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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to assure the notices provided
to each resident being discharged from skilled services contained all the required
information necessary for the resident to appeal the discharge decision. The facility
census was 45.
1. Review of Advance Beneficiary Notice and Notice of Medicare Non-Coverage provided to
each resident prior to discharge from skilled services showed the resident has a right to
appeal this decision. The information needed to appeal (name and toll free number) was
blank.
During an interview on 1/15/19, at 1:25 P.M., the business office manager said the form
issued to residents did not contain appeal contact information both notices.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain a
clean, comfortable, homelike environment which affected two of 21 sampled residents
(Residents #32 and #44) and had the potential to affect all residents in the affected area
of the facility’s South hallway due to the lingering, pungent smell of urine. The facility
census was 45.
1. Review of the facility’s Soiled Laundry and Bedding policy, dated July, 2009, showed:
– Soiled laundry/bedding shall be handled in a manner that prevents gross microbial
contamination of the air and persons handling the linen.
– Environmental Services (ES) staff will clean and disinfect mattresses using EPA
(Environmental Protection Agency, a Federal government agency) registered disinfectants
and will follow the manufacturers’ instructions to avoid damage to the mattresses.
– After review by the ES Director and/or the Administrator, discard mattresses that are
significantly damaged, stained, or have been wet for prolonged periods.
– Maintain, clean and replace air fluidized beds and pressure reducing overlays in
accordance with manufacturers’ instructions.
Review of the facility’s Cleaning/Repairing Carpeting and Cloth Furnishings policy, dated
December, 2009, showed:
– Carpeting and cloth furnishings shall be cleaned regularly and repaired promptly.
– Carpeting shall be deep cleaned periodically, approximately once per month, or more
often as needed.
– Spills of blood or body fluids shall be cleaned promptly; carpet tiles (carpet) will be
replaced if contaminated by blood or body fluids.
– Carpet that becomes wet shall be dried thoroughly within 72 hours.
Review of Pursue Disinfectant Cleaner’s active ingredients showed:
– Octyl decyl [MEDICATION NAME] ammonium chloride- 1.140%.
– Doctyl [MEDICATION NAME] ammonium chloride- 0.456%.
– Didecyl [MEDICATION NAME] ammonium chloride- 0.684%.
– Adkyl [MEDICATION NAME] ammonium chloride- 1.520%.

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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
– Kills 22 different types of viruses, fungi and bacteria including E coli, Salmonella, S.
Schottmelleri, Shigella dysenteriae and Staphylococcus which can cause gastroenteritis,
food poisoning, diarrhea, nausea, cramps, and vomiting.
– Reduces the hazards of cross-contamination from surfaces.
– Fast, easy way to kill a wide variety of harmful microorganisms including germs that
cause odors.
2. Review of Resident #32’s care plan with a revision date of 11/18/17, showed:
– Activities of daily living (ADL) self-care deficit;
– Assist of two staff for toileting;
– Limited physical mobility;
– Bladder incontinence;
– Change brief when wet and PRN (as needed), establish voiding patterns, and provide
perineal care after each incontinent episode.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/21/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– Extensive assist of two or more staff for toileting;
– Frequently incontinent of bladder;
– Occasionally incontinent of bowel;
– Diuretics (rids body of excess fluid which causes swelling and [MEDICAL CONDITION]) in
last seven days;
– Toileting program for bowel and bladder;
– [DIAGNOSES REDACTED]. stroke).
Review of the January, 2019 physician’s orders [REDACTED].
– [MEDICATION NAME] (a diuretic) 20 milligrams (mg) BID (twice daily).
3. Review of Resident #44’s quarterly MDS, dated [DATE], showed:
– Short- and long-term memory problems;
– Severe cognitive impairment, did not make own decisions;
– Extensive assist of two or more staff for toileting and transfers;
– Limited assist of two or more staff for bed mobility;
– Always incontinent of bowel and bladder;
– Physical and verbal behaviors directed towards staff daily;
– [DIAGNOSES REDACTED].
Observation on all days of the survey, 1/14/19 through 1/17/19, showed:
– A lingering, pungent smell of urine on the South hallway of the facility;
– The urine smell was noticeable at the beginning of the hallway and increased in
intensity toward the two residents’ rooms at the middle and end of the hallway;
– The odor permiated from the mattresses of both resident’s beds;
– Urine odor was noticeable in both Resident #32’s and Resident #44’s rooms.
During an interview on 1/16/19, at 3:03 P.M., Certified Nurse’s Aide (CNA) A said:
– He/she cleaned mattresses when he/she changed bed linen.
– He/she did not know where the urine smell came from.
During an interview on 1/16/19, at 3:10 P.M., CNA B said:
– He/she did not know where the urine smell came from.
– He/she said it could be from Resident #32’s room.
– He/she used bleach wipes to clean the mattresses when he/she changed linen.
During an interview on 1/16/19, at 3:15 P.M., Housekeeping Aide (HA) A said:
– He/she did not know where the urine smell came 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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
– He/she thought it might be from Resident #32’s or Resident #44’s rooms.
– Resident rooms are deep cleaned only when a resident is discharged .
– CNAs are responsible for wiping down the mattresses of the residents when they change
the linen.
– He/she cleaned mattresses with Pursue Disinfectant Cleaner by Amway during deep
cleaning.
– CNAs use bleach wipes to clean the mattresses.
– He/she thought the urine odor might be coming from the carpet on the South hallway after
a toilet overflowed and the carpet was not cleaned well.
– He/she removed the mattress cover from Resident #32’s mattress and laundered the cover.
During an interview on 1/16/19, at 6:03 P.M., the Director of Nursing said:
– The urine smell probably came from Resident #44’s room; the resident was a moderate
wetter.
– CNAs reported the smell to her and she noticed the urine smell, but not sure where the
smell came from.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
developed and updated a care plan consistent with residents’ specific conditions and needs
which affected three of 21 sampled residents (Residents #2, #15 and #32). The facility
census was 45.
1. Review of the facility’s Comprehensive Person Centered Care Plans policy, dated
December, (YEAR), showed:
– A comprehensive, person-centered care plan that includes measurable objectives and
timetables to meet the resident’s physical, psychosocial, and functional needs is
developed and implemented for each resident.
– The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or
legal representative, develops and implements a comprehensive, person-centered care plan
for each resident.
– The care plan interventions are derived from a thorough analysis of the information
gathered as part of the comprehensive assessment.
– The IDT includes the attending physician, a registered nurse who has the responsibility
for the resident, a nurse aide who has responsibility for the resident, a member of the
food and nutrition services staff, the resident and the resident’s legal representative if
possible, and other appropriate staff or professionals determined by the resident’s needs
or as requested by the resident.
– The comprehensive care plan will include measurable objectives and timeframes, describe
the services that are to be furnished to attain or maintain the resident’s highest
practicable physical, mental, and psychosocial well-being; describe services that would
otherwise be provided for the above but are not provided due to the resident exercising
his/her rights, including the right to refuse treatment; describe any specialized services
related to mental health assessment; include the resident’s stated goals upon admission
and desired outcomes; incorporate identified problem areas; incorporate risk factors

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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
associated with identified problems; build on the resident’s strengths; identify the
professional services that are responsible for each element of care; aid in preventing or
reducing decline in the resident’s functional status and/or functional levels; enhance the
optimal functioning of the resident by focusing on a rehabilitative program; and reflect
currently recognized standards of practice for problem areas and conditions.
– Areas of concern that are identified during the resident assessment will be evaluated
before interventions are added to the care plan.
– Identifying problem areas and their causes, and developing interventions that are
targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.
– Care plan interventions are chosen only after careful data gathering, proper sequencing
of events, and careful consideration of the relationship between the resident’s problem
areas and their causes, and relevant clinical decision making.
– Assessments of residents are ongoing and care plans are revised as information about the
resident and the resident’s conditions change.
– The IDT must review and update the care plan when there has been a significant change in
the resident’s condition, when the desired outcome is not met, when the resident has been
readmitted to the facility from a hospital stay and at least quarterly, in conjunction
with the required quarterly Minimum Data Set (MDS) assessment, a federally mandated
assessment instrument completed by facility staff.
– The resident has the right to refuse to participate in the development of the care plan
and medical treatments and such refusals will be documented in the resident’s clinical
record.
Review of the facility’s Using the Care Plan policy, dated August, 2006, showed:
– The care plan shall be used in developing the resident’s daily care routines and will be
available to staff personnel who have responsibility for providing care or services to the
resident.
– Certified nurse’s aides (CNAs) are responsible for reporting to the nurse supervisor any
change in the resident’s condition and care plan goals and objectives that have not been
met or expected outcomes that have not been achieved.
– Other facility staff noting a change in the resident’s condition must also report those
changes to the Nurse Supervisor and/or MDS Coordinator.
– Changes in the resident’s condition must be reported to the MDS Coordinator so that a
review of the resident’s assessment and care plan can be made.
– Documentation must be consistent with the resident’s care plan.
2. Review of Resident# 32’s care plan last revised on 11/18/17, showed:
– Limited physical mobility;
– Physical and occupational therapy (PT/OT) referrals as ordered, PRN (as needed);
– Activities of daily living (ADL) self-care deficit;
– Required assist of two staff for toileting;
– Did not assess and care plan need for mechanical lift transfers.
Review of the annual MDS, dated [DATE], showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– Extensive assist of two or more staff for bed mobility, transfers, and toileting;
– Not steady and only able to stabilize with staff assist for moving from seated to
standing position, walking, moving on and off toilet, and surface to surface transfers
(transfers between bed and chair or wheelchair);
– No falls;
– [DIAGNOSES REDACTED]. stroke).
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
Observation on 1/15/19, at 10:00 A.M., showed:
– Two staff transferred the resident to his/her recliner with a mechanical lift.
3. Review of Resident #2’s annual MDS, dated [DATE], showed:
– A BIMS score of 00 which indicated the resident could not complete the Brief Interview
for Mental Status;
– No change in mental status;
– Inattention- behavior continuously present;
– Disorganized thinking- behavior continuously present;
– Altered level of consciousness- not present;
– Delusions;
– Extensive assist of one staff for bed mobility, transfers, and toileting;
– Limited assist of one staff for walking in room and in corridor;
– Limited assist of one staff for locomotion on and off unit;
– Not steady, only able to stabilize with staff assistance for moving from seated to
standing position, walking, turning around, moving on and off toilet, and surface to
surface transfers (transfers between bed and chair or wheelchair);
– No impairment of the upper or lower extremities;
– Walker;
– Urinary catheter (a sterile tube inserted into the urinary bladder to drain urine);
Antipsychotic medications in last seven days;
– [DIAGNOSES REDACTED].
Review of the care plan last revised on 1/16/19, showed:
– ADL self-care deficit;
– Will demonstrate appropriate use of walker to increase stability in ambulation;
– (MONTH) use Sit to Stand (a mechanical lift in which the resident stands and holds to
handle bars to transfer) lift when resident unable to pivot (turn) transfer;
– Use mechanical lift (a lift that uses a body sling to lift and lower residents) PRN when
resident refuses to stand;
– Required assist by staff to move between surfaces;
– The resident uses walker to maximize independence with transferring;
– The resident required stand-by assist by staff to walk with walker and as necessary;
– PT/OT referrals as ordered, PRN;
– Moderate risk for falls related to confusion, gait/balance problems, incontinence,
unaware of safety needs;
– Will be free of falls and injury;
– Impaired visual function;
– Remind resident to wear glasses when up;
– Did not assess, reassess, or care plan for the use of a gait belt for transfers;
– Did not assess or reassess for the most appropriate type of transfer to prevent injury
for the resident.
Observation on 1/15/19, at 10:32 A.M., showed Certified Nurse Aide (CNA) C and CNA D did
and said:
– Assisted the resident out of the bathroom with a gait belt; the resident used his/her
walker;
– CNA C and CNA D held the gait belt with one hand;
– The gait belt was loose around the resident’s waist and pulled up towards the resident’s
upper back when lifted off the toilet and when standing;
– The resident was very confused and attempted to sit in the wheelchair before he/she
reached the wheelchair and almost fell ;
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
– The CNAs assisted him/her to sit in the wheelchair;
– The resident wanted to go to bed and CNA C stood the resident with the walker;
– The gait belt remained loose around the resident’s waist;
– CNA D tightened the gait belt;
– The resident could not stand up straight or pivot;
– CNA C said today was not a good day for the resident;
– CNA C said he/she had good days and bad days;
– CNA C and CNA D sat the resident in the wheelchair and CNA C left the room to obtain the
Sit-to-Stand lift;
– Both CNAs applied the sling around the resident’s torso, attached the sling to the lift,
locked the back casters (wheels), opened the legs to the widest width, raised the resident
out of the wheelchair and placed the resident in bed;
– CNA D said the gait belt should be snug around the resident’s waist and it was not until
she tightened the belt.
During an interview on 1/15/19, at 5:27 P.M., CNA C said:
– Resident #2 was getting worse; he/she fights, kicks, and hits at staff;
– Today staff were able to use the gait belt when he/she went to the bathroom;
– The gait belt should not be tight but loose enough to get two fingers beneath the belt
when transferring;
– The belt was loose and CNA C’s belt had teeth that were not as sharp as some so the belt
did not hold as snug as it should have;
– He/she found out today that staff could use the Sit-to-Stand lift to transfer the
resident;
– The wheels of the Sit-to-Stand and the mechanical lifts should be locked when raising
and lowering a resident;
– The legs of the lifts should be opened fully during a transfer.
4. Review of Resident #15’s quarterly MDS, dated [DATE], showed:
– A BIMS score of 15 which indicated he/she made his/her own decisions;
– Extensive assist of two or more staff for transfers;
– Resident did not walk in room or corridors;
– [DIAGNOSES REDACTED].
Review of the January, 2019 physician’s orders [REDACTED].
– Ace wrap (elastic bandage to help reduce [MEDICAL CONDITION]) to the LLE, apply in the
A.M. and remove in P.M. to decrease swelling;
– Monitor ankle creases closely and skin folds BID (twice daily) for [MEDICAL CONDITION];
– Fluid restriction every shift for swelling, 2,000 milliliters per 24 hours;
– Daily weights in the morning before meal in wheelchair, wheelchair weighs 44.8 pounds;
– Heel protector to left foot at bedtime related to paralysis of left leg and foot;
– Cleanse right buttock wound with wound cleanser, pat dry, apply skin prep around wound
bed edges, apply foam dressing, and change every other day until healed and PRN until
healed;
– Cleanse open area in perineal area next to the buttocks with wound cleanser, apply foam
dressing until healed daily;
– Must lie down in bed for at least one hour in the A.M. and P.M. every day to reduce
pressure to buttocks;
– Weekly skin assessment.
Review of the care plan last revised 12/16/18, showed:
– No plan of care for 4+ (excessive fluid buildup in the lower extremity) [MEDICAL
CONDITION] to the LLE;
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
– No plan of care for monitoring ankle skin creases and skin folds for [MEDICAL
CONDITION];
– No plan of care for the potential wound formation in the ankle crease of the LLE related
to previous open wound to the area;
– No plan of care for elastic ace wrap to LLE to reduce [MEDICAL CONDITION], daily
weights, and fluid restriction to prevent [MEDICAL CONDITION] and [MEDICAL CONDITION];
– No plan of care for wound care to open wounds to perineal area and right buttock;
– No plan of care for weekly skin assessment or preventing pressure to the buttocks and
perineal area.
5. During an interview on 1/16/19, at 3:30 P.M., the MDS/Care Plan Coordinator said:
– She was new to the position;
– She was going through all care plans now to update and would update the care plans
quarterly and as needed;
– Significant medication changes, changes in ADLs, falls, skin issues, and transfers
should all be care planned;
– PRN mechanical lift transfers should not be care planned; CNAs should tell licensed
staff about a change in condition to determine type of transfer to be used for the
resident;
– PRN was used because residents have good days and bad days with transfers;
– Wound care, treatments and areas of potential breakdown should be care planned.
During an interview on 1/16/19, at 6:03 P.M., the Director of Nursing (DON) said:
– Care plans should give a picture of the person;
– Changes should be added PRN;
– Care plans should be updated quarterly and PRN;
– Care plans should include ADLs, wound and wound care, medications, activities,
transfers, special diets, behaviors and anything else pertinent to a resident;
– The previous MDS/Care Plan Coordinator did not update care plans as they should have
been updated;
– Care plans should be updated immediately if issues develop.

F 0689

Level of harm – Actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to transfer
residents in a safe manner to prevent injury or the possibility of injury when they
modified the Apex Lift model 650 HD (a battery operated patient lift), the Apex Lift model
450 E (a battery operated patient lift), and the Medline Sit-to-Stand battery operated
lift with a non-manufacturer approved three ton long arm double piston jack which affected
two of 21 sampled residents (Residents #2 and #32) and had the potential to affect all
residents transferred with a mechanical or Sit-to-Stand lift; failed to support/guide the
resident during a mechanical lift transfer and failed to open the legs of the lift to the
widest position under the resident’s bed which affected Resident #32; and staff
inappropriately applied a gait belt for transfer of Resident #2. The facility census was
45.
1. Review of the facility’s Safe Lifting and Movement of Residents policy, dated July,

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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 7)
(YEAR), showed:
– 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
residents.
– Residents safety, dignity, comfort and medical condition will be incorporated into goals
and decisions regarding the safe lifting and moving of residents.
– Nursing staff, in conjunction with the rehabilitation staff, shall assess individual
residents’ needs for transfer assistance on an ongoing basis. Staff will document resident
transferring and lifting needs in the care plan and shall include resident preference for
assistance, resident’s mobility (degree of dependency), resident’s size, weight bearing
ability, cognitive status, whether the resident is usually cooperative with staff and the
resident’s goals for rehabilitation, including restoring or maintaining functional
abilities.
– Staff responsible for direct resident care will be trained in the use of manual (gait
belts and lateral boards) and mechanical lifting devices.
– Mechanical lifting devices shall be used for heavy lifting, including lifting and moving
residents when necessary.
– Only staff with documented training on the safe use and care of the machines and
equipment used will be allowed to lift or move residents.
– Staff will be observed for competency in using mechanical lifts and observed
periodically for adherence to policies and procedures regarding use of equipment and safe
lifting techniques.
– Mechanical lifts shall be made readily available and accessible to staff 24 hours a day;
back up battery packs on remote chargers shall be provided as needed so that the lifts can
be used 24 hours a day while batteries are being recharged.
– Appropriate slings, in sizes required by residents in need will be available at all
times.
– Maintenance staff shall perform routing checks and maintenance of equipment used for
lifting to ensure that it remains in good working order.
– All equipment design and use will meet or exceed guidelines and regulations concerning
resident safety and the use of restraints.
– Safe lifting and movement of residents is part of an overall facility employee health
and safety program which involves employees in identifying problem areas and implementing
workplace safety and injury prevention strategies; addressed reports of work place
injuries; provides training on safety, ergonomics (designing the workplace, keeping in
mind the capabilities and limitations of the worker) and proper use of equipment; and
continually evaluates the effectiveness of workplace safety and injury prevention
strategies.
Review of the facility’s Using a Mechanical Lifting Machine policy, dated July, (YEAR),
showed:
– The purpose of this procedure is to establish the general principles of safe lifting
using a mechanical lifting device. It is not a substitute for manufacturer’s training or
instruction.
– At least two nursing assistants are needed to safely move a resident with a mechanical
lift.
– Mechanical lifts may be used for transferring a resident from bed to chair, lateral
transfers, toileting/bathing or repositioning.
– Types of lifts that may be available are floor-based, full body sling lifts and
Sit-to-Stand lifts.
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 8)
– Lift design and operation vary across manufacturers; staff must be trained and
demonstrate competency using the specific machines or devices utilized by the facility.
– Before using a lifting device, assess the resident’s current condition including: Can
the resident assist with the transfer; is the resident’s weight and medical condition
appropriate for the use of a lift; can the resident understand and follow instructions;
does the resident express fear or appear anxious about the use of a lift; is the resident
agitated, resistant, or combative?
– Use the proper fitting sling for the resident.
– Prepare the environment by provide an unobstructed path for the lift machine; ensure
there is enough room to pivot; position the lift near the receiving surface and place the
lift at the correct height.
– Make sure the battery is charged.
– Make sure the lift is stable and locked.
– Make sure that all necessary equipment (slings, hooks, chains, staps and supports) is on
hand and in good condition.
– Make sure the sling size is not too large or too small for the resident.
– Check the resident’s comfort level by asking or observing for signs of pinching or
pulling of skin.
– Lift the resident and gently support the resident as he/she is moved, but do not support
any weight.
– Slowly lower resident into receiving surface when reached.
Review of the facility’s Use of a Gait Belt (GB) policy, dated December, (YEAR), showed:
– It is the policy of the facility to use a gait belt for all residents in accordance with
assessed needs, the care plan and standards of practice to provide optimal safety.
– GBs are to be used for all transfers that require staff assistance and when assisting
residents to ambulate.
– The facility requires that each nursing staff member have a GB.
– Staff will be trained in the use of GBs and will be observed for competency in correct
use of a GB.
– Thread the belt through the teeth side first, pull back through on the opening on the
other side, and then secure the GB around the waist.
– Give the belt a slight tug to ensure that it will not slip during the process of
ambulating or transferring the resident.
– Have the resident move to the edge of the bed or chair and place feet flat on the floor.
– Support the weaker leg if necessary.
– Utilize the safe transfer technique: Move with the resident, with staff knees bent and
strong grasp under the GB on each side of the buckle; at no time should staff lift up on
the area under the resident’s arms; at no time should the resident have their hands near
the staff’s neck during a transfer.
– Instruct the resident to place the back of his/her knees against the
wheelchair/chair/bed and to use his/her hands or arms to lower him/herself into the seat.
– Inform the charge nurse of any changes in the resident’s transfer or ambulation skills.
– Nurses will report any changes in ability to ambulate and transfer to the restorative
nurse.
– Changes in condition will be discussed and changes made to ensure safe transfers.
Review of the undated Apex Lift model 650HD battery operated patient lift owner’s manual
showed:
– Purchased, received date 11/24/08, by the facility, written by facility staff on front
of manual.
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 9)
– Special care must be taken with users/patients who cannot themselves provide assistance
while being lifted.
– During lowering or lifting, whenever possible, always keep the base (legs) of the lift
in the widest position.
– The base of the lift should be closed before moving the lift.
– While being lifted in a sling, always keep the user/patient centered over the base and
facing the caregiver operating the lift.
– Maximum weight that can be safely lifted is 600 pounds.
– Select an Apex Lift sling that is both practical and comfortable. The sling selected
should be one that serves the needs of the patient, while providing the patient with
optimal safety.
– Replace any worn parts with only [MEDICATION NAME] Apex Lift parts.
– Apex Lift parts are not interchangeable with parts from other patient lift brands.
– Using other patient lift parts on Apex Lift products is unsafe and may result in serious
injury to user and caregiver.
– Service and repair of the Apex Lift equipment should be performed only by Apex Dynamics
Healthcare Products [MI]L.C. and is not responsible for any consequences resulting from
any unauthorized service or repair.
– Keep lifter base widened and brakes locked during lifting.
Review of the undated Apex Lift model 450 E battery operated patient lift owner’s manual
showed:
– Delivered 1/28/09, written on manual by facility staff.
– Special care must be taken with users/patients who cannot themselves provide assistance
while being lifted.
– Should be used solely for transferring a patient and not for transporting a patient from
one location to another.
– During lifting and lowering, whenever possible, always keep the base of the lift in the
widest position.
– While being lifted in a sling, always keep the user/patient centered over the base and
facing the caregiver operating the lift.
– Maximum weight that can be lifted safely is 400 pounds.
– Select an Apex Lift sling that is both practical and comfortable. The sling selected
should be one that serves the needs of the patient, while providing the patient with
optimal safety.
– Replace any worn parts with only [MEDICATION NAME] Apex Lift parts.
– Apex Lift parts are not interchangeable with parts from other patient lift brands.
– Using other patient lift parts on Apex Lift products is unsafe and may result in serious
injury to user and caregiver.
– Service and repair of the Apex Lift equipment should be performed only by Apex Dynamics
Healthcare Products [MI]L.C. or an authorized dealer and is not responsible for any
consequences resulting from any unauthorized service or repair.
Review of the undated Medline battery operated Sit-to-Stand patient lift owner’s manual
showed:
– No purchase or delivery date recorded by facility staff.
– Replace any worn parts only with [MEDICATION NAME] Medline Lift parts. Medline Lift
parts are not interchangeable with parts from other patient lift brands. Using other
patient lift parts on Medlin Lift products is unsafe and may result in serious injury to
patient and caregiver.
– Service or repair of Medline Lift equipment should be performed only by Medline or 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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 10)
authorized dealer.
– Operating instructions: Position the base of the lift around or under the object; widen
the base and engage the caster brakes.
2. Review of Resident# 32’s care plan last revised on 11/18/17, showed:
– Limited physical mobility;
– Physical and occupational therapy (PT/OT) referrals as ordered, PRN (as needed);
– Activities of daily living (ADL) self-care deficit;
– Required assist of two staff for toileting;
– Did not assess and care plan the need for mechanical lift transfers.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/21/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– Extensive assist of two or more staff for bed mobility, transfers, and toileting;
– Not steady, only able to stabilize with staff assistance when moving from seated to
standing position, walking, moving on and off toilet, and for surface to surface
transfers, transfer between bed and chair or wheelchair;
– Weight: 332 pounds;
– No falls;
– Pain constantly;
– [DIAGNOSES REDACTED]. stroke).
Observation on 1/15/19, at 10:00 A.M., showed:
– Certified Nurse’s Aide (CNA) A and CNA E transferred the resident to his/her recliner
with a mechanical lift;
– Used the Apex Lift Model 650 HD;
– The Apex Lift had been modified by an unknown staff when they removed the electrical,
battery pack equipment from the lift and installed a three ton long ram double piston jack
and a handle to manually work the lift;
– Attached the sling to the lift;
– Did not open the lift to the widest position beneath the resident’s bed and then locked
the back caster brakes;
– CNA E used the hand crank of the lift with some difficulty and lifted the resident off
the bed;
– Unlocked the back caster brakes, rolled the lift from beneath the bed, opened the legs
of the lift with difficulty; CNA E worked the lift; CNA A stepped away from the resident
to move a table;
– The resident swung in the air and complained of the sling hurting him/her;
– CNA A moved a table, then grabbed the sling to guide the resident over the resident’s
chair as CNA E moved the lift around the resident’s chair with legs open;
– CNA E lowered the resident into the chair and CNA A guided the resident as he/she was
lowered;
– The resident said he/she wanted to use the Sit-to-Stand lift for transfers and did not
know why staff had to use the mechanical lift; the sling hurt his/her legs every time they
transferred him/her.
During an interview on 1/16/19, at 3:10 P.M., CNA A said:
– The legs of the lift should be open during a transfer;
– The back caster brakes should be locked;
– The resident should be supported/guided during transfer.
3. Review of Resident #2’s annual MDS, dated [DATE], showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 11)
– A BIMS score of 00 which indicated the resident could not complete the Brief Interview
for Mental Status;
– No change in mental status;
– Inattention- behavior continuously present;
– Disorganized thinking- behavior continuously present;
– Altered level of consciousness- not present;
– Delusions;
– Extensive assist of one staff for bed mobility, transfers, and toileting;
– Limited assist of one staff for walking in room and in corridor;
– Limited assist of one staff for locomotion on and off unit;
– Not steady, only able to stabilize with staff assistance for moving from seated to
standing position, walking, turning around, moving on and off toilet, and surface to
surface transfers (transfers between bed and chair or wheelchair);
– No impairment of the upper or lower extremities;
– Walker;
– Urinary catheter (a sterile tube inserted into the urinary bladder to drain urine);
– Antipsychotic medications in last seven days;
– [DIAGNOSES REDACTED].
Review of the care plan last revised on 1/16/19, showed:
– ADL self-care deficit;
– Will demonstrate appropriate use of walker to increase stability in ambulation
– (MONTH) use Sit to Stand (a mechanical lift in which the resident stands and holds to
handle bars to transfer) lift when resident unable to pivot (turn) transfer;
– Use mechanical lift (a lift that uses a body sling to lift and lower residents) PRN when
resident refuses to stand;
– Required assist by staff to move between surfaces;
– The resident uses walker to maximize independence with transferring;
– The resident required stand-by assist by staff to walk with walker and as necessary;
– PT/OT referrals as ordered, PRN;
– Moderate risk for falls related to confusion, gait/balance problems, incontinence,
unaware of safety needs;
– Will be free of falls and injury;
– Impaired visual function;
– Remind resident to wear glasses when up;
– Did not assess, reassess, or care plan for the use of a gait belt for transfers;
– Did not assess or reassess for the most appropriate type of transfer to prevent injury
for the resident.
Observation on 1/15/19, at 10:32 A.M., showed Certified Nurse’s Aide (CNA) C and CNA D did
and said:
– Assisted the resident out of the bathroom with a gait belt and the resident used his/her
walker;
– CNA C and CNA D held the gait belt with one hand on each side of the belt;
– The gait belt was loose around the resident’s waist and pulled up towards the resident’s
upper back when lifted off the toilet and when standing;
– The resident was very confused and attempted to sit in the wheelchair before he/she
reached the wheelchair and almost fell ;
– The CNAs assisted him/her to sit in the wheelchair;
– The resident wanted to go to bed and CNA C stood the resident with the walker;
– The gait belt remained loose around the resident’s waist;
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 12)
– CNA D tightened the gait belt;
– The resident could not stand up straight or pivot;
– CNA C said today was not a good day for the resident;
– CNA C said he/she had good days and bad days;
– CNA C and CNA D sat the resident in the wheelchair and CNA C left the room to obtain the
Sit-to-Stand lift;
– The battery operated Medline Sit-to-Stand Lift had been modified by unknown staff when
when someone removed the electrical, battery pack equipment from the lift and installed a
three ton long ram double piston jack and a handle to manually work the lift;
– Both CNAs applied the sling around the resident’s torso, attached the sling to the lift,
locked the back casters (wheels), opened the legs to the widest width, raised the resident
out of the wheelchair and placed the resident in bed;
– CNA D said the gait belt should be snug around the resident’s waist and it was not until
she tightened the belt;
– Both CNAs said they notified nursing staff when the resident did not transfer well with
a GB.
During an interview on 1/15/19, at 5:27 P.M., CNA C said:
– Resident #2 was getting worse; he/she fights, kicks, and hits at staff.
– Today, staff were able to use the gait belt when he/she went to the bathroom.
– The gait belt should not be tight but loose enough to get two fingers beneath the belt
when transferring.
– The belt was loose and CNA C’s belt had teeth that were not as sharp as some so the belt
did not hold as snug as it should have.
– He/she found out today that staff could use the Sit-to-Stand lift to transfer the
resident.
– The wheels of the Sit-to-Stand and the mechanical lifts should be locked when raising
and lowering a resident.
– The legs of the lifts should be opened fully during a transfer.
4. During an interview on 1/16/19, at 4:18 P.M., the Director of Nursing (DON) said:
– Only Resident #32 used the mechanical lift and Resident #2 used the Sit-to-Stand lift.
– The modified lifts could be unsafe to use.
– She knew the lifts were modified from battery powered to manual lifts, but did not know
when or who modified them.
– The legs of the mechanical lifts do not work properly, the legs will not engage and lock
in place when staff open them.
– Legs of the lift should be opened fully when under the bed.
– Staff should not lock the back caster brakes.
During an interview on 1/16/19, at 4:18 P.M., Certified Occupational Therapy Assistant
(COTA) A said:
– Resident #32 cannot use the Sit-to-Stand lift because he/she was unsafe to stand and
hold on to the lift properly.
– The resident would only use two fingers to hold onto the handle bar when staff stood
him/her with the lift.
– COTA A did not know facility staff had modified the Sit-to-Stand lift or the mechanical
lifts.
– COTA A said they could be unsafe to use.
During an interview on 1/16/19, at 4:30 P.M., the Assistant Administrator (AA) said:
– The lifts were modified about [AGE] years ago because the batteries kept dying and staff
did not plug in the lifts to recharge the batteries.
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

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 – Actual harm

Residents Affected – Few

(continued… from page 13)
Observation on 1/16/19, at 6:00 P.M., showed:
– Staff brought up a second battery operated Apex Lift, model 450 E, kept in the basement
of the facility.
– Staff had previously modified the Apex Lift when they removed the electrical, battery
pack equipment from the lift and installed a three ton long ram double piston jack and a
handle to manually work the lift.
– The AA removed the two Apex Lifts from the building but the Medline Sit-to-Stand Lift
remained in the facility.
During an interview on 1/16/19, at 6:03 P.M., the DON said:
– Staff told her today Resident #2 did not transfer well with the gait belt.
– Gait belts should always be snug around the resident’s waist during a gait belt
transfer.
– CNAs should report changes in condition of any resident and the nurse should evaluate to
determine the type transfer to perform.
– Care plans should not indicate to use a lift PRN.
Observation on 1/16/19 at 6:10 P.M. showed:
– The maintenance supervisor brought in with the new mechanical lift from a local
pharmacy.
– The MS did not obtain a new Sit-to Stand lift.

F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
documentation that their Quality Assessment and Assurance Committee met on a quarterly
basis with the appropriate attendees; and failed to identify, develop, implement, monitor,
and evaluate system problems. This had the potential to affect all residents of the
facility. The facility census was 45.
1. Review of the facility’s Quality Assurance and Performance Improvement (QAPI) Plan,
dated April, 2014, showed:
– The facility shall develop, implement and maintain an ongoing, facility-wide QAPI Plan
designed to monitor and evaluate the quality and safety of resident care, pursue methods
to improve care quality, and resolve identified problems.
– Objectives of the QAPI plan are to provide a means to identify and resolve present and
potential negative outcomes related to resident care and services; reinforce and build
upon effective systems and processes related to the delivery of quality care and services;
provide structure and processes to correct identified quality and/or safety deficiencies;
establish and implement plans to correct deficiencies, and to monitor the effects of these
action plans on resident outcome; help departments, consultants, and ancillary services
that provide direct or indirect care to residents to communicate effectively, and to
delineate lines of authority, responsibility, and accountability; provide a means to
centralize and coordinate comprehensive QAPI activities in order to meet the needs of the
residents and the facility; and establish systems and processes to maintain documentation
relative to the QAPI Program, as a basis for demonstrating that there is an effective
ongoing program.
– The owner and/or governing body of the facility shall ultimately be responsible for 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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 14)
QAPI Program.
– The Administrator is responsible for assuring that the facility’s QAPI Program complies
with Federal, State, and local regulatory agency requirements.
– The QAPI Committee shall oversee implementation of the QAPI plan. A QAPI Coordinator
shall coordinate QAPI Committee activities, including documentation.
– The committee shall meet monthly to review reports, evaluate the significance of data,
and monitor quality-related activities of all departments, services, or committees.
– The QAPI Committee shall oversee and authorize QAPI activities, including data
collection tools, monitoring tools, and the basis for and appropriateness and
effectiveness of QAPI activities.
– The committee shall approve any corrective actions, including changes in policies and/or
procedures, employment practices, standards of care, etc., and shall also monitor all
corrective activities for appropriateness and/or the need for alternative measures.
– The committee may recommend ways to reinforce and expand identified positive approaches
and outcomes to various departments of service.
– Individual departments or services shall develop quality indicators for programs and
services in which they are involved and which affect their function.
– Information regarding QAPI activities is confidential and may be disclosed only in
accordance with applicable laws and regulations.
– Departments, services, and committees shall submit their reports to the QAPI Committee
as directed by the committee.
– The facility shall evaluate the effectiveness of its QAPI Program at least annually and
shall present their conclusions to the owner/governing board for review.
– The QAPI Committee, Administrator, and the governing board shall review and approve a
summary of problems and corrective measures.
– The QAPI Coordinator shall attend and/or review minutes of meetings of other committees
or departments as needed.
– The QAPI Coordinator will help other committees, individuals, departments, and/or
services develop quality indicators, monitoring tools, criteria, and assessment
methodologies, and help them identify and evaluate concerns impacting resident care and
safety.
– The QAPI Coordinator will act as a liaison among committees, individuals, services,
and/or departments regarding QAPI activities.
Review of the Quality Assurance and Performance Improvement (QAPI) Program, dated April,
2014, showed:
– The facility shall develop, implement, and maintain an ongoing, facility-wide QAPI
program that builds on QAA Program to actively pursue quality of care and quality of life
goals.
– The primary purpose of the QAPI Program is to establish data driven, facility wide
processes that improve the quality of care, quality of life and clinical outcomes of the
residents.
– The QAPI Program has been developed with five strategic elements.
– Design and scope: The program is ongoing and comprehensive; it involves the full range
of services and departments in the facility; it covers all systems of care and management
practices, with priority given to quality care, quality of life and resident choice;
goals, targets and benchmarks are established and measured based on the best available
evidence.
– Governance and leadership: Input is sought from facility staff, residents, family
members and individuals who are involved in the care of residents; resources are allocated
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 15)
to conduct QAPI efforts; members of the facility leadership are accountable for QAPI
efforts; staff are trained in QAPI systems and culture; staff are encouraged to identify
and report quality concerns as well as opportunities for improvement.
– Feedback, data systems, and monitoring: Systems are in place to monitor care and
services; systems are designed to incorporate feedback from caregivers, residents, family
and staff as appropriate.
– Care processes and outcomes are monitored using performance indicators, these
performance indicators are measured against quality benchmarks and targets that the
facility has established; adverse events are tracked, monitored, and investigated as they
occur; action plans are implemented to prevent recurrence of adverse events.
– Performance improvement projects: Performance improvement projects (PIPs) are initiated
when problems are identified; PIPs involve systematically gathering information to clarify
issues and to intervene for improvements.
– Systematic analysis and systematic action: Root Cause Analysis (RCA) is used to
determine whether identified issues are exacerbated by the way care and services are
organized or delivered, and if so, how; RCA serves as a highly structured approach to
fully understanding the nature of an identified problem, its cause and the implications of
making changes to improve the problem.
-The following steps are employed or will be employed to support and enhance the facility
QAPI Program.
– Establishing a QAPI Committee/sub-committee that works in [MEDICATION NAME] with the
facility leadership and the QA&A Committee.
– Allocating resources for QAPI initiatives.
– Providing staff, family members, and residents with information about the QAPI Program
and inviting them to meet with the QAPI leadership.
– Providing concrete channels of communication between staff, residents, family members,
and leadership.
– Establishing a zero tolerance policy for retaliation against individuals who
appropriately report or communicate quality concerns.
– Creating task oriented or goal oriented teams for QAPI; establishing a clear purpose for
each team; defining specific roles for each team member.
– Utilizing established QAPI self-assessment tools to initiate and then periodically
re-evaluate the QAPI program.
– Identifying this facility’s Guiding Principles and the using them to guide decision
making and set priorities.
– Establishing a QAPI Pan that guides quality efforts and serves as the main document that
supports the QAPI implementation.
– Communicating the QAPI Plan and principles to all caregivers, including consultants,
contractors, and business associates.
– Communicating the QAPI Plan and principles to residents and families, and encouraging
their participation in the systems.
– Providing frequent leadership and staff training on the QAPI Plan and its underlying
principles, including the concept that systems of care and business practices must support
quality care or be changed.
– Gathering and using QAPI data in an organized and meaningful way. Areas that may be
appropriate to monitor and evaluate include: Clinical outcomes of pressure ulcers,
infections, medication use, pain, falls, etc.; complaints from residents and families;
re-hospitalization s; staff turnover and assignments; staff satisfaction; care plans;
state surveys and deficiencies; and Minimum Data Set (MDS, a federally mandated assessment
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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 16)
instrument completed by facility staff) assessment data.
– Setting measurable goals for improvement that may include percentage of reductions or
increases from the measured baseline of a particular goal.
– Identifying benchmarks of performance and comparing facility data with national and
state performance benchmarks.
– Recognizing patterns in systems of care that can be associated with quality problems.
– Prioritizing identified quality issues based on risk of harm and frequency of
occurrence, and determining which will become the focus of PIPs.
– Planning, conducting, and documenting PIPs.
– Conducting Root Cause Analysis to identify the underlying issues that contribute to
recognized problems.
– Taking systematic action targeted at the root causes of identified problems. This
encompasses the utilization of corrective actions that provide significant and meaningful
steps to improve processes and do not depend on staff to simply do the right thing.
Review of the facility’s last survey process for the (YEAR)-2018 fiscal year showed a
survey with an exit date of 4/20/18. The revisit for the annual survey was conducted on
6/12/18, and the facility was found in substantial compliance for a deficiency regarding
their QAPI Plan at that time.
During an interview on 1/15/19, at 4:18 P.M., the Owner/Administrator did and said:
– She was cleared as having a QAPI Plan in August, (YEAR), after a citation was issued for
not having the QAPI Plan in place during the annual survey dated 4/20/18.
– She said a QAPI meeting was not held in June, (YEAR), but planned a meeting in August,
(YEAR).
– The meeting in (MONTH) was not held.
– She held a meeting in early October, (YEAR) and late December, (YEAR) but only three
people attended.
– The Medical Director could not attend as she was too busy.
– The Medical Director has too much to do to attend and therefore she does not set a
meeting time.
– Staff are too busy to attend a meeting as they have had problems retaining staff.
– She did not have any documentation of what issues were discussed in the (MONTH) and
December, (YEAR) meetings.
– She did not have any documentation to show who attended the meetings in (MONTH) and
December, (YEAR).
– She knew the QAPI meeting needed to be held and discuss issues but there just was not
enough time or staff to have the meeting.
– She knew there should be at least five attendees at the meetings to include the
Administrator (herself), the Medical Director, the DON, and two other staff.
– She did not say residents or families would be invited as noted in the QAPI Plan.
During an interview on 1/16/19, at 6:03 P.M., the Director of Nursing (DON) said:
– She was aware a QAPI meeting needed to be held quarterly.
– Problems and objections should be discussed at the meeting and a follow up meeting
should take place to discuss outcomes of the issues.
– There should be a list of attendees of each meeting.
– She had spoken with the Medical Director about some issues, but had not documentation of
the issues, monitoring, or conclusions related to the issues.
– No meetings were scheduled so the Medical Director could attend.
– She thought the Medical Director would attend if given prior notice.

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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to implement,
follow and monitor a facility-wide antibiotic stewardship program. The facility had five
residents on antibiotics from 12/31/18 to 1/16/19. This deficient practice had the
potential to affect all residents in the facility. The facility census was 45.
1. Review of the facility’s Antibiotic Stewardship – Orders for Antibiotics policy, dated
December, (YEAR), showed:
– Purpose: To monitor the use of antibiotics in residents of the facility.
– Antibiotics will be prescribed and administered to residents under the guidance of the
facility’s Antibiotic Stewardship Program and in conjunction with the facility’s general
policy for medication utilization and prescribing.
– Appropriate indications for use of antibiotics include criteria met for clinical
definition of active infection or [MEDICAL CONDITION] (infection in the blood stream); and
pathogen susceptibility, based on culture and sensitivity (C&S), to antimicrobial (or
therapy begun while culture is pending).
– Use of an antibiotic based on clinical criteria of [MEDICAL CONDITION] may be
appropriate. The staff and practitioner will document the specific criteria that support
the suspicion in the resident’s clinical record.
– When a C&S is ordered, it will be completed and lab results and the current clinical
situation will be communicated to the prescriber as soon as possible to determine if
antibiotic therapy should be started, continued, modified, or discontinued.
Review of the facility’s Infections – Clinical Protocol, dated (MONTH) (YEAR), showed:
– During the initial assessment the physician or provider will help identify individuals
who have had a recent infection or who are at risk for developing an infection.
– Infection may be suspected based on clinical signs and symptoms and/or temperature.
– For anyone suspected of having an infection, nursing staff will obtain a complete set of
vital signs, and will identify and document specific details of symptoms and physical
findings.
– Nursing will notify the physician or provider of all pertinent details about the
resident’s condition.
– The nursing staff and physician or provider will identify possible complications of
infections such [MEDICAL CONDITION] or [MEDICAL CONDITION].
– The physician or provider and staff will discuss and determine whether an infection
exists or is likely, whether additional evaluations or testing is indicated and whether
other active conditions related to an infection also need treatment.
– Diagnostic tests should be ordered when they add to an understanding of the condition or
are likely to change treatment strategy.
– Generally the physician or provider should focus on low-risk tests that have a
reasonable diagnostic yield and are likely to improve resident management. Testing should
not occur just for the sake of completeness of evaluation or adherence to preconceived
standards of practice.
– The nursing staff and physician or provider will monitor the progress of the resident
with an infection until it is resolved.
– If an initial course of antibiotics does not resolve the issue, the physician/provider
will review the situation and may need to examine the individual before prescribing 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:

265796

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

NAME OF PROVIDER OF SUPPLIER

PEARL’S II EDEN FOR ELDERS

STREET ADDRESS, CITY, STATE, ZIP

611 NORTH COLLEGE
PRINCETON, MO 64673

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
continuation or change in antibiotics.
– The physician/provider will evaluate for the duration of antibiotics, discontinuance of
the antibiotic, and identify and address possible complications resulting from the
antibiotic treatment.
During antibiotic stewardship record review and interview with the Director of Nurses
(DON) on 1/16/19, at 6:03 P.M., the DON said:
– The facility had an Antibiotic Stewardship policy and program, but they did not have a
monitoring system in place.
– She provided Daily Administrative Report sheets, dated 12/31/18 through 1/16/19, that
showed residents who have infections, urinary tract infections (UTIs) and new antibiotics.
– The sheets showed five residents who had infections and were prescribed antibiotics.
– When asked how many residents were on antibiotics, she did not know without counting the
residents written on each report sheet.
– The sheet only showed the resident name, type infection, and name of medication the
resident took.
– She did not follow up, monitor, or record any information related to the infection,
progression, or outcome after treatment and resolving of the infection.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain all building
structural components to assure they remained safe and in good repair. Roof trusses in the
attic bowed and were broken, compromising the roof support assembly. The facility census
was 45.
1. Observation on 1/15/19, at 9:50 A.M., showed three roof trusses above the dining room
area bowed with metal plates attached to the areas where the wood trusses had cracked. The
trusses bowed approximately one foot out of alignment. During an interview at the same
time, the maintenance supervisor said they have been like that for at least two years.
During an interview on 1/15/19, at 3:00 P.M., the owner said he applied the metal plates
to act as braces at the point where the trusses had bowed and cracked. He applied the
plates about [AGE] years ago and was unsure how the bowed, cracked braces effected the
entire roof support system. He was unsure what caused the trusses to break.