.
17. Record review of Resident #97’s quarterly MDS dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-No rejection of care;
-Required limited assistance of one staff for toileting;
-Required physical help of one staff for bathing;
-Required supervision with no set up for personal hygiene;
-Had an indwelling catheter;
-Was continent of bowel.
Review of the resident’s care plan, dated as reviewed 2/22/19, showed the following:
-Problem: The resident requires supervision to limited assist at times with ADL’s;
-Interventions: The resident needs encouragement to take showers or perform own grooming.
When not performing staff will offer assistance although the resident refuses staff
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
assistance. The resident may be more compliant with showers when going on outings with
family so staff may need to adjust shower days. Limited assist with bathing twice weekly
and/or as needed, may need assist with lower body washing and drying. The resident is able
to self perform grooming needs daily with supervision that he/she completes tasks on
his/her own.
Record review of the facility’s shower assignment sheet showed the resident was to receive
a shower on Tuesday and Friday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-The resident had received four showers 2/17/19, 2/19/19, 3/1/19, and 3/5/19 in 64 days.
Observation and interview on 03/17/19 at 2:00 PM., showed the resident said he/she had not
received a shower in four or five days. Observation showed the resident with facial hair
and his/her hair was disheveled and greasy. The resident said he/she would like to shave
daily if he/she could, but the facility had no staff to help.
Observation on 3/18/19 at 4:10 P.M., showed the resident wore in the same clothes as
3/17/19 and was unshaven. His/her hair was disheveled and greasy.
18. Review of Resident #99’s admission MDS, dated [DATE], showed the following:
-Makes self understood and understands others sometimes;
-Had no rejection of care;
-Bathing somewhat important;
-Required total assistance of one staff for bathing;
-Always incontinent of bladder and bowel.
Review of the resident’s care plan, dated 12/5/18, showed the following:
-Requires extensive to full staff support with ADL’s due to [DIAGNOSES REDACTED].
-Dependent on staff for bathing needs. Both washing and drying of upper and lower body.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-The resident received showers on 1/18/19, 1/23/19, 1/26/19, 2/3/19, 2/5/19, 2/9/19,
2/13/19, 2/26/19, 3/3/19, 3/8/19 and 3/15/19;
-The resident received no showers/baths from 1/27/19 through 2/2/19 (6 days);
-The resident received no showers/baths from 2/14/19 through 2/25/19 (11 days);
-The resident received no showers/baths from 3/9/19 through 3/14/19 (6 days);
-The resident received no showers/baths from 3/16/19 through 3/22/19 (6 days).
19. Review of Resident #109’s care plan, dated 7/24/18, showed the following:
-The resident needs extensive assistance with bathing needs especially washing and drying
of lower body;
-Incontinent of bladder and frequently incontinent of bowels requiring use of pad/brief
and full staff support for incontinence.
Review of the resident’s annual MDS dated [DATE], showed the following:
-Short and long term memory problems;
-Had no rejection of care;
-Prefers a shower;
-Required extensive assistance of one staff for bathing and personal hygiene;
-Always incontinent of urine;
-Frequently incontinent of bowel.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-The resident received showers/baths on 2/7/19, 2/18/19, 2/21/19, 2/25/19, and 2/28/19;
-Refused a shower times three on 3/15/19;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
-There was no documentation the resident received a shower 1/17/19 through 2/6/19 (20
days);
-There was no documentation the resident received a shower 2/8/19 through 2/17/19 (9
days);
-There was no documentation the resident received a shower 3/1/19 through 3/22/19 (22
days).
20. Review of Resident #110’s care plan, dated 2/8/19, showed the following:
-Totally dependent on staff to provide bath/shower two times weekly and as necessary;
-Totally dependent on staff for personal hygiene and oral care.
Review of the resident’s 14 day Prospective Payment System (PPS) MDS dated [DATE], showed
the following:
-Cognitively intact;
-Had no rejection of care;
-Required total assistance of two or more staff for bathing;
-Indwelling catheter for bladder and ostomy for bowel.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-The resident received no showers/baths from 1/28/19 through 2/2/19 (5 days);
-The resident received a shower on 2/3/19, bed bath on 2/8/19, shower on 2/17/19, and a
bed bath on 2/19/19;
-Was in the hospital on [DATE] and 2/26/19;
-There was no documentation the resident received a shower 3/1/19 through 3/22/19 (22
days).
Observation on 3/17/19 at 1:45 P.M., showed the resident lay in bed with head of bed up
watching television with long fingernails.
During an interview on 3/17/19 at 1:45 P.M., the resident said he/she has told staff that
he/she wants fingernails trimmed but they have never been trimmed.
During an interview on 3/19/19 at 7:44 A.M., the resident said staff just come in and do a
bed bath when they are ready. It can be a long period between baths and that he/she has
went a couple of weeks without a shower before. He/She doesn’t know why he/she doesn’t get
a bath/shower when scheduled.
21. Review of Resident #111’s care plan dated 3/5/19 showed the following:
-Date initiated 3/14/16 and target date 6/11/19;
-Required one staff assistance with all ADL’s due to the resident’s limited mobility
related to the resident being weaker on the left side.
Record review of the Resident’s annual MDS dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Had no rejection of care;
-Required extensive assistance of one staff for bathing;
-Was always continent of bowel and bladder.
Review of the facility’s shower assignment sheet, showed the resident was to receive
showers on Tuesdays and Fridays during the evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-Staff showered/bathed the resident three days in a (MONTH) 2019;
-Staff showered/bathed the resident two days in 27 days from 2/1/19 to 2/28/19;
-Staff showered and/or bathed the resident one time in 22 days from 3/1/19 to 3/22/19.
Observation and interview on 3/19/19 at 7:35 A.M., showed the resident said he/she does
not get showers as he/she would like or needed. Staff had not given him/her a shower for
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
two weeks. There wasn’t enough staff on evenings to give him/her a showers. He/she would
like to get showers at least twice a week. He/she did not care if he/she got his/her
shower on evenings or days, he/she just wanted a shower. The resident’s finger nails were
long and had brown debris under them. The res (TRUNCATED)

F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide basic life support, including CPR, prior to the arrival of emergency medical
personnel , subject to physician orders and the resident’s advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff were properly
trained in Cardiopulmonary Resuscitation (CPR-process of providing rescue ventilation and
chest compressions to maintain circulation of blood) and subject to accepted professional
guidelines, by allowing the staff to certify/recertify for CPR online. The facility also
failed to have a system in place to ensure CPR certified staff were available on all
shifts 24 hours a day/seven days a week. The facility identified 52 residents as full code
status (CPR required in the event of cardiac or respiratory arrest). The facility census
was 118.
1. Review of the facility policy Emergency Procedure-CPR revised (MONTH) (YEAR) showed the
following:
Policy statement: Personnel have completed training on the initiation of CPR and basic
life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION];
General guidelines:
3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may appear to
be having a [MEDICAL CONDITION]. Training in BLS includes recognizing presentations of
sudden [MEDICAL CONDITION] (SCA);
4. The chances of surviving SCA may be increased if CPR is initiated immediately upon
collapse;
5. Early delivery of a shock with a defibrillator plus CPR within ,[DATE] minutes of
collapse can further increase chances of survival;
6. If an individual (resident, visitor, or staff member) is found unresponsive and not
breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR
unless:
-It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or
external defibrillation exists for that individual or;
-There are obvious signs of irreversible death (e.g. rigor mortis);
7. If the resident’s DNR status is unclear, CPR will be initiated until it is determined
that there is a DNR or a physician’s order no to administer CPR;
Preparation for CPR:
1. Obtain and/or maintain American Red Cross or American Heart Association certification
in BLS/CPR for key clinical staff members who will direct resuscitative efforts, including
non-licensed personnel.
2. Review of Centers for Medicare and Medicaid Services Center for Clinical Standards and
Quality/Survey & Certification Group memorandum revised [DATE] showed the following:
-Subject: CPR in Nursing Homes;
-CPR Certification: Staff must maintain current CPR certification for healthcare providers
through CPR training that includes hands-on practice and in-person skills assessment.
Online-only certification is not acceptable.

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 30)
3. Review of Licensed Practical Nurse (LPN) II’s Community and Workplace certification
cards showed the following:
-LPN II successfully completed CPRToday! Inc. Training Course in BLS, Adult CPR and AED;
-Certified on [DATE]. Expired ,[DATE];
-Certified on [DATE]. Expires on ,[DATE].
During interview on [DATE] at 4:00 P.M. LPN II said his/her CPR recertification in (YEAR)
and [DATE] were online courses only. There was no hands-on component to the certification.
4. Review of Medical Records Staff U Lifeline Training Resources card showed the
following:
-Medical Records Staff U successfully completed all Lifeline Training curriculum
coursework equivalent to (YEAR) EDD/ILCOR and AHA guidelines;
-Certified on [DATE]. Expires [DATE].
During interview on [DATE] at 4:45 P.M. Medical Records Staff U said the following:
-His/her CPR certification was online only;
-He/she did not complete any hands-on skills component.
5. Review of the Director of Nurses (DON)’s CPR certification card showed the following:
-Course date [DATE];
-Recommended renewal date: ,[DATE].
6. Review of Certified Nurse Aide (CNA) KK’s American Health Care Academy CPR
certification card showed the following:
-He/she successfully completed the requirements in accordance with American Health Care
Academy’s curriculum;
-Issue date [DATE]. Renewal date [DATE].
7. Review of LPN LL’s American Health Care Academy CPR certification card showed the
following:
-He/she successfully completed the requirements in accordance with American Health Care
Academy’s curriculum;
-Issue date [DATE]. Renewal date [DATE].
Review of www.cpraedcourse.com showed American Health Care Academy offers nationally
accepted and easy-to-understand Adult, Child and Infant Online CPR certification and
Online First Aid certification courses for the community, school, workplace and Healthcare
Providers.
8. During interview on [DATE] at 2:35 P.M. Unit Manager/LPN W said the following:
-He/she was the staffing coordinator from (MONTH) (YEAR) to [DATE];
-He/she was responsible for scheduling all nursing staff;
-He/she scheduled staff based on fire code;
-He/she did not know who was CPR certified;
-He/she did not staff based on CPR certification and ensuring CPR certified staff were
available on all shifts 24 hours a day/seven days a week;
-It was the responsibility of the DON to make sure CPR certifications were current;
-All licensed staff should be CPR certified.
During interview on [DATE] at 2:45 P.M. LPN P/Staffing Coordinator said the following:
-He/she has been the staffing coordinator for the last week or week and a half;
-He/she was in charge of scheduling all nursing staff;
-All licensed nurses should be CPR certified;
-He/she had not verified all licensed nurses were CPR certified;
-He/she wouldn’t know if a licensed nurse was CPR certified or not unless the facility
receives a CPR card from the nurse;
-He/she does not schedule staff based on ensuring CPR certified staff are in the facility
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 31)
on all shifts.
During interview on [DATE] at 3:50 P.M. the DON said she thought all licensed staff were
CPR certified. She did not follow up or review the schedule to assure there were CPR
certified licensed staff on all shifts.
During interview on [DATE] at 2:15 P.M. and [DATE] at 2:23 P.M. the administrator said the
following:
-The staffing coordinator was responsible for ensuring CPR certified staff are in the
facility on all shifts;
-The staffing coordinator was responsible for ensuring CPR certifications are current and
CPR certification cards are present in the employee files;
-She believed all her licensed staff were CPR certified;
-The DON was responsible for tracking CPR certification and overseeing the staffing
coordinator’s scheduling;
-She thought her staffing coordinator was assuring all licensed staff had CPR
certificates;
-She felt the system needed improvement;
-She would expect all licensed nurses to be CPR certified;
-She had not identified some licensed staff who were not CPR certified;
-She was not aware some of the facility’s licensed staff were CPR certified/recertified
online only;
-She was not aware online only certification was not sufficient;
-She would expect staff to be CPR certified in both the cognitive and hands-on skills
components of CPR.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to provide one
additional resident (Resident #463) the necessary care and services to maintain his/her
highest practicable well-being when staff did not verify the resident’s hospital discharge
orders and administered [MEDICATION NAME] (blood thinning medication) when hospital
discharge orders directed staff to hold the medication until 3/28/19 and did not properly
assess the resident’s skin, documenting the resident had healed wounds when in fact the
resident had an open vascular wound that required treatment. The facility census was 118.
1. Review of the facility policy titled Anticoagulation-Clinical Protocol, dated (MONTH)
2012, showed the following:
-As part of the initial assessment, the physician will help identify individuals who are
currently anticoagulated;
-Assess for any signs or symptoms related to adverse drug reactions due to the medication
alone or in combination with other medications;
-Assess for evidence of effects related to the subtherapeutic or greater than therapeutic
drug level related to that particular drug (for example, a resident with an above
therapeutic level of an anticoagulation medication should be assessed for bleeding);
-In addition, nurses shall assess and document/report current anticoagulation therapy,
including drug and current dosage, recent labs, including therapeutic dose monitoring,

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
other current medications and all active diagnoses;
-The staff and physician will identify and address potential complications in individuals
receiving anticoagulation; for example, someone with a fall risk, history of GI bleed or
poorly controlled hydration;
-The physician will order appropriate lab testing to monitor anticoagulation therapy and
potential complications; for example, periodically checking hemoglobin/hematocrit,
platelets, PT/INR ([MEDICATION NAME] time and international normalized ratio used to check
coagulation of the blood), and stool for occult blood;
-The staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to
follow trends in anticoagulation dosage and response;
-The physician will help review the process of individuals who are being anticoagulated;
for example, to see whether recent-onset [MEDICAL CONDITION] has resolved;
-The physician will periodically identify individuals whose anticoagulation can be
discontinued or reduced, and will document a rationale for continuing anticoagulation over
time, including the medication and current dosage;
-The staff and physician will monitor for possible complications in individuals who are
being anticoagulated, and will manage related problems;
-If an individual on anticoagulation therapy shows signs of excessive bruising,
theatrical, empty, or other evidence of bleeding, the nurse will discuss the situation
with the physician before giving the next scheduled dose of anticoagulant.
2. Review of Resident #463’s medical record dated 1/28/19 showed the following:
-PT of 26.8 (normal limits were 9.5 to 11.8);
-INR of 2.4 (normal limits were 0.9 to 1.1).
Review of the resident’s face sheet, showed the following:
-Readmitted to the facility on [DATE] from an acute care hospital;
-[DIAGNOSES REDACTED]. pressure, and [MEDICAL CONDITION].
Review of the resident’s facility medical record showed the following:
-Hospital discharge note, printed 3/18/19 at 11:42 A.M., that showed the resident was
admitted to the hospital on [DATE];
-Discharge [DIAGNOSES REDACTED].
-Future appointments included anti-coagulation laboratory 3/25/19;
-Continue taking the following medications which have changed;
-[MEDICATION NAME] (blood thinner) 10 milligrams (mg);
-What changed? These instructions start on 3/28/19; if you are uncertain what to do until
then, ask your doctor or other care provider;
-Notes to patient: to be held for ten days then resume on 3/28/19;
-Take one and one half tablets as directed on Mondays and Fridays and one tablet the other
days; start taking on 3/28/19.
Review of the resident’s facility admit/readmit screener, dated 3/18/19 at 2:30 P.M.,
showed the following:
-admitting [DIAGNOSES REDACTED].
-Skin integrity assessment showed the admission nurse documented the resident had healed
wounds to foot from previous double toe amputation.
Review of the resident’s physician order sheets (POS) dated (MONTH) 2019 showed the
following:
-[MEDICATION NAME] 10 mg in the evening (the order was not consistent with the hospital
discharge order which was to hold [MEDICATION NAME] until 3/28/19);
-Cleanse wound, pack loosely with plain packing strip and cover with dry dressing one time
a day, every other day, related to complete traumatic amputation of two or more left
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
lesser toes.
Review of the resident’s (MONTH) 2019 Medication Administration Record [REDACTED]
-Cleanse wound, pack loosely with plain packing strip and cover with dry dressing one time
a day, every other day, scheduled for 9:00 A.M. beginning 3/19/19; the box for 3/19/19 was
blank, indicating the treatment had not been completed;
-[MEDICATION NAME] 10 mg in the evening, scheduled for 5:00 P.M.; (order not consistent
with the hospital discharge orders);
-The administration boxes for the resident’s [MEDICATION NAME] on 3/19/19, 3/20/19 and
3/21/19 at 5:00 P.M. showed staff administered the medication (when the medication should
have been on hold until 3/28/19).
Observation on 3/19/19 at 9:05 A.M. showed the following:
-The resident lay in his/her bed;
-His/her feet were uncovered and his/her left foot had a folded gauze pad secured with
tape to his/her foot.
Observation and interview on 3/20/19 at 2:00 P.M. showed the following:
-The resident said staff had not completed any treatment on his/her left foot or even
looked at the area where his/her toes had been amputated in (MONTH) 2019;
-His/her left foot had a folded gauze pad secured with tape to his/her foot.
Review of the resident’s nursing notes, dated 3/21/19 at 1:37 P.M., showed LPN D obtained
a clarification of the treatment order and documented the treatment order was from a prior
admission, the area was healed, the physician was notified and the treatment discontinued.
During interview on 3/21/19 at 4:03 P.M. LPN D said the following:
-He/she did not actually complete the resident’s treatment as he/she had documented;
-He/she had not assessed the resident’s foot;
-He/she just knew the resident’s toes had been amputated back in (MONTH) and when he/she
was discharged from the facility in January, the area was healed;
-He/she had sought the discontinue order because he/she knew it was old.
Observation on 3/21/19 at 4:50 P.M. of the resident’s left foot showed the following:
-The resident wore tennis shoes with no socks;
-After the resident removed his/her left shoe, the skin of the resident’s foot appeared to
be dry, scaly and peeling a white and yellow slough;
-There was no dressing on the resident’s foot;
-His/her second and third toes were missing;
-The area of the second and third toes showed an open circular area, approximately the
base width of a toe, with depth and a white, moist wound bed and edges.
During interview on 3/21/19 at 4:45 P.M. and 5:00 P.M., Unit Manger/LPN W said the
following:
-He/she had not observed the resident’s left foot; he/she thought the area was healed
before the resident discharged from his/her previous stay;
-He/she had not reviewed the resident’s hospital discharge orders; once reviewed, the
orders appeared to read to hold the resident’s [MEDICATION NAME] until 3/28/19. He/she was
not the resident’s admission nurse and he/she did not know what took place or why the
facility POS and MAR indicated [REDACTED]
Review of the resident’s nurses’ notes, dated 3/22/19 at 7:54 A.M., showed the following:
-The resident’s physician was called regarding the resident’s left toe area draining due
to the resident pulling a scab off the incision line from double toe amputation back in
January;
-Order received to apply triple antibiotic ointment and dry dressing for seven days and
then re-evaluate
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
During interview on 3/22/19 at 8:00 A.M., LPN M said the following:
-Unit Manager/LPN W had instructed him/her to call the resident’s physician and report
his/her left toe area draining due to the resident pulling a scab off the incision line
from his/her double toe amputation back in January;
-He/she had not assessed the resident’s foot prior to calling the physician, he/she just
reported what the Unit Manager/LPN W had told him/her;
-A physician’s order was received to apply triple antibiotic ointment and dry dressing for
seven days and then re-evaluate.
During interview on 3/22/19 at 8:10 A.M. LPN I said the following:
-He/she was the facility admitting nurse;
-When the resident arrived to the facility for admission on 3/18/19, he/she came with no
hospital discharge orders. He/she did not see the hospital discharge orders until 3/22/19;
-On 3/18/19 he/she called the resident’s physician’s office for a current medication list
(this was the medication list found in the chart); she had not called the hospital for
discharge orders;
-He/she did not know how the [MEDICATION NAME] order on the medication list did not get
entered correctly on the resident’s facility POS and MAR, it must have populated from
his/her previous stay; after reviewing the facility POS and MAR indicated [REDACTED]
-On 3/18/19 he/she completed a skin assessment and found there to be a scabbed area on the
resident’s right foot; he/she denied there was a dressing on the resident’s foot; he/she
would not consider a scab as something that needed treatment;
-He/she thought the treatment order to cleanse wound, pack loosely with plain packing
strip and cover with dry dressing one time a day, every other day, related to complete
traumatic amputation of two or more left lesser toes populated from the resident’s
previous stay;
-He/she knew LPN S had helped him/her with the admission but was not sure what, if any
reports he/she had given her about the resident.
During interview on 3/22/19 at 8:20 A.M. LPN S said the following:
-He/she helped LPN I with the resident’s admission;
-He/she had taken verbal report from the hospital and the written note in the resident’s
medical record was the information he/she had taken from that verbal report;
-He/she was aware the resident’s [MEDICATION NAME] was to be held for 10 days;
-He/she thought he/she told LPN I the [MEDICATION NAME] was to be held;
-He/she did not enter any of the resident’s medication orders in the computer .
Observation on 3/22/19 at 10:40 A.M. showed the following:
-The resident lay in his/her bed, gripper socks on both feet;
-The resident removed the sock off his/her left foot;
-The physician assessed the resident’s left foot;
-The skin of the resident’s foot appeared to be dry, scaly and peeling a white and yellow
slough;
-There was no dressing on the resident’s foot;
-His/her second and third toes were missing;
-The area of the second and third toes showed an open circular area, approximately the
base width of a toe, with depth and a white, moist wound bed and edges.
During interview on 3/22/19 at 10:40 A.M., the resident’s physician said the following:
-The area on the resident’s left foot was a vascular wound at the previous amputation cite
and needed treatment; she did not believe there had been a scab over the area and observed
the area to have been open, with drainage and depth for what she thought was a while;
-She would expect the facility to follow physician orders;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 35)
-If a resident presents for admission from a hospital, she would expect the facility to
confirm discharge medication orders and not physician office orders as the orders may have
changed;
-She said the resident’s [MEDICATION NAME] should have been held as ordered due to the
resident’s [DIAGNOSES REDACTED].
During interview on 3/22/19 at 3:53 P.M. the director of nursing (DON) said the following:
-Nurses should complete skin assessments and document daily;
-Nurses should inspect resident’s skin themselves prior to calling a physician for an
order;
-All licensed nurses are qualified to assess resident’s skin and wounds;
-Staff should follow physician orders;
-When a resident is admitted to the facility, the admitting nurse should confirm the
resident’s current orders from the sending facility;
-Nursing staff should be reviewing resident’s medications and ensuring that any monitoring
that needs done is ordered;
-Residents on [MEDICATION NAME] are at risk for bleeding, especially if they have a
history or [DIAGNOSES REDACTED].

F 0686

Level of harm – Actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide necessary
treatment and services consistent with standards of practice to assess, identify and
promote healing of pressure ulcers (a localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, or pressure in combination
with shear and /or friction) for one resident (Resident #110) of 24 sampled residents and
one additional resident (Resident #100), the facility identified at risk of developing new
pressure ulcers and had existing pressure ulcers. Staff failed to complete a dressing
change on Resident #110 to an existing ulcer per order, and failed to provide treatment as
ordered for one additional resident (Resident #100), resulting in the resident acquiring
an unstageable pressure ulcer. The facility census was 118.
1. Review of the facility’s Pressure Ulcer/Injury Risk Assessment policy, dated as revised
(MONTH) (YEAR), showed the following:
-Purpose: The purpose of this procedure is to provide guidelines for the structured
assessment and identification of residents at risk of developing pressure ulcers/injuries;
-The purpose of a structured risk assessment is to identify all risk factors and then to
determine which can be modified and which cannot, or which can be immediately addressed
and which will take time to modify;
-Risk factors that increase a resident’s susceptibility to develop or to not heal pressure
ulcers or pressure injuries include, but are not limited to: Under nutrition,
malnutrition, and hydration deficits. Impaired/decreased mobility and decreased functional
ability. The presence of previously healed pressure ulcers/injuries. Exposure to skin to
urinary and fecal incontinence. Impaired diffuse or localized blood flow, for example,
generalized [MEDICAL CONDITION] (hardening of the arteries) or lower extremity arterial
insufficiency. Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease, or
diabetes mellitus. Drugs such as steroids that may affect healing. Cognitive impairment.

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 36)
Resident refusal of some aspects of care and treatment;
-Conduct structured pressure ulcer/injury risk assessment using a facility-approved tool;
-Conduct a comprehensive skin assessment with every risk assessment. Once inspection of
the skin is completed document the findings on a facility-approved skin assessment tool.
If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to
the type of alteration in the skin;
-Develop the resident centered care plan and interventions based on the risk factors
identified in the assessments, the condition of the skin, the resident’s overall clinical
condition, and the resident’s stated wishes and goals. The interventions must be based on
current, recognized standards of care. The effects of the interventions must be evaluated.
The care plan must be modified as the resident’s condition changes, or if current
interventions are deemed inadequate;
-The following information should be recorded in the resident’s medical record utilizing
facility forms: The type of assessment(s) conducted. The date and time and type of skin
care provided, if appropriate. The name and title (or initials) of the individual who
conducted the assessment. Any change in the resident’s condition, if identified. The
condition of the resident’s skin (i.e., the size, and location of any red or tender
areas), if identified. How the resident tolerated the procedure or his/her ability to
participate to the procedure. Any problems or complaints made by the resident related to
the procedure. If the resident refused the treatment, the reason for refusal and the
resident’s response to the explanation of the risks of refusing the procedure, the
benefits of accepting and available alternatives. Document family and physician
notification of refusal. Observation of anything unusual exhibited by the resident. The
signature and title (or initials) of the person recording the data. Initiation of a
(pressure or non-pressure) form related to the type of alteration in skin if new skin
alterations is noted. Document in medical record addressing physician notification if new
skin alteration noted with change of plan of care, if indicated. Documentation in medical
record addressing family, guardian, or resident notification if new skin alteration noted
with change of plan of care, if indicated;
-Notify the supervisor if the resident refuses the procedure;
-Report other information in accordance with facility policy and professional standards of
practice;
-Notify attending physician if new skin alteration noted;
-Notify family, guardian, or resident update if new skin alterations noted.
2. Review of the RAI User’s Manual (Long-term Care Facility Resident Assessment
Instrument User’s Manual) Chapter 3, Section M, defines the different stages of pressure
ulcers (localized injury to the skin and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure in combination with shear and/or
friction) as follows:
-Stage I: an observable, pressure related alteration of intact skin, whose indicators as
compared to an adjacent or opposite area on the body may include changes in skin
temperature, tissue consistency, sensation, and/or a defined area of persistent redness;
-Stage II: Partial thickness loss of dermis (the inner layer that makes up skin)
presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable
yellow, tan, gray, green or brown tissue). (MONTH) also present as an intact or
open/ruptured blister;
-Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon
or muscle is not exposed. Slough may be present but does not obscure the depth of tissue
loss. (MONTH) include undermining (destruction of tissue or ulceration extending under 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 37)
skin edges) or tunneling (a passage way of tissue destruction under the skin surface that
has an opening at the skin level from the edge of the wound);
-Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or
eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown,
or tan in color) may be present on some parts of the wound bed. Often includes undermining
and tunneling;
-Unstageable pressure ulcers related to suspected deep tissue injury. Purple or maroon
area of discolored intact skin due to damage of underlying soft tissue. The area may be
preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue.
3. Review of the facility policy from the Nursing Services Policy and Procedure Manual for
Long-Term Care, Wound Care, revised (MONTH) (YEAR), showed the following:
-The purpose of this procedure is to provide guidelines for the care of wounds to promote
healing;
-Dress wound. Mark tape with initials, time, and date and apply to dressing.
-Documentation: The following information should be recorded in the resident’s medical
record;
-The type of wound care given;
-The date and time the wound care was given;
-The name and title of the individual performing the wound care;
-All assessment data (i.e., wound bed color, size, drainage, ect.) obtained when
inspecting the wound;
-If the resident refused the treatment and the reason (s) why;
-The signature and title of the person recording the data.
4. Record review of Resident #100’s Annual Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/18/19, showed the following:
-Resident cognitively intact for daily decision making;
-Had no rejection of care (e.g., bloodwork, taking medications, ADL assistance);
-Required extensive assist of one staff for bed mobility, transfers, dressing, and
personal hygiene;
-Was dependent on one staff for toileting and bathing;
-Had impairment in functional limitation of range of motion on one side of lower
extremity;
-Used wheelchair as mobility device;
-Was always incontinent of bladder and bowel;
-Active [DIAGNOSES REDACTED].
-Was at risk for developing pressure ulcers;
-Had no unhealed Stage I (intact skin with non-blanchable redness of a localized area
usually over a bony prominence) or higher pressure ulcers;
-Skin and Ulcer treatments included: pressure reducing device for bed, turning and
repositioning program, surgical wound care, application of nonsurgical dressing (with or
without topical medications) other than to feet, and applications of ointments/medications
other than to feet.
Review of the resident’s care plan, dated as last revised on 2/25/19, showed the
following:
-Problem: The resident is at risk for development of pressure ulcers related to
incontinence and the need for assistance with bed mobility and repositioning. On 10/11/18
the resident had a scab located to left lower leg requiring treatment with previous venous
ulcer that reopens and heals continuously. On 2/4/19 the resident was readmitted from 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 38)
hospital with a surgical graft right leg requiring treatment and observation. On 2/25/19
the resident has a pressure area to the right distal heel requiring treatment and
observation;
-Approaches: Float heels when in bed. Position to keep pressure off heel. Heel protectors
on when in bed. Educate importance of keeping pressure off heel and encourage compliance
when in bed. The resident has a pressure reducing mattress in place. Extensive assist to
turn/reposition as need or requested, may attempt to self perform but staff must supervise
to assure performance affective. Observe for signs and symptoms of infection when venous
ulcers are present and report to physician changes in venous ulcers when occur. Provide
incontinence care after each incontinent episode, apply moisture barrier cream as needed.
Treatment as ordered to right heel. Observe the right heel for signs and symptoms of
infection and report any declines to the resident’s physician. Weekly skin assessments to
be obtained and documented per facility policy. Report any new areas of redness or
concern.
Review of the resident’s physician’s orders dated 2/25/19, showed heel protector and float
right heel while in bed every shift.
Review of the resident’s Treatment Administration Record (TAR), dated 2/1/19 through
2/28/19, showed the following:
-Heel protector and float right heel while in bed every shift;
-No documentation/evidence staff completed the treatment as ordered on night shift on 2/26
and on night shift 2/28.
Review of the resident’s TAR, dated 3/1/19 through 3/31/19, showed the following:
-Heel protector and float right heel while in bed every shift;
-No documentation/evidence staff completed the ordered treatment on the evening on 3/1,
3/2, 3/3, 3/10, 3/15, 3/16, 3/17, and 3/21;
-No documentation/evidence staff completed the ordered treatment on the night shift on
3/1, 3/2, 3/3, 3/6, 3/7, 3/8, 3/9, 3/10, 3/11, 3/12, 3/13, 3/15, 3/16, 3/17, 3/18, and
3/20.
Review of the resident’s Wound Consultant’s weekly wound note, dated 3/12/19, showed the
following:
-Stage II pressure ulcer to right heel healed;
-No documentation of any areas to the right lateral heel.
Review of the resident’s skin observation tool, dated 3/14/19, showed skin warm and dry.
Turgor fair. Open area noted to right thigh- see wound report for measurements.
Review of the resident’s nurse’s notes dated 3/1/19 through 3/14/19 showed no
documentation the resident refused to wear heel protector or free float his/her right
heel.
Observations on 3/18/19, showed the following:
-At 9:33 A.M., the resident lay in his/her bed on his/her back with no heel protector on
and right foot, the right heel was not free floating;
-At 4:08 P.M., the resident lay in his/her bed on his/her back with no heel protector on
and right foot/heel was not free floating.
Observations on 3/19/19, showed the following:
-At 5:40 A.M., the resident in his/her bed on his/her back with no heel protector on and
right foot was not free floating;
-At 7:40 A.M., the resident in his/her bed on his/her back with no heel protector on and
right foot was not free floating;
-At 10:40 A.M., the resident in his/her bed on his/her back with no heel protector on and
right foot was not free floating.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 39)
Observation and interview on 3/20/19, showed the following:
-At 11:50 A.M., the resident lay in his/her bed on his/her back with no heel protector on
and right foot was not free floating. The resident’s right foot was kicked outside of the
sheet with a blackened area noted to the right lateral heel;
-At 12:13 P.M., the Unit Manager Licensed Practical Nurse (LPN) W said that he/she wasn’t
sure if the resident had a pressure ulcer, but did not think the resident did. He/she
observed the blackened area to the right lateral foot and would not say if he/she thought
it was a pressure ulcer. He/she said the wound physician would be at the facility that day
and would have him look at the area. He/she did not apply the heel protector or free float
the resident’s right heel while in the room;
-At 2:20 P.M., the Physician Wound Consultant was in to see the resident. He said he
expected orders to be followed and that the area to the right lateral heel was a new area
and might have been prevented if the facility applied the heel protectors. He said the
area was an unstageable pressure ulcer. He applied the heel protector to the resident’s
right foot.
Review of the resident’s nurse’s notes 3/14/19 through 3/20/19 showed no documentation the
resident refused to wear the heel protector or free float his/her right heel.
Review of the resident’s Wound Consultant’s weekly wound note, dated 3/20/19, showed the
following:
-New right lateral heel unstageable pressure ulcer;
-Location: Right lateral heel;
-Eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges,
may be softer or harder than surrounding skin);
-Measurement: 2.0 centimeter (cm) by 1.0 cm;
-Treatment ordered: Heel protector to right heel.
Observation on 3/21/19 at 8:54 P.M., showed the resident in his/her bed on his/her back
eating breakfast with no heel protector on and right foot was not free floating.
5. Review of Resident #110’s Admission record showed an original admitted [DATE].
Review of the resident’s Braden Scale for predicting pressure ulcer risk, dated 1/28/19,
showed a score of 14 indicating moderate risk for pressure ulcers.
Review of the resident’s hospital record, sacrum pressure ulcer, dated 2/22/19 at 2:00
P.M., showed the following:
-Consulted for wound to sacrum present on admission. Patient with history of [MEDICAL
CONDITION], and is bed bound. He/she has an unstageable wound to his/her sacrum with a
moderate amount of serous (clear, thin, watery plasma) brown drainage. Wound presents as a
pressure wound. Planning on use of Dakin’s (antiseptic used to cleanse wounds in order to
prevent infection), wet to dry dressing to assist with debridement;
-Wound bed assessment: Black; Deep purple; Deep pink; Yellow; Brown;
-Exudate description: Moderate; Serous;
-Length: 6 centimeters (cm);
-Width: 10 cm;
-Depth: 0.3 cm;
-Staging: Unstageable;
-Peri-wound skin assessment: [DIAGNOSES REDACTED]/Red;
-Dressing/Treatment: Silicone dressing;
-Dressing status: Clean, Dry, intact.
Review of the resident’s progress note dated 3/1/19 at 6:48 P.M, showed the resident
returned from hospital. Wound to the coccyx (tailbone), 11 cm in length (L) x 7.5 cm width
(W). Upper portion of the wound bed has 8 cm L x 7.5 cm that is black. The lower portion
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 40)
of the wound bed is pink with some yellow. Physician’s office notified of return and
orders faxed to pharmacy.
Review of the resident’s transfer orders for receiving facility from the hospital, dated
3/1/19, showed current discharge medication list included Santyl, (sterile enzymatic
[MEDICATION NAME] ointment that works by helping to break up and remove dead skin and
tissue) apply to open area on coccyx every day for wounds. Cleanse wound, apply skin prep
to periwound, apply Santyl to necrotic tissue, and cover with a dry dressing. Change daily
and as needed (PRN).
Review of the resident’s care plan, last revised 3/1/19, showed the following:
-Readmitted to the facility on [DATE];
-readmitted with Stage III pressure ulcer (3/1/19 increase from Stage II prior to
hospitalization ) to coccyx requiring treatment and observation and has potential for
pressure ulcer development related to impaired mobility and incontinence;
-Administer treatments as ordered and monitor for effectiveness;
-Assess/record/monitor wound healing weekly. Measure length, width and depth where
possible. Assess and document status of wound perimeter, wound bed and healing progress.
Report improvements and declines to the physician;
-Follow facility policies/protocols for the prevention/treatment of
[REDACTED].>-Currently using pressure reducing mattress;
-Needs full staff assistance to turn/reposition at least every two hours, more often as
needed or requested;
-Totally dependent on staff to provide bath/shower two times weekly and as necessary;
-Totally dependent on staff for personal hygiene.
Review of the resident’s Skin Observation Tool, dated 3/1/19, showed the following:
-Stage III pressure ulcer to coccyx at 11 cm x 7.5 cm x 0.2 cm;
-Notes – coccyx wound 11 cm length x 7.5 cm width, upper portion of the wound bed has 8 cm
in length x 7.5 cm width that is black, the lower portion of the wound bed is pink with
some yellow.
Review of the resident’s Skin Observation Tool, dated 3/8/19, showed skin warm and dry to
touch, turgor fair, pressure wound to coccyx.
Review of the resident’s treatment administration record (TAR) dated 3/1/19 to 3/31/19
showed the following:
-Dakin’s Solution, apply to coccyx wound topically every 12 hours for coccyx wound. Start
date 3/1/19 at 9:00 P.M.;
-Scheduled for 9:00 A.M. and 9:00 P.M.;
-On 3/1/19 at 9:00 P.M., treatment blank;
-On 3/2/19 at 9:00 A.M. and 9:00 P.M., treatment blank;
-On 3/3/19 at 9:00 P.M., treatment blank;
-On 3/6/19 at 9:00 P.M., treatment blank;
-On 3/7/19 at 9:00 P.M., treatment blank;
-On 3/11/19 at 9:00 A.M. and 9:00 P.M., treatment blank;
-On 3/12/19 at 9:00 P.M., treatment blank.
Review of the weekly pressure ulcer QI (quality improvement) log, dated 3/13/19, showed
the following:
-Stage IV;
-Coccyx – 5.4 cm x 9.2, medium drainage;
-No treatment listed.
Review of the resident’s Skin Observation Tool, dated 3/15/19, showed the following:
-Stage IV pressure ulcer to coccyx at 5.4 cm x 9.2 cm x 0.3 cm;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 41)
-Notes – skin warm and dry to touch, turgor fair, pressure wound to coccyx 5.4 cm x 9.2
cm.
Review of the resident’s 14 day Prospective Payment System (PPS) MDS, dated [DATE], showed
the following:
-Cognitively intact;
-Had no rejection of care;
-Required total assistance of two or more staff for bed mobility, transfer and bathing;
-Required total assistance of one staff for dressing, eating, toileting and personal
hygiene;
-One unstageable pressure ulcer.
Review of the resident’s TAR dated 3/1/19 to 3/31/19 showed the following:
-Dakin’s Solution, apply to coccyx wound topically every 12 hours for coccyx wound. Start
date 3/1/19 at 9:00 P.M.;
-Scheduled for 9:00 A.M. and 9:00 P.M.;
-On 3/15/19 at 9:00 A.M. and 9:00 P.M., treatment blank;
-On 3/16/19 at 9:00 P.M., treatment blank;
-On 3/17/19 at 9:00 P.M., treatment blank;
-On 3/18/19 at 9:00 A.M., treatment blank.
Observation and interview on 3/18/19 at 10:00 A.M., showed Registered Nurse (RN)R and
Certified Nurse Aide (CNA) MM repositioned the resident in bed. The resident had a
dressing on his/her coccyx dated 3/17/19 and timed 11:00 A.M. RN R said he/she didn’t know
anything about it, as he/she doesn’t normally work on this hall. CNA MM said the resident
had a wound. RN R did not change the dressing.
Review of the resident’s physician order sheet (POS) dated 3/18/19 at 3:12 P.M., showed
the following:
-Discontinue Dakin’s solution;
-Santyl Ointment 250 UNIT/gram (GM), apply to coccyx topically every day shift for
pressure ulcer. Cleanse open area (OA) to coccyx with normal saline (NS), apply Santyl and
[MEDICATION NAME] (antibiotic ointment), to wound bed cover with dry dressing daily and as
needed (PRN) until healed;
-[MEDICATION NAME] ointment 2%, apply to coccyx topically every day shift for pressure
ulcer. Cleanse open area (OA) to coccyx with normal saline (NS), apply Santyl and
[MEDICATION NAME] to wound bed, cover with dry dressing daily and as needed (PRN) until
healed.
Observation and interview on 3/19/19 at 1:52 P.M., showed the following:
-RN R and CNA MM transferred the resident to bed with the Hoyer lift;
-RN R removed a dressing dated 3/17/19 at 11:00 A.M. from the resident’s coccyx;
-The wound measured approximately 10 cm x 6 cm, with the edges pink and beefy red about
1-2 cm around the outside edge and in the center the area was tan edges and a black
center;
-RN R cleansed the wound with normal saline (NS), applied Santyl and covered with adhesive
dressing;
-RN R said the [MEDICATION NAME] was not in from the pharmacy yet and that he/she did not
get the dressing change done yesterday due to the resident was up in his/her chair. He/she
reported it to Licensed Practical Nurse (LPN) NN at shift change that worked from 3:00
P.M. to 7:00 P.M. that he/she did not get the resident’s dressing change completed on the
resident’s coccyx.
During an interview on 3/19/19 at 3:00 P.M. and 4:15 P.M., LPN NN said he/she did not do a
treatment on the resident yesterday (3/18/19). He/she did not have time. He/she was by
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 42)
him/herself and the night nurse came in at 7:00 P.M. He/she didn’t have time to go to the
resident’s room in the time span of 3:00 P.M. to 7:00 P.M. The order didn’t pop up on the
TAR since he/she worked a different shift than the order was due.
During an interview on 3/19/19 at 3:50 P.M., the unit manager LPN W said he/she keeps the
wound measurement sheets. The unit manager measure wounds weekly on Mondays but it has not
been done this week due to he/she was working the floor yesterday (Monday 3/18/19). The
staff nurse should measure wounds with dressing changes.
During an interview on 3/20/19 at 11:48 A.M., the resident’s physician said orders should
be followed and if missed there should be documentation as to why the treatment was
missed. He would check as to why the Santyl was not used as ordered when the resident
returned from the hospital.
Review of the Mobile Limb Preservation record, from the physician wound consultant, dated
3/20/19 at 1:52 P.M., showed the following:
-Coccyx wound;
-Pre debridement: 6.0 cm x 9.0 cm x 0.8 cm;
-Post debridement: 6.0 cm x 9.0 cm x 0.9 cm;
-[MEDICATION NAME] (an insoluble protein formed from [MEDICATION NAME] during the clotting
of blood. It forms a fibrous mesh that impedes the flow of blood): yes, 50 %;
-Granulation tissue (new vascular tissue in granular form on an ulcer or the healing
surface of a wound): 50 % pink;
-No odor;
-No eschar;
-Drainage amount: moderate;
-Drainage color: serous;
-Periwound appearance: intact;
-Debridement: yes;
-Debridement level: skin and subcutaneous tissue;
-Bleeding: minimal;
-Treatment ordered: Apply Santyl, Silver Alginate, 4 x 4’s, Abdominal Pad (ABD) Dressing,
used for large wounds or for wounds requiring high absorbency), tape – change daily. Turn
schedule, off – loading coccyx. Low air loss mattress and Roho (pressure relief) cushion.
During an interview on 3/20/19 at 1:50 P.M. and 2:10 P.M., the physician wound consultant
said it was the first time he/she had seen the resident and his/her wound. He/she makes
rounds at the facility every two weeks. Orders should be followed as written by physician.
Not changing a dressing could cause bacteria to grow.
During an interview on 3/20/19 at 2:22 P.M., RN OO said he/she was the admitting nurse on
3/1/19 and he/she could not explain or find an order as to why the Santyl was discontinued
and the Dakin’s treatment was started on the resident’s wound. The Santyl order was missed
on the hospital discharge instructions. He/she thought the hospital nurse said they were
using Dakin on the resident’s wound.
6. During interview on 3/22/19 at 3:53 P.M., the DON said the following:
-Staff should report any pressure ulcer as soon as possible;
-Skin assessments should be done daily;
-Nurses should do the skin assessment and document;
-CNAs can check the skin and report any changes to the nurse;
-Nurses should inspect skin prior to calling for an order;
-Dressings should be completed as ordered;
-All licensed nurses are qualified to do a dressing change and assess;
-Staff should document on the TAR when a dressing change is completed;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 43)
-She could not give a reason why there was missing documentation in the TAR;
-Staff should follow physician orders;
-Blanks in the MARS and TARS should be documented as refused or missed;
-She expects all skin issues to be referred to the physician wound consultant;
-A dressing done 48 hours after ordered could cause infection;
-A dressing ordered at 9:00 A.M., should be done at 9:00 A.M.;
-She would expect the next shift staff to get a dressing change completed if not completed
as ordered on the prior shift.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 on observation, interview, and record review the facility failed to provide
restorative services as ordered for four residents (Resident #12, #53, #71, and #101), in
a review of 24 sampled residents. The facility census was 118.
1. Review of the facility policy titled Restorative Nursing Services, dated (MONTH)
(YEAR), showed the following:
-Resident’s will receive restorative nursing care as needed to help promote optimal safety
and independence;
-Restorative nursing care consists of nursing interventions that may or may not be
accompanied by formalized rehabilitative services (physical, occupational or speech
therapy);
-Residents may be started on restorative nursing program 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;
-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 recourses, maintaining his/her
dignity, independence and self-esteem and participating in the development and
implementation of his/her plan of care.
2. Review of the facility policy titled Staffing, dated (MONTH) 2007, showed the
following:
-Our facility policy provides adequate staffing to meet needed care and services for our
resident population;
-Other support services (dietary, activities/recreational, social, therapy, environmental,
etc) are adequately staffed to ensure that resident needs are met.
3. Review of Resident #12’s (MONTH) 2019 physician order sheets (POS) showed the
following:
-[DIAGNOSES REDACTED].
-Restorative Therapy Program one time a day (two to five times a week) until goals are
met.
Review of the resident’s Restorative Therapy Program orders, dated 1/03/19, showed the
following:
-Frequency: two to five times a 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 – Some

(continued… from page 44)
– Ambulation: one loop of square, approximately 575 feet with front wheeled walker and
care giver assist;
-Signed by the therapist 1/16/19.
Review of the resident’s updated care plan, dated 1/31/19 showed the following:
-The resident required minimal assistance due to fluctuating weakness;
-Encourage and remind the resident to use walker when ambulating;
-Observe for good endurance and steady gait;
-Nursing rehab/restorative: Active Range of Motion (AROM) to bilateral upper extremities
using two pound (lb) weight in all planes for 20 reps times two sets, except for right
shoulder against gravity only as tolerated by the resident; initiated 6/27/18;
-Nursing rehab/restorative: walking program: one loop around 500 hall/600 hall square
equals 575 feet using front wheeled walker and care giver assist; initiated 1/07/19.
Review of the resident’s (MONTH) 2019 POS showed the following:
-[DIAGNOSES REDACTED].
-Restorative Therapy Program one time a day (two to five times a week) until goals are
met.
Record review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument, completed by facility staff, dated 3/15/19, showed the following:
-Brief interview for mental status (BIMS) of 15 indicating no cognitive impairment (BIMS
scores range from 0-15, the higher the score, the lower the impairment to the cognitive
response);
-Limited assistance of one staff for bed mobility, transfer and walking in room;
-Walking in corridor, activity did not occur, activity of daily living (ADL) activity
itself did not occur;
-Locomotion on/off unit required supervision with set up help only;
-Extensive assistance of one staff for toilet use;
-Not steady, only able to stabilize with staff assistance for walking, moving on/off the
toilet and transferring between bed and chair and wheelchair;
-Used wheelchair and walker for mobility device.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time (3/7/19) for the week of 3/4/19 through 3/10/19;
-Restorative therapy completed one time (3/15/19) for the week of 3/11/19 through 3/17/19;
-The facility failed to complete restorative as ordered.
During interview on 3/21/19 at 4:00 P.M. the resident said very rarely did any therapy
work with him/her or did they walk him/her in the hallway.
4. Review of Resident #53’s (MONTH) 2019 POS showed the following:
-[DIAGNOSES REDACTED].
-Restorative Therapy Program one time a day (two to five times a week) until goals are
met.
Review of the resident’s Restorative Therapy Program orders, dated 2/12/19, showed the
following:
-Frequency: two to five times a week;
-Precautions: fall risk;
-General Exercise: wheelchair push-ups, five reps times three sets; two lb weight,
bilateral upper extremities times one set to all planes;
-Ambulation assistance: ambulate 100 feet with front wheeled walker and stand by assist to
gym and climb up and down stairs times two;
-Signed by the therapist 2/16/19.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 – Some

(continued… from page 45)
Review of the resident’s updated care plan, dated 2/27/19 showed the following:
-Required extensive assistance with toileting due to transfers, maneuvering clothing and
hygiene or incontinence;
-Gait currently unsteady, therefore frequent reminders that assist is required for safety
to be provided;
-Limited assistance with bed/chair repositioning, grooming and locomotion on/off the unit;
-Observe for gait unsteadiness when staff assisting with ambulation;
-Remind resident not to stand without assistance;
-Restorative therapy is ordered until goals are met;
-Nursing rehab/restorative: AROM to bilateral upper extremity exercises in all planes for
20 reps times one set using two lb weight and wheelchair push-ups times five reps times
three sets or as tolerated; initiated 2/13/19;
-Nursing rehab/restorative: walking program: ambulate 100 feet with front wheeled walker
and standby assist followed by up and down stairs times two as tolerated; initiated
2/13/19.
Review of the resident’s (MONTH) 2019 POS showed the following:
-[DIAGNOSES REDACTED].
-Restorative Therapy Program one time a day (two to five times a week) until goals are
met.
Record review of the resident’s MDS, dated [DATE], showed the following:
-Limited assistance of one staff for transfers;
-Requires extensive assistance and assist of one staff for walking in room and corridor;
-Locomotion on unit required supervision with set up help only;
-Locomotion off unit required limited assistance with assist of one staff;
-Extensive assistance of one staff for toilet use;
-Not steady, only able to stabilize with staff assistance for walking,
-Used wheelchair and walker for mobility device.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time (3/14/19) for the week of 3/9/19 through 3/15/19;
-Restorative therapy completed only one time (3/18/19) for the week of 3/16/19 through
3/22/19;
-The facility failed to complete restorative as ordered.
During interview on 3/20/19 at 2:20 P.M. the resident’s spouse said he/she did not think
therapy was working with him/her as much as they should be.
5. Review of Resident #71’s (MONTH) 2019 POS showed the following:
-[DIAGNOSES REDACTED].
-Restorative Therapy Program one time a day (two to five times a week) until goals are
met.
Review of the resident’s Restorative Therapy Program orders, dated 1/16/19, showed the
following:
-Diagnoses: [REDACTED].
-Frequency: one time day/two to five times a week;
-Passive Range of Motion (PROM): Bilateral lower extremities and trunk to reduce joint
stiffness;
-Signed by the therapist 1/16/19.
Review of the resident’s updated care plan, dated 1/24/19 showed the following:
-Nursing rehab/restorative: AROM to bilateral upper extremities in all planes as
tolerated; initiated 10/22/18;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 – Some

(continued… from page 46)
-Nursing rehab/restorative: walking program: sit to stand with prolonged standing at bar
or in parallel bars to tolerance; initiated 6/27/18.
Record review of the resident’s MDS, dated [DATE], showed the following:
-BIMS of 6;
-Extensive assistance of one staff for bed mobility, dressing, personal hygiene, eating
and drinking;
-Total dependence of two staff for transfers, and toileting;
-Extensive assistance of one staff for locomotion on and off the unit;
-Used wheelchair for mobility device.
Review of the resident’s (MONTH) 2019 POS showed the following:
-[DIAGNOSES REDACTED].
-Restorative Therapy Program one time a day (two to five times a week) until goals are
met.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time (2/4/19) for the week of 2/4/19 through 2/10/19;
-Restorative therapy completed one time (2/11/19) for the week of 2/11/19 through 2/17/19;
-Restorative therapy completed one time (2/18/19) for the week of 2/18/19 through 2/24/19;
-The facility failed to complete restorative as ordered.
6. Record review of Resident #101’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-No rejection of care (e.g., bloodwork, taking medications, ADL assistance);
-Total dependence of two staff for bed mobility, transfers, and toileting;
-Total dependence of one staff for locomotion on and off the unit, dressing, and bathing;
-Extensive assist of one staff for personal hygiene;
-Independent with set-up help for eating;
-Had limitation in Range of Motion on both sides of lower extremity;
-Used wheelchair for mobility;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-Received [MEDICAL TREATMENT] while a resident;
-No restorative nursing program in the previous seven days.
Review of the resident’s Physician’s orders dated 1/24/19, showed may begin Restorative
Therapy Program two to five times a week until progress ceases or goals are met.
Review of the resident’s Restorative Therapy Program orders, dated 1/24/19, showed the
following:
-Frequency: two to five times a week;
-Precautions: Left shoulder pain with limited flexion (action of bending or the condition
of being bent)/abduction (the movement of a limb or other part away from the midline of
the body, or from another part);
-General Exercise: Bilateral upper extremity exercises using 1 pound weight times 20 reps
for all planes;
-Signed by the therapist 1/24/19.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-No record restorative therapy completed for the week of 2/4/19 through 2/10/19;
-The facility failed to complete restorative as ordered.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 – Some

(continued… from page 47)
-No rejection of care (e.g., bloodwork, taking medications, ADL assistance);
-Total dependence of two staff for transfers, and toileting;
-Total dependence of one staff for locomotion on and off the unit, dressing, and bathing;
-Extensive assist of two staff for bed mobility;
-Extensive assist of one staff for personal hygiene;
-Independent with set-up help for eating;
-Had limitation in Range of Motion on both sides of lower extremity;
-Used wheelchair for mobility;
-Always incontinent of bladder and bowel;
-Received [MEDICAL TREATMENT] while a resident;
-No restorative nursing program in the previous seven days.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time during the week of 3/4/19 through 3/10/19;
-Restorative therapy completed one time during the week of 3/11/19 through 3/17/19;
-The facility failed to complete restorative as ordered.
Observation and interview on 3/18/19 at 9:15 A.M., showed the following:
-The resident in his/her wheelchair with his/her left arm pulled up close to him/her;
-The resident said he/she had pain and limited range of motion in his/her left arm;
-The resident said he/she was to be getting restorative therapy, but there would be days
that the restorative aide would get pulled to work the floor.
During an interview on 3/19/19 at 4:05 P.M., Restorative Aide (RA) V, said the following:
-Resident #101 was on restorative therapy for his/her left arm;
-He/she gets pulled from restorative therapy to work the floor.
During an interview on 3/22/19 at 3:53 P.M., the Director of Nurses (DON) said the
following:
-Restorative should be done as ordered to prevent decline or improve the resident’s range
of motion;
-She would expect staff to document if a resident refuses restorative.

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, facility staff failed to safely
transfer one resident (Resident #71) who was unable to bear weight, in a review of 24
sampled residents, and failed to follow the facility smoking policy for one additional
resident (Resident #463). The facility census was 118.
1. Review of the facility’s Smoking Policy, undated, showed the following:
-Smoking risk assessments will be completed upon identification of a resident who
expresses a desire to smoke, any resident found to be smoking on facility property,
quarterly, and with any significant change in condition;
-All residents able to smoke will do so in the facility’s designated smoking area only.
Residents identified as being independent with smoking may do so without supervision,
however, must follow the facility safety rules;
-Smoking materials will be kept at the nurse’s station and held by nursing staff. No

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 48)
smoking materials are allowed in resident rooms. This means no lighters, no cigarettes, no
e-cigarettes, no chewing tobacco etc.;
-Smoking by residents is only allowed during the posted smoking time while on company
property. No exceptions allowed.
2. Review of the facility’s policy safe lifting and movement of the resident, revised
7/2017, showed the following:
-In order to protect the safety and well-being of staff and residents, and to promote
quality care, the facility uses appropriate techniques and devices to lift and move the
the residents;
-Manual lifting of residents shall be eliminated when feasible.
3. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference Manual,
2001 revision, showed the following:
-For a resident who is weak, you must have control of the resident’s shoulders and hips
during the transfer;
-Do not attempt to transfer a resident who cannot bear any of his/her own body weight by
yourself. Determine beforehand how many people are needed for the transfer. If it takes
more than two persons to transfer the resident, use a mechanical lift.
4. Review of Resident #71’s care plan, last revised 2/8/19, showed the following:
-Required assistance with activities of daily living (ADLs);
-Dependent on staff for incontinent cares, dressing and bathing;
-Required extensive assistance of one or two staff for personal grooming;
-Required gait belt and two staff assistance for transfers;
-Incontinent of bowel and bladder.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/13/19, showed the following:
-Severe cognitive impairment;
-Extensive assistance of two staff for personal hygiene and bed mobility;
-Dependent on two or more staff for transfers;
-Always incontinent of bowel and bladder.
Observation on 3/19/19 at 6:45 A.M. showed the following:
-Certified Nurse Assistant (CNA) J and CNA RR assisted the resident to sit on the side of
the bed;
-CNA RR placed a gait belt on the resident, stood on the resident’s right side, and
grasped the gait belt at the resident’s waist;
-CNA J stood on the resident’s left side and grasped the gait belt;
-The CNAs lifted the resident from the side of the bed;
-The resident’s feet dragged on the floor as the CNAs moved the resident to his/her
wheelchair. The resident did not assist in lifting his/her feet or pivoting during the
transfer;
-CNA J and CNA RR cradled the resident and lifted the resident up and back into his/her
wheelchair.
During an interview on 3/19/19 at 10:35 A.M. CNA J said the following:
-The resident did not bear weight during the transfer;
-Sometimes the resident would bear weight and sometimes he/she did not;
-He/she did not report the resident not bearing weight to anyone, it’s just part of the
job;
-The resident could not help with repositioning and that is why staff had to pick the
resident up and position him/her in the wheel chair.
During an interview on 3/19/19 at 10:40 A.M., CNA RR said the following;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 49)
-The resident did not bear weight during the transfer;
-At times the resident would bear weight;
-The resident required two person assist and a gait belt for all transfers.
During an interview on 3/19/19 at 3:10 P.M., CNA/restorative aide (RA) V said the
following:
-The resident required two staff and the use of a sit-to-stand mechanical lift a couple of
weeks ago when the resident wasn’t standing;
-Some staff said the resident wasn’t standing and staff was having issues with transfers.
During interview on 3/22/19 at 3:53 P.M., the director of nursing (DON) said the
following:
-He/she expected a resident to bear weight with a gait belt transfer;
-He/she did not expect staff to cradle or pick up a resident;
-There is risk for injury if staff pick up a resident, lift a resident, or if a resident
does not bear weight with transfers.
5. Review of Resident #463’s face sheet showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s facility admit/readmit screener, dated 3/18/19 at 2:30 P.M.,
showed the resident was a current smoker.
During interview on 3/18/19 at 4:36 P.M., the resident said he/she had his/her cigarettes
and lighter in his/her pocket. He/she keeps his/her cigarettes and lighter in his/her
pocket. Staff does not know he/she was smoking.
Observation on 3/18/19 at 4:36 P.M. showed the following:
-The resident entered a code at the keypad locked exit door off of the facility kitchen to
open the door which lead to an entryway toward another locked door;
-The resident entered a code at a second keypad locked exit door, beside the maintenance
storage closet, leading outside to a parking lot to open the door;
-The resident removed a pack of cigarettes and lighter from his/her pocket, lit the
cigarette and smoked. The resident smoked two cigarettes.
During interview on 3/19/19 at 8:24 A.M., the resident said he/she had his/her cigarettes
and lighter in his/her pocket.
Staff did not know he/she was smoking;
Observation on 3/19/19 at 8:24 A.M., showed the following:
-The resident entered a code at the keypad locked exit door off of the facility kitchen to
open the door which lead to an entryway toward another locked door;
-The resident entered a code at a second keypad locked exit door, beside the maintenance
storage closet, leading outside to a parking lot to open the door;
-The resident removed a pack of cigarettes and lighter from his/her pocket, lit the
cigarette and smoked; the resident smoked a total of two cigarettes.
During interview on 3/19/19 at 3:30 P.M., the resident said he/she was headed out to smoke
and staff still did not know he/she was smoking.
Observation on 3/19/19 at 8:24 A.M. showed the following:
-The resident entered a code at the keypad locked exit door off of the facility kitchen to
open the door which lead to an entryway toward another locked door;
-The resident entered a code at a second keypad locked exit door, beside the maintenance
storage closet, leading outside to a parking lot to open the door;
-The resident removed a pack of cigarettes and lighter from his/her pocket, lit the
cigarette and smoked.
Record review of the resident’s Safe Smoking Assessment Form, dated 3/19/19, showed 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 50)
following:
-The resident was safe to smoke unsupervised;
-All smoking materials will be kept at the nurses’ station;
-The resident was notified of restrictions.
During interview on 3/20/19 at 1:18 P.M., the resident said he/she was headed out to
smoke. He/She still had his/her cigarettes and lighter; he/she had not been told to turn
them in.
Observation on 3/20/19 at 1:18 P.M., showed the following:
-The resident entered a code at the keypad locked exit door off of the facility kitchen to
open the door which lead to an entryway toward another locked door;
-The resident entered a code at a second keypad locked exit door, beside the maintenance
storage closet, leading outside to a parking lot to open the door;
-The resident removed a pack of cigarettes and lighter from his/her pocket, light the
cigarette and smoked.
During interview on 3/22/19 at 8:10 A.M., Licensed Practical Nurse (LPN) I said the
following:
-He/she was the resident’s facility admitting nurse;
-He/she did not ask the resident if he/she was a smoker on admission or complete a smoking
assessment at that time because the facility was a smoke free facility at that time;
-He/she knew from the resident’s previous stay that he/she was a smoker and had refused to
stop smoking;
-In the afternoon on 3/18/19, after the resident was admitted , he/she learned the
facility was a smoking facility; he/she did not complete a smoking assessment at that
time.
During interview on 3/22/19 at 3:53 P.M., the director of nursing (DON) said the
following:
-A smoking assessment should be completed upon admission;
-Cigarettes and lighters should be kept with the nurse.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
appropriate treatment and services consistent with acceptable standards of practice to
prevent a urinary tract infection [MEDICAL CONDITION] for one resident (Resident #29) who
had been hospitalized for [REDACTED].#27 and #97) and failed to provide catheter care
consistent with acceptable standards of practice for two residents (Resident #27 and
Resident #97), in a review of 24 sampled residents. The facility census was 118.
1. Review of the facility Indwelling Urinary Catheter Care Policy and Procedure, dated as
revised 11/24/15, showed the following:
-Change the catheter and drainage bags per physician order, using a sterile technique;
-Change the catheter and drainage bags on the basis of as needed when clinical indications
show such as infection, obstruction, or when a closed system has been compromised;

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 51)
-Maintain a sterile, closed, gravity-drainage system and avoid breaking the system;
-Secure catheters to the upper thigh or lower abdomen to avoid bladder and urethral
trauma;
-Keep the collection bag below the level of the bladder at all times. Do not rest the bag
on the floor;
-Use clean techniques in emptying and changing the drainage system. Wash hands before and
after cleaning the resident’s catheter;
-Clean the catheter daily in the evening with soapy water. Avoid frequent and vigorous
cleaning of the catheter entry site;
-Consider the resident’s privacy and cover or conceal the catheter drainage bag when the
resident is in the common facility areas such as the dining room.
2. Review of the facility Perineal Care Policy, dated as revised (MONTH) 2010, showed the
following:
-Purpose: The purpose of this procedure are to provide cleanliness and comfort to the
resident, to prevent infections and skin irritation, and to observe the resident’s skin
condition;
-Wash and dry hands thoroughly;
-Put on gloves;
-Wash the perineal area, wiping from front to back;
-Remove gloves and discard into designated container. Wash and dry hands thoroughly.
3. Review of the Nurse Assistant in a Long Term Care Facility, 2001, revision, showed the
following:
-The bladder is considered sterile, the catheter, drainage tubing and bag are a sterile
system;
-Drainage tubing/bags must not touch the floor;
-Prevent tubing from hanging below the level of the drainage bag.
4. Review of Resident #29’s face sheet showed the following:
-He/she was admitted to the facility on [DATE];
-His/her [DIAGNOSES REDACTED].
Review of the resident’s Admission Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 1/7/19, showed the following:
-Cognitively intact for daily decision making;
-Had no rejection of care (e.g., bloodwork, taking medications, ADL assistance);
-Required extensive assistance of one staff for personal hygiene;
-Dependent on one staff for toileting;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-Active [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 1/13/19, showed the following:
-Problem: The resident required extensive to full staff assistance with ADL’s;
-Interventions: The resident is to be toileted every two to three hours per urologist and
family request to prompt voiding to assist with reducing reoccurring UTI. When toileted
brief is moist therefore incontinent cares required. Preferred toileting times may be
prior to dressing in the morning, mid morning, mid afternoon, and when preparing for the
night. Do not wait until the resident notifies you of the urge to void. Toilet routinely
per urologist. The resident is totally dependent on staff for toilet use or incontinent
care;
-Problem: The resident has a UTI requiring antibiotic with history of reoccurring
infections prior to admission. At risk for repeat infection and/or complications from
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 52)
infection;
-Interventions: Check and change on routine rounds and provide cares for incontinence,
including washing, rinsing, and drying soiled areas. Encourage adequate fluids. Give
antibiotics as ordered and monitor/document for side effects and effectiveness. Monitor
and report to physician as needed signs and symptoms of UTI: Frequency, urgency, malaise
(general sense of being unwell), foul smelling urine, dysuria (difficulty voiding), fever,
nausea, vomiting, flank pain, suprapubic pain (lower abdomen near where hips and many
important organs are located), hematuria (blood in urine), cloudy urine, altered mental
status, loss of appetite, and behavioral changes. Monitor vital signs as needed and notify
physician of significant abnormalities. The resident, his/her family, and caregiver
teaching should include: Good hygiene practices- wiping front to back, cleansing the peri
area well after bowel movement in order to help prevent bacteria in the urinary tract.
Offer cranberry juice or prune juice to help keep urine acidic. Void at first urge. Do not
hold urine for extended amount of time. Wear clean underwear daily. Take the full course
of antibiotic therapy even if much improved after a few days of therapy. The resident is
to be toileted every two to three hours per urologist and family request to prompt voiding
to assist with reducing reoccurring UTI. When toileted brief is moist therefore
incontinent cares required. Preferred toileting times may be prior to dressing in the
morning, mid morning, mid afternoon, and when preparing for the night. Do not wait until
the resident notifies you of the urge to void. Toilet routinely per urologist. Observe for
signs and symptoms of dehydration possible caused by infection. Obtain and monitor
lab/diagnostic work as ordered and report results to physician and follow up as indicated.
When toileting the resident in the main shower rooms, close the door and provide privacy
during use of the toilet.
Review of the resident’s nurse’s note dated 2/25/2019 at 10:21 A.M., showed the following:
The resident was lethargic this a.m., and had difficulty eating breakfast. Trouble keeping
eyes open and answering direct questions which is not baseline for this resident. VS:
temperature was 99.0 temporal (normal= 97 to 99), blood pressure was 118/70 (normal=
120/80-140/90), pulse was 74 (normal= 60-100), and respirations was 18 (normal= 12 to 20).
Lungs clear. Answered with some difficulty that he/she has pain in his/her pelvic area.
Family member also expressed concern regarding the resident’s altered mental status.
Physician notified, new order to send the resident to the emergency room (ER) for
evaluation. Call placed for an ambulance and they arrived a brief time later and
transferred the resident to the ER.
Review of the resident’s Admission Summary Note dated 3/4/2019 at 6:46 P.M., showed the
resident was readmitted to facility from the hospital with an admission [DIAGNOSES
REDACTED].
During an interview on 3/17/19 at 3:05 P.M., the resident’s family member said the
following:
-The resident was to be toileted every two to three hours per the resident’s urologist
orders;
-On many occasions the resident did not get toileted every two to three hours and just had
returned to the facility from the hospital with another UTI;
-He/she was at the facility daily from about 8:30 A.M. until 5 or 6:00 P.M., everyday and
had witnessed many days where the resident went five or six hours before getting toileted.
Observation on 3/18/19 at 9:53 A.M., showed the following:
-Certified Nurse Assistant (CNA) X transferred the resident from his/her wheelchair to the
toilet;
-The resident had been incontinent of bowel and bladder;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 53)
-CNA X applied gloves without washing his/her hands;
-CNA X wiped the resident’s buttocks with disposable wipes until clean, then without
changing gloves or washing his/her hands, CNA X applied barrier ointment to the resident’s
buttocks;
-CNA X assisted the resident to stand using the grab bar and with the same soiled gloved
hands pull up the resident’s clean brief;
-CNA X then removed his/her gloves and used alcohol based hand sanitizer;
-CNA X did not provide peri care to the resident’s front perineum (area between anus and
scrotum on males and area between anus and vulva on females).
During an interview on 3/18/19 at 10:06 A.M., CNA X said the following:
-He/she did not realize that he/she needed to change gloves and wash hands after cleaning
the resident’s bowel movement and before applying protective barrier;
-He/she did not clean the perineum because the resident could not stand for very long and
tried to reach as best he/she could when the resident was sitting on the toilet.
Observation and interview on 3/18/19 at 4:07 P.M., showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident said that he/she had not been toileted since after breakfast.
5. Review of Resident #27’s Annual MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Required limited assistance of one staff for transfer and toileting;
-Had an indwelling urinary catheter.
Review of the resident’s care plan, dated as reviewed 1/6/19, showed the following:
-Problem: The resident has an indwelling urinary catheter and requires assist times one
for elimination care needs and is at risk for skin breakdown;
-Interventions: Provide catheter care each shift and as needed. Report to charge nurse
signs and symptoms of UTI- confusion, urgency, frequency, bladder spasms, nocturia
(urinating frequently at night), burning pain, difficulty urinating, low back pain,
malaise (general sense of being unwell), nausea/vomiting, chills, fever, foul odor,
concentrated urine, blood in the urine. Store urinary drainage bag inside a protective
dignity pouch.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Treatment Administration Record (TAR) dated 1/1/19 through
1/31/19, showed the following:
-Urinary catheter care every shift (Day, Eve, Night);
-No documentation/evidence staff completed catheter care on 1/1, 1/8, 1/10, 1/12, 1/14,
1/25, and 1/27 day shift;
-No documentation/evidence staff completed catheter care on 1/8, 1/9, 1/10, 1/11, 1/12,
1/17, 1/18, 1/20, 1/24, 1/25, 1/26, and 1/27 evening shift;
-No documentation/evidence staff completed catheter care on 1/11, 1/13, 1/18, 1/19, 1/20,
1/21, 1/22, 1/23, 1/24, 1/25, 1/26, and 1/27 night shift.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s TAR, dated 2/1/19 through 2/28/19, showed the following:
-Urinary catheter care every shift (Day, Eve, Night);
-No documentation/evidence staff completed catheter care on 2/18, 2/22, and 2/23 day
shift;
-No documentation/evidence staff completed catheter care on 2/1, 2/2, 2/3, 2/8, 2/9, 2/10,
2/16, 2/17, 2/22, 2/23, and 2/24 evening shift;
-No documentation/evidence staff completed catheter care on 2/1, 2/3, 2/15, 2/16, 2/17,
2/19, 2/21, 2/22, 2/23, 2/24, 2/26, and 2/28 night shift.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 54)
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s TAR, dated 3/1/19 through 3/20/19, showed the following:
-Urinary catheter care every shift (Day, Eve, Night);
-No documentation/evidence staff completed catheter care on 3/1, 3/2, 3/3, 3/10, 3/15,
3/16, and 3/17 on evening shift;
-No documentation/evidence staff completed catheter care on 3/1, 3/2, 3/3, 3/6, 3/7, 3/8,
3/9, 3/10, 3/11, 3/12, 3/13, 3/15, 3/16, and 3/17 on night shift.
Observation and interview on 3/17/19 at 4:20 P.M., showed the following:
-The resident sat on the edge of his/her bed to the left side of his/her bed, his/her
urinary catheter drainage bag was attached to wheelchair underneath to the right of the
resident and was half on the floor and half hanging from the wheelchair;
-The resident said his/her catheter was to be changed monthly and some months it did not
occur and he/she would have to remind the staff.
Observation on 3/18/19 at 10:10 A.M., showed the resident sat on the edge of his/her bed
to the left side of his/her bed, his/her urinary catheter drainage bag was attached to
wheelchair underneath to the right of the resident and was half on the floor and half
hanging from the wheelchair.
6. Review of Resident #97’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Had no rejection of care;
-Required limited assistance of one staff for toileting and personal hygiene;
-Had an indwelling urinary catheter.
Review of the resident’s care plan dated as reviewed 12/4/18, showed the following:
-Problem: The resident has a history of [MEDICAL CONDITION] and has a suprapubic catheter
and is at risk for complications or infection;
-Interventions: Assess the resident for pain or discomfort at catheter site/abdomen.
Assist him/her in emptying the catheter leg bag and in changing the leg bag to 24 hour bag
at night. Assure catheter cares performed daily either by the resident or with staff
assistance. Change catheter as ordered. Observe output after every catheter change.
Encourage the resident to keep drainage bag below bladder level when in bed, during
transfer or during ambulation if using leg bag. Limited assistance with urine elimination
due to the need for staff assist at times emptying bag or catheter care daily. Monitor and
report any signs/symptoms of infection: redness, irritation or leakage from suprapubic
insertion site. Observe for sedimentation, blood in the urine, odor, and/or color of
urinary output which could signify possible infections.
Review of the resident’s physician’s orders [REDACTED].>Review of the resident’s TAR,
dated 1/1/19 through 1/31/19, showed the following:
-Urinary catheter care every shift (Day, Eve, Night);
-No documentation/evidence staff completed catheter care on 1/1, 1/3, 1/4, 1/6, 1/7, 1/9,
1/12, 1/21, 1/25, and 1/28 day shift;
-No documentation/evidence staff completed catheter care on 1/6, 1/9, 1/11, 1/12, 1/17,
1/18, 1/20, 1/21, 1/25, 1/26, and 1/27 evening shift;
-No documentation/evidence staff completed catheter care on 1/11, 1/13, 1/18, 1/19, 1/20,
1/21, 1/22, 1/23, 1/24, 1/25, 1/26, and 1/27 night shift.
Review of the resident’s physician’s orders [REDACTED].>Review of the resident’s TAR,
dated 2/1/19 through 2/28/19, showed the following:
-Urinary catheter care every shift (Day, Eve, Night);
-No documentation/evidence staff completed catheter care on 2/2, 2/3, 2/16, 2/17 and 2/24
day shift ;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 55)
-No documentation/evidence staff completed catheter care on 2/1, 2/2, 2/3,2/8, 2/9, 2/10,
2/16, 2/17, 2/22, 2/23 and 2/24 evening shift;
-No documentation/evidence staff completed catheter care on 2/1, 2/3, 2/15, 2/16, 2/17,
2/19, 2/21, 2/22, 2/23, 2/24 and 2/26 night shift.
Review of the resident’s physician’s orders [REDACTED].>Review of the resident’s TAR,
dated 3/1/19 through 3/20/19, showed the following:
-Urinary catheter care every shift (Day, Eve, Night);
-No documentation/evidence staff completed catheter care on 3/15 day shift;
-No documentation/evidence staff completed catheter care on 3/1, 3/2, 3/3, 3/10, and 3/15
evening shift;
-No documentation/evidence staff completed catheter care on 3/1, 3/2, 3/3, 3/6, 3/7, 3/8,
3/9, 3/10, 3/11, 3/12, 3/13, 3/15, 3/16, and 3/17 night shift.
Observation and interview on 3/17/19 at 2:00 P.M., showed the following:
-The resident sat on the edge of his/her bed;
-His/her drainage bag was to the left of the resident hanging half off the bed frame and
half on the floor with urine in the bag and the drainage tube laying on the floor;
-The resident said he/she currently wore a leg bag. Staff was to empty the catheter bag
and put it up during the day and staff failed to do that on most days.
7. During an interview on 3/19/19 at 10:40 A.M., Certified Nurse Assistant (CNA) K said
the following:
-Catheter care was to be done shiftly;
-Drainage bags and tubing should not be on the floor;
-Catheters should be emptied at the end of the shift.
During an interview on 3/19/19 at 10:35 A.M., Licensed Practical Nurse (LPN) I said the
following:
-Catheter care should be done shiftly;
-If catheter care was not done, it should be documented in the notes as to why it was not
completed;
-Drainage bags and tubing should not be on the floor because could this could lead to an
infection.
During an interview on 3/22/19 at 3:53 P.M., the Director of Nurses (DON) said the
following:
-She expected staff to provide peri care as taught in the CNA manual, front to back and
from clean to dirty;
-Nurses should clean catheters every shift;
-Catheter drainage bags, and catheter tubing should not be on the floor;
-Catheter care should be documented on the TAR/MAR or in the progress note.

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide five
residents (Resident #71, #12, #22, #69 and #101) of 24 sampled residents and three
additional residents (Resident #43, #28 and #5) sufficient fluid intake to maintain proper
hydration and health. The facility census was 118.
1. Review of the facility’s policy and procedure for Preventing Dehydration/Promoting

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 56)
Hydration (undated) showed the following:
-It is the policy of the facility to ensure that the residents receive sufficient fluid to
maintain proper hydration and health;
-Staff will offer comfort measures, such as frequent mouth care and/or other interventions
that are acceptable to the resident;
-Interventions will be developed and placed in the care plan to treat and/or prevent the
occurrence of dehydration;
-Each resident’s hydration needs will be met by the interdisciplinary care team;
-Staff will be educated on the signs and symptoms of dehydration;
-Offering fluids to residents is the responsibility of all staff who are qualified to
assist with fluid intake;
-Fluids will be offered when staff is interacting with residents throughout each shift.
2. Review of Resident #71’s care plan, dated (MONTH) (YEAR), showed the following:
-Requires mechanically altered diet;
-Has difficulty holding a cup;
-Is at risk for poor nutritional intake and aspiration;
-May need assistance with eating and drinking;
-Resident is not able to feed him/herself, therefore staff assistance is required;
-Encourage fluids between meals.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/19/19 showed the following:
-Brief interview for mental status (BIMS) of six indicating cognitive impairment (BIMS
scores range from 0-15, the higher the score, the lower the impairment to the cognitive
response);
-Resident required extensive assistance with eating and drinking.
Review of the resident’s physician orders (POS) dated (MONTH) 2019, showed the following:
-[DIAGNOSES REDACTED].
-A physician ordered diet of mechanical soft texture, regular consistency;
-Med pass (nutritional supplement) with meals.
Observation on 3/17/19 at 2:15 P.M., in the resident’s room showed the following:
-The resident lay awake in bed;
-The resident had no water pitcher or cup in his/her room;
-There were no fluids available for the resident in his/her room.
Observation and interview on 3/17/19 at 4:15 P.M. in the resident’s room, showed the
following:
-The resident lay in bed on his/her left side;
-There were no fluids available in the resident’s room;
-When asked if staff offered fluids, the resident said no;
-When asked if he/she was thirsty the resident said yes.
Observation on 3/18/19 at 10:00 A.M. in the resident’s room showed the following:
-The resident lay in bed with his/her eyes closed;
-His/her lips had dry patches with white matter at the corner of his/her mouth;
-No fluid container in the resident’s room.
Observation on 3/18/19 at 10:30 A.M., showed the following:
-Certified Nursing Assistant (CNA) G and Licensed Practical Nurse (LPN) H at the
resident’s bedside providing incontinence care and wound care;
-CNA G and LPN H did not offer the resident a drink during or after providing care;
-No fluid container in the resident’s room.
Observation on 3/19/19 at 5:15 A.M. in the resident’s room showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 57)
-The resident lay in bed on his/her left side with his/her eyes open;
-No fluid container in the resident’s room.
Observation on 3/19/19 at 7:05 A.M., showed the following:
-CNA G transported the resident to the dining room;
-CNA G left the resident at the dining room table with no drinks;
-The resident’s lips were dry and cracked;
-The resident sat at the dining room table without drinks from 7:05 A.M. until 8:20 A.M.
Continuous observation on 3/20/19 in the assisted dining room showed the following:
-At 8:14 A.M. an unidentified staff member pushed the resident up to the assisted dining
room table, placed a clothing protector on the resident, sat three drinks (one being an
unopened carton of milk) on the dining room table out of the resident’s reach and left the
resident sitting at the table;
-The resident sat at the table with his/her eyes and mouth open; the resident’s lips were
dry and cracked, reddened with white flakes and the resident’s tongue appeared dry;
-At 8:25 A.M. the resident sat at the table with his/her eyes closed; the resident’s
drinks sat on the table out of reach of the resident;
-At 8:34 A.M. CNA K opened the resident’s milk carton and sat it back down on the table in
front of the resident, the resident had his/her eyes closed. CNA K stood beside the
resident, touched the resident’s shoulder and asked if he/she wanted a drink; the resident
opened his/her eyes but did not respond; the drinks sat on the table in front of the
resident, CNA K did not attempt to offer the resident fluids;
-At 8:37 A.M. unidentified staff brought a tray to the resident. CNA K sat in a chair next
to the resident and assisted the resident with eating and drinking; the resident drank two
of the three drinks staff assisted him/her with.
During interview on 3/21/19 at 2:00 P.M. CNA N said the following:
-Resident #71 required staff to provide all cares for him/her;
-Resident #71 was not always able to verbally request a drink or help due to cognitive
impairment;
-Staff was to offer drinks to the residents during and after cares and in between meals,
but he/she thought the licensed staff did that with the medication pass;
-He/she was so busy with his/her own job duties he/she did not have time to pass fresh
water or ice.
3. Review of Resident #12’s quarterly MDS dated [DATE], showed the following:
-BIMS of 15 indicating intact cognition;
-Eating, required limited assistance of one staff member; physical assist.
Review of the resident’s care plan revised 1/31/19, showed the following:
-[DIAGNOSES REDACTED].
-Monitor for signs of [MEDICAL CONDITION] ( high blood sugar), including increased thirst;
-Report refusal of meals/liquids; instruct resident on importance of not skipping meals or
snacks;
-Offer fluids between meals, ensure water pitcher is in room and is filled with water and
ice.
Review of the resident’s POS dated (MONTH) 2019 showed the following:
-A physician ordered regular diet, regular consistency;
-Med pass supplement three times daily.
Observation on 3/17/19 at 4:05 P.M. in the resident’s room showed the following:
-The resident lay in bed with his/her eyes closed;
-His/her lips were dry and cracked and his/her oral cavity was visibly dry;
-No fluid container in the resident’s room.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 58)
Observation and interview on 3/18/19 at 2:00 P.M., in the resident’s room showed the
following:
-The resident lay in bed with his/her eyes open;
-The resident’s lips were dry with peeling skin;
-No fluid container in the resident’s room;
-When asked if staff offers him/her fresh water or ice, he/she said, no, they never do;
-He/she only gets fluids at meal times and then he/she sometimes has to beg for what
he/she wants;
-If he/she is thirsty between meals, he/she has to get his/her own drink, sometimes
cupping his/her hand under the bathroom sink to collect the water.
4. Review of Resident #22’s quarterly MDS dated [DATE], showed the following:
-BIMS of 14 indicating intact cognition;
-Was independent with eating, only required set up assistance;
-Had an indwelling catheter.
Review of the resident’s care plan revised 2/21/19, showed the following:
-[DIAGNOSES REDACTED].
-Provide homelike environment for the resident on a daily basis;
-At risk for dehydration due to diuretic therapy;
-Discuss and educate the resident about the importance of maintaining adequate fluid
intake;
-Encourage resident to consume 100% of fluids at meals and self consume water from water
pitcher kept in room between meals; water pitcher to be kept within reach of recliner;
-Mechanically altered diet; mechanical soft;
-Enjoys coffee, chocolate milk and hot chocolate at meals;
-Supra pubic catheter placement;
-Keep water pitcher within reach and refresh as needed throughout the day, encouraging
100% consumption of fluids at meals and water between meals.
Review of the resident’s POS dated (MONTH) 2019 showed the following:
-No physician ordered diet;
-Med pass supplement three times daily.
Review of the resident’s dietician note, dated 3/08/19 showed the resident received a
mechanical soft diet.
Observation on 3/17/19 at 4:10 P.M. in the resident’s room showed the following:
-The resident’s lower extremities were dry, with peeling skin;
-The resident’s lips had a dry cracked appearance;
-No fluid container in the resident’s room.
Observation and interview on 3/18/19 at 9:00 A.M., in the resident’s room showed the
following:
-The resident was up in his/her wheelchair;
-The resident’s lips were dry with peeling skin;
-No fluid container in the resident’s room;
-When asked if staff offers him/her fresh water or ice, he/she said, no, they never have;
-The resident said he/she only gets fluids at meal times;
-The resident said he/she sometimes asks the staff administering medications if he/she can
keep the cup given to him/her at that time so if he/she is thirsty between meals, he/she
has a cup to get water from the bathroom sink;
-Observation in the resident’s bathroom showed a stack of three disposable cups on the
back of the toilet.
5. Review of Resident #5’s quarterly MDS dated [DATE] showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 59)
-BIMS of nine indicating cognitive impairment;
-Supervision, requiring set up assistance with eating.
Review of the resident’s care plan dated 12/13/18 showed the following:
-[DIAGNOSES REDACTED].
-Continues to try and transfer on his/her own;
-Keep personal items close by to avoid reaching or transferring to get them.
Review of the resident’s (MONTH) 2019 POS showed a physician ordered regular diet.
Observation on 3/19/19 at 6:06 A.M., showed the following:
-The resident lay in bed with his/her eyes closed;
-His/her lips had dry patches with white matter at the corner of his/her mouth;
-A fluid container sat on a table out of he resident’s reach in the resident’s room;
-CNA L provided incontinence care, dressing assistance and transferred the resident from
his/her bed to his/her wheelchair;
-CNA L did not offer the resident a drink during or after providing care.
6. Review of Resident #28’s care plan revised 10/02/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident is at risk for dehydration due to receiving a diuretic;
-Observed for signs and symptoms of dehydration due to diuretic use;
-Encourage 100% fluid intake at meals and assist as needed consuming fluids/water from
water pitcher between meals;
-Offer fluids between meals to assist with flushing bladder and free from signs and
symptoms of infection.
Review of the resident’s annual MDS dated [DATE], showed the following:
-BIMS of seven indicating cognitive impairment;
-Eating, required limited assistance of one staff member; physical assist.
Review of the resident’s POS dated (MONTH) 2019 showed the following:
-A physician ordered diet of mechanical soft, regular consistency;
-Med pass supplement three times daily;
-Increase oral fluid intake three times daily (each shift), due to weakness.
Observation on 3/19/19 at 5:52 A.M., showed the following:
-The resident lay in bed with his/her eyes closed;
-The resident’s lips and tongue were visibly dry;
-CNA L provided incontinence care, dressing assistance and transferred the resident from
his/her bed to his/her wheelchair;
-CNA L did not offer the resident a drink during or after providing care.
7. During resident council meeting on 03/18/19 at 3:00 P.M. residents said the following:
-Resident #101 said staff does not bring him/her water in his/her room to drink; he/she
has no jug or cup in his/her room;
-Resident #43 said staff does not provide ice or fresh water to him/her when he/she is in
his/her room;
-Resident #69 said staff does not keep his/her cup filled with ice or fresh water; if
he/she wants ice he/she has to ask and does not always get it and he/she usually has to
get fresh water him/herself from the fountain.
During interview on 3/18/19 at 9:55 A.M., CNA K said he/she can tell if someone is thirsty
if they are licking their lips, their mouth was parched or if they had dry debris in the
corner of their mouth.
During interview on 3/19/18 at 6:50 A.M., CNA L said the following:
-He/she does not know if the residents are supposed to have a water pitcher or cup in
their rooms;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 60)
-Residents appear to be thirsty when they have parched lips;
-He/she tries to wet residents’ mouths every time he/she gives care especially if their
mouth is open and appeared dry.
During interview on 3/20/19 at 8:55 A.M., CNA J said if residents’ lips and mouth were
dry, he/she would wipe their lips and apply Chap Stick.
During interview on 3/21/19 at 10:00 A.M. CNA V said the following:
-Resident #71 required total care from staff for all cares;
-Resident #71 required staff assistance to eat and drink;
-Resident #28 and #5 were probably the same as #71;
-He/she thought Resident #12 and #22 could get their own drinks;
-Nursing staff was to offer drinks when providing cares, but he/she frequently forgot,
he/she had so many tasks to complete it was just something he/she did not think to do.
During interview on 03/22/19 at 3:53 P.M., the Director of Nursing (DON) said the
following:
-Residents should have cups or water readily available;
-Water should be passed at least twice a shift;
-Residents should have cups in their rooms;
-She would expect staff to give residents drinks in their room between meals;
-Signs and symptoms of dehydration included dry mouth, dry skin and dry lips.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure one resident (Resident
#101) in a review of 24 sampled residents, who received [MEDICAL TREATMENT], had a
physician’s orders [REDACTED]. The facility census was 118.
1. Record review of the facility’s [MEDICAL TREATMENT] Policy, undated, showed the
following:
-Policy: The facility shall provide adequate management of [MEDICAL TREATMENT] Services to
ensure that residents attain or maintain the highest practicable physical, mental, and
psychosocial well-being;
-It is essential that a communication process be established between the nursing home and
the [MEDICAL TREATMENT] facility to be used 24-hours a day. The care of the resident
receiving [MEDICAL TREATMENT] services must reflect ongoing communication, coordination,
and collaboration between the nursing home and the [MEDICAL TREATMENT] staff. The
communication process should include how the communication will occur, who is responsible
for communicating, and where the communication and responses will be documented in the
medical record, including but not limited to: Timely medication administration by the
nursing home and/or [MEDICAL TREATMENT]. Physician/treatment orders, laboratory values,
and vital signs. Advance Directives and code status- specific directives about treatment
choices; and any changes or need further discussion with the resident/representative, and
practitioners. Nutritional/fluid management including documentation of weights, resident
compliance with food/fluid restrictions or the provision of meals before, during an/or
after [MEDICAL TREATMENT] and monitoring intake and output measurements as ordered.
[MEDICAL TREATMENT] treatment provided and resident’s response, including declines in
functional status, falls, the identification of symptoms such as anxiety, depression,

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 61)
confusion, and/or behavioral symptoms that interfere with treatments. [MEDICAL TREATMENT]
adverse reactions/complications and/or recommendations for follow up observations and
monitoring, and/or concerns related to the vascular access site/PD catheter. Change and/or
decline in condition unrelated to [MEDICAL TREATMENT]. This would include communication
related to care concerns such as a resident who is at risk for or who has a pressure
ulcer, receiving appropriate interventions. The occurrence or risk of falls and any
concerns related to transportation to and from the [MEDICAL TREATMENT] facility;
-Coordination of Physician Services between the Nursing Home and the [MEDICAL TREATMENT]
facility. For a resident receiving [MEDICAL TREATMENT], the nursing home staff must
immediately contact and communicate with the attending physician practitioner,
resident/resident representative, and designated [MEDICAL TREATMENT] staff regarding any
significant changes in the resident’s status related to clinical complications or emergent
situations that may impact the [MEDICAL TREATMENT] portion of the care plan;
-Procedures for methods of communication between the nursing home and the [MEDICAL
TREATMENT] facility include how it will occur, with whom, and where the communication and
responses will be documented;
-The development and implementation of coordinated comprehensive care plans that
identifies nursing home and [MEDICAL TREATMENT] responsibilities and provides direction
for nursing home staff;
-The development and implementation of interventions, based upon current standards of
practice handling, but not limited to documentation and monitoring of complications,
pre-and-post [MEDICAL TREATMENT] weights, access sites, nutrition and hydration, lab
tests, vital signs including blood pressure, and medications;
-The provision of medications on [MEDICAL TREATMENT] treatment days;
-Procedures for monitoring and documenting nutritional/hydration needs including the
provision of meals on days that [MEDICAL TREATMENT] treatments are provided;
-Assessing, observing, and documenting care of access sites, as applicable, such as:
Auscultation/palpation of the AV fistula (pulse, bruit, and thrill) to assure adequate
blood flow. Significant changes in the extremity when compared to the opposite extremity
([MEDICAL CONDITION], pain, redness). Steal Syndrome (pain, numbness, discoloration, or
cold to touch in the fingers or hand indicating inadequate arterial flow). Skin integrity
(waxy skin, ulcerations, drainage from incisions). Bruising/hematoma. Collateral vein
distention (veins in access are close to AV fistula becoming larger). Complaints of pain
or numbness. Evidence of infection at the surgical site, such as drainage, redness,
tenderness at incision site, and fever;
-A copy of the Advanced Directive will be furnished to the receiving [MEDICAL TREATMENT]
Center;
-The [MEDICAL TREATMENT] Center will be notified when the resident declines [MEDICAL
TREATMENT];
-Two or more refusals then a referral will be made to the social worker and physician(s)
for adjustment in plan, however physician will be notified immediately upon the first
refusal.
2. Record review of Resident #101’s face sheet showed the resident was admitted to the
facility on [DATE] and then readmitted on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s Physician order [REDACTED].
Review of the resident’s physician orders [REDACTED].
Record review of the resident’s care plan, dated 12/5/18, showed the following:
-Problem: The resident needs [MEDICAL TREATMENT] related to [MEDICAL CONDITION] since
returning from the hospital;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 62)
-Approaches: Encourage the resident to go for the scheduled [MEDICAL TREATMENT]
appointments. The resident receives [MEDICAL TREATMENT] Monday, Wednesday, and Friday
unless changed by [MEDICAL TREATMENT] center. Monitor/document and report to physician
signs and symptoms of depression. Obtain order for mental health consult if needed.
Monitor/document report as needed signs/symptoms of infection to access site: Redness,
swelling, warmth, or drainage. Monitor/document/report as needed for signs/symptoms of
[MEDICAL CONDITION]: changes in level of consciousness, changes in skin turgor, oral
mucosa, changes in heart and lung sounds. Monitor/document/report as needed for
signs/symptoms of the following: Bleeding, hemorrhage (copious or heavy discharge of blood
from the blood vessels), bacteremia (presence of bacteria in the blood), septic shock (a
widespread infection causing organ failure and dangerously low blood pressure). Work with
the resident to relieve discomfort for side effects of the disease and treatment:
cramping, fatigue, headaches, itching, [MEDICAL CONDITION], bone demineralization, body
image change, and role disruption.
Review of the resident’s physician’s orders [REDACTED].>Record review of the resident’s
weight record, showed no documentation the facility weighed the resident as ordered on
[DATE], 12/9/18, 12/10/18, 12/12/18, 12/15/18, 12/16/18, 12/18/18, 12/19/18, 12/20/18 and
12/21/18.
Record review of the resident’s nurse’s notes, dated 12/23/18 through 12/30/18, showed the
following:
-No documentation of assessment or monitoring of the resident’s [MEDICAL TREATMENT]
catheter (used for exchanging blood to and from a [MEDICAL TREATMENT] machine and a
patient);
-No documentation of assessing or monitoring the resident before or after [MEDICAL
TREATMENT] treatments.
Record review of the resident’s weight record, showed no documentation the facility
weighed the resident as ordered on [DATE], 12/24/18, 12/25/18, 12/26/18, 12/27/18,
12/29/18 and 12/30/18.
Record review of the resident’s nurse’s notes, dated 12/31/18 at 5:21 P.M., showed the
[MEDICAL TREATMENT] clinic called and said the resident was being taken to the hospital
for an infected [MEDICAL TREATMENT] catheter.
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s nurse’s notes, dated 1/1/19 at 11:22 A.M., showed the
resident was admitted to the hospital for an infected [MEDICAL TREATMENT] catheter.
Record review of the resident’s nurse’s notes, dated 1/2/19 at 3:13 P.M., showed the
resident was being treated for [REDACTED].
Record review of the resident’s nurse’s notes, dated 1/4/19 at 10:23 P.M., showed the
resident returned to the facility by ambulance.
Record review of the resident’s nurse’s notes, dated 1/5/19 through 1/8/19 showed the
following:
-No documentation of assessment or monitoring of the resident’s [MEDICAL TREATMENT]
catheter;
-No documentation of assessing or monitoring the resident before or after [MEDICAL
TREATMENT] treatments.
Record review of the resident’s weight record, showed the facility failed to weigh the
resident on
1/6/19 and 1/8/19.
Record review of the resident’s nurse’s notes, dated 1/9/19 at 10:20 A.M., showed the
following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 63)
-The resident was alert and able to make his/her needs known. The resident was responsible
for self and had made the choice not to go to [MEDICAL TREATMENT] today;
-No documentation the resident’s physician was notified of the refusal to go to [MEDICAL
TREATMENT].
Record review of the resident’s nurse’s notes, dated 1/10/19 through 1/15/19 showed the
following:
-No documentation of assessment or monitoring of the resident’s [MEDICAL TREATMENT]
catheter;
-No documentation of assessing or monitoring the resident before or after [MEDICAL
TREATMENT] treatments.
Record review of the resident’s weight record, showed no documentation the facility failed
weighed the resident as ordered on [DATE].
Record review of the resident’s nurse’s notes, dated 1/17/19 through 1/30/19 showed the
following:
-No documentation of assessment or monitoring of the resident’s [MEDICAL TREATMENT]
catheter;
-No documentation of assessing or monitoring the resident before or after [MEDICAL
TREATMENT] treatments.
Record review of the resident’s weight record, showed the facility failed to weigh the
resident on
1/20/19 and 1/25/19.
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s nurse’s notes, dated 2/1/19 through 2/28/19 showed the
following:
-No documentation of assessment or monitoring of the resident’s [MEDICAL TREATMENT]
catheter;
-No documentation of assessing or monitoring the resident before or after [MEDICAL
TREATMENT] treatments.
Record review of the resident’s weight record, showed no documentation the facility
weighed the resident as ordered on [DATE], 2/9/19, 2/12/19, 2/13/19, 2/18/19, 2/20/19,
2/25/19 and 2/27/19.
Record review of the resident’s physician’s orders [REDACTED].
Record review of the resident’s weight record showed no documentation the facility
obtained the resident’s ordered weights on 3/1/19, 3/3/19, 3/5/19 and 3/10/19.
Review of the resident’s medical record showed the following:
-No documentation of assessment and/or monitoring of the resident’s [MEDICAL TREATMENT]
catheter;
-No documentation of any communications between the facility and the [MEDICAL TREATMENT]
clinic, including daily weights, vital signs, fluid intake, and resident status prior to
and post [MEDICAL TREATMENT];
-No documentation of assessment for signs and symptoms of infection and bleeding.
During an interview on 4/3/19 at 6:34 A.M., Licensed Practical Nurse (LPN) Z, said the
following:
-He/she had no specialized training with [MEDICAL TREATMENT] residents other than what
he/she had received in school;
-The facility does not have communication sheets that they fill out and send with the
[MEDICAL TREATMENT] residents to the [MEDICAL TREATMENT] Clinic;
-physician’s orders [REDACTED].
-The facility does not do intake sheets on the resident as he/she was non-compliant 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 64)
his/her fluid restriction;
-When a resident is non-compliant it should be documented in their medical record and the
resident’s physician should be notified.
During an interview on 3/22/19 at 3:53 P.M., the Director of Nursing said the following:
-She expected physician’s orders [REDACTED].
-She expected a resident receiving [MEDICAL TREATMENT] to have an order for
[REDACTED].>-She expected staff to document in the resident’s medical record post
assessments following [MEDICAL TREATMENT] appointments and with any changes.
Review of e-mail communication dated 4/2/19 at 4:23 P.M., showed the administrator wrote
the following:
-The facility had no communication sheets between the facility and the [MEDICAL TREATMENT]
Clinic for the resident;
-The facility had no intake records on the resident.
During an interview on 4/2/19 at 4:48 P.M., the resident’s physician, said the following:
-He expected physician orders [REDACTED].>-He expected to be notified when orders were
not being followed;
-He expected the facility to communicate information to the [MEDICAL TREATMENT] clinic for
continuum of care, such as weights, vital signs and fluid intake as could impact the
actual [MEDICAL TREATMENT] for that day.

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide enough nursing staff every day to meet the needs of every resident; and have a
licensed nurse in charge on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
sufficient nursing staff to meet residents’ needs for 11 residents (Residents #12, #22,
#27, #29, #43, #53 #57, #69, #71, #101 and #110), in a review of 24 sampled residents, and
for five additional residents (Residents #9, #14, #25, #38 and #75). Staff failed to
provide routine showers to ensure good personal hygiene and prevent body odors, failed to
respond timely to call lights, failed to provide restorative therapy when the restorative
aide (RA) was pulled to work as a certified nurse assistant (CNA) and was unable to
complete duties for the restorative therapy nursing program, failed to get residents up
for the evening meal when the CNA was the only staff working that unit and the residents
required a two-person transfer, and failed to toilet residents routinely resulting in
incontinence. The facility census was 118.
1. Review of the facility policy titled Staffing, dated (MONTH) 2007, showed the
following:
-Our facility policy provides adequate staffing to meet needed care and services for our
resident population;
-Our facility maintains adequate staffing on each shift to ensure that our resident’s
needs and services are met. Licensed registered nursing and licensed nursing staff are
available to provide and monitor the delivery of resident care services;
-Certified nursing assistants are available on each shift to provide the needed care and
services of each resident as outlined on the resident’s comprehensive care plan;
-Other support services (dietary, activities/recreational, social, therapy, environmental,
etc) are adequately staffed to ensure that resident needs are met.

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 65)
2. During group interview on 03/18/19 at 2:00 P.M., eight residents in attendance said
they had to wait extensive amounts of time (1.5 hours) for staff assistance, for things
such as toileting.
3. Review of Resident #14’s revised care plan, dated 12/17/18, showed the following:
-Assist the resident with transfers;
-Required limited assist with toileting;
-Requires staff assistance with maneuvering of clothing at times due to left sided
weakness.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument, completed by facility staff, dated 3/13/19, showed the following:
-Cognitively intact;
-Required limited assistance of one staff for transfers;
-Required limited assistance of one staff for toileting.
During interview on 03/18/19 at 2:00 P.M., the resident said the following:
-Staff is not readily available for things such as toileting;
-Many times he/she has accidents or has to urinate in his/her incontinent brief because it
takes staff too long to get to him/her or he/she cannot find help;
-Urinating in his/her incontinent briefs makes him/her feel humiliated.
4. Review of Resident #25’s revised care plan, dated 12/24/18, showed the following:
-Limited assistance with toileting needs and incontinence;
-Has frequent incontinent episodes requiring adult brief use.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance of one staff for transfers;
-Required extensive assistance of one staff for toileting;
-Frequently incontinent of urine.
During interview on 03/18/19 at 2:00 P.M., the resident said the following:
-Staff is not readily available for things such as toileting;
-Frequently he/she has accidents or has to urinate in his/her incontinent brief because it
takes staff too long to get to him/her or he/she cannot find help;
-Urinating in his/her incontinent briefs makes him/her feel embarrassed and humiliated.
5. Record review of Resident #27’s annual MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-Did not reject care;
-Required limited assistance of one staff for transfers, dressing, and toileting;
-Required physical help in part of bathing activity with assist of one staff;
-Had an indwelling catheter;
-Was always continent of bowel.
Review of the resident’s care plan, dated as revised 1/6/19 and 2/1/19, showed the
following:
-Problem: The resident is at risk for falls due to potential for weakness due to
respiratory problem and psychoactive medication;
-Interventions: Keep call light within reach at all times. Respond to call light promptly;
-Problem: The resident requires staff assistance with grooming and bathing;
-Approaches: Extensive assist with bathing needs especially with washing and drying of
lower body. Limited assist with toileting needs. Staff does have to assist with catheter
cares and emptying of catheter drainage bag. Set up at sink for the resident to self
perform own grooming needs.
Review of the facility shower assignment showed the resident was to get a shower on Monday
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 66)
and Thursday day shift.
Observation and interview on 3/17/19 at 4:20 P.M., showed the resident said he/she does
not get showers. Observations showed the resident’s hair was disheveled and greasy. He/She
had an area of dried blood on his/her lower right leg. The resident wore a yellow hospital
gown. The resident had a brownish colored area to the foot of his/her bed on the sheets.
Observation and interview on 3/18/19 at 10:10 A.M., showed the resident was wearing the
same yellow gown as on 3/17/19 and the area of dried blood on his/her lower right leg
remained. The resident said he/she had not had a shower and had not had his/her sheets
changed. Observation showed the resident’s hair was disheveled and greasy and he/she still
had the brownish colored area to the foot of his/her bed on the sheets.
Observations on 3/19/19 showed the following:
-At 5:26 A.M., the resident had turned on his/her call light;
-At 5:56 A.M. (30 minutes later), CNA AA answered the call light. The resident requested
ice.
During an interview on 3/19/19 at 5:57 A.M., CNA AA said he/she was the only aide on the
resident’s hall until 7:00 A.M. and that was why it took so long to answer the resident’s
call light.
Observation and interview on 3/19/19 at 10:49 A.M., showed the resident wore the same
yellow gown as 3/17/19 and still had an area of dried blood on his/her lower right leg.
The resident said he/she had not had a shower and had not had his/her sheets changed.
Observation showed the resident’s hair was disheveled and greasy and he/she still had the
brownish colored area to the foot of his/her bed on the sheets. The resident resided in
the room by himself/herself. The resident’s room had a foul odor.
Observation and interview on 3/20/19 at 11:53 A.M., showed the resident wore the same
yellow gown as 3/17/19 and still had an area of dried blood on his/her lower right leg.
The resident said he/she had not had a shower and had not had his/her sheets changed.
Observation showed the resident’s hair was disheveled and greasy and he/she still had the
brownish colored area to the foot of his/her bed on the sheets. The resident’s room had a
foul odor.
Observation and interview on 3/21/19 at 9:07 A.M., showed the resident wore the same
yellow gown as on 3/17/19 and still had an area of dried blood on his/her lower right leg.
The resident said he/she had not had a shower and had not had his/her sheets changed.
Observation showed the resident’s hair was disheveled and greasy and he/she still had the
brownish colored area to the foot of his/her bed on the sheets. The resident’s room had a
foul odor.
6. Review of Resident #43’s face sheet showed [DIAGNOSES REDACTED].
Review of the resident’s revised care plan, dated 1/15/19, showed the following:
-Limited assistance of one staff for transfer;
-Toilet after dinner meal. Do not wait for the resident to notify staff. Staff to assist
with toileting.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance of one staff for transfers and toileting;
-Frequently incontinent of urine.
During interview on 03/18/19 at 2:00 P.M., the resident said the following:
-Staff is not readily available for things such as toileting;
-Many times he/she has accidents or has to urinate in his/her incontinence brief because
it takes staff too long to get to him/her or he/she cannot find help;
-Urinating in his/her incontinent briefs makes him/her feel mad.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 67)
7. Review of Resident #69’s face sheet showed he/she had [DIAGNOSES REDACTED].
Review of the resident’s revised care plan, dated 2/7/19, showed the following:
-Provide limited assistance with toileting as requested;
-Transfer with minimal assistance of one staff;
-Encourage resident to alert staff as soon as urge to void is present.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance of one staff for transfers and toileting;
-Occasionally incontinent of urine.
During interview on 03/18/19 at 2:00 P.M., the resident said the following:
-Staff is not readily available for things such as toileting;
-Many times he/she has accidents or has to urinate in his/her incontinent brief because it
takes staff too long to get to him/her or he/she cannot find help;
-Urinating in his/her incontinent briefs makes him/her feel humiliated, mad and angry.
8. Review of Resident #101’s face sheet showed he/she had [DIAGNOSES REDACTED].
Review of the resident’s physician’s orders, dated 1/24/19, showed may begin Restorative
Therapy Program two to five times a week until progress ceases or goals are met.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed no
record restorative therapy was completed for the week of 2/4/19 through 2/10/19.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time during the week of 3/4/19 through 3/10/19;
-Restorative therapy completed one time during the week of 3/11/19 through 3/17/19;
-The facility did not to complete restorative as ordered.
Review of the resident’s revised care plan, dated 3/1/19 showed the following:
-Limited in physical mobility and requires assistance of one to three staff for daily
care;
-Can make needs known;
-Incontinent and dependent on staff for incontinent care.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Totally dependant on two or more staff for transfer and toileting needs;
-Always incontinent of bowel and bladder.
During interview on 03/18/19 at 2:00 P.M., the resident said the following:
-Staff is not readily available for things such as toileting;
-Many times he/she has accidents or has to urinate in his/her incontinent brief because it
takes staff too long to get to him/her or he/she cannot find help;
-Urinating in his/her incontinent briefs makes him/her feel embarrassed.
9. Review of Resident #71’s Restorative Therapy Program orders, dated 1/16/19, showed the
following:
-Frequency: one time day/two to five times a week;
-Passive Range of Motion (PROM): Bilateral lower extremities and trunk to reduce joint
stiffness;
-Signed by the therapist 1/16/19.
Review of the resident’s care plan, revised 2/8/19, showed the following:
-Dependent on staff for locomotion;
-Transfer with two staff;
-At risk for functional decline, social isolation and increased agitation;
-Allow to make simple decisions;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 68)
-Requires mechanically altered diet;
-At risk for aspiration;
-Difficulty holding a cup and utensils;
-At risk for poor nutritional intake;
-May need assistance with eating and drinking;
-Staff to spoon feed at meals; encourage participation although resident is not
successful.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-BIMS of six indicating severely impaired cognition;
-Extensive assistance of one staff for bed mobility, eating and drinking;
-Total dependence of two staff for transfers;
-Extensive assistance of one staff for locomotion on and off the unit;
-Used wheelchair for mobility device.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time (2/4/19) for the week of 2/4/19 through 2/10/19;
-Restorative therapy completed one time (2/11/19) for the week of 2/11/19 through 2/17/19;
-Restorative therapy completed one time (2/18/19) for the week of 2/18/19 through 2/24/19;
-The facility did not to complete restorative as ordered.
Review of the resident’s (MONTH) 2019 physician order sheets (POS) showed the following:
-[DIAGNOSES REDACTED].
-Physician ordered diet of mechanical soft texture, regular consistency.
Observation on 3/20/19 at 4:40 P.M. showed the resident lay in bed in his/her room.
During interview on 3/20/19 at 4:40 P.M., the resident said he/she knew it was about
supper time. He/she was hungry. Staff usually helped him/her get up for meals.
Observation on 3/20/19 at 5:40 P.M. showed the resident lay in his/her bed. The head of
the resident’s bed was elevated and he/she lay on his/her left side. CNA N assisted the
resident with his/her evening meal at the resident’s bedside.
During interview on 3/20/19 at 6:00 P.M., the resident said the following:
-He/she ate supper in bed;
-He/she did not know why staff did not get him/her up;
-No one asked him/her if he/she wanted to eat in bed.
10. Review of Resident #75’s care plan, revised 2/16/19, showed the following:
-Use Hoyer lift (mechanical lift) if resident is weak, with assist of two staff;
-Resident is limited in physical mobility and requires assistance from one to two staff
with daily care;
-Resident uses a wheelchair for locomotion, can stand and ambulate with a quad cane/grab
bar with assist times from one to two staff;
-He/she is able to make his/her needs known and can be impatient, may transfer
himself/herself;
-Mechanical soft diet with recommendation to be on thickened liquids but has requested to
remain on thin liquids; at risk for aspiration;
-Eats in the assisted dining area; observe closely for signs of difficulty swallowing and
or/aspiration; alert charge nurse of increased coughing or choking.
Review of the resident’s annual MDS, dated [DATE], showed the following:
-Cognition intact;
-Extensive assistance of one staff for bed mobility and locomotion on and off the unit;
-Extensive assistance of two staff for transfers;
-Independent with eating, requiring set up help only;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 69)
-Used wheelchair for mobility device.
Observation on 03/20/19 at 4:50 P.M. showed the resident lay in his/her bed in his/her
room.
During interview on 03/20/19 at 4:50 P.M., the resident said the following:
-He/she knew it was about supper time;
-He/she was hungry;
-Staff usually helped him/her get up for meals but CNA N told him/her he/she would be
eating in bed this evening because CNA N was the only one working the hall;
-He/she would rather be up for meals, but what was he/she to do?
Observation on 3/20/19 at 5:45 P.M. showed the following:
-The resident lay in his/her bed;
-The resident’s evening meal was on his/her bedside table and the resident fed
himself/herself;
During interview on 3/20/19 at 5:45 P.M., the resident said the facility was always short
staffed and this occasionally happened that they did not get him/her up for the supper
meal.
During an interview on 3/20/19 at 4:22 P.M., CNA N said the following:
-Resident #71 and #75 required two staff to transfer;
-He/she was the only staff working the unit at that time;
-There was a floating staff member, but they were usually too busy to assist him/her when
needed;
-Resident #71 and #75 would be staying in bed for the evening meal because he/she did not
have help to get them up;
-The facility was frequently short staffed and it was difficult for him/her to complete
her tasks for his/her shift.
11. Review of Resident #110’s care plan, dated 2/8/19, showed the following:
-Totally dependent on staff to provide bath/shower two times weekly and as necessary;
-Totally dependent on staff for personal hygiene and oral care.
Review of the resident’s 14-day Prospective Payment System (PPS) MDS, dated [DATE], showed
the following:
-Cognitively intact;
-Did not reject care;
-Required total assistance of two or more staff for bathing.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-No evidence the resident received a shower/bath from 1/28/19 through 2/2/19 (five days);
-The resident received a shower on 2/3/19, abed bath on 2/8/19, a shower on 2/17/19, and a
bed bath on 2/19/19;
-The resident was in the hospital on [DATE] and 2/26/19;
-There was no documentation the resident received a shower 3/1/19 through 3/22/19 (22
days).
Observation on 3/17/19 at 1:45 P.M., showed the resident lay in bed . The resident’s
fingernails were long.
During an interviews on 3/17/19 at 1:45 P.M. and 3/19/19 at 7:44 A.M., the resident said
he/she has told staff he/she wants his/her fingernails trimmed but they have never been
trimmed. Staff just come in and do a bed bath when they are ready. It can be a long period
between baths and he/she has went a couple of weeks without a shower before. He/she
doesn’t know why he/she doesn’t get a bath/shower when scheduled.
12. Record review of Resident #9’s admission MDS, dated [DATE], showed the following:
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 70)
-Cognitively intact for daily decision making;
-Had no rejection of care;
-Required limited assist of one staff for personal hygiene;
-Required physical help of one staff for bathing;
-Was occasionally incontinent of urine;
-Was always continent of bowel.
Review of the resident’s care plan, dated as reviewed 3/11/19, showed the following:
-Problem: The resident requires limited to extensive assist with ADLs;
-Interventions: The resident requires extensive assist from staff with showering two times
weekly and as necessary.
Review of the facility’s shower assignment sheet, showed the resident was to receive a
shower on Tuesday and Friday during the day shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-On 1/30/19, there was no hot water, so shower was not given;
-The resident received a shower on 2/25/19, 3/2/19, and 3/8/19;
-No documentation to show the resident received a shower on other days between 1/17/19 and
3/22/19.
Observation on 3/18/19 at 4:12 P.M., showed the resident was in bed. He/she only wore an
incontinence brief and was covered with a sheet. The resident’s hair was disheveled and
greasy. The room had an unidentifiable odor.
During an interview on 3/18/19 at 4:12 P.M., the resident said he/she does not get
showers. He/she had not received a shower for over ten days. He/she would prefer his/her
family member be at the facility when he/she takes a shower and would prefer a bench over
the shower chair.
13. Review of Resident #12’s updated care plan, dated 1/31/19, showed the following:
-Requires minimal assistance due to fluctuating weakness for many ADLs and/or requiring
supervision for completion for ADLs;
-Does need extensive assistance with bathing needs;
-Does refuse showers at times; approach at different times of day for showers;
-Supervise to ensure personal hygiene is met;
-Refuses to shave chin at times; continue to offer assistance in tasks until resident is
agreeable with completion.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-Required limited assistance from one staff for personal hygiene, including bathing,
combing of hair and shaving.
Review of the resident’s (MONTH) 2019 physician order sheets (POS) showed Restorative
Therapy Program one time a day (two to five times a week) until goals are met.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time (3/7/19) for the week of 3/4/19 through 3/10/19;
-Restorative therapy completed one time (3/15/19) for the week of 3/11/19 through 3/17/19;
-The facility did not to complete restorative as ordered.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday on the day shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the following:
-The resident’s last documented shower was on 2/21/19;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 71)
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 02/25/19, 02/28/19, 03/04/19, 03/07/19, 03/11/19, 03/14/19, 03/18/19 and
03/21/19.
Observation on 3/17/19 at 12:58 P.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and was unkempt.
Observation on 3/18/19 at 9:25 A.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt.
Observation on 3/19/19 at 8:10 A.M. showed the following:
-The resident lay in bed in his/her room;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt.
Observation on 3/22/19 at 10:05 A.M. showed the following:
-The resident sat in his/her wheelchair in the facility hallway;
-The resident had unshaven facial hair resembling stubble;
-The resident’s hair appeared greasy and unkempt;
During interview on 3/22/19 at 10:05 A.M., the resident said the following:
-He/she needed help shaving his/her facial hair and staff never assisted him/her;
-He/she sometimes asked for supplies to shave and assistance, but staff never brought them
or offered to help;
-He/she likes to be clean shaven;
-Staff does not always help him/her with bathing;
-He/she used to go to the shower room and linen room on his/her own because he/she got
tired of waiting on staff to help, but he/she got in trouble with staff for doing that so
he/she doesn’t do it anymore;
-He/she does not even have a comb or wash clothes to clean up at the sink if he/she wanted
to.
14. Review of Resident #22’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance with personal hygiene, including shaving;
-Required physical help in part of bathing assistance.
Review of the resident’s care plan, revised 2/21/19, showed the following:
-Requires supervision to limited assistance at times with ADLs;
-The resident will be appropriately assisted with ADLs as needed;
-Allow the resident to do as much as possible for him/herself and offer assistance when
needed;
-Encourage the resident to allow staff to assist with hygiene and bathing; encourage staff
assist and completion of these tasks;
-Limited assistance with bathing;
-Set up and supervision for grooming needs to assure the resident is completing task.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday on the day shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the following:
-The resident’s last documented shower was on 2/21/19;
-No documentation to show the resident had been shaved or that cares had been provided or
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 72)
refused on 02/25/19, 02/28/19, 03/04/19, 03/07/19, 03/11/19, 03/14/19, 03/18/19 and
03/21/19.
Observation on 03/17/19 at 12:02 P.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 3/18/19 at 9:25 A.M. showed the following:
-The resident sat in his/her wheelchair in the main dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 3/19/19 at 8:10 A.M. showed the following:
-The resident sat in a wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
Observation on 3/22/19 at 10:15 A.M. showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
During an interview on 3/22/19 at 10:15 A.M., the resident said the following:
-He/she needed help shaving his/her facial hair and staff never assisted him/her;
-He/she sometimes asked for supplies to shave and assistance, but they never brought them
or offered to help;
-He/she likes to be clean shaven;
-Staff does not always help him/her with bathing because they are short staffed;
-It had been a long time since he/she had a shower and he/she felt dirty.
15. Record review of Resident #29’s admission MDS, dated [DATE], showed the following:
-Cognitively intact for daily decision making;
-No rejection of care;
-Was dependent on one staff for dressing, toileting, and bathing;
-Required extensive assist of one staff for bed mobility, transfers, and personal hygiene;
-Always incontinent of bladder;
-Frequently incontinent of bowel.
Review of the resident’s care plan, dated 1/13/19, showed the following:
-Problem: The resident requires extensive to full staff assistance with ADLs;
-Interventions: The resident is totally dependent on one staff to provide showers twice
weekly and as necessary.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday on the evening shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-The resident received one shower on 3/7/19;
-No documentation to show the resident refused or received a shower for the other days.
Observation on 03/17/19 at 3:05 P.M., showed the resident’s hair appeared greasy.
During interview on 03/17/19 at 3:05 P.M., the resident’s family member said the resident
did not receive showers like he/she should. The resident had been at the facility since
12/31/18 and as far as he/she knew had only received three showers.
During an interview on 3/19/19 at 8:30 A.M., the resident’s family member said the
resident did not receive his/her shower last night. Observation showed the resident’s hair
appeared greasy.
Observation on 3/22/19 at 10:53 A.M., showed a hand written sign on the resident’s door
that said, Shower time!
During an interview on 3/22/19 at 11:13 A.M., the resident’s family member said he/she put
the sign on the resident’s door to remind staff to do the resident’s shower. He/she was
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 73)
unsure if the resident received his/her shower the night before.
16. Review of Resident #38’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance from one staff for personal hygiene;
-Totally dependent on staff for bathing.
Review of the resident’s care plan, revised 1/22/19, showed the following:
-Requires extensive assist to full assist with daily cares;
-Staff to assist to make sure basic care needs are met;
-Is incontinent of bladder with occasional incontinence of bowel.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday on the evening shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for (MONTH) 2019 through (MONTH) 2019, showed the following:
-The resident received a shower on 2/07/19;
-No documentation the resident received a shower as scheduled on 02/11/19, 02/14/19,
02/18/19, 02/21/19, 02/25/19, 02/28/19, 03/04/19, 03/10/19, 03/11/19, 03/14/19 and
03/18/19.
Observation on 03/17/19 at 2:45 P.M. showed the resident lay in bed watching television.
The resident’s hair appeared greasy. The resident ran his/her hands through his/her hair
and it stood up on end.
During an interview on 03/17/19 at 2:45 P.M., the resident said the following:
-He/she had not had a shower for six weeks;
-Staff said he/she does not get his/her shower because they are low on staff; this
includes no hair washing;
-His/her hair felt greasy.
17. Review of Resident #53’s (MONTH) 2019 POS showed Restorative Therapy Program one time
a day (two to five times a week) until goals are met.
Review of the resident’s Restorative Care Flow Record, dated (MONTH) 2019, showed the
following:
-Restorative therapy completed one time (3/14/19) for the week of 3/9/19 through 3/15/19;
-Restorative therapy completed only one time (3/18/19) for the week of 3/16/19 through
3/22/19;
-The facility did not complete restorative as ordered.
18. Review of Resident #57’s care plan, dated 7/25/18, showed the following:
-Check frequently for wetness and change after incontinence occurs;
-Continent of bowel and bladder with occasional incontinence requiring pads/briefs;
-The resident often refuses showers. Does shave as needed. Staff is to encourage shower or
at minimal washing body at sink to prevent odor or complications from poor hygiene.
Review of the resident’s annual MDS, dated [DATE], showed the following:
-Cognition moderately impaired;
-Had no rejection of care;
-Bathing somewhat important;
-Required extensive assistance of one staff for bathing;
-Frequently incontinent of urine.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for 1/17/19 through 3/22/19, showed the following:
-Refused a shower on 3/8/19;
-The resident received a shower on 3/14/19;
-There was no documentation the resident received a shower 1/17/19 through 3/13/19 (55
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 74)
days).
Observation on 3/20/19 at 1:35 P.M., showed the resident walked the halls of the facility.
The resident’s hair was disheveled.
19. During interview on 3/19/19 at 4:05 P.M., Restorative Aide (RA) V said he/she gets
pulled from restorative therapy to work the floor.
During interview on 3/18/19 at 2:32 P.M., Unit Manager LPN W said the following:
-He/she was the staffing coordinator until just recently;
-He/she staffed according to census not acuity.
During interview on 4/4/19 at 9:57 A.M., LPN WW said he/she feels like there is not enough
staff. When two staff are caring for a resident and they are needed in another room and
the staff cannot get to them, the resident then tries to do it on their own and may fall.
During interview on 3/19/19 at 7:35 A.M., Registered Nurse (RN) PP said the following:
-He/she worked double shifts to help with staffing;
-One CNA to work the hall was not enough staff to answer call lights in a timely manner or
provide care for the residents;
-The facility was short staffed.
During interview on 03/22/19 at 3:53 P.M. the director of nursing (DON) said the
following:
-There is not sufficient staff;
-She still expects staff to get help to get residents out of bed for things like meals,
unless the resident wishes to stay in bed;
-Call lights sh (TRUNCATED)

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Some

Post nurse staffing information every day.

Based on observation and interview, the facility failed to post the total number of
nursing staff working every shift by Registered Nurses (RN), Licensed Practical Nurses
(LPN) and Certified Nursing Assistants (CNA) that were directly responsible for resident
care, and the resident census on a daily basis at the beginning of each shift. The
facility failed to post information in a clear and readable format, in a prominent place
readily accessible to residents and visitors. The facility failed to maintain the posted
daily nursing staff data for six of six survey days. The facility census was 118.
1. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, dated
(MONTH) (YEAR), showed the following:
-The facility would post, on a daily basis for each shift, the number of nursing personnel
responsible for providing direct care to residents;
-Within two hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs
and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for
resident care will be posted in a prominent location (accessible for residents and
visitors) and in a clear and readable format.
2. Observation on 03/17/19 from 12:33 P.M. to 7:45 P.M. showed no posted nursing staff
seen about the facility that included the facility name, the current date, the total
number and the actual hours worked by licensed and unlicensed nursing staff directly
responsible for resident care per shift including RNs, LPNs or LVNs, CNAs and the resident
census.
3. Observation on 03/18/19 from 7:40 A.M. to 7:45 P.M. showed no posted nursing staff seen

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0732

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 75)
about the facility that included the facility name, the current date, the total number and
the actual hours worked by licensed and unlicensed nursing staff directly responsible for
resident care per shift including RNs, LPNs or LVNs, CNAs and the resident census
4. Observation on 03/19/19 from 4:30 A.M. to 5:10 P.M. showed no posted nursing staff seen
about the facility that included the facility name, the current date, the total number and
the actual hours worked by licensed and unlicensed nursing staff directly responsible for
resident care per shift including RNs, LPNs or LVNs, CNAs and the resident census.
5. Observation on 03/20/19 from 8:10 A.M. to 6:30 P.M. showed no posted nursing staff seen
about the facility that included the facility name, the current date, the total number and
the actual hours worked by licensed and unlicensed nursing staff directly responsible for
resident care per shift including RNs, LPNs or LVNs, CNAs and the resident census.
6. Observation on 03/21/19 from 8:00 A.M. to 7:15 P.M. showed no posted nursing staff seen
about the facility that included the facility name, the current date, the total number and
the actual hours worked by licensed and unlicensed nursing staff directly responsible for
resident care per shift including RNs, LPNs or LVNs, CNAs and the resident census.
7. Observation on 03/22/19 from 8:00 A.M. to 6:00 P.M. showed no posted nursing staff seen
about the facility that included the facility name, the current date, the total number and
the actual hours worked by licensed and unlicensed nursing staff directly responsible for
resident care per shift including RNs, LPNs or LVNs, CNAs and the resident census.
During an interview on 3/18/19 at 2:32 P.M. Unit Coordinator/LPN W said the staffing was
posted back by the employee clock and should be posted at the receptionist desk.
During interview on 03/22/19 at 3:53 P.M., the Director of Nursing (DON) said staffing
should be posted where residents and families can see the information.

F 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide sufficient support personnel to safely and effectively carry out the functions
of the food and nutrition service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed provide sufficient support
personnel in the dietary department to effectively carry out the functions of the food
service. The facility census was 118.
1. Observation on 03/17/19 at 6:00 P.M. showed 21 residents ate the supper meal in the
assisted dining room. Staff served the residents’ evening meal on Styrofoam plates and
bowls with plastic utensils. Staff served beverages in Styrofoam cups.
Observation on 03/17/19 at 6:16 P.M. showed 33 residents ate the supper meal in the main
dining room. Staff served the residents’ evening meal on Styrofoam plates and bowls with
plastic utensils. Staff served beverages in Styrofoam cups.
During an interview on 3/17/19 at 6:01 P.M., Resident #27 said the facility serves meals
on Styrofoam regularly. There will be times when he/she will get either just a plastic
spoon or plastic fork and the entree may require a different utensil, such as staff may
serve soup and provide a plastic fork to eat the soup.
During an interview on 3/17/19 at 6:18 P.M., Resident #39 said the facility did not have
enough staff to do dishes and this is the reason they have to eat on Styrofoam plates and
use plastic utensils. The facility served on Styrofoam and used plastic utensils on a
regular basis.
During an interview on 3/17/19 at 6:05 P.M., Resident #72 said staff served meals 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 76)
Styrofoam regularly with plastic silverware.
During an interview on 3/21/19 at 9:54 A.M., Resident #95 said the following:
-It bothers him/her to use plastic silverware;
-He/she can’t do anything with plastic silverware;
-It is usually the spoon that is plastic, but can be all plastic utensils at times;
-Have been served plastic utensils a lot lately.
During an interview on 3/17/19 at 6:30 P.M., Resident #97 said the facility served meals
regularly on Styrofoam.
During an interview on 3/17/19 at 6:18 P.M., Resident #111 said the facility served on
Styrofoam and used plastic utensils on a regular basis.
During the resident council meeting on 03/18/19 at 2:50 P.M. residents in attendance said
the following:
-Meals were frequently served on Styrofoam/paper products;
-Reasons given for the use of the Styrofoam/paper products vs. real dishes included the
facility being short staffed, not enough time for staff to wash real dishes and/or the
dishwasher was broken.
During interview on 3/18/19 at 12:40 P.M., Dietary Aide DD said sometimes he/she was the
only one staff working in the kitchen and could not get everything completed. They had to
serve off of Styrofoam plates and use disposable utensils and cups just to get the
residents served.
Observation and interview on 03/20/19 at 8:30 A.M. showed the following:
-Resident #59 sat in the main dining room eating Rice Krispie cereal with a plastic fork;
-The resident said staff told him/her there were no spoons available;
-Two other unidentified residents were eating oatmeal and cream of wheat cereal with a
plastic fork.
During an interview on 3/20/19 at 1:42 P.M., Dietary Aide CC said there wasn’t enough
staff to get everything done including dishes. They had to serve the residents on
disposable plates, silverware and cups because staff couldn’t get the dishes clean in
time.
2. Observations on 3/18/19 showed the following:
-At 12:48 P.M., staff announced food service was to begin in the main dining room over the
intercom system;
-At 1:04 P.M., dietary staff prepared meal trays in the kitchen for the main dining ran.
Staff ran out of clean and prepared flatware for the meal before all meal trays were
prepared;
-Between 1:04 P.M. and 1:09 P.M., Dietary Aide SS obtained soiled flatware (which had been
on the dirty side of the dishmachine since breakfast) and washed it in the dish machine;
-At 1:09 P.M., showed Dietary Aide FF wrapped wet flatware in paper napkins;
-At 1:14 P.M., staff placed the meal trays for the main dining room on the meal cart and
took the cart to the main dining room. Not all residents received flatware and were
waiting on more flatware;
-At 1:25 P.M., staff ran out of spoons. Residents in the main dining room did not receive
spoons for the meal.
3. During an interview on 03/19/19 at 9:50 A.M., Resident #12 said staff does not offer
the residents a bedtime snack.
During an interview on 03/18/19 at 3:00 P.M., Resident #14 said staff only gives him/her a
snack if he/she asked, but they did not always have something available.
During an interview on 03/20/19 at 2:00 P.M., Resident #22 said staff doesn’t offer snacks
at bedtime.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 77)
During an interview on 03/18/19 at 3:00 P.M., Resident #25 said staff does not offer
bedtime snacks.
During an interview on 3/17/19 at 4:20 P.M., Resident #27 said he/she did not get bedtime
snacks.
During an interview on 03/18/19 at 3:00 P.M., Resident #59 said he/she sometimes gets
hungry through the night and staff does not offer snacks.
During an interview on 03/18/19 at 3:00 P.M., Resident #62 said staff used to come along
with a juice and snack cart in the evenings, but they have not done so for over a year.
During an interview on 03/18/19 at 3:00 P.M., Resident #69 said staff will give him/her a
snack in the evening only if they have something available and they often times do not.
During an interview on 03/18/19 at 3:00 P.M., Resident #92 said staff does not offer
him/her a bedtime snack and he/she wished they did.
During interview on 3/19/19 at 7:35 A.M. Registered Nurse (RN) PP said they did not have
bedtime snacks or any snacks to give the residents on 3/18/19 evening. He/she did not
think they passed bedtime snacks to the residents.
During interview on 3/20/19 at 8:28 A.M., Dietary Aide EE said evening snacks were not
prepared because there wasn’t enough staff to prepare snacks.
4. Observations on 3/18/19 at 11:44 A.M. and on 3/19/19 at 8:15 A.M. showed the following:
-The fryer baskets were hanging above the fryer with dark crispy debris stuck to them;
-The oil in the deep fat fryer was almost black;
-There was a heavy greasy buildup on the sides, behind, underneath, and around the fryer;
-The front of the fryer had white splatters across the surface;
-Inside the vat of the fryer was a black buildup all across the stainless steel;
-Where the baskets hung from the fryer there was a buildup of solid crumb-like debris;
-The tilt skillet was dirty with a buildup of a yellowish debris along the cooking
surface;
-The convection oven had a buildup of dark debris on the outside and inside surfaces;
-The griddle was dark with debris, large chunks of solid debris littered the cooking
surface of the griddle, a dirty spatula lay resting on the griddle. The outside surface of
the griddle was layered with dark and light debris;
-The stainless steel backsplash of the range was dark with a buildup of debris;
-Eight of eight ceiling vents, located above the food preparation areas, cooking surfaces,
clean side of the dishwashing area, and clean dish storage, were all dirty with a buildup
of fuzzy and dark debris;
-The vent above the steamtable had a heavy buildup with debris that extended to four
ceiling tiles surrounding the vent and 2 feet across one tile to the light fixture on the
other side that was also above the steamtable.
Observations on 3/18/19 at 12:04 P.M. showed the reach-in refrigerator had remnants of
what appeared to be a yellow liquid that was spilled as well as a dried puddle and
splatters of blood-red substances. Above the staining was an opened tube of Braunschweiger
(a pork liverwurst) that was undated.
Observations on 3/18/19 at 12:08 P.M. showed the milk cooler had a large accumulation of
dried solidified spilled milk that extended across most of the floor in either a pool or
splatters. The spilled milk had turned yellow and green.
During interview on 3/19/19 at 11:39 A.M., Dietary Aide HH said there used to be a
cleaning list and chores in the kitchen, but with such little staff there isn’t enough
people to get things done so something had to fall off in order to get the residents fed.
5. Observations on 3/18/19 at 12:11 P.M. showed dishes were stacked wet. Drops of water
dripped off the dishes and when separated, water was on the surfaces of the dishes. All
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 78)
dishes that were stacked were stacked wet. Staff placed the flatware in a utensil
[MEDICATION NAME] while wet.
Observations on 3/18/19 at 12:13 P.M. showed Dietary Aide FF rolled flatware. Further
observations showed the flatware was wet. Staff placed the damp flatware on a tray for
food service.
Observations on 3/18/19 between 12:31 P.M. showed staff placed food on the wet plates and
bowls that had been stacked wet. The trays, plates, bowls, and napkin wrapped flatware
were wet when used for the meal service.
During interview on 3/18/19 at 12:40 P.M., Dietary Aide SS said staff stacked the dishes
when they were wet because there isn’t enough help to get all the dishes done and let them
dry before more dishes are needed for meal service.
6. Observations on 3/19/19 at 7:45 A.M. showed a large stack of dishes piled in the dish
area.
During interview on 3/20/19 at 2:50 P.M., Dietary Aide CC said he/she left the dirty
dishes in the dish area on the evening of 3/18/19 because there was not enough staff to
get them done.
During interview on 3/19/19 at 11:40 A.M., Dietary Aide EE said none of the dishes were
cleaned the evening of 3/18/19. When he/she wanted to make breakfast, all dishes had to be
cleaned first.
7. Review of an undated facility provided document titled Meal Times, showed supper was to
be served at 5:30 P.M.
Observations on 3/18/19 between 6:28 and 7:00 P.M. staff passed meal trays to residents in
the main dining room.
During interview on 3/18/19 at 6:22 P.M., Dietary Aide CC said meals are often late
because there isn’t enough staff to get everything done on time.
During interview on 3/18/19 at 1:10 P.M., Dietary Aide EE said meals are almost always
late because there isn’t enough staff to get things done, including getting dishes washed
and ready to cook on, dishes cleaned to serve on, items cooked on time, food items
prepared on time for individual service, meals passed out to residents, equipment cleaned
and ready for use, items put away correctly after receiving truck order, and truck order
placed correctly.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, the facility failed to serve food that was palatable
and at a safe and appetizing temperature. The facility census was 118.
Observation on 3/18/19 at 1:37 P.M. of the test tray, provided by the facility after the
last resident was served, showed the temperature (taken with a calibrated, analog,
metal-stem thermometer) of the au gratin potatoes was 115 degrees Fahrenheit (F). The
temperature of the Salisbury steak was 115 degrees F.
Observation on 3/19/19 at 8:30 A.M. showed a pot filled with water and broccoli florets
sat on the stove top. The stove top was turned on and the water in the pot was boiling.
Observation on 3/19/19 at 12:00 P.M. showed staff removed the boiling pot of water and
broccoli florets from the stove. The water in the pot was green and some of the broccoli

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 79)
had turned brown.
Observation on 3/19/19 at 1:35 P.M. of the test tray, provided by the facility during meal
service, showed the following:
-The chicken was 80 degrees F and was tough;
-The rice was 96 degrees F;
-The potatoes were 100 degrees F;
-The broccoli was 108 degrees F and was overcooked and mushy.
During an interview on 3/19/19 at 1:27 P.M., Resident #421 and Resident #422 said the food
was cold and not very good. The chicken was too tough to eat.
During an interview on 03/17/19 at 3:05 P.M., Resident #29’s family member said the food
is terrible. He/she fed the resident his/her lunch meal and there would be days he/she
would have to leave and go get something different because the food was so bad.

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure one
resident (Resident #39) received food in the proper form in accordance with his/her
physician’s orders [REDACTED].
Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 1/19/19, showed the
following:
-Cognitively intact;
-Understood others and made self understood;
-Independent with eating, but needed staff assistance for set up only.
Review of the resident’s physician orders, dated (MONTH) 2019, showed the resident was on
a regular diet.
Observation on 3/18/19 at 5:45 P.M. showed Dietary Aide CC prepared Resident #39’s meal
tray. The resident’s diet card lay on the resident’s tray with his/her name and diet. The
diet card showed the resident was on a mechanical soft diet. Dietary Aide DD said Resident
#39 was on a regular diet. Dietary Aide CC told Dietary Aide DD Resident #39’s diet was
switched to mechanical soft.
During interview on 3/18/19 at 5:46 P.M., Dietary Aide DD said Resident #39’s diet card
showed the resident was to be served a mechanical soft diet.
Observation on 3/18/19 at 5:47 P.M. showed Dietary Aide CC placed ground turkey on a slice
of bread on the resident’s tray, and placed the tray on the cart to be served in the
dining room. (Staff served sliced turkey to residents on a regular diet.)
Observation on 3/19/19 at 1:30 P.M. showed Dietary Staff EE prepared Resident #39’s meal
tray. The resident’s diet card lay on the resident’s tray with his/her name and diet. The
diet card showed the resident was on a mechanical soft diet. Observation showed Dietary
Staff EE placed ground pork topped with gravy on the resident’s tray, and placed the tray
on the cart to be served in the dining room. (Staff served whole pork chops or chicken on
the bone to residents on a regular diet.)
During an interview on 3/21/19 at 10:40 A.M., Resident #39 said, they served me mashed up

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 80)
food and I’m not eating it. The food is not any good but the mashed up food is disgusting.

During an interview on 4/5/19 at 10:10 A.M., the registered dietician said Resident #39
had a physician’s orders [REDACTED].>

F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident receives and the facility provides food that accommodates resident
allergies, intolerances, and preferences, as well as appealing options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide food
and drinks consistent with resident preferences for seven residents (Residents #12, #25,
#39, #43, #111, #115 and #116). The facility census was 118.
1. Review of Resident #12’s Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 3/15/19, showed the
following:
-Cognitively intact;
-Independent with eating, set up help only.
Observation on 3/18/19 at 8:15 A.M. showed the resident asked the dietary aide for a cup
of coffee, and the dietary aide said the facility did not have any coffee.
During an interview on 03/18/19 at 8:28 A.M., the resident said the following:
-He/She wished he/she had some coffee;
-Staff told him/her there was no coffee, which was nothing new.
2. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with eating, set up help only.
Observation on 3/17/19 at 1:15 P.M. showed the resident asked the dietary aide for a cup
of coffee, and the dietary aide said the facility did not have any coffee.
During an interview on 03/18/19 at 8:40 A.M., the resident said the following:
-The facility ran out of coffee all the time;
-He/She liked drinking coffee and he/she didn’t understand why they could not have
something as simple as coffee.
3. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with eating but needed staff assistance for set up only.
Review of the resident’s care plan dated 1/20/19 showed the resident enjoyed coffee with
every meal.
Observation on 3/17/19 at 1:15 P.M. showed the resident asked the dietary aide for coffee,
and the dietary aide said the facility was out of coffee.
During an interview on 3/17/19 at 1:16 P.M., the resident said the following:
-The facility ran out of coffee all the time;
-He/She liked drinking coffee and was frustrated he/she was not able to enjoy a cup of
coffee;
-He/She had asked staff why they never get coffee anymore and staff just ignore him/her;
-He/She reported his/her concerns about not having coffee to the administrator but nothing
was done;
-The facility would try to give him/her instant coffee sometimes but he/she will not drink
it because it tasted like dirt.

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 81)
4. Review of Resident #43’s MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with eating, set up help only.
During interview on 3/17/19 at 2:07 P.M., the resident said he/she would like to have
coffee with every meal but when he/she requested coffee, staff said they do not have any
coffee and they are sorry. He/She gets disappointed because he/she enjoys drinking coffee.

5. Review of Resident #111’s annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with eating but required staff set up only.
Observation on 3/17/19 at 1:10 P.M. showed the resident asked the dietary aide for a cup
of coffee, and the dietary aide said the facility did not have any coffee.
During an interview on 3/17/19 at 1:12 P.M., the resident said he/she would like coffee to
drink. He/She enjoyed drinking coffee but the facility rarely offered coffee or had coffee
available.
6. During an interview on 3/19/19 at 10:35 A.M., Dietary Aide DD said the following:
-The last two food orders did not have coffee on them;
-The facility had been with out coffee for at least two weeks;
-Due to not having a dietary manager, food order items were being missed.
During interview on 3/19/19 at 11:07 A.M., Dietary Aide CC said the food/supply truck came
in at 7:30 A.M. and there was still no coffee ordered for this truck.
7. Review of Resident #115’s dietary card showed the resident disliked eggs (no direction
to not serve the resident gravy or pasta).
Observation on 3/19/19 at 1:00 P.M. showed staff served Resident #115 potatoes with gravy.
During interview on 3/19/19 at 1:10 P.M., Resident #115’s family member said the resident
does not like pasta and does not like gravy on his/her potatoes. The resident’s family
member said the facility has been told repeatedly the resident does not like these things
but nothing changes.
During interview on 3/20/19 at 1:15 P.M., Dietary Aide HH said Resident #115’s family
members had come to the kitchen in the past to tell staff the resident did not like gravy
on his/her potatoes.
8. Review of Resident #116’s dietary card showed he/she disliked eggs, beets, and broccoli
(no direction to not serve the resident spicy foods).
Observations on 3/18/19 at 6:01 P.M. showed Dietary Aide CC made tomato soup and added
various spices to the soup.
Observation on 3/18/19 at 6:31 P.M. showed staff served Resident #116 a bowl of tomato
soup. The resident began yelling in frustration about being served another spicy item.
During interview on 3/18/19 at 6:32 P.M., Resident #116 said he/she has told the facility
repeatedly he/she does not like spicy food but they keep serving them to him/her.
9. During interview on 3/19/19 at 2:00 P.M., Dietary Aide DD said it is the dietary
supervisor’s responsibility to change preferences on dietary cards but the facility is
without a dietary supervisor so dietary cards cannot be changed. He/she said the dietary
cards are on a program on the computer. Dietary staff do not have access to the computer
program so they cannot change the cards when needed.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure meals and snacks are served at times in accordance with resident’s needs,
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 82)
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide nourishing snacks
when substantial meals were scheduled 14 hours apart. This deficient practice had the
potential to affect all residents. Eight of eight residents (Resident #14, #25, #43, #59,
#62, #69, #92 and #101) participating in group interview and three additional residents
(Resident #12, #22, and #27) reported snacks were not offered on a routine basis at the
facility. The census was 118.
1. Review of the facility policy titled Frequency of meals, dated (MONTH) (YEAR), showed
the following:
-A schedule of meal times and snacks shall be posted in resident areas;
-Nourishing snacks will be available for residents who need or desire additional food
between meals;
-Evening snacks will be offered routinely to all residents; timing of the snacks will
consider relevant factors;
-Residents will also be offered nourishing snacks if the time span between the evening
meal and the next day’s breakfast exceeds fourteen hours;
-Nourishing snacks are items from the basic food groups, offered either separately or with
each other;
-The facility will choose the snacks that are served at bedtime, however, the dietician
and food services manager will solicit input from the residents and/or the resident
council.
Review of a facility provided document that was undated and titled Meal Times, showed
supper was scheduled at 5:30 P.M. and breakfast was scheduled at 7:30 A.M.
2. Review of the POS [REDACTED].
3. Review of Resident #12’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/19/19 at 9:50 A.M., Resident #12 said the following:
-Staff do not offer the residents a bedtime snack;
-He/she liked having a bedtime snack; especially since breakfast was always served late.
There were too many hours (more than fourteen) between supper and breakfast not to have a
snack in between and he/she got hungry.
4. Review of Resident #14’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said staff only gives him/her a
snack if he/she asked, but they did not always have something available.
5. Review of Resident #22’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/20/19 at 2:00 P.M., Resident #22 said the following:
-Staff don’t offer snacks at bedtime;
-If staff offered him/her a snack, he/she would eat the snack.
6. Review of Resident #25’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said he/she sometimes gets
hungry through the night and the staff does not offer bedtime snacks.
7. Review of Resident #27’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 3/17/19 at 4:20 P.M., the resident said he/she was diabetic and did
not get bedtime snacks.
8. Review of Resident #43’s face sheet showed he/she had [DIAGNOSES 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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 83)
During an interview on 03/18/19 at 3:00 P.M., the resident said staff will give him/her
cookies, but only if he/she asks; he/she would just like staff to offer them like they
used to.
9. Review of Resident #59’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said there are too many hours
between supper and breakfast, and a bedtime snack would help tide him/her over. He/She
sometimes gets hungry through the night and staff does not offer snacks.
10. Review of Resident #62’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said staff used to come along
with a juice and snack cart in the evenings, but they have not done so for over a year.
He/She mainly ate snacks in his/her room that he/she purchased because he/she could not
depend on the facility to have snacks available.
11. Review of Resident #69’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said he/she is a diabetic;
staff will give him/her a snack in the evening only if they have something available and
they often times do not. He/She snacks on his/her own foods in his/her room. Nursing staff
that administer his/her insulin always tell him/her to eat a snack from his/her room
because they know the meals are never on time.
12. Review of Resident #92’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said staff does not offer
him/her a bedtime snack and he/she wished they did.
13. Review of Resident #101’s face sheet showed he/she had [DIAGNOSES REDACTED].
During an interview on 03/18/19 at 3:00 P.M., the resident said the facility does not
offer bedtime snacks, but if they did, he/she would eat them.
14. During the group interview on 03/18/19 at 3:00 P.M., all eight residents in attendance
said if staff offered them a bedtime snack, they would eat the snack. No staff had ever
asked them about their input on what snacks they would like to see available.
During interview on 3/19/19 at 7:35 A.M. Registered Nurse (RN) PP said they did not have
bedtime snacks or any snacks to give the residents on 3/18/19 evening. He/she did not
think they passed bedtime snacks to the residents.
During interview on 3/20/19 at 8:28 A.M., Dietary Aide EE said evening snacks were not
prepared because there wasn’t enough staff to prepare snacks.
During an interview on 3/22/19 at 3:53 P.M., the director of nursing (DON) said she
expected bedtime snacks to be passed and offered to residents nightly.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to follow proper sanitation and
food handling practices in the kitchen. The facility census was 118.
1. Observations on 3/18/19 at 11:44 A.M. showed the following:
-The fryer baskets were hanging above the fryer with dark crispy debris stuck to them;
-Where the baskets hung from the fryer there was a buildup of solid crumb-like debris;
-The oil in the deep fat fryer appeared almost black in color;
-Inside the vat of the fryer was a black buildup all across the stainless steel;

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 84)
-There was a heavy greasy buildup on the sides, behind, underneath, and around the fryer;
-The front of the fryer had white splatters across the surface;
-The tilt skillet had a buildup of a yellowish debris along the cooking surface;
-The convection oven had a buildup of dark debris on the outside and inside surfaces;
-The griddle was dark with debris. Large chunks of solid debris littered the cooking
surface of the griddle. A dirty spatula lay resting on the griddle. The outside surface of
the griddle was layered with dark and light debris;
-The stainless steel backsplash of the range was dark with a buildup of debris;
-Eight of eight ceiling vents, located above the food preparation areas, cooking surfaces,
clean side of the dishwashing area, and clean dish storage, were all dirty with a buildup
of fuzzy and dark debris;
-The vent above the steamtable had a heavy buildup with debris that extended to four
ceiling tiles surrounding the vent and 2 feet across one tile to the light fixture on the
other side that was also above the steamtable.
Observations on 3/19/19 at 8:15 A.M. showed the following:
-The fryer baskets were hanging above the fryer with dark crispy debris stuck to them;
-Where the baskets hung from the fryer there was a buildup of solid crumb-like debris;
-The oil in the deep fat fryer appeared almost black in color;
-Inside the vat of the fryer was a black buildup all across the stainless steel;
-There was a heavy greasy buildup on the sides of, behind, underneath, and around the
fryer;
-The front of the fryer had white splatters across the surface;
-The convection oven had a buildup of dark debris on the outside and inside surfaces;
-The griddle was dark with debris, large chunks of solid debris littered the cooking
surface of the griddle, a dirty spatula lay resting on the griddle. The outside surface of
the griddle was layered with dark and light debris;
-The stainless steel backsplash of the range was dark with a buildup of debris;
-Eight of eight kitchen vents, located above food preparation areas, cooking surfaces,
clean side of the dishwashing area, and clean dish storage, were all dirty with a buildup
of fuzzy and dark debris;
-The vent above the steamtable had a heavy buildup with debris that extended to four
ceiling tiles surrounding the vent and two feet across one tile to the light fixture on
the other side that was also above the steamtable.
2. Observations on 3/18/19 at 12:11 P.M. showed dishes were stacked wet. Drops of water
dripped off the dishes and when separated, water was on the surfaces of the dishes. All
dishes that were stacked were stacked wet. Staff placed the flatware in a utensil
[MEDICATION NAME] while wet.
Observations on 3/18/19 at 12:13 P.M. showed Dietary Aide FF rolled flatware without
washing his/her hands or wearing gloves. He/she grabbed the flatware by the food contact
surface and placed them on top of a napkin. Further observations showed the flatware was
wet, causing the napkins to become saturated in some places. Staff then placed the damp
flatware on a tray for food service.
Observations on 3/18/19 between 12:31 P.M. showed staff placed food on the wet plates and
bowls that had been stacked wet. The trays, plates, bowls, and napkin wrapped flatware
were wet when used for the meal service.
Observations on 3/18/19 at 12:37 P.M. showed Dietary Aide FF stopped wrapping flatware,
got ice out of the ice machine, placed a milk container from the milk cooler into a
container with the ice, and returned to wrapping the flatware without washing his/her
hands and putting on gloves.
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 85)
Observations on 3/18/19 at 1:09 P.M. showed Dietary Aide SS began washing soiled flatware.
He/she moved to the clean side of the dish machine, and without washing his/her hands and
putting on gloves, touched the clean flatware on the food contact surfaces, and began
wrapping the flatware in napkins while the flatware was still wet.
Observations on 3/18/19 at 1:37 P.M. showed the flatware served on the test tray was
soiled with chunks of solid debris.
Observations on 3/18/19 at 4:03 P.M. showed Dietary Aide DD, without washing his/her hands
and putting on gloves, wrapped flatware in napkins and touched the food contact surfaces
of the flatware with his/her bare hands.
Observations on 3/18/19 at 6:04 P.M. showed Dietary Aide DD, without washing his/her hands
and wearing gloves, began wrapping plasticware and touched the food contact surfaces with
his/her bare hands.
During interview on 3/18/19 at 12:40 P.M., Dietary Aide SS said staff stacked the dishes
when they were wet because there isn’t enough help to get all the dishes done and let them
dry before more dishes are needed for meal service.
3. Observations on 3/18/19 at 11:58 P.M. showed the following:
-Two boxes of juices sat on the floor of the walk-in refrigerator;
-A stack of boxes 10 boxes high in the walk-in freezer were stacked from floor to ceiling.
The bottom box sat directly on the freezer floor;
-Two other boxes of food items sat directly on the freezer floor;
-A large accumulation of ice on the freezer floor that measured approximately 2 feet by 4
feet and ice had formed in a mound that was approximately 6 inches high. Ice had formed on
bags and boxes located within the freezer along with the shelving.
Observations on 3/19/19 at 8:15 A.M. showed boxes were stacked on the floor in the dry
food storage.
Observations on 3/19/19 at 8:12 A.M. showed 12 crates of 50 cartons of milk each, sat out
at room temperature.
Observations on 3/19/19 at 8:36 A.M. showed the following:
-Dietary Aide SS began putting the 600 cartons of milk in the milk cooler;
-The milk had an internal temperature that measured to be 50 degrees Fahrenheit.
During interview on 03/18/19 at 4:09 P.M., Dietary Aide CC said the freezer has had an ice
accumulation in it for several weeks and no one has been able to clean it or anything else
due to a lack of staffing. He/she said this was the same reason boxes were stacked on the
floor.
During interview on 3/19/19 at 11:07 A.M., Dietary Aide EE said truck came in at 7:30 A.M.
and the milk and all the other boxes got stacked on the floor because there wasn’t enough
staff to put the stuff away and cook.
4. Observations on 3/18/19 at 12:04 P.M. showed the reach-in refrigerator had remnants of
what appeared to be a yellow liquid that was spilled as well as a dried puddle and
splatters of blood-red substances. Above the staining was an opened tube of Braunschweiger
(a pork liverwurst) that was undated.
Observations on 3/18/19 at 12:08 P.M. showed the milk cooler had a large accumulation of
dried solidified spilled milk that extended across most of the floor in either a pool or
splatters. The spilled milk had turned yellow and green.
Observations on 3/19/19 at 8:36 A.M. showed the milk cooler was still dirty with a buildup
of old spilled milk at the bottom of the cooler.
Observations on 03/18/19 at 12:09 P.M. showed scoops were stored in the large flour and
sugar bins. The scoop handles were buried underneath the contents in the containers.
5. Observation on 3/18/19 at 11:44 A.M. showed four of five trash cans in the kitchen did
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 86)
not have lids on them. The trash cans were not in use.
Observations on 3/18/19 at 4:05 P.M. showed four of five trash cans in the kitchen
contained trash. The trash cans were not in use and were left uncovered.
Observation on 3/18/19 at 4:16 P.M. showed the counter mounted can opener had a buildup of
black and brown chunky debris along the blade. Then non-food contact surfaces had splatter
and debris on them.
Observations on 3/19/19 at 8:15 A.M. showed four of five trash cans in the kitchen did not
have lids on them, food was being prepared, and the trash cans were not in use.
Observations on 3/19/19 at 10:34 A.M. showed four of five trash cans were uncovered and
not in use.
6. Observations on 3/18/19 at 4:21 P.M. showed the dish machine in the kitchen utilized
chemical sanitizer to sanitize the dishes. The container of sanitizer that supplied the
dish machine and the container of washing agent that supplied the dish machine were both
empty.
During interview on 3/18/19 at 4:24 P.M., Dietary Aide DD said they were out of sanitizer
until the truck delivered more on 3/19/19.
Observations on 3/18/19 at 4:22 P.M. showed staff washed dishes in the dish machine. The
dish machine had run out of both soap and sanitizer. Further observations showed the water
temperature in the dish machine (as observed on the temperature dial on the machine) did
not get above 110 degrees Fahrenheit.
During interview on 03/18/19 at 6:15 P.M., Dietary Aide DD said the dish machine water was
coming out ice cold.
7. Observations on 3/18/19 at 12:00 P.M. showed the following;
-Two large cans of tomato salsa had deep, angled dents along the lip of the cans;
-A 4-pound, 2.5 ounce can of tuna had a long dent and fold along the lip;
-A large can of kidney beans had a large dent along the lip;
-A large can of butterscotch pudding had a 2 inch dent along the lip.
8. Observations on 3/18/19 between 5:45 P.M. and 7:00 P.M. showed Dietary Aide TT had
facial hair and served the supper meal without wearing a beard restraint.
9. During interview on 3/19/19 at 11:39 A.M., Dietary Aide HH said there used to be a
cleaning list and chores to complete in the kitchen, but with such little staff, there
aren’t enough people to get things done so something had to fall off in order to get the
residents fed.

F 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Dispose of garbage and refuse properly.

Based on observation and interview, the facility failed to ensure the dumpsters, utilized
for facility trash, were equipped with covers and kept covered. The facility capacity
census was 118.
Observations on 3/18/19 at 12:00 P.M. showed a large rectangular dumpster without a
lid/cover was located near the building just outside the kitchen door. Two additional
dumpsters were located across the driveway outside the kitchen. All three dumpsters
contained bags full of trash and were not covered.
Observations on 3/18/19 at 4:33 P.M. showed all three dumpsters contained bags of trash
and were not covered.

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 87)
Observations on 3/19/19 at 11:10 A.M. showed all three dumpsters contained bags of trash
and were not covered.
Observations on 3/19/19 at 4:09 P.M. showed all three dumpsters contained bags of trash
and were not covered. Large pieces of refuse including boxes, bags, and paper were
littered along the grounds, east of the dumpsters.
Observations on 3/19/19 at 7:40 P.M. showed all three dumpsters contained bags of trash
and were not covered.
During interview on 3/20/19 at 1:42 P.M., Dietary Aide CC said the dumpsters were always
open; it makes it easier to take out the trash.

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Safeguard resident-identifiable information and/or maintain medical records on each
resident that are in accordance with accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the medical record for
one resident, (Resident #110) of 24 sampled residents was completed in accordance with
accepted professional standards of practice when missing documentation regarding scheduled
treatments was changed to reflect staff completed the treatment using a nurse’s initials
who no longer worked at the facility. The facility census was 118.
1. Review of the facility policy, Wound Care, dated (MONTH) 2010, showed:
-Purpose – The purpose of this procedure is to provide guidelines for the care of wounds
to promote healing;
-Documentation – The following information should be recorded in the resident’s medical
record;
-The type of wound care given;
-The date and time the wound care was given;
-The name and title of the individual performing the wound care;
-All assessment data obtained when inspecting the wound;
-If the resident refused the treatment and the reason(s) why;
-The signature and title of the person recording the data.
2. Review of Resident #110’s Admission record, showed the following:
-Original admitted [DATE];
-Readmitted on [DATE].
Review of the resident’s care plan, dated 2/8/19 and updated 3/1/19, showed the following:
-admitted with Stage III pressure ulcer to the coccyx (tailbone) requiring treatment and
observation and has potential for pressure ulcer development related to impaired mobility
and incontinence;
-Administer treatments as ordered and monitor for effectiveness.
Review of the resident’s progress note on 3/1/19 at 6:48 P.M, showed the resident returned
from hospital. Wound to the coccyx 11 cm in length (L) x 7.5 cm width (W). Upper portion
of the wound bed has 8 cm L x 7.5 cm W that is black. The lower portion of the wound bed
is pink with some yellow.
Review of the resident’s physician order sheet (POS) dated 3/1/19 through 3/31/19 showed
an order for [REDACTED].
Review of the resident’s treatment administration record (TAR) on 3/19/19 at 1:44 P.M.,
dated 3/1/19 to 3/31/19 showed the following:

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 88)
-Dakin’s Solution, apply to coccyx wound topically every 12 hours for coccyx wound. Start
date 3/1/19 at 9:00 P.M.;
-Scheduled for 9:00 A.M. and 9:00 P.M.;
-3/1/19 at 9:00 P.M., treatment blank (blank indicates treatment not completed);
-3/2/19 at 9:00 A.M. and 9:00 P.M., treatment blank;
-3/3/19 at 9:00 P.M., treatment blank;
-3/6/19 at 9:00 P.M., treatment blank;
-3/7/19 at 9:00 P.M., treatment blank;
-3/11/19 at 9:00 A.M. and 9:00 P.M., treatment blank;
-3/12/19 at 9:00 P.M., treatment blank;
-3/15/19 at 9:00 A.M. and 9:00 P.M., treatment blank.
-3/16/19 at 9:00 P.M., treatment blank;
-3/17/19 at 9:00 P.M., treatment blank;
-3/18/19 at 9:00 A.M., treatment blank.
Record review of the resident’s same TAR on 3/20/19 at 5:56 P.M., showed the previous
missing documentation on the (MONTH) 2019 TAR, 14 treatments total, were documented as
completed by Licensed Practical Nurse (LPN) QQ.
During interview on 3/21/19 at 9:28 A.M., LPN M said the initials on the TAR for the dates
that were previously blank belonged to LPN QQ. He/She thought LPN QQ’s last day of
employment was a couple weeks ago around 3/8/19.
During interview on 3/21/19 at 9:50 A.M., Registered Nurse (RN) R said the initials on the
TAR belonged to LPN QQ and that he/she no longer worked at the facility and had been gone
for a couple of weeks.
During telephone interview on 3/21/19 at 10:51 A.M., 12:32 P.M. and 5:01 P.M., LPN QQ said
the following:
-He/she worked the floor on 3/4/19 on the evening shift and had to stay over to cover the
next shift due to a Certified Nurse Aide (CNA) called in. He/She did not get out of the
facility until 4:00 A.M. to 4:30 A.M. on 3/5/19. (MONTH) 4, 2019 was the last shift he/she
worked at the facility;
-He/She has not returned to the facility since 3/4/19;
-He/She has not signed into the facility’s Electronic Medical Record from outside the
facility and signed off on any resident’s TARs regarding treatments being completed.
During interview on 3/21/19 at 2:13 P.M., unit manager/LPN W said TARs can be charted on
late, but it will show late if charted late.
Record review of the facility Signature List provided by the facility on 3/21/19 at 6:07
P.M. showed there was only one set of initials matching the initials on the TAR for the
holes that had been previously blank and those initials belonged to LPN QQ.
During interview on 3/22/19 at 3:53 P.M., the Director of Nurses (DON) said the following:

-Staff should document on the TAR when a dressing change is completed;
-She could not explain why the blank documentation reviewed on the TAR on 3/19/19 were
completed on 3/20/19;
-If a treatment is not completed it should be circled;
-Blanks in TARS should be documented as refused or missed;
-The initials on the TAR belonged to a former employee, LPN QQ and his/her last day was
3/11/19;
-The former employee’s initials, LPN QQ on the TAR after he/she was gone would be false
documentation.
During interview on 3/22/19 at 5:13 P.M., the administrator said the following:

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 89)
-If a treatment is not done, then it should be documented as such;
-She was not aware of anyone having access to another staff member’s login on the
computer, she only has access to her computer login.

F 0850

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Hire a qualified full-time social worker in a facility with more than 120 beds.

Based on interview and record review, the facility failed to employee a full time Social
Service Director (SSD). During resident interviews the residents did not feel their needs
were being met and did not know who to go to with concerns and grievances. The facility
census was 118.
1. Review of the facility’s Social Worker Policy, dated 3/1997, showed the following:
-Purpose: This job description defining qualifications, basic functions, general
responsibilities, and duties for the entitled position, is intended as guideline for the
employee; and duties listed here are not to be considered all inclusive. This job position
performs these and other duties as may be assigned by the Administrator;
-Must be able to work well with the residents, their families, family services agency,
other placement agencies and all social service organizations;
-Upon admission, responsible for identifying residents who display mental or psychosocial
adjustment difficulty. In response to needs identified, will develop and implement as
appropriate treatment plan designed to insure residents function at their highest
practicable mental and psychosocial level. Will also assist or assume responsibilities of
Admissions Coordinator when needed. In order to ensure the delivery of quality services to
the residents or perspective, an employee may be required to report to work for shifts not
routine scheduled and/or work beyond regularly scheduled hours;
-Periodically monitor social service portion of care plans to ensure residents are
receiving car in accordance with the care plan. Offer assistance to nursing staff as
necessary to ensure compliance or modify plan if unrealistic;
-Work with families and residents on social interaction, reality orientation, validation
therapy, and intellectual stimulation as necessary;
-Offer counseling services to help residents and families deal with feeling about
disabilities, death, or dying and other emotional, mental, environmental or physical
limitations;
-Coordinate outside services in accordance with physicians orders;
-Participate in Resident Council meetings according to the directions of the residents;
-Provide staff development programs for all staff members addressing the facility’s social
service program and assist with Residents’ Rights general orientation for all staff
members;
-Assist with arrangements for resident office visits to physicians, dentists,
optometrists, podiatrists, etc ;
-Assist residents and/or families in the purchase of personal items;
-Responsible for maintaining compliance with all regulations governing the facility
(local, state, and federal) in the area of social services.
2. Review of the facility policy titled Staffing, dated (MONTH) 2007, showed the
following:
-Our facility policy provides adequate staffing to meet needed care and services for our

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0850

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 90)
resident population;
-Other support services (dietary, activities/recreational, social, therapy, environmental,
etc) are adequately staffed to ensure that resident needs are met.
3. Record review of the facility assessment tool completed by the administrator dated
2/15/19, showed the following:
-Average daily census was 84;
-In addition to nursing staff other staff needed for behavioral healthcare and services
included Social Services Director.
4. During interview on 03/21/19 at 12:00 PM the administrator said the following:
-The facility did not currently employ a full time SSD;
-The SSD walked out and left a mess;
-The SSD’s last day of employment was 3/3/19.
5. During an interview on 3/17/19 at 1:10 P.M. Resident #39 said the following:
-The facility had been through multiple administrators in the last year and terminated the
SSD a few weeks ago. He/she did not have anyone tell his/her concerns to and if he/she did
report concerns to nursing staff and/or the administrator they did nothing about them.
During an interview on 3/17/19 at 3:05 P.M., . Resident #29’s family member said the
following:
-The resident had needed assistance with transportation to physician appointments six
times since admission 12/31/18 and had only received help twice;
-The resident needs to see the podiatrist and dentist and the facility had no one to
assist with making those appointments, he/she had told the nurses over a month ago and
nothing had been done.
During an interview on 3/17/19 at 6:34 P.M., Resident #46 said the following:
-He/she had wanted to see dentist due to a broken tooth and an ENT (ear, nose, and throat)
physician because he/she was having difficulty hearing;
-He/she had informed staff of these requests about one to two months ago, but nothing had
ever been done.
During an interview on 3/19/19 at 10:00 A.M. Resident #43 said:
-He/she had been without bottom dentures since (MONTH) (YEAR);
-He/she had reported the loss of his/her dentures to the previous SSD, nursing staff, and
administrator;
-He/she continued to report the loss of his/her dentures to the new administrator and
nursing staff but the facility did not have a SSD to report to and had not had an SSD to
report to for several weeks;
-He/she also needed his/her hearing aids that he/she had been tested for in the facility
in (MONTH) (YEAR);
-He/she had difficulty hearing and had to try to read peoples’ lips;
-His/her mouth hurt and he/she could not eat meats and certain foods because he/she did
not have his/her bottom dentures;
-It frustrated and made him/her sad that staff were not helping him/her get his/her
hearing and dentures;
-He/she had been reporting to staff his/her need for bottom dentures and hearing aids for
months.
During an interview on 3/21/19 at 11:30 A.M. Resident #43’s family member said the
following:
-The resident had been without his/her bottom dentures since (MONTH) (YEAR);
-He/she had reported the resident’s missing dentures and desire to get new dentures to the
previous SSD, the administrator, and to staff back in (MONTH) (YEAR) and finally two weeks
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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 0850

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 91)
ago he/she reported the issue to the DON;
-He/she did not feel the previous SSD, administrator, and/or other staff listened to the
resident or followed up on the resident’s concerns;
-The resident has a sore mouth from eating food without his/her bottom dentures and cannot
eat certain food because he/she did not have dentures;
-The previous SSD assisted the resident in getting tested for a hearing aid back in
(MONTH) (YEAR). The hearing test showed the resident needed hearing aides. He/she has
reported the resident’s need for hearing aides to the facility staff but nobody has
followed up on it;
-He/she had even given the administrator and nursing staff a copy of the correspondence
letter with the hearing aid company that outlined what was needed from the facility for
the resident to receive hearing aids but the staff still have not provided the information
to allow the resident to get hearing aids.
Review of Resident 43’s correspondence with the hearing aid company dated (MONTH) 13,
(YEAR) showed the hearing aid company sent a letter outlining the benefit and needed
information for the resident to get hearing aids.
MO 7

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to practice
acceptable infection control practices when nursing staff failed to washed their hands and
change gloves during direct resident contact and when indicated by professional standards
of practice during provision of resident care for one resident (Resident #71) in a review
of 24 sampled residents and two additional residents (Resident #5 and #28). The facility
also failed to prevent cross-contamination during blood glucose monitoring and to
appropriately sanitize the glucometer after use for two sampled residents (Resident ##53,
and #69) and one additional resident (Resident #77). The facility census was 118.
1. Review of the facility policy titled Handwashing/hand hygiene, dated (MONTH) (YEAR),
showed the following:
-The facility considers hand hygiene the primary means to prevent the spread of
infections;
-All personnel shall be trained and regularly in-serviced on the importance of hand
hygiene in preventing the transmission of health-care associated infections;
-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the
spread of infections to other personnel, residents and visitors;
-Hand hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rub, etc)
shall be readily accessible and convenient for staff use to encourage compliance with hand
hygiene policies;
-Wash hands with soap and water when they are visibly soiled and after contact with a
resident with infectious diarrhea;
-Use alcohol-based hand rub or soap and water before and after coming on duty, before and
after direct contact with residents, before preparing or handling medications, before
performing any non-surgical invasive procedure, before and after handling an invasive
device (urinary catheter), before moving from a contaminated body site to a clean body

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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 92)
site during resident care, after contact with the resident’s skin, after contact with
blood or bodily fluids, after removing gloves;
-Hand hygiene is the final step after removing and disposing of personal protective
equipment.
2. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 revision,
showed the following:
-Handwashing is the single most important means of preventing the spread of infections;
-Wash hands before and after contact with residents;
-Always wash hands for at least 15 seconds before and after glove use.
3. Review of Resident #5’s care plan, updated 12/13/18, showed the following:
-The resident will have all of his/her basic needs met with staff assistance;
-Assist times one for elimination care needs;
-Extensive assistance with bathing needs;
-Limited assistance with toileting needs to assure proper hygiene during toileting;
-Keep clean and dry.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 3/13/19, showed the
following:
-Extensive assistance of one staff for toileting;
-Limited assistance of one staff for personal hygiene;
-Frequently incontinent of bowel and bladder.
Observation on 3/19/19 at 05:52 A.M., showed the following:
-The resident lay in his/her bed on his/her left side;
-CNA L entered the room, washed hands and applied gloves;
-CNA L removed wipes from a package, placed them in a trash bag and applied peri-wash to
the wipes and then placed the trash bag on the resident’s bed;
-CNA L assisted the resident to lay on his/her back;
-The resident was incontinent of bowel and bladder;
-CNA L provided perineal care to the resident’s front genitalia, removing a clean wipe
from the trash bag and after use, placing it in another trash bag on the resident’s bed;
-Without removing his/her gloves or washing his/her hands, CNA L assisted the resident to
roll to his/her left side, touching the resident’s right hip and shoulder areas with
soiled gloved hands;
-CNA L cleansed the resident’s buttock and rectal area, reaching in the trash bag with
his/her soiled gloves to get clean wipe and then placing the soiled wipe in the dirty
trash bag;
-Without removing his/her gloves or washing his/her hands, CNA L picked up a clean
incontinence brief, tucked it behind the resident, assisted the resident to roll to
his/her right side, cleansed the resident’s left hip/buttock area, untucked the left side
of the clean incontinence brief, assisted the resident to roll to his/her back and secured
the clean incontinence brief;
-With the same soiled gloves, CNA L gathered the resident’s clean clothing, dressed the
resident and transferred the resident to his/her wheelchair;
-CNA L removed his/her gloves, placed the gloves and the remaining wipes from the clean
trash bag down into the soiled trash bag, and without washing his/her hands, combed the
resident’s hair and applied a stocking cap;
-With the same soiled hands, CNA L made the resident’s bed, gathered the trash bag, tying
it closed, and held the trash bag in his/her left hand while assisting the resident to the
day area by pushing his/her wheelchair with his/her soiled hands;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 93)
-CNA L carried the trash bag to the dirty utility room and washed his/her hands.
4. Review of Resident #28’s annual MDS, dated [DATE], showed the following:
-Frequent incontinence of bowel and bladder;
-Extensive assistance of one staff for toileting and hygiene needs.
Review of the resident’s care plan, updated 11/12/18, showed the following:
-The resident was limited in ability for all ADL’s and required the assist of one staff;
-Extensive assistance with grooming, toileting, hygiene, incontinence cares and bathing
needs, both upper and lower body;
-At risk for pressure ulcers due to frequent incontinent episodes and the need for
extensive assist from staff;
-Receives daily diuretics;
-Staff to ensure resident remains clean and dry.
Observation on 3/19/19 at 6:06 A.M. showed the following:
-The resident lay in bed on his/her back;
-CNA L entered the room, washed his/her hands and put on gloves;
-CNA L removed wipes from a package, placed them in a trash bag and applied peri-wash to
the wipes and then placed the trash bag on the resident’s bed;
-CNA L removed the resident’s urine saturated incontinence brief, placing it in a trash
bag on the resident’s bed;
-CNA L obtained a clean wipe from the trash bag and cleansed the resident’s right groin
crease with an upward stroke and then used the same soiled wipe to cleanse the left groin
crease before placing the soiled wipe in the dirty trash bag;
-CNA L assisted the resident to roll to his/her left side touching the resident’s right
hip and shoulder areas with his/her soiled gloves;
-CNA L reached into the trash bag to remove a wipe and cleansed the resident’s buttock and
rectal area and placed with wipe in the dirty trash bag;
-Without removing his/her gloves, CNA L picked up a clean incontinence brief, tucked it
behind the resident, assisted the resident to roll to his/her right side, untucked the
left side of the incontinence brief, assisted the resident to roll to his/her back and
secured the clean incontinence brief;
-With the same soiled gloves, CNA L gathered the resident’s clean clothing and assisted
the resident in dressing and transferred the resident to his/her wheelchair;
-CNA L removed his/her gloves, placed them and the remaining wipes from the clean trash
bag down into the soiled trash bag, did not wash his/her hands with soap and water and
combed the resident’s hair;
-CNA L made the resident’s bed, gathered the trash bag, tying it closed, and held the
trash bag in his/her left hand while assisting the resident to the day area off by pushing
the resident’s wheelchair with his/her soiled hands;
-CNA L took the trash bag to the dirty utility room and washed his/her hands.
During interview on 3/19/19 at 6:25 A.M., CNA L said the following:
-He/she had been a CNA for over a year;
-He/she had been trained on proper handwashing;
-He/she should wash his/her hands when he/she enters resident rooms;
-He/she should replace gloves when they become soiled;
-He/she should wash his/her hands after providing care;
-He/she should wash his/her hands before touching clean items.
5. Review of Resident #71’s care plan last revised 2/8/19 showed the following:
-Resident required assistance with ADLS;
-Dependent on staff for incontinent cares, dressing and bathing;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 94)
-Required extensive assistance of one or two staff for personal grooming;
-Required gait belt and two staff assistance for transfers;
-Incontinent of bowel and bladder.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Severe cognitive impairment;
-Extensive assistance of two staff for personal hygiene and bed mobility;
-Dependent on two or more staff for transfers;
-Always incontinent of bowel and bladder.
Observation on 3/19/19 at 6:45 A.M. showed the following:
-CNA J and CNA RR entered the resident’s room;
-The resident lay in his/her bed;
-CNA J and CNA RR applied gloves;
-CNA RR pulled the resident’s covers back;
-The resident was visibly soiled from middle of his/her back to his/her knees in urine;
-The resident’s sheets were visibly saturated through to the mattress;
-CNA RR rolled the soiled sheets under the resident;
-With same soiled gloves CNA RR turned the resident toward him/her holding onto the
resident’s arm and back;
-CNA J removed the soiled sheets;
-With the same soiled gloves CNA J put a clean sheet under the resident;
-The resident’s bed had visible wet and dried rings on it and smelled of urine;
-CNA RR provided perineal care;
-With the same soiled gloves CNA J and CNA RR turned the resident from left to right and
put the sheet and clean brief under the resident. CNA RR secured the brief;
-CNA J changed his/her gloves without washing hands;
-CNA J put the resident’s pant on the bed;
-With the same soiled gloves CNA RR assisted with putting the residents pants on the
resident, touching the clean clothes and the resident’s legs, hips, back and arms.
During an interview on 3/19/19 at 10:35 A.M. CNA J said;
-He/she normally washed his/her hands and changed his/her gloves when they became soiled;
-He/she forgot to change gloves and wash his/her hands;
-He/she made the resident’s bed and did not clean the mattress;
-The resident’s mattress was visibly soiled with urine and he/she should have cleaned it
prior to making the bed.
During an interview on 3/19/19 at 10:40 A.M. CNA RR said the following;
-He/she should have washed his/her hands and changed his/her gloves after cleaning the
resident;
-He/she was rushing and forgot to change his/her gloves and wash his/her hands.
During interview on 3/22/19 at 3:53 P.M., the director of nursing (DON) said she expected
staff change gloves or use alcohol hand sanitizer when their hands became dirty.
6. Review of the Assure Platinum glucometer manufacturer’s guidelines, showed the
following for the Cleaning and Disinfecting Procedures:
-Two disposable wipes will be needed for each cleaning and disinfecting procedure, one
wipe for cleaning and a second wipe for disinfecting;
-Cleaning: Wear appropriate protective gear such as disposable gloves;
-Open the cap of the disinfectant container and pull out one towelette and close the cap;
-Wipe the entire surface of the meter three times horizontally and three times vertically
using one towelette to clean blood and other body fluids;
-Dispose of the used towelette in a trash bin. The meter should be cleaned prior to each
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 95)
disinfection step;
-No actual drying of the meter is necessary before starting the disinfecting procedure;
-Disinfecting: Pull out one new towelette and wipe the entire surface of the meter three
times horizontally and three times vertically using a new towelette to remove blood-borne
pathogens;
-Dispose of the used towelette in a trash bin;
-Allow exteriors to remain wet for the corresponding contact time for each disinfectant;
-After disinfection, the user’s gloves should be removed to be thrown away and hands
washed before proceeding to the next patient.
7. Review of Resident #77’s electronic medical record (EMR) showed the following:
-[DIAGNOSES REDACTED].
-Accucheck (a quick check for the amount of glucose in the blood) four times a day.
Observation on 3/19/18 at 5:10 A.M., showed the following:
-RN PP picked the glucometer off the medication cart and carried the glucometer into
Resident #77’s room;
-RN PP sat the glucometer on the resident’s bed;
-RN PP checked the resident’s blood glucose by sticking the resident’s finger with a
lancet, obtaining a drop of blood and applying the drop to the test strip in the
glucometer;
-RN PP held the glucometer, used lancet, and used alcohol swab in one hand;
-RN PP carried the glucometer and used supplies out of the resident’s room to the
medication cart;
-RN PP threw the used lancet and glucose strip in the sharps dispenser, threw the alcohol
swab in the trash and placed the lactometer on top of the medication cart;
-RN PP pushed the medication cart to Resident #69’s room.
10. Review of Resident #69’s EMR showed the following:
-[DIAGNOSES REDACTED].
-Accucheck before meals.
Observation on 3/19/18 at 5:15 A.M., showed the following:
-RN PP picked up the same glucometer he/she used on Resident #77 without cleaning it and
carried the glucometer into Resident #69’s room. RN PP laid the glucometer on the arm of
the resident’s chair;
-RN PP checked the resident’s blood glucose with the glucometer and disposable one use
lancet;
-RN PP held the glucometer, used lancet, and used alcohol swab in one hand;
-RN PP carried the glucometer and used supplies out of the resident’s room to the
medication cart;
-RN PP threw the used lancet and glucose strip in the sharps dispenser, threw the alcohol
swab in the trash and placed the glucometer on top of the medication cart;
-RN PP pushed the medication cart to Resident #53’s room.
11. Review of Resident #53’s EMR showed the following:
-[DIAGNOSES REDACTED].
-Accucheck four times a day.
Observation on 3/19/18 at 5:23 A.M., showed the following:
-RN PP picked the dirty glucometer up off the medication cart and carried the glucometer
into Resident #53’s room and laid the glucometer on the resident’s bed;
-RN PP cleaned the resident’s finger;
-The resident said no and closed his/her fingers into a fist;
-RN PP said ok, he/she would come back later;
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:

265319

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

NAME OF PROVIDER OF SUPPLIER

PARKLANE CARE AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

401 MAR-LE DRIVE
WENTZVILLE, MO 63385

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 96)
-RN PP picked the glucometer up off the resident’s bed and carried the glucometer to the
medication cart;
-RN PP placed the glucometer on top of the medication cart.
During interview on 3/19/19 at 7:35 A.M., RN PP said the following:
-He/she forgot to clean the glucometer in between residents;
-He/she normally cleaned the glucometer with an alcohol swab;
-He/she did not think he/she needed a barrier between the glucometer and the resident’s
personal belongings;
-He/she should have cleaned the medication cart in between resident’s with an alcohol swab
too but he/she forgot.
12. During interview on 3/22/18 at 3:50 P.M., the Director of Nurses (DON) said the
following:
-She expected staff to clean the glucometer before and after every use with a sani cloth;
-He/she expected staff to use a barrier of some sort before placing any equipment or
supplies on any of the resident’s personal belongings;
-Alcohol was not appropriate for cleaning equipment including glucometers.

F 0908

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Keep all essential equipment working safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to maintain
equipment in the kitchen in a safe operating condition. The facility census was 118.
1. Observation on 3/18/19 at 12:55 P.M. showed the springs on the plate warmer, located in
the kitchen, no longer functioned to bring the stacked plates to the top of the warmer.
Staff had to reach inside where the metal was heated in order to retrieve plates.
Observation on 3/19/19 at 8:27 A.M. showed the electrical cord for the plate warmer had
pulled away from the warmer frame, and the wiring insulation had separated, exposing both
wires within the insulated sleeve.
During interview on 3/18/19 at 1:12 P.M., Cook GG said he/she [MEDICAL CONDITION]/herself
while reaching into the plate warmer for plates.
2. Observation on 3/18/19 at 11:45 A.M. showed a steam jacketed kettle in the kitchen
located under the range hood.
Record review showed there was no inspection of the steam jacketed kettle.
During interview on 3/20/19 at 1:45 P.M., Dietary Aide HH said months ago the steam
jacketed kettle made a loud pop, steam came pouring out of it very rapidly, and has not
been able to be used since.