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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 observations, interview and record review, the facility failed to ensure there
were not pungent urine odors in resident room [ROOM NUMBER] and in the shared restrooms of
106/107 and 101/100; to ensure night lights illuminated when the switch was activated in
resident rooms 514, 513, 509, 508, and 506; to ensure large areas of dust and cobwebs were
cleaned in resident room [ROOM NUMBER] and 207; to maintain a fall mat in 303 in an easily
cleanable condition; to maintain the tub in the shower room close to the 200 Hall, free
from areas that were not easily cleaned; and to maintain a mattress in Resident #15’s room
free from tears that caused the mattress to stay wet. This practice potentially affected
at least 40 residents who reside in or use those areas. The facility census was 79
residents.
1. Observation on 1/8/19 at 9:55 A.M., showed a pungent urine odor in resident room [ROOM
NUMBER] and
-At 1:09 P.M., a pungent urine odor was noted in the shared restroom of resident rooms
[ROOM NUMBERS], and at 1:11 P.M., and a pungent urine odor in the shared restroom of
resident room [ROOM NUMBER] and 107.
Observation on 1/10/19 at 12:34 P.M., showed the pungent urine odor in the shared restroom
of 101 and 100 and at 12:35 P.M., and the pungent urine odor was present in the shared
restroom of resident rooms [ROOM NUMBERS].
During interviews on 1/10/19 at 1:03 P.M. the Director of Nursing (DON), the Assistant
Director of Nursing (ADON) and Licensed Practical Nurse (LPN) C said the residents in
resident rooms [ROOM NUMBERS] did not use the restrooms properly and the ADON said he/she
had noticed the urine odors in the past.
During an interview on 1/10/19 at 1:11 P.M., Housekeeper A said:
– He/she used a tile and grout rejuvenator when there is urine on the floor;
– He/she used an enzyme activator;
– Sometimes those restrooms with urine odor are cleaned two to three times per day and
– The odor is still there.
During an interview on 1/10/19 at 1:13 P.M.,the Housekeeping Supervisor said they try to
clean resident room [ROOM NUMBER] restrooms daily and at times 3-4 times per day.
2. Observations with the Housekeeping Supervisor and the Incoming Administrator on 1/8/19
from 9:51 A.M., through 10:13 A.M., showed the night lights in resident rooms 514, 513,
509, 508, and 506 did not illuminate when the switch for the night lights in those rooms
was turned on.
During interviews on 1/8/19 at the times of the observations, the both the Housekeeping
Supervisor and the Incoming Administrator acknowledged the night lights did not
illuminate.
3. Observations on 1/8/19, showed the following:
– At 10:09 A.M., there was a buildup of dust and cobwebs in resident room [ROOM NUMBER]
and
– At 10:56 A.M., there was a buildup of dust and cobwebs in the corner at the other side
of the climate control unit, in resident room [ROOM NUMBER].
Observations with the Housekeeping Supervisor on 1/10/19 at 1:16 P.M., showed a buildup of
dust and cobwebs in resident room [ROOM NUMBER] and
– At 1:19 P.M., showed a buildup of dust and cobwebs in the corner at the other side of
the climate control unit, in resident room [ROOM NUMBER].
During an interview on 1/10/19 at 1:17 P.M., the Housekeeping Supervisor said the

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

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
housekeepers should use dust mops to get at the cobwebs and the dust area that are not
usually seen in the resident rooms.
4. Observation with the Housekeeping Supervisor on 1/8/19 at 11:31 A.M., showed a 4 inch
(in.) rip in the fall mat in resident room [ROOM NUMBER], which rendered it not easily
cleanable.
During an interview on 1/8/19 at 11:35 A.M., Certified Medication Technician (CMT) A said
he/she did not know about that rip in the fall mat in resident room [ROOM NUMBER].
5. Observation with the Housekeeping Supervisor on 1/8/19 at 11:08 A.M., showed a 3 in.
gouge and a 4 in. gouge in the shower tub in the shower room close to the 200 Hall.
During an interview on 1/8/19 at 11:33 A.M., Certified Nurse’s Assistant (CNA) B said the
chair portion of the lift scraped against the tub which caused the gouges and areas that
were not easily cleanable.
6. Record review of the Resident #15’s quarterly Minimum Data Set (MDS- a federally
mandated assessment tool required to be completed by facility staff for care planning)
dated 10/10/18, showed he/she was able to understand others and make self-understood and
had Brief Interview for Mental Status (BIMS) of 14.
During an Interview on 1/8/19 at 8:55 A.M., the resident said:
– The linens were not change in timely and properly and the bed remained wet even after
the sheet were changed;
– License Practical Nurses (LPN) D checked the resident after the resident used the call
light and CNA E came in to change the sheets, and did not wipe the bed down and
– The bed was still wet.
During an interview on 1/9/19 at 5:00 A.M., CNA E said:
-The LPN D checked on the resident and the resident sheets were changed, and he/she wiped
the resident’s mattress;
– After about 30 minutes the resident used the call light again and the resident said the
bed was soaked again after the CNA E asked the resident what was the matter;
– He/she saw that the mattress was damaged with cracks and the liquid had soaked into the
mattress and
– The resident needed a new mattress,
During an interview on 1/9/18 at 6:15 A.M., LPN D said:
-The resident’s sheets had sweat stains on them, when he/she was in the room and
– He/she was not aware of the juice had been spilled in the resident bed, or there was a
wet bed issue.
Observations on 1/10/19 at 2:01 showed an 8 inch diameter area of the mattress where the
mattress cover was worn away and the presence of a 1 in. tear towards the foot end of the
mattress.
During interviews on 1/10/19 at 2:02 P.M., LPN A and CNA A said the following after
observing the damaged mattress:
-CNA A said that mattress has been used by Resident #15 since before Thanksgiving and
he/she has noticed the worn area and
– LPN A said he/she did not know that Resident #15’s mattress was damaged.
During an interview on 1/11/19 at 10:55 A.M., the Maintenance Supervisor said they changed
the mattress in room [ROOM NUMBER], and before yesterday (1/10/19) he/she had not heard
about the mattress being damaged.
Complaint MO 114

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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the resident and/or
the resident’s representative(s) with a discharge letter explaining the reasons for the
residents discharge or transfer to the hospital for three sampled residents (Resident #18,
#37 and #181) out of 22 sampled residents. The facility census was 79 residents.
1. Record review of Resident #18’s facility Admission Record showed he/she was initially
admitted on [DATE] with the following Diagnoses: [REDACTED].
-End Stage [MEDICAL CONDITION] (ERSD-The kidneys have stopped filtering excess fluids and
toxins from the blood stream);
-[MEDICAL CONDITION]-(Low levels of [MEDICAL CONDITION] hormone that helps regulate the
body’s metabolism) and
-[MEDICAL TREATMENT] (is a process that removes excess water, solutes, and toxins from the
blood in people whose kidneys can no longer perform these functions naturally).
Record review of the resident’s Quarterly Minimum Data Set (MDS- a federally mandated
assessment completed by facility staff to be used for care planning) dated 10/29/18
showed:
-The resident was cognitively intact;
-He/She required supervision only in Activities of Daily Living (ADL’s) and
-He/she received [MEDICAL TREATMENT] treatment for [REDACTED].
Record review of the resident’s MDS assessments showed he/she had been discharged with
return anticipated on the following dates:
-May 1, (YEAR);
-June 16, (YEAR);
-August 6, (YEAR) and
-November 11, (YEAR).
During an interview on 1/11/19 at 9:30 A.M., Licensed Practical Nurse (LPN) B said:
-He/she had prepared a computer discharge summary for the hospital with information about
the resident;
-He/she would have had written a nurse note in the resident’s chart with the reason for
the transfer/discharge and
-He/she has not given a discharge letter to a resident or to a resident’s
representative(s).
During an interview on 1/11/19 at 9:35 A.M., LPN A said:
-He/she has filled in the discharge summary which is given to the hospital and was
primarily information found on the resident’s face sheet and
-He/she has not had a resident or resident’s representative request a copy of the
discharge summary.
During an interview on 1/11/19 at 10:00 A.M., the Social Service Designee (SSD) said:
-He/she had not done a discharge letter for the resident or the resident’s
representative(s) and
-He/she had faxed the Ombudsman about reasons for discharge.
2. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS 11/28/18, showed he/she:
-Was alert and oriented with communication deficits;
-Needed total assistance of two staff members for bathing, dressing, mobility and

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

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
toileting and
-Had limited range of motion in both upper and lower extremities.
Record review of the resident’s Medical Record showed the following hospitalization s:
-From 12/21/18-12/27/18 for chronic urinary tract infection, inflammation of the rectum
and elevated blood nitrogen levels;
-From 12/3/18 -12/5/18 for nausea, vomiting recurrent urinary tract infection.
-On 10/28/18 for abdominal pain and
-From 10/10/18 -10/16/18 due to pneumonia and complicated urinary tract infection.
Record review of the resident’s Medical Record showed there was no documentation the
resident or the resident’s responsible party was informed of the resident’s discharge to
the hospital or anticipated return to the facility.
3. Record review of Resident #181’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed he/she:
-Had memory problems and
-Needed extensive assistance with bathing, grooming, dressing, mobility, and toileting.
Record review of the resident’s Medical Record showed he/she was hospitalized from [DATE]
to 11/10/18 and from 12/27/15 to 1/5/19. There was no documentation showing the facility
had notified the resident or his/her responsible party of the reasons for his/her
hospitalization or information regarding his/her rights to return to the facility.
4. During an interview on 1/11/19 at 10:34 A.M., the Director of Nursing (DON) said:
-He/she did not know the facility was required to give the resident or the resident’s
representative a letter with the reasons for the discharge or transfer to a different
facility and
-He/she knew that a discharge letter had not been given to resident or the resident’s
representative.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide the facility’s bed
hold policy to one sampled resident (Resident# 18) or the resident’s representative out of
22 sampled residents. The facility census was 79 residents.
1. Record review Resident # 18’s Admission Record showed he/she was admitted on [DATE]
with the following Diagnoses: [REDACTED].
-End stage [MEDICAL CONDITION] (ERSD-The kidneys have stopped filtering excess fluids and
toxins from the blood stream);
-[MEDICAL CONDITION]-(Low production by the [MEDICAL CONDITION] of a hormone that helps
regulate the body’s metabolism) and
-Dependence on [MEDICAL TREATMENT] (an artificial process that removes metabolic wastes,
toxins and excess fluids from the blood stream).
Record review of the resident’s Quarterly Minimum Data Set (MDS- a federally mandated
assessment completed by facility staff to be used for care planning) dated 10/29/18
showed:

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

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-The resident was cognitively intact;
-He/she required supervision only in Activities of Daily Living (ADL’s) and
-He/she received [MEDICAL TREATMENT] treatment for [REDACTED].
Record review of the resident’s MDS assessments showed the resident had been discharged
with return anticipated on the following dates:
-May 1, (YEAR);
-June 16, (YEAR);
-August 6, (YEAR) and
-November 11, (YEAR).
During an interview on 1/11/19 at 9:30 A.M., Licensed Practical Nurse (LPN) B said:
-He/she did a computer discharge summary for the hospital and
-He/she did not give a bed hold letter to a resident or the resident’s representative.
During an interview on 1/11/19 at 9:35 A.M. , LPN A said:
-He/she did not give a bed hold policy letter to residents at discharge and
-He she did not know what a bed hold policy letter was.
During an interview on 1/11/19 at 10:00 A.M., the Social Service Designee (SSD) said:
-The bed hold policy was reviewed at admissions with the resident and representatives and
-He/she did not send out a copy of the bed hold policy when a resident was discharged or
transferred.
During an interview on 1/11/19 at 10:34 A.M., the Director of Nursing (DON) said:
-He/she was not aware the facility needed to give the resident or the resident’s
representative a copy of the facility’s bed hold policy at discharge or transfer and
-He/she knew a copy of the bed hold policy was not provided to the resident or the
resident’s representative(s).

F 0675

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor each resident’s preferences, choices, values and beliefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
necessary clothing and to provide the choice to get dressed daily for one sampled resident
(Resident #3), out of 22 sampled residents. The facility census was 79 residents.
1. Record review of Resident #3 Admission Face Sheet showed he/she was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION](MS is a nervous
system disease that affects your brain and spinal cord. It damages the myelin sheath);
-Urinary tract infection (UTI is an infection in any part of your urinary system);
-Gastrostomy status (A surgical opening into the stomach for internal feeding);
-Tracheotomy (is a surgically created hole (stoma) in your windpipe (trachea) that
provides an alternative airway for breathing);
-Flaccid neuropathic bladder (is bladder dysfunction (flaccid or spastic) caused by
neurological damage);
-[MEDICAL CONDITION] (is defined as paralysis of all four limbs);
-[MEDICAL CONDITION] (is an opening called a stoma that connects the colon to the surface
of the abdomen);
-Came in to the facility with an indwelling catheter (is a tube drains urine from your
bladder into a bag outside your body) and had contractures (deformity is the result of
stiffness or [MEDICATION NAME] in the connective tissues of your body).

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

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 0675

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
Record review of the resident Care Plan dated 1/2/19 showed:
-Staff are to assist the resident with all Activity of Daily Living (ADL’s) as needed;
-Inadequate nutritional intake-gastric tube for nutritional support;
–Head of bed evaluated;
–Observe for signs and symptoms of worsening condition and notify the resident’s
physician of changes and
–Provide opportunity and encourage resident to attend activities and other social events
per his/her preference.
Record review of the resident’s Entry Tracking Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 1/1/19 showed:
-No documentation related to the resident’s daily preferences and
-Was admitted to the facility on [DATE].
Record review of the resident’s progress notes dated from 1/1/19 to 1/9/19 showed no
documentation from social services related to the admission and related to preferences of
wanting to get dressed in the mornings or wearing a hospital gown all day.
Record review of the resident’s medical record showed his/her inventory sheet listed one
pair of jeans, one T-shirt and a pair of shoes.
During an interview and observation on 1/7/19 at 8:01 A.M., showed:
-The resident was in his/her bed with a hospital gown on with no sheets during the
interview;
-Had not been up in his/her wheel chair as much;
-Had not felt like getting out of bed, care staff had been repositioning the resident and
-His/her catheter bag was covered hanging off the side of the bed.
Observation and interview on 1/7/19 at 11:40 A.M. showed:
-The resident lying in bed with the head of the bed elevated;
-Had contractures of his/her hands and had a specialized call light system that you blow
into for assistance;
-Had a Low air lost mattress on his/her bed;
-Had a catheter and the catheter drainage bag was covered in low position on the side bed
rail;
-Had a tracheotomy in place and had a suction machine at the bed side for use as needed;
-Had oxygen in place per an oxygen concentrator;
-Denied any concerns with staff not providing care as needed;
-No odors noted in the resident’s room and
-The resident was wearing a hospital gown.
Observation on 1/8/19 at 1:25 P.M. showed the resident after his/her shower:
-Certified Nurse Assistant (CNA) F had redressed the resident into a clean hospital gown;
-The care staff did not offer or ask the resident about getting dressed in regular clothes
and
-The resident had contractures to both his/her arms and hands.
During an interview on 1/8/19 at 2:00 P.M., the Director of Nursing (DON) and CNA F said:
-The resident prefer to wear a hospital gown;
-He/she does not have any other clothes at the facility, except for the jeans that the
resident likes;
-The DON said was easier for the resident to have gown on because of all the tubes and
appliance the resident had and the resident did not have any other clothes at the
facility;
-The resident’s spouse had not brought back any other clothes for the resident and
-The resident got hot easily and didn’t like to have a blanket on.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 0675

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
Observation on 1/9/18 at 12:15 P.M., showed the resident:
-Had been placed in his/her wheelchair and was sitting in the bistro dining area;
-Other residents were eating lunch and the television was on and
-Had a hospital a gown on and had a sheet covering his/her legs.
During an interview on 1/11/19 at 9:30 A.M., the resident said:
-He/she would like to be able to have regular clothes on during the day time, and had not
been offered thee choice of what to wear except for the hospital gown;
-When the resident lived at home, he/she would get dressed in regular clothes daily and
-The jeans in the closet did not fit right, related to his/her ostomy and catheter, had
complained of discomfort when he/she had worn them.
Observation on 1/11/19 at 9:33 A.M. of the resident’s closet showed one pair of jeans, one
T-shirt and one pair of shoes.
During an interview on 1/11/19 9:40 A.M., Social Service Designee (SSD) said:
-He/she was not aware the resident did not have clothes or that resident wish to get
dressed daily;
-Upon admission the staff completed the inventory sheet and he/she completed the social
service assessment, which include daily routines and preferences;
-If a resident is admitted with no clothes he/she would ask the resident’s family first to
provide clothing;
-Then he/she would reach out to local groups to assist and the facility does have a fund
to be able to get clothes for the residents;
-The family thought the resident was only going to be at the facility temporarily and but
now the facility will be the resident’s home;
-He/she will reach out to the resident’s family for clothes and
-Nursing staff or the housekeeping staff will let him/her know if a resident’s clothes are
worn out, too big or too small, then he/she will follow-up.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
activities were provided for resident’s who were unable to go to group activities without
assistance and for whom one to one individualized activities were to be administered for
three sampled residents (Resident #37, #62 and #3); to ensure measurable goals were
identified on the care plan for one sampled resident (Resident #37); and to provide
scheduled evening activities for residents. The facility sample was 22 residents. The
facility census was 79 residents.
Record review of the facility’s Activity policy and procedure dated 5/1/2012, showed the
facility:
Purpose: To provide activity program staff with a reference, as to the role of the
activity program department in the facility, and the organization of that department.
Standard: According to federal regulations, the facility must provide for an ongoing
program of activities designed to meet, in accordance with the comprehensive assessment,
the interest and physical, mental and psychosocial well-being of each resident.
Process: Activities should be designed to provide meaningful activity to each resident,
consistent with their background and interest, 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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
In planning activities, the staff should consider:
-Resident choice and abilities
-Plans to encourage residents to attend, or to promote activities
-Assistance for residents to get to activities.
-Means to record participation and resident response to activities.
1. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS- a federally mandated
assessment tool to be completed by facility staff for care planning) dated 11/28/18,
showed the resident:
-Was alert and oriented with communication deficits;
-Needed total assistance of two staff members for bathing, dressing, mobility, and
toileting and
-Had limited range of motion in both upper and lower extremities.
Record review of the resident’s Care Plan dated 12/31/18, showed the resident’s activity
care plan identified the resident liked visiting with residents, staff, family and peers,
computer access, religious activities, going outside, watching television and musical
activities. The care plan did not show any measurable goals for activities for the
resident (to include frequency of attendance) and did not show that the facility provided
any one to one activities with the resident.
Record review of the resident’s Group Activity Participation Record dated (MONTH) 2019,
showed:
-The resident refused to participate in from two to four activities daily;
-Everyday the resident participated in an independent activity;
-On 1/7/19 it showed the resident chose not to attend social programs and physical
programs;
-On 1/8/19 it showed the resident refused intellectual programs, religious programs and
social programs;
-On 1/9/18 it showed the resident refuse to participate in social programs;
-On 1/10/19 it showed the resident refused to participate in diversional programs, social
programs and physical programs and
-There was no documentation on 1/11/19.
Record review of the facility’s Activity Calendar showed:
-On 1/7/19 showed activities for the day were 9:30 A.M. Unit Reminiscing; 10:30 A.M.
Sittersize; 11:00 A.M. Rob the table and 2:30 P.M. Bingo. There were no scheduled
activities after 2:30 P.M;
-On 1/8/19 showed the activities for the day were 9:30 A.M. Unit Music; 10:30 A.M. Bible
Study; 1:30 P.M. Riddle Me This and 2:30 P.M. Music with a scheduled musician. There were
no scheduled activities after 2:30 P.M;
-On 1/9/19 showed the activities for the day were 9:30 A.M. Unit Volleyball; 10:30 A.M.
Life Stories; 1:30 P.M. Dominoes and 2:30 P.M. Bingo;
-On 1/10/18 showed the activities for the day were 9:30 A.M. Unit Reading; 10:30 A.M. Warm
Up; 10:45 A.M. Noodle Wars; 1:30 P.M. Crafts and 2:30 P.M. Billy Winds;
– On 1/11/18 showed the activities for the day were 9:30 A.M. Unit Crafts, 10:30 A.M. Pass
the Pigs; 1:30 P.M., Bistro Board Game and 2:30 P.M. Happy Hour;
-Record review of the Activity Calendar showed the latest daily activity for the week
began at 2:30 PM. There were no activities scheduled after 2:30 PM from 1/7/19 to 1/11/18.
Observations from 1/7/19 to 1/9/19, showed the resident stayed in his/her bed during the
day. Nursing staff did not get the resident up out of bed into his/her wheelchair during
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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
the day shift (7:00 A.M. to 3:00 P.M.) or the night shift (11:00 P.M. to 7:00 A.M.). There
were no observations of the resident participating in scheduled activities. The resident
was observed to watch television during the day while in bed.
Observation at 1/10/18 at 5:30 P.M., showed the resident was up in his/her specialized
wheelchair in the television room watching television with other residents. There was no
structured activity at this time. At 6:00 P.M., nursing staff took the resident back to
his/her room.
During an interview on 1/9/19 at 5:30 A.M., Certified Nursing Assistant (CNA) Q said they
normally do not get the resident up on the night shift. The resident usually is in bed for
most of the day, but staff will get the resident up in the evening (around 4:00 P.M.-5:00
P.M.), at the resident’s request, and the resident usually stays up late into the evening.
He/she did not know if the resident received activities during the day while he/she was in
his/her room.
During an interview on 1/11/19 at 9:49 A.M., the Activity Director said:
-He/she writes the activity care plan and he/she was new to the process and was still
learning to write them;
-He/she provided one to one activities to the residents who were total care and do not/can
not come to group activities;
-He/she documents the activity participation sheets to show the activities he/she does
individually with residents;
-He/she tries to provide one to one activities twice weekly;
-He/she will complete the last activity of the day at 2:30 PM and that will last longer
than some of the other activities, but he/she leaves at 5:00 P.M. unless he/she is going
to do an evening activity then he/she will stay later;
-He/she does not schedule an evening activity daily, maybe twice monthly;
-He/she does not complete an evening activity schedule for the nursing staff to initiate
for the residents;
-He/she was the only person who initiates activities;
-He/she had not gotten around to providing one to one activities with some of the
residents this week;
-He/she had not provided activities with the resident this week;
– The resident did not get up during the day and usually staff got him/her up in the
evening;
– The resident watched television during the day and when he/she was up in the evening,
he/she liked to get on his/her computer;
-He/she provided one to one activities to the resident because he/she needed total
assistance and he/she did not usually get up during the day (when scheduled activities are
provided);
-Normally when he/she goes to provide one to one activities to the resident he/she will
talk to him/her;
-He/she made a mistake on the resident’s activity documentation and had written that
he/she provided one to one activities to him/her this week and that was not correct.
2. Record review of Resident #3’s Admission Face Sheet showed he/she was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED]. direct airway through an incision in the
trachea), Flaccid neuropathic bladder (caused by neurological damage that can cause
incontinence, [MEDICAL CONDITION], frequency and urgency), [MEDICAL CONDITION] (paralysis
caused by an injury or illness that results in the partial or total loss of use of all
four limbs and torso), [MEDICAL CONDITION] (a surgical operation in which a piece of the
colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged
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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
part of the colon);
-Came in with an indwelling catheter ( a tube inserted into the bladder to drain the
urine) and had contractures (a muscle or tendon that is shortened or tightened to the
point that it can’t stretch normally).
Record review of the resident Care Plan dated 1/2/19 showed:
-Staff are to assist the resident with all Activity of Daily Living (ADL’s) as needed and
-Provide opportunity and to encourage the resident to attend activities and other social
events per his/her preference
Record review of the resident’s Entry Tracking MDS, dated [DATE] showed he/she was
admitted to the facility in 1/1/19 and the staff did not document the resident’s
preferences.
Record review of the resident’s Activity Documentation showed:
-October (YEAR) choose not to attend most group activity and under independent activity
had social contact;
–At the top of the page the staff wrote the resident talks to his/her spouse daily and
sits in the bristo, top page hand written talks to wife daily sit in bistro;
-November (YEAR) choose not to attend most group activity and under independent activity
had social contact and television;
–top page hand written talks to wife daily sit in bistro and
-Was admitted to hospital from 11/25/18 to 12/31/18.
Record review of the resident’s Activity Admission Review dated 1/1/19 showed:
-Had a [DIAGNOSES REDACTED].
-Able to make self-understood and understand others clear comprehension;
-Had unclear speech, no difficulty seeing;
-Preference and customary routine include passive activity sitting outdoors, movies and
television;
-Other observation details had; talks to wife daily, sits in bistro and watches Television
and
-No other documentation found related to specialty activity plan or assessment for
resident with limitation.
During an interview on 1/11/19 at 9:15 A.M., Activity Director said:
-The resident’s like to watch Television, talks to wife on the phone daily and goes to
Bistro sometime;
-Activity staff try to provide one on one with the resident at least 1-2 times a week;
-Was not sure if the resident care plan included one-one activity with the resident;
-On the facility monthly activity calendar are the days marked for 1-1 visit or room
visit;
-During those room visit would provide information about the current news, read to them,
nail care, lotion and massage of arms and hands provide during one on one;
-He/she said at this time does not currently have any special activity for resident that
are bed bound or that require special equipment, such as resident with limited use of
hands;
-Activity staff had not provided or inquired about the resident’s past interest or
occupation for possible ideas for initialized type activities for the resident;
-Had not reach out to occupation therapy or speech therapy for resources for resident with
limitation;
-Had been working on putting in place a sensory box for use with the residents and
-He/she had online training for his/her position as Activity Director.
3. Record review of Resident #62’s face sheet showed he/she was admitted to the facility
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
on [DATE] with the following Diagnoses: [REDACTED].
-[MEDICAL CONDITION] (Persistent problems falling and staying asleep);
-Parkinson (A disorder of the central nervous system that affects movement, often
including tremors) and
-Type II Diabetes (A chronic condition that affects the way the body processes blood
sugar).
Record review of the resident’s annual MDS dated [DATE] showed he/she:
-Had a Brief Interview Mental Status (BIMS) score of 12, which describes the resident was
cognitive alert and oriented;
-Was able to express some ideas and wants to others in a consistent and reasonable manner;
-Was a one person assist with Activities of Daily Living (ADL) for eating, bathing,
dressing, transferring, personal hygiene and mobility needs and
-Was able to eat independently with set up help only.
Record review of the resident’s Care Plan dated, 4/21/17 showed he/she:
-Was to encourage family visits;
-Deliver mail timely;
-Resident often enjoys doing exercises in room including standing and stretching along
door frame and sitting on floor for stretching and
-He/she enjoys music activities.
Record review of the resident’s Group Activity Participation Record dated (MONTH) (YEAR),
(MONTH) (YEAR), and (MONTH) (YEAR) showed resident:
-Had participated in the following activities during the morning hours intellectual,
spiritual/religious, community based, social programs, physical programs and independent
activities;
-The above group activity participation recorded dated (MONTH) (YEAR), (MONTH) (YEAR) and
(MONTH) (YEAR) did not indicate the resident had participated in evening activities and no
timeframes had been indicated for the resident and
-Did not have an individual activity participation record on file when the information was
requested during annual survey process.
Observations showed the resident:
-On 1/7/19 at 10:30 A.M. was resting in bed;
-On 1/8/19 at 10:25 A.M. was sleeping in bed;
-On 1/9/19 at 11:00 A.M. was standing near the nurse’s station alone;
-On 1/9/19 at 3:00 P.M. was laying in his/her bed and
-On 1/9/19 at 4:30 P.M. was laying in his/her bed and talking to his/her roommate.
Record review of the facility monthly calendar dated (MONTH) (YEAR), (MONTH) (YEAR) and
(MONTH) (YEAR) showed activities starting between the hours of 10:30 A.M. – 2:30 P.M.
Record review of the facility monthly calendars for the month of October, (MONTH) and
(MONTH) indicated one evening activity for the above months during the holiday season,
(i.e. Halloween, Thanksgiving and Christmas);
-The remaining nine months calendar did not show or indicate an evening activities for
resident to select or choose from after 2:30 P.M. and
-The weekend activities consisted of morning church or devotional activities.
Non-religious activities were not found on the 12 month activity calendar for the
residents.
4. During an interview on 1/10/19 at 1:30 P.M. the Activity Director said:
-He/she provided monthly activities for the residents;
-He/she had recorded group activity participation record and had been behind on his/her
charting record to show how he/she individualize for the residents at the facility;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-He/she was the only Activity Director to provide activities for 70 residents;
-He/she said sometime the nursing staff were able to assist him/her with activities for
the resident but not on a consistent basis;
-He/she tries to come back on the weekend and evenings to assist with activities with the
resident but the current monthly calendars of the month only showed evening’s activities
during the month of Thanksgiving (YEAR) and (MONTH) (YEAR) and
-He/she mainly offers evening activities during the holiday months.
During an interview on 1/11/19 at 11:00 A.M., the MDS Coordinator said:
-He/she had only worked the facility for a few months and desire to work closely with the
Activities Director to promote and enhance the resident’s cognitive and emotional health
and development of each resident through structured learning activities;
-He/she was interested in documenting positive outcomes for each resident as he/she
continues to work with the Activities Director for the resident’s to have self-expression
and to meet the interests and needs of the residents and
-He/she stressed the importance of creating an individualized and structured learning plan
for each resident.
During an interview on 1/11/19 at 12 Noon, the Social Services Designee said:
-He/she expected activities to be offered during day and evening hours to help promote the
resident psycho-social development of each resident within the facility and
-He/she expected activities need to go into the community so that the residents can
maintain in touch with their community and participate in social events (i.e. gardening,
arts, crafts and music).
During an interview on 1/11/19 at 12:15 P.M., the Charge Nurse said activities are offered
to the residents mainly doing the morning hours;
-He/she said the facility currently only had one Activity Director for approximately 70
residents and
-He/she said the nursing staff tries to provide assistant to the Activities Director but
it depends on what nursing cares are immediate needed to the residents on the varied
floors and work shifts.
During an interview on 1/11/19 at 12:30 P.M., the Director of Nursing ( DON) said:
-Activities are very important to the resident because it provides stimulation, and the
activities help to meet the resident emotional health and it allows for self-expression
and support and their choices of activities;
-He/she tries to assist the Activities Director with getting the residents to the planned
activities and
-He/she encourages the resident to participate and he/she is responsive to the
psych-social needs of each resident.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure to
document blood sugar results and follow-up care assessment for one sampled resident
(Resident #15) out 22 sampled residents. The facility census 79 residents.
1. Record review of Resident #15’s Admission Face Sheet showed he/she was admitted to 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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
facility on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s Quarterly Minimum Data Set (MDS – a federally mandated
assessment instrument completed by facility staff for care planning) dated 10/10/18
showed;
-Able to understand others and make self-understood;
-Had Brief Interview for Mental Status (BIMS,is used to get a quick snapshot of how well
you are functioning cognitively at the moment) of 14 score, not cognitively impaired;
-Medication insulin injections were given during look back period and
-Had [DIAGNOSES REDACTED].
Record review of the resident’s physician’s orders [REDACTED].>-Had a [DIAGNOSES
REDACTED].>-[MEDICATION NAME] (long-acting insulin) administer 45 units subcutaneous (
sub-q-under the skin) every day at bedtime and
-Check the resident’s blood Sugar at bedtime and notify the resident’s physician
immediately if below 60 and/or above 400.
Record review of the resident’s Medication Administration Record [REDACTED]
-At 9:00 P.M., check the resident’s blood sugar at bedtime and to notify the resident’s
physician immediately if the blood sugar results were below 60 and/or above 400;
-The last blood sugar documented was on 1/7/19 at 7:35 P.M. and it was 206;
-On 1/7/19 the resident was to receive [MEDICATION NAME] 45 units sub-q daily at bedtime
and
-The staff did no document the resident’s blood sugar of 87 that was taken on the night
shift on 1/7/19.
During an interview on 1/8/19 at 8:55 A.M., the resident said:
-Had concerns with his/her blood sugar that had dropped on 1/7/19 and felt the staff did
not care for him/her as they should had;
– Licensed Practical Nurse (LPN) D had checked the resident’s blood sugar and gave him/her
a glass of apple juice with no lid or straw;
-Was not able to remember what his/her blood sugar was at that time, but felt weak most of
the night afterwards;
-He/she was weak and ended up spilling the glass of apple juice, Certified Nurse Assistant
(CNA) E had assisted the resident with changing his/her sheets and
-LPN D did not recheck the resident blood sugar after giving him/her the apple juice, or
follow up to see how he/she was feeling.
During an interview on 1/9/19 at 5:00 A.M., CNA E said:
-LPN D had checked on the resident and his/her blood sugar had dropped and LPN D gave the
resident a glass of apple juice;
-CNA E and LPN D had went into the resident’s room at separate times;
-The resident does have monitoring of his/her blood sugar when they are low or high;
-The staff did not stay with the resident after the resident received his/her apple juice;

-The resident had a history of [REDACTED].
-CNA E answered the resident’s call light and the resident said he/she had fallen asleep
and spilled his/her apple juice and wanted some orange juice and
-The resident was able to provide his/her own care and the staff does assist the resident
as needed.
During an interview on 1/9/18 at 6:15 A.M., LPN D said:
-The resident had reported, he/she had felt sweaty and clammy, wanted LPN D to check
his/her blood sugar;
-The resident’s blood sugar was 87 and was within normal range;

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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-Gave the resident’s apple juice in a regular cup and then left the resident’s room;
-He/she did not follow-up with the resident after he/she had given the resident the apple
juice and did not recheck his/her blood sugar;
-The protocol would have been to call the resident’s physician if the resident’s blood
sugar was less than 70 or above 400;
-LPN D said the resident requested to have his/her blood sugar checked and had behaviors
of not receiving his/her juice as requested;
-The staff does not tell the resident his/her blood sugar results;
-The staff does document the resident’s bloods sugar results in the nurse’s progress notes
or on the resident’s MAR;
-Did not document or report that the resident was sweaty and clammy;
-The LPN D said the resident’s sheets had sweat stains on the sheets;
-He/she was not aware the resident had spilled his/her juice and
-The resident does not need a specialty cup and was able to transfer himself/herself as
needed.
During an interview on 1/11/19 at 8:55 A.M., Assistant Director of Nursing (ADON) said;
-The resident complains of not feeling well and requests to have his/her blood sugar
tested ;
-For a blood sugars of 87 the staff would give the resident a snack or juice;
-He/she would expect the nursing staff to follow-up with the resident, to see how he/she
was feeling and
-Would expect the nursing staff to document in the nurse’s progress note or the nursing 24
hour report about the resident’s blood sugar and/or if was having related attention
seeking behaviors for liquids and this still needed to be documented in the resident’s
medical record.
During an interview on 1/11/19 at 9:50 A.M., LPN A said;
-If a resident is not feeling well and their blood sugar was 87, he/she would follow-up to
see how the resident was feeling and
-Should have documented in the resident’s medical record if the resident had a blood sugar
check done and any steps that were taken.
During an interview on 1/11/19 at 11:58 A.M., Director of Nursing (DON) said:
-Would expect the resident’s blood sugar check to be documented in the resident’s medical
record, if the resident had his/her blood sugar checked with complaints of not feeling
well;
-If a resident requesting blood sugar checks was related to a behavior pattern, he/she
would still expect the nursing staff to document it in the resident’s behavioral progress
note and
-When the resident was given apple juice as an intervention for the resident’s blood
sugars, he/he would expect the nursing staff to document the follow-up.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
restorative services were provided to prevent further decline of range of motion and 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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
maintain accurate documentation of services when services were not provided for two
sampled residents (Resident #37 and #53) out of 22 sampled residents. The facility census
was 79 residents.
1. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS- a federally mandated
assessment tool to be completed by facility staff for care planning) dated 11/28/18,
showed he/she:
-Was alert and oriented with communication deficits;
-Needed total assistance of two staff members for bathing, dressing, mobility, and
toileting and
-Had limited range of motion in both upper and lower extremities.
Record review of the resident’s Physician’s Order Sheet (POS) dated 12/2018 and 1/2019,
did not show any physician’s orders for rehabilitative services.
Record review of the resident’s Functional Maintenance plan dated 11/6/18, showed
Occupational Therapy (OT) recommended the resident to receive active and passive range of
motion, if tolerated, to the resident’s bilateral upper extremities, to include shoulder
flexion, elbow flexion, forearm and wrist flexion and extension to decrease risk of
further contractures and skin breakdown. Complete 10-20 reps to his/her tolerance up to
three times weekly.
Record review of the resident’s Restorative Nursing Record showed he/she was scheduled to
receive restorative services on Tuesday, Wednesday and Thursday. The records instructed
the restorative aide to report all the refusals to the charge nurse and to write a note.
The resident’s restorative report showed:
-From 11/6/18 to 11/30/18, the resident received restorative services on 11/13, 11/15,
11/16, 11/20, 11/23, 11/27 and 11/30/18. There was no documentation showing why
restorative services were not provided or if the restorative service was offered and the
resident refused services;
-From 12/1/18 to 12/31/18, the resident received restorative services on 12/18, 12/19,
12/20, 12/28 and 12/31/18. There was no documentation showing why restorative services
were not provided or if the restorative service was offered and the resident refused
services and
-The resident had documentation showing he/she received restorative services three times
from 1/1/19 to 1/9/19.
Observation on 1/7/19 at 10:25 A.M., showed the resident was laying in his/her bed on
his/her back with the head of his/her bed up at least 30 degrees. The resident was
non-verbal, but was able to use a communication board to make his/her needs known. He/she
had contractures in both hands and had a rolled up towel in his/her right hand. The
resident was able to use his/her call light to call for assistance and to raise and lower
his/her bed.
2. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s Admission MDS dated [DATE], showed the resident:
-Was alert and oriented with some confusion and
-Needed extensive assistance with bathing, dressing, grooming, mobility, and toileting.
Record review of the resident’s POS dated 12/2018 and 1/2019, showed there were no
physician’s orders for restorative services.
Record review of the resident’s Physical Therapy Functional Maintenance Plan dated
10/29/18, showed he/she was to receive left lower extremity strengthening and right lower
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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
extremity passive and active range of motion upon discharge from therapy services.
Record review of the resident’s Restorative Nursing Record showed the resident was to
receive restorative services on Tuesday, Wednesday and Thursday. Directions also
instructed the Restorative Aide to report all that refuse to the charge nurse and to write
a note. The resident’s restorative report showed:
-From 10/1/18 to 10/19/18, the resident received restorative services on 10/16, 10/17,
10/18, and 10/19. The restorative aide documented the resident was in the hospital from
10/20 to 10/30/18;
-From 11/1/18 to 11/30/18, the resident received restorative services on 11/2, 11/5, 11/6,
11/8, 11/13, 11/15, 11/16, 11/20 and 11/21 and
-There was no documentation of restorative services recorded from 11/22 to 11/30 and there
was no documentation showing why no services were offered or provided to the resident
during that time.
Record review of the resident’s Physical Therapy Functional Maintenance Plan dated
12/17/18, showed he/she was to receive left lower extremity strengthening and right lower
extremity passive and active range of motion upon discharge from therapy services. There
was documentation showing the resident was refusing to participate in therapy.
Record review of the resident’s Restorative Nursing Record showed he/she was to receive
restorative services on Tuesday, Wednesday and Thursday:
-From 12/1/18 to 12/31/18 showed the resident received restorative services on 12/20,
12/28 and 12/31 and
-There was no documentation showing why restorative services wee not offered or provided
up to three times weekly.
Observation on 1/7/19 at 10:25 A.M., showed the resident was sitting in his/her wheelchair
in his/her room. The resident was leaning to the right side in his/her wheelchair and
complained of pain. He/she said that he/she had not yet told the nurse. The call light was
turned on and the Restorative Nurse Aide (RNA) came in within two minutes and asked the
resident what he/she needed. The resident said that he/she was experiencing some shoulder
and back pain. The RNA said that the resident’s pain may be because of his/her positioning
in his/her wheelchair and asked if he/she could assist the resident to re-position. The
RNA tried to assist the resident to reposition and asked if he/she wanted to go to the
exercise group-the resident said no. The RNA told the resident that he/she would tell the
nurse that he/she was having pain and assisted to lay the resident down. The resident said
he/she did not always go to the exercise group.
During an interview on 1/11/19 at 10:53 A.M., The RNA said:
-He/she received orders for restorative services from the rehabilitation team (Physical
Therapy, Occupational Therapy and Speech Therapy);
-Once he/she received the orders for restorative services, he/she will begin providing
service once he/she receives the stop date from therapy and will start the following day;
-He/she would only wait to start restorative services if he/she was pulled to the floor to
work or if the resident went to the hospital before services started;
-He/she tried to provide restorative services to everyone on his/her restorative list at
least twice weekly, but tried to provide restorative services three times weekly to those
residents who were unable to move at all independently, like Resident #37;
-Depending on his/her caseload, the frequency that he/she was able to provide restorative
services may vary-currently he/she had 13 residents on his/her caseload and was able to
see everyone at least twice weekly;
-Every time a resident goes to the hospital, he/she cannot resume restorative services
until the therapist re-evaluated the resident and wrote a new order for restorative
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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
services;
-If a resident refused restorative services, he/she was able to document that on the RNA
record;
-He/she documents all of the restorative services he/she provided on the RNA records;
-He/she tried to document on the RNA record as he/she provided the service, but sometimes
he/she doesn’t get around to it and has to chart later;
-He/she has on occasion had to work on the floor and has been unable to complete
restorative services on those days, but it has not happened often and
-He/she should ensure that when he/she was not able to provide restorative services to the
resident, he/she documented why on the resident’s restorative record.
During an interview on 1/11/19 at 12:18 P.M., Licensed Practical Nurse (LPN) C said:
-The RNA sometimes is pulled to work the floor and is not able to provide restorative
service when that occurs. He/she said it does not occur often, but it has occurred and
-The RNA should document when he/she provided restorative services and he/she would assume
that if the RNA was not able to provide the service, he/she would also document that in
the resident’s restorative record .
During an interview on 1/11/19 at 1:42 P.M., the Director of Nursing (DON) said:
-If the RNA is unable to complete service to the resident for any reason they should
document that in their restorative charting;
-If there is any additional documentation or reasoning for why services were not provided,
it should be documented on the back of the RNA’s charting;
-Sometimes the RNA is pulled to the floor but that rarely happens;
-The RNA did not seem to be giving himself/herself credit for the services that he/she is
providing and the documentation needed to be there and
-He/she will work on that with the RNA.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, Interview and record review, the facility failed to ensure to
provide supervision, and oversight during meals for one sampled resident (Resident #6) who
was at a high risk for aspiration and received thickened liquids; and to ensure the
resident’s care plan was updated with the current [DIAGNOSES REDACTED]. The facility
census 79 residents.
1. Record review of Resident #6’s Admission Face sheet showed he/she was admitted to the
facility on [DATE] and was readmitted to the facility on [DATE] with the following
Diagnoses: [REDACTED].
-Congested Heart Failure ([MEDICAL CONDITION]-a chronic condition in which the heart does
not pump blood as well as it should);
Anxiety;
– [MEDICAL CONDITION] following a cerebral infarction of the right side (this affects the
right dominate side, for the residual right-sided weakness due to a stroke) and
-Had no [DIAGNOSES REDACTED].
Record review of the resident’s Speech Therapy (ST) discharge summary dated 8/10/18
showed:

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

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-The resident had a [DIAGNOSES REDACTED].
-Post discharge instructions recommended the staff to follow through on encouragement
education with the resident regarding use of provale cup (is specialty cup for a place for
your nose so your head does not tilt back to prevent aspiration) to improve carryover of
small drinks that would help to reduce the signs and symptoms of aspiration with thin
liquids.
-Precautions: Staff was to ask the resident questions that he/she can answer with using
yes and no;
-Required staff supervision at meals and
-Resident had been discharged from skilled nursing and the staff had been educated on
providing the resident with a provale cup at meals for cold drinks, and the resident may
continue with coffee in a regular cup.
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 9/28/18 showed
he/she:
-Weighed 228 pounds and had no swallowing problems;
-Required one person assistance during meal time for supervision, cueing, oversight and
encouragement;
-Usually was able to understand others (difficulty communicating some word or finishing
thoughts, but is able if prompted or given time) and was able to be understood by others;
– Was cognitively intact and was alert and oriented with a Brief Interview for Mental
Status (BIMS) score of 14 (showing he/she was alert and orientated) and
-Had no documentation related to his/her dysphasia.
Record review of the resident’s Registered Dietician (RD) progress notes dated 10/06/18,
showed the resident:
-Was on a Consistent Carbohydrate diet;
-Required meal set up in the bistro dining room and was able to feed himself/herself;
-Had no swallowing problems and
-Had no documentation related to his/her dysphasia.
Record review of the resident’s discharge MDS dated [DATE] showed he/she:
-Had been discharged on [DATE] to the hospital;
-Required supervision of one staff member during meal times for oversight, encouragement
or cueing;
-Had no documentation marked under swallowing disorder or difficultly swallowing and
-Weighed 221 pounds (on admission he/she weighed 228 pounds) and the staff did not
document that the resident had any weight loss since being admitted on [DATE].
Record review of the resident’s hospital Speech Pathology Oropharyngeal Swallow Function
Evaluation Test dated 12/13/18 showed:
-The resident has pharyngeal dysphasia (arises from abnormalities of muscles, nerves,
pharynx, and upper [MEDICAL CONDITION] sphincter) and possible aspiration;
-Recommendation were to have Nothing by mouth (NPO) / due to unsafe feeding and
-Speech Pathologist recommends video function swallow study for further assessment of
swallow function and risk for aspiration.
Record review of the resident’s hospital Video Film Swallow Study record dated 12/14/18
showed:
-He/she had a history of [REDACTED].
-Impression: Abnormal swallow, there may be increased risk for aspiration pneumonia.
Review of the resident’s Physician order [REDACTED].>-Nectar thickened liquids;
-May crush medications and mix with applesauce pudding/yogurt and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-Pureed Consistent Carbohydrate diet.
Record review of resident’s nurses progress notes showed:
-On 12/17/18 at 2:16 P.M., The resident arrived to facility at 1:15 P.M.,
— Had been readmitted with [DIAGNOSES REDACTED].
–The resident was totally dependent on staff for cares;
–The resident returns with physician’s orders [REDACTED].
-On 12/19/18 at 9:01 A.M., the resident required staff assistance with meal set up and
cueing during the morning meal.
Review of the resident’s nutritional care plan was updated on 12/13/18 showed:
-He/she was to have a Registered Dietician (RD) consult;
-The resident will not have any signs and system of aspiration;
-The staff are to observe the resident for signs and symptoms of aspiration; congestion,
fever, wet breath sounds;
-On 12/21/18, the resident had a new intervention to administer the resident the Thrive
dietary supplement at lunch and dinner;
-On 12/28/18, the resident had a new intervention to administer Med plus (a dietary
supplement 60 cubic centimeter (cc) four times a day and
–There was no interventions in place to instruct the staff to offer the nectar thicken
liquids or a puree diet.
Record review of the resident’s Registered Dietician (RD) Progress noted dated 12/20/18
showed the resident:
-Was on a puree Consistent Carbohydrate diet;
-Required the staff to assist the resident with setting up his/her meals and the resident
eats his/her meals in the bistro dining room;
-The resident needed encouragement to eat;
-Had a decline in oral intake and it was recommended the resident to be given Med Plus 60
cc three times a day between meals and at bedtime;
-Did not have any swallowing problems and
-The RD did not document anything related to the resident’s dysphasia.
Record review of the resident’s weight review progress notes dated 12/21/18 at 2:17 P.M.,
showed:
-The resident had been readmitted on a Consistent Carbohydrate Diet pureed diet with
nectar thickened liquids;
-The resident required assistance at times during meals;
-Requested a RD consult due to the change in the resident’s weight and diet on readmission
and
-Continue to monitor the resident’s weight weekly and update the resident’s care plan.
Record review of the resident’s Care Plan updated and reviewed on 12/24/18 showed the
resident will have speech therapy (ST) evaluate and treat him/her for possible aspiration
pneumonia,
Record review of the resident’s Progress Notes on 12/24/18 at 1:41 P.M. showed the
resident:
-The resident has pneumonia and
–Upon his/her return ST did evaluate and changed the resident’s diet.
Observation on 1/08/19 at 8:07 A.M., of the resident’s room showed the resident had two
glasses of thickened liquids on the bedside table that were approximately half full.
Observation on 1/8/19 at 8:55 A.M., showed the resident:
-Was in the bistro dining room with two other resident’s eating breakfast;
-Was sitting in his/her wheelchair at the table;
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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
-Had a glass of thickened liquid and coffee and his/her meal was served in a divided
plate;
-The resident was able to feed himself/herself with his/her left hand;
-Observed his/her left hand shaking while trying to feed himself/herself;
-The resident’s speech was difficult to understand at times and
-There were no staff members in the bistro dining room during this meal observation.
Observation on 1/08/19 at 12:16 P.M., showed the resident:
-Sitting in the bistro dining room;
-Had pureed food on a divided plate and had thickened liquid drinks in regular cups;
-The staff assisted the resident with setting up his/her meal and the resident able to
feed himself/herself;
-No facility staff stayed in the bistro dining area during meal time and
-Bistro dining room area had a total of four resident’s eating lunch.
Observation on 1/9/19 at 5:46 A.M., showed the resident:
-Had a glass of thickened liquids left in his/her room on the bedside table;
-Licensed Practical Nurse (LPN) D said the resident was allowed to have thickened liquids
in his/her room; The resident has the right to drink and
-The resident had a history of [REDACTED].
During an interview on 1/9/19 at 5:00 A.M., Certified Nursing Assistant (CNA) E said:
-The resident had not been able to reach the thicken liquid that was left in the room;
-He/she requires assistance from staff;
-For convince at night for the staff and the resident, they have been leaving thicken
liquid drinks in the resident’s room and
-The resident requires staff supervision or a mindful eye during meals and with drinks.
During an interview 1/9/18 at 6:15 A.M. LPN D said the resident :
-Was on nectar thicken liquids, had a special cup for liquids and was to have his/her head
of the bed up when taking pills;
-Should have some supervision at some level with meals and liquids;
-Prefers not to eat in the main dining area;
-Does not like crowds and has increase anxiety in crowded areas;
-The bistro dining room area was a high traffic area;
-Staff are walking by the bistro dining area all the time;
-During meals times the resident does have some supervision when the staff are setting-up
the meal and for follow-up assistance if needed and
-Most of the time there are nursing staff behind the nursing station desk which is located
behind the bistro dining area.
During an interview on 1/9/19 at 10:00 A.M., the Speech Therapist said:
-He/she would expect the staff to frequently monitor the resident during meal times;
-The resident was now on nectar thickened liquid;
-Hew/she has not provided a re-evaluation of the resident since his/her return from the
hospital on [DATE];
-The facility and the rehab department are aware of resident’s swallowing issues;
-The resident’s preference was to have meals in the bistro dining room and,
-Prior recommendation was for the resident to have a special cup, because of his/her
refusal of the nectar thicken liquids.
During an interview on 1/11/19 at 8:55 A.M., Assistant Director of Nursing (ADON) said:
-During the morning staff meeting the resident is talked about a lot;
-If the resident was on thickened liquids then the resident should have supervision during
meals and it was not recommended for the resident to eat in his/her bedroom and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
-The staff needed to be within eye sight during meal times.
During an interview on 1/11/19 at 11:58 A.M., Director of Nursing (DON) said;
-The resident prefers eat in the bistro dining area due to it is a smaller area;
–The staff set-up the resident’s meals;
-The staff do not stay in that dining area, they leave the area;
-He/she said since there were other resident’s in the bistro dining room area, those
residents could call for help if anything would had happen to the resident;
–The facility nursing staff and CNAs will check on the residents throughout the meal
times;
–Other staff members and visitors pass by the dining several times during the meal;
–Do not have a facility staff member assigned to stay in the bistro dining area during
meal times;
-The resident does not require ongoing or one on one supervision at this time;
-The resident was able to feed himself/herself and had been on a pureed diet with thicken
liquids and
-Was not planning on placing a time frame on how often the staff are required to make
rounds or check on resident’s that require extra supervision during meal time.

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 ensure infection
control practices were implemented to prevent cross contamination during resident
transfers for two sampled residents (Residents #13 and #53); during resident cares for one
sampled resident (Resident #3 ); to ensure the resident’s catheter (a flexible tube
inserted through a narrow opening into the bladder, drains into a collection bag for
removing fluid from the body) bag was kept below the bladder for one sampled resident
resident (Residents #3) and off of the floor for one sampled resident (Resident # 37), and
to ensure proper hand hygiene during cleaning of glucometer after two supplemental
resident’s blood sugar monitoring ( Resident #62 and Resident #57),out of 22 sampled
residents. The facility census was 79 residents.
1. Record Review of Resident #13’s Face Sheet showed he/she was admitted on [DATE], with
[DIAGNOSES REDACTED].
Record review of the resident’s significant change Minimum Data Set (MDS-a federally
mandated assessment instrument completed by facility staff for care planning) dated
1/4/19, showed the resident:
-Had short-term and long-term memory loss;
-Needed extensive assistance with bathing, dressing and transferring, mobility, grooming
and toileting.
Observation on 1/08/19 at 11:16 A.M., showed:
-Certified Nursing Assistant (CNA) P and CNA D entered the resident’s room;
-The resident was laying down on his/her bed fully dressed the sling was under the
resident;
-Certified Nurses Aide (CNA) P and CNA D, without washing their hands brought the
mechanical full body lift into the resident’s room and without washing their hands, they
positioned the sling at the resident’s bedside and began attaching the sling to the lift;

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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 21)
-CNA D then instructed the resident to hold onto the sling or cross his/her arms as he/she
lifted the resident;
-CNA P positioned the resident’s specialized wheelchair at an angle from the lift;
-CNA D transferred the resident into his/her wheelchair while CNA P assisted with
positioning the resident;
-Once CNA D and CNA P had positioned the resident in his/her wheelchair, CNA P began to
groom the resident and CNA D moved the resident’s wheelchair out of the resident’s room;
-CNA P without washing his/her hands, then took the resident out of the room to go to the
lunch room and
-CNA D went back into the resident’s room and washed his/her hands.
During an interview on 1/8/19 at 11:30 A.M., CNA P and CNA D, CNA P said:
-They were instructed to wash their hands before they begin care on a resident;
-During care they usually have one CNA who completes the clean task and one who completes
the dirty task;
-After care is provided they are supposed to wash their hands and then again before they
leave the resident’s room;
-Both CNA P and CNA D said that if they are only going in to transfer the resident, they
did not need to wash their hands prior to doing so and
-They said they had just finished completing incontinence care on the resident and exited
the room, but they did not know that they should have washed their hands upon re-entering
the resident’s room since they were only going to transfer the resident.
2. Record review of Resident #37’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s quarterly MDS dated [DATE], showed the resident:
-Was alert and oriented with communication deficits;
-Needed total assistance of two staff for bathing, dressing, mobility, and toileting and
-Had limited range of motion in both upper and lower extremities.
Observation on 1/9/19 at 4:36 A.M., showed the resident laying in his/her bed with his/her
eyes closed. The resident’s bed was low to the floor and his/her call light was within
reach. The resident’s catheter was below his/her bladder but there was nothing on the
floor preventing the resident’s catheter bag from resting on the floor.
Observation on 1/9/19 at 6:35 A.M.,showed the resident laying in his/her bed awake, with
his/her call light within reach. The resident’s bed was low to the floor and his/her
catheter bag was still resting on the floor without a barrier between the catheter bag and
the floor.
3. Record review of Resident #53’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s Admission MDS dated [DATE], showed the resident:
-Was alert and oriented with some confusion and
-Needed extensive assistance with bathing, dressing, grooming, mobility, and toileting.
Observation on 1/7/19 at 10:50 A.M., showed:
-The resident was sitting in his/her wheelchair in his/her room;
-CNA N and CNA O brought the full body lift into the resident’s room and told the resident
they were going to lay him/her down;
-Without washing their hands, CNA N and CNA O began to attach the sling to the lift;
-Once in place, CNA O operated the lift while CNA N assisted with moving the resident to
his/her bed;
-Once they transferred the resident to his/her bed, CNA O and CNA N washed their hands and
assisted the resident to roll to the side to remove the sling from underneath him/her and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 22)
-CNA N and CNA O then washed their hands before leaving the resident’s room.
During an interview on 1/7/18 at 11:05 A.M., CNA N said that they are supposed to wash
their hands upon entering the resident’s room, during care when they go from a clean to
dirty task, after changing their gloves and before leaving the resident’s room.
4. Record review of Resident #3’s Admission Face Sheet showed he/she was admitted to the
facility on [DATE], with [DIAGNOSES REDACTED].
Observation on 01/08/19 at 1:25 P.M., of the resident when returning from the shower
showed:
-The resident was transferred from the shower chair to his/her bed;
-The staff placed the resident’s catheter drainage bag on top of his/her bed after
completing his/her transfer;
-Staff proceeded to roll the resident to his/her side to removing the sling from
underneath the resident and
-After removing the sling the CNA’s finished dressing the resident, while the catheter
drainage bag remained on top of his/her bed.
Observation 01/10/19 2:22 at P.M., of the resident catheter tubing and bag showed:
-Had to have red ting urine and clots flowing through the tube into the bag;
-Licensed Practical Nurse (LPN) A said the resident supra pubic catheter was changed last
night because was clogged, and was not flowing and
-After the catheter had been changed by facility nursing staff it may cause irritation or
bleeding afterwards.
During an interview on 1/11/19 at 10:07 A.M., CNA G and CNA H said:
-The resident’s catheter should be kept below the bladder and not be laid on bed during
cares and
-Upon enter and exiting the resident’s room they should wash hands and place gloves on for
cares
During an interview on 1/11/19 at 9:50 A.M., LPN A said:
-During resident care the catheter should be kept below the bladder and not lied on the
bed and
-Should wash hand your hands when enter the resident’s room and before leave the resident
room.
5. Observation 1/9/19 at 8:00 A.M., of Resident #62’s accu check (a blood sugar reading
obtained by a small sample of blood from the finger) by LPN E showed:
-LPN E entered the residents room to check his/her blood sugar;
-When finished he/she removed his/her gloves and washed his/her hands;
-He/she returned to the nurse’s medication cart and obtained a bleach wipe with no gloves
on his/her hands;
-He/she proceeded to clean the soiled glucometer with the disinfecting bleach wipes;
-He/she then wrapped the glucometer with the bleach wipe let it set;
-Sanitized his/her hands with hand sanitizer then proceed to obtain the second glucometer;
-LPN E then entered Resident #57’s room proceeded with the resident’s blood sugar testing;

-Returned to the nurse’s medication cart and obtained a bleach wipe with no gloves on
his/her hands, then proceeded to clean the second soiled machine without gloves on his/her
hands,
-Sanitized his/her hands after cleaning the soiled glucometer by using hand sanitizer;
-Placed gloves on hands and drew- up insulin for the resident, and
-Entered the resident’s room and washed his/her hands, donned gloves and proceeded to
given the resident’s insulin without any concerns.

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:

265565

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

NAME OF PROVIDER OF SUPPLIER

PLEASANT HILL HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

1300 BROADWAY
PLEASANT HILL, MO 64080

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 23)
During an interview on 1/9/19 at 8:10 A.M., with LPN C said when cleaning the soiled
glucometer gloves should had worn.
6. During an interview on 1/11/19 at 11:58 A.M., the Director of Nursing (DON) said:
-The resident catheter drainage bag should kept below level of the bladder;
-The bag should not be placed on top of the resident’s bed during care;
-All catheter bags should be covered-right now they are using the leaf bags but the also
have privacy bags;
-The catheter bag should not be on the floor at any time;
-Regarding Handwashing-nursing staff was supposed to wash their hands upon entering the
resident’s room, before they leave the resident’s room, and when they go from performing a
dirty to clean task, that is the standard;
-She expected the nursing staff to wash their hands or use hand sanitizer upon entering
the resident’s room, prior to providing cares turning off call lights and with transfers;
-During care anytime they take off gloves and go from dirty to clean tasks, and before
leaving the room they should wash their hands;
-The resident’s catheter bag should be kept below the resident’s bladder and should not be
on the floor at anytime;
-He/she expected nursing staff to wear gloves when cleaning the glucometer with bleach
wipes and
-When completing a transfer with a Hoyer lift, gloves are not required unless there is
possible exposure to bodily fluids, then he/she would expect staff to wear gloves.

F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure there is a pest control program to prevent/deal with mice, insects, or other
pests.

Based on observation and interview, the facility failed to ensure the attic areas above
the 300 Halls, 400 Halls and above the kitchen free from openings that could potentially
let pests in. This practice potentially affected at least 22 residents who resided on the
300 and 400 Halls. The facility census was 79 residents.
1. Observations with the Maintenance Director on 1/10/19, showed the following:
– At 9:40 A.M., there were two small holes around the screen at the outside wall of the
attic area above the 400 Hall;
– At 10:19 A.M., there was a 1.5 inch (in.) long by 2.0 in. wide torn area within the
screen over the vent over the outside wall of the attic area above the 300 Hall and gaps
were present around the whole fixture at the outside wall of the 300 Hall; and
– At 10:58 A.M., there was a 10 in. tear in the screen and areas around the screen fixture
which needed caulking at the outside wall of the attic area above the kitchen and there
were mouse droppings present on the floor of the attic area above the kitchen area.
During interviews on 1/10/19 at the times of the observations, the Maintenance Director
acknowledged those areas in the attics needed to be repaired to keep pests out.