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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview the facility failed to provide housekeeping and
maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
The facility census was 24.
1. Observations of room [ROOM NUMBER] on 5/8/19 at 8:59 A.M. showed:
– The air vent with dark colored buildup of debris;
– Two 2 foot (ft.) by 4 ft ceiling tiles with large brown circles;
– One 1 ft by 4 ft with large dark circle;
– One 2 ft by 2 ft small dark colored circle;
– One 1 ft by 2 ft ceiling tile loose and ajar;
– Perimeter of the room with buildup of dirt along the baseboards.
2. Observation on 5/9/19 at 11:30 A.M. showed:
– room [ROOM NUMBER] – 1 ft. x 5 ft area of bubbled paint and drywall in room near the
second bed, a 2 ft by 2 ft ceiling tile with a large dark colored circle with a smaller
circle with a black substance buildup;
– room [ROOM NUMBER] – air vent with build up debris;
– room [ROOM NUMBER] – 2 ft by 4 ft ceiling tile with dark circle, 6 inch by 4 ft ceiling
tile with small dark circle, 1 ft x 2 ft discolored ceiling tile;
– room [ROOM NUMBER] -15 curtain hooks missing on the first privacy curtain, missing
privacy curtain between the two residents, a 2 ft area of baseboard loose detached from
the wall;
– room [ROOM NUMBER] -10 curtain hooks missing on the privacy curtain by the door, no
privacy curtain between the two residents;
– room [ROOM NUMBER] – window blinds with buildup of debris and dust, perimeter of the
room with build up of dirt along the baseboard.
During an interview on 5/10/19 at 10:30 A.M. Licensed Practical Nurse (LPN) C said if a
repair is needed, a repair slip is filled out and placed in the box and maintenance does
get to it when they can. There is so much to do and they take care of the hospital and
this facility. He/she said there is a list of things that need to be repaired.
During an interview on 5/10/19 at 10:50 A.M. the Director of Nursing (DON) said there is
numerous things that need to be repaired and they have a list and have notified the
necessary staff for the repairs. She said there is a fairly new housekeeping company that
is cleaning the long-term care now and hope it would get better.
During an interview on 5/10/19 at 1:00 P.M. the Chief Nursing Officer (CNO) said she was
not aware of missing curtains, she and the DON said the curtains had been taken down to
clean and probably not been replaced.
The facility did not provide a policy.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to document a
complete and accurate Minimum Data Set (MDS), a federally mandated assessment to be
completed by the facility for two residents (Resident #3 and #15) of 12 sampled residents.
The facility census was 24.

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
1. Record review of Resident #3’s quarterly MDS dated , 4/8/19, showed a [DIAGNOSES
REDACTED].
Record review of the resident’s physician’s orders [REDACTED].
During an interview on 5/9/19 at 12:01 P.M., the MDS coordinator said the MDS was
completed by the previous MDS coordinator and was not sure what happened.
During an interview on 5/9/19 at 12:15 P.M., the Chief Nursing Officer (CNO) said the
resident does not have a [DIAGNOSES REDACTED].
2. Record review of Resident #15’s Admission MDS, dated [DATE], showed the Pre-Admission
Screening and Resident Review (PASARR) marked no for screened for mental disorder or
intellectual disability.
Record review of the resident’s medical chart showed the PASARR completed on 8/7/17.
During an interview on 5/9/19 at 2:00 P.M., The MDS coordinator said she was new to the
position and did not know she was to mark that section of the MDS. She said she would get
it corrected.
During an interview on 5/9/19 at 4:30 P.M. the CNO said the MDS coordinator did not
realize the PASARR was the same as the DA-124 review. She said the MDS coordinator would
get this corrected.

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 screen resident’s for a
mental disorder or intellectual disability prior to admission for one resident (Resident
#11) of two sampled residents. The facility census was 24.
1. Review of Resident #11’s medical record, showed:
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– No documentation of a Level I Preadmission Screening and Resident Review (PASARR), a
federal requirement to help ensure individuals are not inappropriately placed in a nursing
home for long term care.
During an interview on 5/9/19 at 3:05 P.M. the Social Services Director said the facility
had no screenings on Resident #11 and it would need to be resubmitted.
No policy was provided by the facility.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan consistent with the resident’s specific conditions, needs, and risks
within 48 hours of admission to properly care for one resident (Resident #17), and failed
to give a written summary of the baseline care plan to one resident (Resident #5) for two
sampled residents. The facility census was 24.
1. Record review of Resident #17’s admission orders [REDACTED]
– [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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
Record review of baseline care plan for Resident #17 showed:
– The baseline care plan form undated and no information.
2. Record review of Resident #5’s admission orders [REDACTED]
– [DIAGNOSES REDACTED].
Record review of the baseline care plan for Resident #5 showed:
– No signature of resident or representative;
– No documentation that a written summary given to resident and representative.
During an interview on 5/9/19 at 10:00 A.M., Licensed Practical Nurse (LPN) C said:
– He/she did not know the resident and representative should be given a written summary of
the baseline care plan;
– The baseline care plan for Resident #17 had just been missed.
During an interview on 5/9/19 at 10:05 A.M., the MDS Coordinator said:
– He/she did not know the resident and representative were supposed to receive a written
summary of the baseline care plan;
– The baseline care plan for Resident #17 had apparently just been missed.
Record review of the facility’s undated Resident Plan of Care showed:
– A temporary plan of care will be developed as a result of assessments from nursing,
activities, social services and dietary;
– Nursing personnel will utilize the temporary plan of care for the first fourteen days,
or until the comprehensive care plan is completed;
– A care card/temporary care plan will be kept on all residents;
– A temporary care plan will be completed on all new admissions to be used until the
comprehensive care plan is in the resident’s medical record.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to involve the residents in
developing the care plan and making decisions about his/her care for six sampled residents
(#4, #8, #13, #14, #19, and #22) out of 12 sampled residents. The facility census was 24.
1. During an interview on 5/8/19 at 9:35 A.M., Resident #19 said:
– He/she had never been invited to a care plan meeting.
During an interview on 5/9/19 at 11:55 A.M. the Social Services Director (SSD) said
resident #19 was not invited to the care plan meeting dated 4/4/19 due to I just did not
get a chance to invite him/her.
2. During a group interview on 5/8/19 at 1:00 P.M., Residents #4, #8, #13, #14, and #22
said:
– They have not been invited to a care plan meeting;
– The staff have not set down with them in a meeting to discuss their health care needs.
3. Record review of Resident #4’s Minimum Data Set (MDS) (a federally mandated assessment
instrument completed by facility staff), showed:
– Admission MDS completed 10/24/18;
– Quarterly MDS completed 1/24/19 and 4/26/19.
Record review of the care plan, dated 4/9/19, showed:
– [DIAGNOSES REDACTED].
– The resident is on a regular diet, Ensure ordered twice daily at lunch and supper, feeds

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
self.
4. Record review of Resident #8’s MDS, showed:
– An annual MDS completed on 6/28/18;
– Quarterly MDS completed on 1/0419 and 4/08/19.
Record review of the care plan, dated 2/26/19 showed:
– [DIAGNOSES REDACTED].
– The resident smokes, and independent in eating, transferring, and ambulating, resist
care and is verbally abusive.
5. Record review of Resident #13’s MDS, showed:
– An annual MDS completed on 10/25/18;
– Quarterly MDS completed on 1/25/19 and 4/29/19.
Record review of the care plan, dated 2/26/19 showed:
– [DIAGNOSES REDACTED].
– Can make routine daily decisions, impaired communications, at risk for falls, diet for
no concentrated sweet (NCS) pureed meats.
6. Record review of Resident #14’s MDS, showed:
– An annual MDS completed on 7/30/18;
– Quarterly MDS completed on 1/29/19 and 5/2/19.
Record review of the care plan, dated 4/4/19 showed:
– [DIAGNOSES REDACTED].
– Needs assistance of one for bathing, dressing, and grooming, at risk for falls, history
[MEDICAL CONDITION], pain, diet for low residue (low fiber), snacks three times a day,
Ensure once daily with lunch, and potential for skin breakdown.
7. Record review of Resident #22’s MDS, showed:
– An annual MDS completed on 3/26/19;
– Quarterly MDS completed on 9/25/18 and 1/4/19.
Record review of the care plan, dated 3/21/19 showed:
– [DIAGNOSES REDACTED].
– Regular diet with no fried foods, impaired decision making skills, depression, potential
for nutritional risk, uses tobacco products, and potential for psychosocial distress.
During an interview on 5/9/19 at 9:40 A.M. the Social Services Director (SSD) said:
– He/she sent invitation to the resident’s representative, but not to the resident;
– He/she just didn’t get a chance to invite the resident.
Record review of the facility’s Resident Plan of Care policy, revised on 10/2015 showed:
– The Comprehensive Care Plan will be reviewed on a scheduled quarterly basis or more
frequently as needed upon change of condition or per family’s request;
– The Long-Term Care Plan of Care Team (DON, Dietary, Restorative Aides, Social Services,
LPN and CNA) will meet weekly to review all residents scheduled and other residents with
any change of condition;
– The resident’s significant other (s) will be included in the plan of care process;
– Nursing team members will attend care plan meetings for the residents they are assigned,
and they will sign an attendance sheet to validate participation.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 – Some

Based on observation, interview, and record review, the facility failed to assess and
complete quarterly smoking assessments for six residents (Resident #3, #9, #11, #19, #21,
and #22) out of 6 sampled residents. The facility census was 24.
Record review of the facility’s policy on Resident smoking, dated 2/2018 showed:
– Smoking shall be prohibited in all enclosed areas of the Long-Term Care Unit except for;
– One indoor designated smoking area, one on the west wing;
– One outside designated smoking area on the north side of the west wing;
– All smoking items must be kept at the Nursing Station, including but not limited to
cigarettes, cigars, lighters, matches, and any other smoking paraphernalia;
– If resident has a smoking assessment completed and is deemed capable for independent
smoking, he or she may smoke in the designated outside area unsupervised at his or her
discretion.
1. Record review of Resident #3’s smoking assessment completed 4/25/18, showed resident
exhibits cognitive ability to smoke independently.
Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is
to be completed on admission and quarterly thereafter.
Record review of the resident’s medical record from 4/25/18 – 5/9/19, showed:
– No smoking assessments completed for the resident;
– The facility failed to complete quarterly safe smoking assessments for the resident.
2. Record review of Resident #9’s smoking assessment completed 4/25/18, showed resident
exhibits cognitive ability to smoke independently.
Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is
to be completed on admission and quarterly thereafter.
Record review of the resident’s medical record from 4/25/18 – 5/9/19, showed:
– No smoking assessments completed for the resident;
– The facility failed to complete quarterly safe smoking assessments for the resident.
3. Record review of Resident #11’s smoking assessment completed 4/28/18, showed the
resident does not exhibit cognitive ability to smoke independently.
Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is
to be completed on admission and quarterly thereafter.
Record review of the resident’s medical record from 4/25/18- 5/9/19, showed:
– No smoking assessments completed for the resident;
– The facility failed to complete quarterly safe smoking assessments for the resident
4. Record review of Resident #19’s smoking assessment completed 4/25/18, showed resident
does not exhibit cognitive ability to smoke independently.
Observation on 5/7/19 and 5/8/19 at 12:30 P.M., the resident sat outside the indoor
smoking room waiting for staff to bring the cigarettes.
Observation on 5/8/19 at 12:45 P.M., showed staff sitting in the hall at the doorway of
smoke room, observing residents smoking.
Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is
to be completed on admission and quarterly thereafter.
Record review of the resident’s medical record from 4/25/19 – 5/9/19, showed:
– No smoking assessments completed for the resident;
– The facility failed to complete quarterly safe smoking assessments for the resident
5. Record review of Resident #21’s smoking assessment completed 4/25/18, showed resident
does not exhibit cognitive ability to smoke independently.
Observation on 5/7/19 and 5/8/19 at 12:30 p.m. the resident sat outside the indoor smoking
room waiting for staff to bring the cigarettes.
Record review of resident’s smoking assessment completed 4/25/18, showed resident does not
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 – Some

(continued… from page 5)
exhibit cognitive ability to smoke independently.
Record review of the resident’s medical record from 4/25/19 – 5/9/19, showed:
– No smoking assessments completed for the resident;
– The facility failed to complete quarterly safe smoking assessments for the resident
6. Record review of Resident #22’s smoking assessment completed 4/25/18, showed resident
exhibits cognitive ability to smoke independently.
Record review of the resident’s care plan, dated 2/27/18, showed the smoking assessment is
to be completed on admission and quarterly thereafter.
Record review of the resident’s medical record from 4/25/19 – 5/9/19, showed:
– No smoking assessments completed for the resident;
– The facility failed to complete quarterly safe smoking assessments for the resident
During an interview on 5/9/19 at 12:00 P.M. the Director of Nursing (DON) said she was not
aware of the smoking assessments needing to be done on a quarterly basis.
During an interview on 5/10/19 at 7:57 A.M. the Chief Nursing Officer (CNO) said they have
a policy stating how often the smoking assessments should be completed and thought they
did all assessments annually. The CNO was not aware the care plan said they were to be
done quarterly.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Observe each nurse aide’s job performance and give regular training.

Based on record review and interview the facility failed to conduct at least twelve hours
of nurse aide in-service education per year based on the nurse aides individual
performance review. The facility census was 24.
Record review of the facility’s In-service records showed:
– The facility provided a file folder which contained July, August, and (MONTH) (YEAR)
In-services, with no time frame or any performance reviews;
– (MONTH) 2019 In-service with one hour written at the top of the page, no time-frame, no
performance reviews.
During an interview on 5/10/19 AT 11:50 a.m., the Director of Nurses (DON) said the
Vocational Technology (Vo-tech) School teacher comes to the facility and does the
In-service training for the Certified Nurse Aides (CNA’s). She said the In-services were
not taught off of the performance reviews. The DON said she would contact the Vo-Tech
teacher, however knew there was not enough information and not being completed correctly.
Record review of the facility’s policy on In-Service Nursing, dated 11/2013 showed:
– Nursing will provide and document optimum orientation for each new employee;
– Provide monthly scheduled in-service programs for all levels of staff;
– Provide information to all staff on current trends, issues, and practice;
– Maintain a computerized system of documentation of all in-service programs and
continuing education activities;
– Continuing education records will be maintained in the nursing office. It is the
responsibility of each instructor to provide a list of employees’ attending in-service.

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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

Level of harm – Potential for minimal harm

Residents Affected – Many

Based on observation, interview, and record review, the facility failed to post the nurse
staffing data in a prominent place readily accessible to residents and visitors on a daily
basis at the beginning of each shift. The facility census was 24.
1. Observations showed:
– On 5/07/19 the nurse staffing data sheet not posted in the facility;
– On 5/08/19 the nurse staffing data sheet not posted in the facility;
– On 5/09/19 the nurse staffing data sheet not posted in the facility;
– On 5/10/19 the nurse staffing data sheet not posted in the facility.
During an interview on 5/09/19 at 3:30 P.M. Licensed Practical Nurse (LPN) C said the
posting should be on the bulletin board by the front door. LPN C said the Director of
Nursing (DON) completes the forms and puts them on the bulletin board, however the form
has not been there all week.
During an interview on 5/10/19 at 7:45 A.M. the Chief Nursing Officer (CNO) said the
staffing sheets are usually posted on the bulletin board and it has not been posted this
week. The forms just did not get put up.
During an interview on 5/10/19 at 10:45 A.M. the DON said she had the staffing sheets
completed for the days of survey, however did not get them hung up this week.
Record review of the Nurse Staffing Information facility policy, dated 7/2018 showed:
– It is the responsibility of the Director of Nursing or designee to update the staffing
plan;
– The facility must post the nurse staffing data sheet on a daily bases at the beginning
of each shift;
– The information must be clear and in a readable format;
– The data sheets must be located in a prominent place, readily accessible to residents
and visitors.

F 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide the appropriate treatment and services to a resident who displays or is
diagnosed with dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
residents diagnosed with [REDACTED]. level of functioning and psychosocial needs for one
resident (Resident #10) out of one sampled resident. The facility census was 24.
1. Record review of Resident #10’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by the facility staff, dated 2/12/19, showed:
– Brief Interview for Mental Status (BIMS) of 15 (cognitively intact);
– [DIAGNOSES REDACTED].
Record review of the resident’s care plan, last updated on 3/28/19, showed:
– Did not address specific interventions for dementia care;
– Did not address specific interventions for activities for a resident with a [DIAGNOSES
REDACTED].
Observations of the resident on 5/07/19 at 9:30 A.M., 11:30 A.M. and at 2:30 P.M. showed:
– The resident sat in the chair in his/her room reading.
Observations of the resident on 5/08//19 at 8:00 A.M. and 11:00 A.M. showed:
– The resident lay in bed with his/her eyes closed.
Observations of the resident on 5/09/19 at 9:00 A.M. and 2:00 P.M., showed:
– The resident sat in the chair in his/her room reading.

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
Observations of the resident on 5/10/19 at 9:30 A.M. and 1:45 P.M. showed:
– The resident lay in bed with his/her eyes closed.
During an interview on 5/10/19 at 11:45 A.M. the resident said he/she attends the
activities that he/she chooses but likes to stay in his/her room.
During an interview on 5/9/19 at 2:40 P.M. Licensed Practical Nurse (LPN) C said the
resident stays pretty much to himself/herself most of the time. He/she needs re-direction
at times, but not very often.
During an interview on 5/10/19 at 11:50 A.M. the Director of Nursing (DON) said the family
is very involved with the resident and takes him/her out of the facility often. She said
the resident is very easily directed and expected the dementia to be addressed on the care
plan.
Record review of the facility’s care plan policy, dated 10/2015 showed:
– It is the responsibility of nursing personnel to participate in the development and
implementation of the resident’s plan of care;
– A comprehensive care plan will be located in the resident’s medical record and will be
accessible to the nursing staff and multi-disciplinary team at all times.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the pharmacy
consultant identified an appropriate [DIAGNOSES REDACTED].#10) out of five sampled
residents and failed to ensure the pharmacist made recommendations in regards to the
resident’s antipsychotic medication for two residents (Resident #2 and #10). The facility
census was 24.
1. Record review of Resident #2’s Physician order [REDACTED].
– A [DIAGNOSES REDACTED].
– An order, dated 5/16/18 for [MEDICATION NAME] (an anti-psychotic medications) 5
milligram (mg) one tablet daily at bedtime.
– An order, dated 5/31/18 for [MEDICATION NAME] (an anti-anxiety medication) 5 mg one
tablet twice daily.
Record review of the resident’s Medication Regimen Review (MRR), dated (MONTH) (YEAR)
through (MONTH) 2019 showed
– No irregularities or recommendations on the reviews.
2. Record review of Resident #10’s medical record showed:
– [DIAGNOSES REDACTED].
– An order, dated 4/25/18 for [MEDICATION NAME] (an anti-psychotic medication that treat
depression) 10 milligram (mg) one tablet daily at bedtime;
-an order for [REDACTED].
Record review of the resident’s pharmacy MMR, dated (MONTH) (YEAR) through (MONTH) 2019
showed:
– No recommendations or request to adjust the medications.
Record review of the monthly pharmacy reviews for Resident #10, showed no recommendations
for GDR’s since admission (4/25/18).
During an interview on 5/9/19 at 2:30 P.M. Licensed Practical Nurse (LPN) C said the

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

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
pharmacist had not made any recommendations on the MMR’s.
During an interview on 5/10/19 at 10:05 A.M., the Director of Nursing (DON) said she would
expect the pharmacist to complete a medication review on an antipsychotic medication and
to review the [DIAGNOSES REDACTED]. She said she would expect the physician to the
antipsychotic for an appropriate diagnosis. The DON said she could not find any
documentation stating there had been any recommendations on these medications to reduce or
taper them.
Record review of the facility’s policy on Drug Regimen Review, dated 10/2015 showed:
– The drug regimen review consist of a review and analysis of prescribed medication
therapy and medication use review;
– The consultant pharmacist reviews the medications at least monthly;
– Findings and recommendations are reported the Administrator, DON, the responsible
physician;
– The consultant pharmacist documents potential or actual medication therapy problems and
communicates them to the responsible physician;
– In performing drug regimen review, the consultant pharmacist utilized federal-mandated
standards of care, in addition to other applicable standards.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to ensure an appropriate
[DIAGNOSES REDACTED].#10) and failed to attempt gradual dose reductions (GDR’s) for two
residents (Resident #2 and #10) out of five sampled residents. The facility census was 24.
1. Record review of Resident #2’s Physician order [REDACTED].
– A [DIAGNOSES REDACTED].
– an order for [REDACTED].
– an order for [REDACTED].
Record review of the resident’s medical chart showed:
– Start date for the [MEDICATION NAME] 5/16/18;
– Start date for the [MEDICATION NAME] 5/31/18;
– No GDR’s attempted since the start dates;
– No documentation of contraindications of medications adjustments.
Record review of the pharmacy Medication Regimen Review (MRR), dated (MONTH) (YEAR)
through (MONTH) 2019 showed no recommendations for GDR’s.
2. Record review of Resident #10’s medical record showed:
– The resident admitted to the facility on [DATE];
– [DIAGNOSES REDACTED]. activities);
– an order for [REDACTED].> -an order for [REDACTED].
Record review of the resident’s medical chart showed:
– Start date for the [MEDICATION NAME] 4/25/18;
– Start date for the [MEDICATION NAME] 4/25/18;
– No GDR’s attempted since the start dates;
– No documentation of contraindications of medications adjustments;

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
– No attempt by the facility to document an appropriate [DIAGNOSES REDACTED].
Record review of the monthly pharmacy reviews for Resident #10, showed no recommendations
for GDR’s since admission (4/25/18).
During an interview on 5/9/19 at 2:30 P.M. Licensed Practical Nurse (LPN) C said he/she
did not think there had been any recommendations made by pharmacy and no GDR’s had been
attempted.
During an interview on 5/10/19 at 10:05 A.M., the Director of Nursing (DON) said the
pharmacist almost always has no recommendations marked on his reviews. She said the
pharmacist should have addressed recommendations to the physician. The DON said she could
not find any documentation stating there had been any recommendations on these
medications. She said the medications should have been reviewed and an attempt for
reduction should have been completed.
Record review of the facility’s policy on Drug Regimen Review, dated 10/2015 showed:
– The drug regimen review consist of a review and analysis of prescribed medication
therapy and medication use review;
– The consultant pharmacist reviews the medications at least monthly;
– Findings and recommendations are reported the Administrator, DON, the responsible
physician;
The consultant pharmacist documents potential or actual medication therapy problems and
communicates them to the responsible physician;
– In performing drug regimen review, the consultant pharmacist utilized federal-mandated
standards of care, in addition to other applicable standards.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation, interview and record review the facility failed to follow the
approved recipe for one lunch meal for one resident (Resident #13) of one sampled
resident. The facility census was 24.
1. Record review of the residents on a pureed diet (food that has been blended to a
pudding type consistency) showed resident #13 on a pureed diet.
Record review for the recipe for the pureed beef taco salad for a serving of one showed:
– Milk 2 percent (%), low fat, one fluid (fl) ounce (oz);
– Beef taco salad, one each.
Observation on 5/09/19 at 10:46 A.M. to 11:08 A.M., showed:
– Food Service Staff (FSS) A took an unmeasured amount of ground taco beef from a pan into
the mixer and pureed the beef, adding an unmeasured amount of 2% low fat milk;
– FSS A then placed the pureed taco beef into a pan and placed on steam table;
– FSS A then took an unmeasured amount of chopped tomatoes from a pan and placed into the
mixer and added an unmeasured amount of 2% low fat milk;
– FSS A then placed the pureed tomatoes into one small bowl;
– FSS A then took an unmeasured amount of shredded lettuce from a pan and placed into the
mixer and added an unmeasured amount of 2% low fat milk;
– FSS A then placed the pureed lettuce into a small bowl;
– FSS A then took an unmeasured amount from a can of nacho cheese dip into a small bowl;
– FSS A then took an unmeasured amount of taco chips and placed in the mixer and blended

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
with an unmeasured amount of 2% low fat milk;
– FSS A then placed the pureed chips into a pan on the steam table;
– FSS A did not have a pureed recipe for the taco beef, tomatoes, lettuce or chips.
During an interview on 5/09/19 at 11:10 A.M., FSS B said:
– He/she thought that the ground taco beef that was taken from the pan to be pureed was
about two or three cups, but was not sure.
During an interview on 5/9/19 at 11:12 A.M., FSS A said:
– He/she thought the ground taco beef taken from the pan was about two or three cups;
– He/she also thought the pureed lettuce, tomatoes, and chips was about two or three cups;
– He/she did not puree the shredded cheese, but instead just poured some nacho cheese dip
from the can into a small bowl.
During an interview on 5/10/19 at 8:00 A.M., the Dietary Manager said:
– FSS A was new and has only worked there a few weeks;
– He/she could not find a pureed recipe for the lettuce, tomatoes, chips, or shredded
cheese.
The facility did not provide a policy for following a pureed diet.

F 0807

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides drinks consistent with resident
needs and preferences and sufficient to maintain resident hydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to follow
physician orders [REDACTED].#9) of 12 sampled residents. The facility census was 24.
1. Record review of Resident #9’s physician’s orders [REDACTED].
– A [DIAGNOSES REDACTED].
– On 4/10/19 an order for [REDACTED].>Record review of the residents care plan, dated
4/10/19, showed provide nectar thickened liquids as ordered.
Record review of Swallow Evaluation dated 4/10/19, showed:
– Recommendation for nectar thickened liquids;
– Aspiration noted with thin liquids.
Observations on 5/08/19 at 12:10 P.M., showed:
– The resident lay in bed with eyes closed;
– Lunch tray with a small glass of beverage with regular consistency on bedside table;
– No packet of thickener on the tray;
– Water pitcher with regular consistency water on night table at bedside.
During an interview on 5/08/19 at 12:15 P.M., Licensed Practical Nurse (LPN) C said the
resident should have thickened liquids.
Observation made on 5/08/19 at 12:30 P.M., showed:
– Meal tray with mechanical soft diet and no beverage to small dining room on 100 hall;
– No packet of thickener on the tray;
– Diet lemon drink brought to tray, regular consistency.
During an interview on 05/08/19 at 1:05 P.M., LPN C said the resident has not been getting
thickened liquids. There are regular consistency drinks and snacks available in the
refrigerator at the nurses station and the residents can get what they want freely.
Observation of refrigerator at nurses station on 5/08/19 at 3:25 P.M., showed sodas, water
bottles, milk, and juice.
During an interview on 5/08/19 at 3:40 P.M., Certified Medication Technician (CMT) D said

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

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 0807

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
he/she was unsure about the residents liquids, they weren’t thickened yesterday.
During an interview on 5/8/19 at 3:45 P.M., the Transportation Clerk (TC) said he/she
gives the resident chips, peanut butter and crackers and sodas, he/she also sees the
resident going up and down the hall, in and out of resident rooms, eating and drinking
anything he/she can get his/her hands on.
Observation on 5/8/19 3:45 P.M., showed a mug of water and a bottle of water (regular
consistency) in residents room.
During an interview on 5/8/19 at 3:55 P.M., LPN C said the resident has been in here this
afternoon getting food, graham crackers, two bags of chips and peanut butter crackers and
a soda.
During an interview on 5/08/19 at 4:00 P.M., the Director of Nursing (DON) said there are
issues with the kitchen sending the wrong diet, if a resident has an order for [REDACTED].

During an interview on 5/08/219 at 4:05 P.M., the Dietary Manager said the dietary staff
doesn’t thicken the drinks, the packets of thickener are placed on the tray.
During an interview on 5/08/19 at 4:30 P.M. Certified Nurse Aide (CNA) E said the resident
drinks milk, Glucerna and coke that are regular liquid.
During an interview on 5/08/19 at 4:35 P.M., CNA F said the resident drinks really quick
and can drink three milks at a time.
Observation on 5/09/19 at 7:40 A.M., showed:
– The resident sitting in front of the nurses station;
– No water mug in his/her room.
During an interview on 5/9/19 at 7:50 A.M., the Physician said the resident had a swallow
study and it was recommended that he/she be on a mechanical soft diet with nectar
thickened liquids. The physician said he/she would expect that order to be followed.
He/she said the residents do not need to have access to a refrigerator for a lot of other
reasons, it makes it very difficult to regulate a residents blood sugar and then there are
the issues of infection control. The refrigerator needs to be moved and all of the staff
need in-serviced on resident’s needs.
During an interview on 5/09/19 at 8:30 A.M., the DON said when he/she checked the
residents room this morning a mug of regular consistency water sat in his/her room. It was
removed and staff would be made aware of the liquids and snacks that the resident can have
would need to be available.
Observations made on 5/09/19, showed:
– At 9:55 A.M., the resident lay in bed, eyes closed, no water mug in room;
– At 11:34 A.M., the resident lay in bed, eyes closed, no water mug in room;
– At 12:20 P.M., the resident lay in bed, eyes closed, no water mug in room.
Observations made on 5/10/19, showed:
– At 8:15 A.M., the resident lay in bed, no water mug in room, refrigerator and snacks
remains at nurses station;
– At 10:20 A.M., the resident sat on resident #18’s bed, drinking from cups on his/her
bedside table.
During an interview on 5/10/19 at 8:48 A.M., LPN C said he/she got a can of thickener and
placed it on his/her cart to use to thicken the residents liquids.
No policy was provided.

F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure therapeutic diets are prescribed by the attending physician and may be delegated
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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
to a registered or licensed dietitian, to the extent allowed by State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to follow
physician orders [REDACTED].#9) of 12 sampled residents. The facility census was 24.
1. Record review of Resident #9’s physician’s orders [REDACTED].
– A [DIAGNOSES REDACTED].
– On 3/14/19 an order for [REDACTED].>- On 4/10/19 an order for [REDACTED].>Record
review of the residents care plan, dated 4/10/19, showed:
– Provide diet as ordered, mechanical soft with nectar thickened liquids;
– Monitor and report chewing and swallowing problems to physician.
Record review of Swallow Evaluation dated 4/10/19, showed;
– Recommendation for mechanical soft diet with nectar thickened liquids;
– Aspiration noted with thin liquids and solid consistencies.
Observations on 5/8/19 at 12:10 P.M., showed:
– The resident lay in bed with eyes closed;
– Plate with regular diet with chicken parmesan and a small glass of beverage regular
consistency on bedside table;
– Water pitcher with regular consistency water on night table at bedside.
During an interview on 5/8/19 at 12:15 P.M., Licensed Practical Nurse (LPN) C said the
resident should be awakened and staff should make sure he/she is eating. The LPN said the
resident’s diet is incorrect, it should be mechanical soft and thickened liquids. The
staff will remove the tray and get the correct diet.
Observation made on 5/8/19 at 12:30 P.M., showed:
– Meal tray with mechanical soft diet and no beverage to small dining room on 100 hall;
– Diet lemon drink brought to tray, regular consistency;
– Resident to dining room and sat in front of his/her meal by unknown staff;
– Staff left room;
– Resident took a couple of bites and got up and walked out in the hall.
During an interview on 05/08/19 at 1:05 P.M., LPN C said the resident has not been getting
thickened liquids. He/she said the resident had eaten four sandwiches before lunch and
might not have been hungry. There are drinks and snacks available in the refrigerator at
the nurses station and the residents can get what they want freely. The resident is also
very bad about getting other residents food and drinks if given a chance, he/she has even
been seen getting in the trash can to get food out.
Observation of refrigerator at nurses station on 5/8/19 at 3:25 P.M., showed;
– Sodas, water bottles, milk, juice;
– Assorted sandwiches, (turkey, ham, chicken salad) pudding, jello;
– Top of refrigerator with assortment of chips;
– Beside refrigerator, saltine crackers, graham crackers and peanut butter crackers.
During an interview on 5/8/19 at 3:40 P.M., Certified Medication Technician (CMT) D said
the resident is on a mechanical soft diet but he/she was unsure about the liquids, they
weren’t thickened yesterday.
During an interview on 5/8/19 at 3:45 P.M., the Transportation Clerk (TC) said he/she
gives the resident chips, peanut butter and crackers and sodas, he/she also sees the
resident going up and down the hall, in and out of resident rooms, eating and drinking
anything he/she can get his/her hands on.
Observation on 5/8/19 3:45 P.M., showed a mug of water and a bottle of water (regular
consistency) in residents 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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
During an interview on 5/8/19 at 3:55 P.M., LPN C said the resident has been in here this
afternoon getting food, graham crackers, two bags of chips and peanut butter crackers and
a soda.
During an interview on 5/8/19 at 4:00 P.M., the Director of Nursing (DON) said there are
issues with the kitchen sending the wrong diet, if a resident has an order for [REDACTED].
During an interview on 5/8/219 at 4:05 P.M., the Dietary Manager said the staff knows not
to send a regular diet when a mechanical soft diet is ordered. He/she said they just
weren’t paying attention to it. Dietary staff doesn’t thicken the drinks, the packets of
thickener are placed on the tray.
During an interview on 5/8/19 at 4:10 P.M., Food Service Staff (FSS) A said he/she just
missed the order and would pay more attention from now on.
During an interview on 5/8/19 at 4:30 P.M. Certified Nurse Aide (CNA) E said the resident
has a mechanical soft diet since his/her swallow study, he/she drinks milk, Glucerna and
coke that are regular liquid.
During an interview on 5/8/19 at 4:35 P.M., CNA F said the resident walks into other
residents rooms and will take food if he/she sees any. During activities or in the dining
room he/she takes food and drinks off other resident trays causing complete chaos. He/she
said the resident also digs in the trash can and eats chips popcorn or whatever he/she can
find, eats and drinks really quick, can drink three milks at a time.
Observation on 5/9/19 at 7:40 A.M., showed:
– The resident sitting in front of the nurses station;
– No water mug in his room.
During an interview on 5/9/19 at 7:50 A.M., the Physician said the resident had a swallow
study and it was recommended that he/she be on a mechanical soft diet with nectar thick
liquids and the physician would expect that order to be followed. He/she said the
residents do not need to have access to that refrigerator for a lot of other reasons, it
makes it very difficult to regulate a residents blood sugar and then there are the issues
of infection control. That refrigerator needs to be moved. All the staff need in-serviced
on this resident’s needs.
During an interview on 5/9/19 at 8:30 A.M., the DON said when she checked the residents
room this morning, a mug of regular consistency water sat in his/her room. It was removed
and staff would be made aware of liquids and snacks that the resident can have would need
to be available.
Observations made on 5/9/19, showed:
– At 9:55 A.M., the resident lay in bed, eyes closed, no water mug in room;
– At 11:34 A.M., the resident lay in bed, eyes closed, no water mug in room;
– At 12:20 P.M., the resident lay in bed, eyes closed, no water mug in room;
– At 12:25 P.M., the noon tray delivered to small dining room on 100 hall, regular diet,
returned to the kitchen for mechanical soft diet.
Observations made on 5/10/19, showed:
– At 8:15 A.M., the resident lay in bed, no water mug in room, refrigerator and snacks
remains at nurses station;
– At 10:20 A.M., the resident sat on Resident #18’s bed, drinking two regular consistency
drinks from the residents bedside table;
– At 12:40 A.M., refrigerator and snacks remain at nurses station.
During an interview on 5/10/19 at 8:47 A.M., the Chief Nursing Officer (CNO) said he/she
was aware the resident got the wrong diet again at lunch yesterday but wasn’t aware he/she
got the wrong one again last night at super. He/she just didn’t think the kitchen cared.
The refrigerator would be moved today.
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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
During an interview on 5/10/19 at 9:20 A.M., the Dietary Manger said the cook fixes the
plates, there is a sheet that says what should be on the plate for therapeutic diets.
Tortilla chips should not be on a mechanical soft diet plate. The cook that was working
has just been here a couple of weeks and he/she just probably doesn’t know.
During an interview on 5/10/19 at 9:32 A.M., FSS G said no training is given, staff just
has to watch and do what everyone else does.
No policy was provided on therapeutic diets.

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.

Based on observation, interview, and record review the facility failed to store, prepare,
and distribute food under sanitary conditions. This affected all residents of the
facility. The facility census was 24.
1. Observation of the kitchen on 5/07/19 at 9:54 A.M., showed:
– The walk in refrigeration unit labeled leftovers, had sections of the door seal missing
and deteriorated;
– The walk in refrigeration unit labeled produce, had sections of the door seal missing
and deteriorated and four metal racks had rusted areas;
– The walk in refrigeration unit labeled juice, had sections of the door seal missing and
deteriorated, twelve racks had rusted areas and a three foot (ft) by two ft. section of
the wall rusted;
– The oven had one knob missing;
– The cart holding pans and other cooking utensils had two racks rusted;
– Four floor tiles near the stove had chipped and missing areas;
– Grease and dirt build up on the floor behind the stove;
– The plastic handle on two deep fryer baskets had chipped and missing parts;
– Blackend baked on substance around the edges of four baking sheets.
During an interview on 5/10/19 at 8:00 A.M., the Dietary Manager said:
– He/she really has not checked the door seals lately, but they will be repaired;
– He/she did not know about the knob missing on the stove but it will be fixed;
– He/she said the racks will be cleaned or repaired;
– The plastic handles on the deep fryer baskets will be replaced;
– The baking sheets will be cleaned or replaced;
– The wall in the walk in refrigeration unit will be repaired;
– The floors should be cleaned daily, but sometimes they are missed.
Record review of the facility’s undated Ambassador Cleaning List showed:
– Every day mop kitchen floor;
– Every day when you stock the fridge, clean the fridge.

F 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Conduct and document a facility-wide assessment to determine what resources are
necessary to care for residents competently during both day-to-day operations and
emergencies.

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Based on interview and record review, the facility failed to review and update the
comprehensive facility assessment annually in accordance with all applicable Federal
requirements. Failure to review and update the comprehensive facility assessment annually
could delay the services needed to care for the residents in day-to-day operations and in
emergencies. This failure could affect all facility occupants. The facility census was 24
with a capacity of 66.
1. Record review showed the facility did not have a policy for a facility assessment.
During an interview on 5/8/19 at 1:25 P.M. The Chief Nursing Officer (CNO) said she
thought the facility had several pieces of the facility assessment but not in a binder
like it needs to be. She said she had been reading on the requirements of the facility
assessment, will be working on it and would have one in place soon.

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 maintain
infection control practices to prevent the development and transmission of infection for
residents accessed with the multiple use blood glucometer (a device used to measure blood
sugar) for one resident (Resident #15) out of one sampled residents, one resident
(Resident #7) outside the sample, and wound care for one residents (Resident #15). The
facility also failed to correctly screen two residents (Resident #2 and #6) out of five
sampled residents for [MEDICAL CONDITION] (TB) (an infectious disease characterized by the
growth of nodules in the tissues, especially the lungs) required by state regulation 19
CSR 20-20.100. The facility census 24.
1. Observations on 5/08/19 at 4:00 P.M., showed:
– Licensed Practical Nurse (LPN) H performed blood sugar monitoring with the multiple use
glucometer for Resident #15;
– Wiped the glucometer for 20 seconds with a sani-cloth (a germicidal disposable wipe
which should be used to clean the glucometer and left wet for two minutes) and placed it
on top of the medication cart.
2. Observation on 5/08/19 at 4:05 P.M., showed:
– Using the same glucometer LPN H performed blood sugar monitoring for Resident #7;
– LPN H cleaned the glucometer for 10 seconds with a sani-cloth and placed it on top of
the medication cart.
During an interview on 5/8/19 at 4:15 P.M., LPN H said he/she was not aware the glucometer
needed to be cleaned for at least two minutes. He/she thought the glucometer should be
wiped down good and let air dry.
Record review of the facility’s policy, undated Accu-check cleaning and disinfecting,
showed:
– Place the glucose meter on a level surface;
– Power off the meter, put on a pair of gloves;
– Remove the disinfecting wipe form its container and cleanse all surfaces;
– The minimum contact time is five minutes.
3. Observation on 5/09/19 at 9:55 A.M., showed:
– LPN H entered Resident #15’s room to perform wound care;
– LPN H placed the treatment cart inside the resident’s room;
– LPN H performed wound care for Resident #15, when completed rolled the treatment cart 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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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 16)
the hall.
During an interview on 5/09/19 at 10:00 A.M., LPN H, he/she said the supplies that are
needed are in the cart and it just makes sense to bring the cart inside the room instead
of leaving it in the hall.
During an interview on 5/09/19 at 11:00 A.M., LPN C said he/she leaves the treatment cart
in the hall, that would be cross contamination if staff takes the cart in the room.
During an interview on 5/10/19 at 8:00 A.M., the Chief Nursing Officer (CNO) said the
treatment cart should not be taken in the resident’s rooms. She said it should be left in
the hall and supplies brought from the cart to the room.
4. Record review of Resident #2’s medical record showed:
– The resident admitted to the facility on [DATE];
– The resident received annual TB on 5/07/19;
– No documentation of results in millimeters (mm).
5. Record review of Resident #6’s medical record showed:
– The resident admitted to the facility 11/09/18;
– The resident received annual TB on 2/06/19;
– No documentation of results in mm.
During an interview on 5/10/19 at 12:30 P.M. the Director of Nursing said the
immunizations records are kept in the residents’ charts. She said the TB’s are given
annually in May. She was not aware the results needed to be documented in millimeters.
No facility policy provided.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide information and
education to each resident or the resident’s representative for the pneumococcal vaccines,
and offer the pneumococcal vaccines upon admission for four residents (Resident #2, #5,
#6, and #21) out of five sampled residents. This deficient practice had the potential to
affect all residents. The facility census was 24.
1. Review of the US Department of Health and Human Services Centers for Disease Control
(CDC) Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following:
– CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate
vaccine (PCV 13, Prevnar 13) and 23-valent pneumococcal vaccine (PPSV 23, [MEDICATION
NAME] 23);
– CDC recommends vaccination with PCV 13 for all adults [AGE] years or older and adults 19
through [AGE] years old with certain medical conditions:
– CDC recommends vaccination with PPSV 23 for all adults [AGE] years or older and adults
19 through [AGE] years old with certain medical conditions.
2. Review of Resident #2’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines.
3. Review of Resident #5’s medical record showed:
– The resident admitted on [DATE];

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:

26A469

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

NAME OF PROVIDER OF SUPPLIER

PEMISCOT COUNTY MEMORIAL HOSPITAL

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines.
4. Review of Resident #6’s medical record showed:
– The resident admitted on [DATE];
– The resident 87 old;
– [DIAGNOSES REDACTED].
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines.
5. Review of Resident #21’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].>- Staff did not document the resident’s pneumococcal history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines.
During an interview on 5/10/19 at 12:05 P.M. the Director of Nursing (DON) said the
facility does not document giving the education to the residents or the residents
representative. The pneumococcal vaccine is given to the residents prior to being admitted
to this facility.
During an interview on 5/10/19 at 12:10 P.M. the Social Services Director (SSD) said she
puts the education sheet for immunizations in the admission packet, but does not have any
documentation of giving the education to the residents’ or the representative.
During an interview on 5/10/19 at 12:10 P.M. the Chief Nursing Officer (CNO) said the
facility had been looking at the different pneumococcal vaccines and the recommendation in
giving the injection to the residents.
Record review of the facility’s policy on Pneumococcal vaccine policy, dated 7/2018
showed:
– It is the policy of this facility to offer and administer annual influenza vaccination
prior to the onset of the flu season, unless contraindicated, and the pneumococcal
vaccination as indicated;
– There is evidence that vaccinating the elderly in long-term care facilities may provide
some protection against pneumonia, hospitalization and mortality;
– Residents (or their next-of-kin if the resident is incapable of providing informed
consent) should be provided with adequate information about the vaccine to enable them to
make an informed decision about whether to be vaccinated or not;
– Vaccine administration should be documented in the residents’ health care records;
– New residents without prior evidence of receipt of pneumococcal vaccination should also
be offered this vaccine.