Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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.

Based on observation and interview, the facility failed to provide a comfortable and
homelike environment free from the presence of persistent urine odors. The facility census
was 57.
1. During an interview on 6/13/19 at 12:20 P.M. the administrator said the facility did
not have a policy on odors.
2. Review of the facility’s undated resident’s rights showed the following:
-Mission statement: it is the intent of the facility to promote and ensure that the
highest standards of conduct and reliability by it’s employees and consultants to in turn
produce environments in the facility that promote the highest standards of care and
security for our residents and the families we serve;
-Purpose: Our residents will always be provided with the highest level of care and
services.
3. Observation on 6/9/19 at 12:35 P.M. showed a strong odor of urine present upon entering
the facility, around the nurses station and on 100 and 200 hall.
Observation on 6/09/19 at 2:02 P.M. showed a strong odor of urine present on the 200 Hall.
Observation on 6/9/19 at 5:35 P.M. showed a strong odor of urine present upon entering the
facility, around the nurses station and on 100 and 200 hall.
Observation on 6/10/19 at 9:00 A.M. showed a strong urine odor present at the nurses
station and down 100 and 200 hall.
Observation on 6/10/19 at 10:00 A.M. showed a strong odor of urine noted on the 200 Hall.
Observation on 6/10/19 at 5:15 P.M. showed a strong odor of urine noted at the nurses
station and down 100 and 200 hall.
Observation on 6/11/19 at 5:25 A.M. showed a strong odor of urine noted on the 200 Hall.
Observation on 6/11/19 throughout the day from 5:30 A.M. to 10:00 A.M. and 12:30 P.M. to
3:00 P.M. showed a strong odor of urine noted on the 100 Hall.
Observation on 6/11/19 at 3:58 P.M. showed the following:
-Resident #24 was incontinent of bowel and bladder;
-The resident’s room had a strong odor of urine;
-The resident’s bed was saturated with urine through to the mattress;
-Certified Nurse Assistant (CNA) L cleaned the resident with water only, transferred the
resident into the wheelchair and removed the urine soiled linens from the bed;
-CNA L applied clean linens to the soiled mattress;
-CNA L did not clean the resident’s mattress prior to applying clean linens.
During an interview on 6/12/19 at 5:10 P.M., CNA L said the following:
-The resident’s urine saturated through to the mattress;
-He/She did not clean the mattress prior to making the resident’s bed because he/she was
busy and trying to get the residents to supper;
-Not cleaning the resident with soap or cleaning the bed could cause the resident and the
resident’s room to smell of urine.
During an interview on 6/11/19 at 11:23 A.M., Resident #14 said the 200 hall smelled like
urine. It was gross and made him/her sick.
During an interview on 6/11/19 at 11:53 A.M., Resident # 47 said the following:
-He/She noted a strong urine odor on the 100 and 200 hall when he/she went down that hall
to go outside to smoke;
-The odor was bad and he/she did not like it.
During an interview on 6/11/19 at 1:45 P.M., Resident #18 said the 100 and 200 hall

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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)
smelled of urine and he/she did not like it.
Observations on 6/12/19 at 8:56 A.M. and throughout the day showed a strong odor of urine
noted upon entrance to the facility and on the 100 Hall.
Observation on 6/12/19 at 10:56 A.M. showed a strong odor of urine present upon entrance
to the facility and on the 200 Hall.
During an interview on 6/13/19 at 2:10 P.M., the housekeeping manager said the following:
-There were cans of Lysol or springtime air freshener located in the janitor’s closet for
staff to use for increased odors when needed after housekeeping hours;
-Staff were aware the charge nurse had access to the closet.
During an interview on 6/13/19 3:55 P.M. the Director of Nursing (DON) and the care
plan/Minimum Data Set (MDS), coordinator said the following:
-They would expect the staff to use disinfectants to clean the residents’ beds and use
periwash or soap to clean the residents;
-Unclean resident beds, rooms, and residents could cause the facility to smell.

F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure residents do not lose the ability to perform activities of daily living unless
there is a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to provide
restorative nursing services and ensure that residents attained/maintained the highest
practicable physical well-being as determined by their comprehensive assessment and plan
of care for five residents (Resident #25, #30, #31, #50, and #54) in a review of 15
sampled residents. The facility census was 57.
1. Review of the facility’s policy for the restorative nursing program from the
restorative nursing manual dated (MONTH) of 2006 showed the following:
-It was the purpose of the facility to see that each resident received and the facility
provided the necessary care and services to attain or maintain the highest practicable
physical, mental, and psychosocial well-being in accordance with the comprehensive
assessment and plan of care Omnibus Budget Reconciliation Act (OBRA) 1987;
-It was the entire staff’s responsibility to prevent deterioration and further functional
loss of each resident in the facility;
-The objective of the restorative nurse aide (RNA) was to provide restorative care
necessary to meet the needs of all residents to enable them to achieve the standard of
care as described by OBRA, 1987;
-Restorative services were to be made available seven days a week per resident’s assessed
needs.
2. Review of Resident #25’s quarterly Minimum Data Set (MDS), a federally mandated
assessment to be completed by facility staff, dated 3/15/19, showed the following:
-The resident’s [DIAGNOSES REDACTED].
-The resident’s cognition was moderately impaired;
-The resident required extensive assist of one staff with transfers and dressing;
-The resident received restorative therapy for passive range of motion (PROM – involves
assistance in moving a joint) two days out of the last seven;
-The resident received restorative therapy for walking four days out of the last seven.
Review of the resident’s care plan last reviewed on 4/2/19 showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-The resident is limited in ability to transfer self, related-to visual impairment and
weakness:
-Restorative program three times weekly for PROM to upper body and ambulation;
-Instruct the resident in proper transfer techniques;
-Provide assistance for transferring.
Review of the resident’s undated Certified Nurse Aide (CNA) Care Card showed restorative
and nursing interventions for walk to dine, multi podus boots (used for those at risk for
plantar flexion contracture, foot drop, hip rotation and decubitus heel ulcers) on as
tolerated and AFO (ankle and foot orthoses brace) on while in wheelchair.
Review of the resident’s physician orders [REDACTED].
Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed staff
documented the resident received restorative therapy one day out of two days for active
range of motion (AROM – exercises the resident is able to perform independently) and
walking.
Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the
following:
-Staff documented the resident received restorative therapy zero days out of 34 for PROM;
-Staff documented the resident received restorative therapy eight days out of 34 for
walking.
3. Review of Resident #30’s annual MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-The resident’s cognition was severely impaired;
-The resident did not reject care;
-The resident was dependent on two or more staff for transfers, dressing and toilet use;
-The resident was dependent on one staff with bed mobility, eating, locomotion on the
unit, personal hygiene and bathing;
-The resident did not walk in his/her room or in the corridor;
-The resident used a wheelchair for assistance with mobility;
-Staff performed passive range of motion one time for 15 minutes in the last week.
Review of the resident’s physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Restorative aide three times a week for range of motion for upper extremities and lower
extremities.
Review of resident’s care plan last reviewed 4/4/19 showed the following:
-The resident’s ability to perform activities of daily living (ADLs) was at risk for
deterioration due to weakness and [DIAGNOSES REDACTED].
-The resident required assistance of one staff with ADLs;
-The resident was to receive restorative therapy three times a week for neck support and
range of motion (ROM).
Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed staff
documented the resident received restorative therapy six days out of 12.
Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed staff
documented the resident received restorative therapy three days out of 12.
During an interview on 6/11/19 at 4:00 P.M., Restorative Aide/CNA (RA/CNA) A said the
following:
-The resident was supposed to receive restorative therapy three times a week;
-He/She was unable to provide therapy because he/she was pulled to work other areas and
tasks due to staff shortage;
-Not receiving restorative care could cause a decline.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
4. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
-The resident had [DIAGNOSES REDACTED].
-The resident’s cognition was severely impaired;
-The resident required extensive assistance of one staff with transfers and toilet use;
-The resident was dependent on one staff with personal hygiene and bathing;
-The resident did not walk in his/her room or in the corridor;
-The resident required limited assistance of one staff with locomotion on and off of the
unit (on 12/29/18 quarterly MDS the resident did not require assistance with locomotion on
and off from the unit);
-The resident used a wheelchair for assistance with mobility.
Review of resident’s care plan last reviewed 4/4/19 showed the following:
-The resident’s ability to perform activities of daily living (ADLs) was at risk for
deterioration due to weakness and [DIAGNOSES REDACTED].
-The resident required assistance of one staff with ADLs;
-The resident was to receive restorative therapy three times a week for neck support and
range of motion (ROM).
Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed the
facility’s staff documented the resident received restorative therapy four days out of 12.
Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed staff
documented the resident received restorative therapy two days out of 12.
During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following:
-The resident was supposed to receive restorative therapy three times a week;
-He/She was unable to provide therapy because he/she was pulled to work other areas and
tasks due to staff shortage;
-The resident had declined within the last couple of weeks;
-The resident had orders to walk to dine, but it was not being done because he/she was
unable to walk with him/her.
5. Review of Resident #40’s quarterly MDS dated [DATE] showed the following:
-The resident’s [DIAGNOSES REDACTED].
-The resident’s cognition was moderately impaired;
-The resident was dependent on two staff with transfers and dressing;
-The resident received restorative therapy one day out of the last seven days.
Review of the resident’s care plan last reviewed on 4/29/19 showed the following:
-The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION]
([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of
the body), weakness, impaired mobility, and unsteady balance;
-The resident was to receive restorative therapy three times a week with staff performing
PROM to all of the resident’s joints to improve and maintain the resident’s left upper
extremity range of motion;
-The resident was supposed to wear a resting hand splint (on his/her left hand).
Review of the resident’s undated CNA Care Card showed no documentation the resident
received restorative nursing services or that he/she was supposed to wear a hand splint.
Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed the
following:
-Staff documented the resident received restorative therapy six days out of 12;
-There was no documentation to show the resident refused to wear the left hand splint.
Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the
following:
-Staff documented the resident received restorative therapy one day out of 12;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-There was no documentation to show the resident refused to wear the left hand splint.
Observation on 6/09/19 at 4:00 P.M. showed the following:
-The resident sat in his/her wheelchair outside of his/her room. His/her head leaned to
the right side;
-The resident’s left hand was contracted;
-There was no splint on his/her left hand.
Observation on 6/10/19 at 8:59 A.M. showed the following:
-The resident sat in his/her wheelchair;
-The resident’s left hand and left foot were contracted;
– There was no splint on his/her left hand.
During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following:
-The resident was supposed to have restorative therapy three times a week, but he/she had
been pulled from his/her restorative nursing duties to perform care;
-He/She was also unable to complete restorative nursing duties because he/she took
residents to appointments, completed residents’ weights and vital signs, attended care
plan meetings, and updated CNA Care Cards;
-There was a second CNA trained to assist with restorative therapy, but he/she worked as a
CNA on the day shift and was unable to assist with restorative therapy;
-The resident was supposed to wear a brace to his/her left hand and he/she had tried, but
the resident refused to wear the brace.
6. Review of Resident 54’s annual MDS dated [DATE] showed the following:
-The resident’s cognition was intact;
-The resident’s [DIAGNOSES REDACTED].
-The resident was dependent on two staff with bed mobility;
-The resident required extensive assistance of two staff with transfers;
-The resident required extensive assistance of one staff with dressing and toileting;
-The resident did not walk in his/her room or in the corridor;
-The resident’s range of motion was impaired on one side of upper and lower extremities;
-The resident required the use of a wheelchair for mobility;
-The resident received restorative therapy three out of the previous seven days.
Review of the resident’s care plan last updated on 6/9/19 showed the following:
-The resident required extensive assistance with ADLs related to [DIAGNOSES REDACTED].
-The resident was to wear a splint to his/her left hand to assist with contraction;
-The resident was to have restorative therapy three times a week for left upper extremity
range of motion and right upper extremity strength.
Review of the resident’s undated care card showed the following:
-The resident had left sided weakness;
-He/She was to have a splint applied in the morning and removed at night (no documentation
to show the type of splint the resident was to wear).
Review of the resident’s Restorative Nursing Report dated 4/12/19 to 5/11/19 showed the
following:
-Staff documented the resident received restorative therapy six days out of 12;
-There was no documentation to show the resident refused wearing the left hand splint.
Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the
following:
-Staff documented the resident received restorative therapy two days out of 12;
-There was no documentation to show the resident refused wearing the left hand splint.
Observation on 6/10/19 at 1:47 P.M. showed the following:
-The resident’s left hand was contracted;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-No splint on his/her left hand.
During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following:
-The resident was supposed to have restorative therapy three times a week;
-The resident was supposed to have a brace on his/her left hand, but he/she refused to
wear the brace;
-He/She was unable to complete the resident’s restorative therapy the last couple of weeks
because he/she was pulled from his/her restorative nursing duties to provide resident
care;
-He/She was pulled from his/her restorative nursing duties to provide resident care at
least once or twice a week due to lack of staff.
7. During interview on 6/11/19 at 10:30 A.M., RA/CNA A said the following:
-He/She was working as a CNA today. There is a backup RA when he/she was not here but the
backup RA was off today;
-He/She was to do RA today but got pulled to the floor due to short staffed for CNAs;
-He/She has been pulled from RA to CNA a lot lately, like twice a week. He/She was hired
to be a RA and he/she feels like he/she is letting the residents down as they are not
getting what they are supposed to get for restorative;
-He/She felt like residents were declining as he/she was unable to do the restorative when
he/she gets pulled to the floor.
During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan Coordinator said the
following:
-He/She would not expect the RA to be pulled from restorative duties to provide resident
care;
-The RA had been pulled from his/her restorative nursing duties to provide resident care
within the last month or two due to lack of staff.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review the facility failed to provide
necessary services to maintain good personal hygiene and prevent body odors for seven
residents (Resident #4, #16, #24, #25, #29, #37 and #40) in a review of 15 sampled
residents and two additional residents (Resident #11 and #41). Staff failed to provide
showers, nail care, oral care, complete peri care and grooming to include shaving. The
facility census was 57.
1. Review of the facility’s A.M. Care Policy dated (MONTH) (YEAR) showed the following:
-The purpose was to provide cleanliness, comfort and neatness;
-Quietly awaken the resident;
-Take the resident to the bathroom or provide perineal care;
-Allow resident to brush teeth, or brush teeth or dentures for the resident if he/she was
not able;
-Wash the resident’s face and hands and dry well;
-Position the resident comfortably.
2. Review of the facility’s Perineal Care Policy dated (MONTH) (YEAR) showed the
following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-The purpose was to cleanse the perineum and prevent infection and odor;
-Prepare supplies including warm water and perineal solution;
-Wash hands and apply gloves;
-Wash all frontal perineal skin folds front to back with wet wash cloth and soap and water
or perineal wash, rinse and pat dry;
-Wash buttocks with clean wash cloth and soap and water or perineal wash, rinse and pat
dry;
-Remove gloves and wash hands.
3. Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual,
showed the purpose of peri-care (perineal) is to clean the peri area for the resident who
is unable to or has difficulty with adequately cleaning self, prevents itching, burning,
and odor, and prevents infections. The manual also showed the resident who is continent
should have peri-care daily with morning care, the resident who is incontinent, after each
voiding or stool, and perineal care is very important in maintaining the resident’s
comfort. More frequent care is required for residents who are incontinent.
Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual,
also showed the procedures staff were to follow when they provided peri-care for a male
(steps 7 through 13) included the following:
-Cover the resident;
-Expose the perineal areas included, wash the penis from the tip downward, rinse, and dry
(specific instructions for uncircumcised);
-Wash and rinse the scrotum;
-Wash and rinse other skin areas between the legs;
-Wash and rinse the anal area;
-Pat the area dry.
For the female resident (steps 7 through 14) included the following:
-Cover the resident;
-Expose the peri area, wash the inner legs and outer peri area along the outside of the
labia (Labia Majora);
-Use a clean area of the washcloth for each wipe of the peri area;
-Wash the outer skin folds from front to back;
-Wash the inner labia (Labia Minora) from front to back;
-Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area)
from front to back;
-Rinse the area well, start from the innermost area and proceed outward;
-Wash and rinse the anal area;
-Pat the peri area dry.
4. Review of the Nurse Assistant in a Long Term Care Facility manual, Revision (MONTH)
2001, showed the following:
-Purposes of oral hygiene (mouth care): A clean mouth and properly functioning teeth are
essential for physical and mental well-being of the resident, prevent infections in mouth,
remove food particles and plaque, stimulate circulation of gums, eliminate bad taste in
mouth, thus food is more appetizing.
5. Review of Resident #40’s quarterly MDS dated [DATE] showed the following:
-The resident’s cognition was moderately impaired;
-The resident was dependent on two staff with transfers and dressing;
-The resident was dependent on one staff with personal hygiene and bathing;
-The resident was always incontinent of bowel and bladder;
-There was no documentation to show the resident’s dental/oral status.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
Review of the resident’s care plan last reviewed on 4/29/19 showed the following:
-The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION]
([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of
the body), weakness, impaired mobility, and unsteady balance;
-Staff were to provide reminders and supervision as needed for all ADLs;
-Staff were to assist the resident with bathing body parts that the resident could not do
her/himself;
-The resident was at risk for skin breakdown related to episodes of incontinence;
-Staff were to keep the resident’s skin clean and dry
-Staff were to wash the resident’s skin with soap, rinse, and dry all areas.
Review of the resident’s undated CNA Care Card showed the following:
-The resident required assistance of one staff with brushing his/her gums (no teeth),
providing peri-care, and shaving;
-The resident required assistance of one staff with dressing;
-The resident required assistance of one staff with showers which were scheduled on
Tuesdays and Fridays;
-The resident was incontinent of bowel and bladder, and wore an adult brief.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 4/1/19 to
4/30/19 showed the resident’s showers were scheduled Tuesdays and Fridays. There was no
documentation to show the resident received showers on 4/9/19, 4/12/19, 4/16/19, 4/19/19,
4/22/19, 4/26/19, and 4/30/19.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 5/1/19 to
5/30/19 showed the resident’s showers were scheduled Tuesdays and Fridays. There was no
documentation to show the resident received showers on 5/3/19, 5/7/19, 5/10/19, and
5/21/19. The resident received showers on 5/13/19, 5/19/19 and 5/24/19.
Observation on 6/9/19 1:30 P.M., showed the following:
-The resident sat in his/her wheelchair and had a strong urine odor;
-The resident appeared unkempt with greasy uncombed hair, and dried white substance around
his/her mouth.
Observation on 6/10/19 at 8:53 A.M. showed the following:
-The resident had a strong urine odor;
-The resident’s mouth had a dried white substance around his/her mouth.
Observation on 6/11/19 at 6:41 A.M. showed the resident laid in bed with a strong urine
odor noted.
Observation on 6/11/19 at 6:45 A.M. showed the following:
-CNA G entered the resident’s room to provide perineal/post-incontinence care;
-The Director of Nurses (DON) entered the resident’s room to assist CNA G with providing
care;
-There was a strong odor of urine noted in the room;
-The resident’s bed linens were saturated with urine;
-The resident was incontinent of a large amount of feces;
-CNA G used wash cloths to remove feces from the resident by smearing stool around the
resident’s buttocks in a circular motion,;
-The DON instructed CNA G to clean the resident up as best as he/she could because the
resident was going to go to shower after he/she ate breakfast;
-CNA G sprayed peri spray on a towel and used the towel to finish removing feces by wiping
several times without changing the surface of the towel;
-Staff assisted the resident to his/her right side; there was feces on his/her buttocks
and coccyx (tailbone);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-CNA G and the DON applied an adult brief without removing feces from the resident’s right
buttock and without washing the resident’s front perineal area;
-CNA G told the DON that feces remained on the resident and it appeared that he/she was
not done with having a bowel movement;
-The DON obtained a wash cloth and cleansed the right buttock, but did not wash the
resident’s front perineal or coccyx areas;
-CNA G and the DON finished dressing the resident;
-Staff continued prepping the resident for transfer even though bowel and bladder
incontinence continued;
-Staff transferred the resident to his/her wheelchair and then assisted him/her into the
dining room for breakfast.
During an interview on 6/11/19 at 7:30 A.M. CNA G said the following:
-He/She should have allowed the resident to finish voiding before they placed him/her in
the wheelchair;
-They were just trying to get him/her down to eat breakfast;
-It was difficult to get all tasks done due to shortage of staff.
During an interview on 6/13/19 at 3:55 P.M., the DON said the following:
-He/She was not used to the process regarding performance of peri-care and knew they were
not performing it properly;
-They should have stopped and let the resident finish voiding before they took him/her to
the dining room to eat;
-The resident should have been clean before going to breakfast.
Observation on 6/11/19 10:54 A.M. showed the following:
-The resident had a strong odor of urine;
-The resident had a dried white substance around his/her mouth;
-The resident’s hair appeared greasy.
During an interview on 6/11/19 at 10:48 A.M., CNA D said the following:
-He/She had not given the resident a shower yet this morning or had not started any of the
scheduled showers;
-It was hard to get everything done that needed to be done because of short staffing.
Observation on 6/11/19 showed the following:
-At 2:49 P.M., the resident lay in bed with a fecal odor noted; he/she dug at his/her peri
area with his/her fingers
-At 2:58 P.M., staff prepared the resident for transfer from the bed to his/her
wheelchair;
-The resident had smeared feces noted on his/her bed pad;
-CNA E removed feces from the resident’s rectal and inner buttock areas by wiping multiple
times without changing the surface of the cloth;
-Staff did not provide peri-care to the resident’s front perineal area.
Observation on 6/12/19 at 9:45 A.M. showed the following:
-The resident sat in his/her wheelchair in his/her room with urine odor noted;
-The resident had a dried white substance around his/her mouth.
6. Review of Resident #24’s 30 day prospective payment system (PPS) MDS dated [DATE]
showed the following:
-The resident’s cognition was moderately impaired;
-The resident was dependent on two staff with transfers and dressing;
-The resident was dependent on one staff with personal hygiene and bathing;
-The resident was always incontinent of bowel and bladder.
Review of the resident’s care plan last reviewed on 4/29/19 showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-The resident was required staff assistance with ADL’s related to intellectual disability;
-Required staff assistance with pericare after each incontinence episode;
-The resident was at risk for skin breakdown related to episodes of incontinence.
Review of the resident’s undated CNA Care Card located in the resident’s room showed the
following:
-The resident required assistance of one staff for peri-care and incontinency care;
-The resident wore incontinency briefs;
-The resident was incontinent of bowel and bladder and required assistance of one staff
with post-incontinence care.
Observation on 6/11/19 at 3:58 P.M. showed the following:
-CNA L entered the resident’s room;
-The resident lay in bed on his/her left side;
-The resident was incontinent of urine, his/her room had a strong urine odor and his/her
bedding was saturated with urine;
-The resident was incontinent of a moderate amount of feces;
-CNA L removed feces with a wet wash cloth;
-CNA L used a wet wash cloth without soap or peri wash to clean the resident’s perineal
area and rectum;
-CNA L used a wet wash cloth without soap or perineal wash to clean the resident’s inner
and outer thighs, left side of the resident’s back and the resident’s buttocks that were
in contact with urine.
During an interview on 6/12/19 at 5:10 P.M. CNA L said the following:
-The resident was incontinent of bowel and bladder;
-The facility was short staffed which made staff rush with resident cares so they can get
to the next resident;
-He/She normally used soap or perineal wash to clean the incontinent residents;
-The resident was saturated in urine from the middle of his/her back to his/her knees;
-He/She was in a hurry when caring for the resident and failed to use soap or peri wash to
clean the resident and failed to clean all areas of the resident that were in contact with
urine and/or feces;
-Not using soap or peri wash to clean the resident could cause the resident to get urinary
tract infections and smell bad.
7. Record review of Resident #4’s annual MDS dated [DATE], showed the following:
-Short term and long term memory problems;
-Bathing somewhat important;
-Frequently incontinent of bowel and bladder.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Short term and long term memory problems;
-No rejection of care;
-Required extensive assistance of one staff for dressing and bathing;
-Required total assistance of one staff for personal hygiene;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 5/24/19, showed the following:
-Assist as needed with oral care;
-Assist with activities of daily living (ADLs);
-Requires extensive assist with dressing, bathing, hygiene and bathing related to impaired
cognition and visual function;
-Shower two times per week. Check finger and toenails.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
Review of the resident’s CNA care card located in the resident’s closet, undated, showed
the following:
-Personal hygiene – brush teeth, comb hair, shave with assist of one staff;
-Dressing – assist of one staff;
-Bathing – shower with assist of one staff.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Tuesday and Friday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following:
-The resident’s last documented shower was on 5/30/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/8/19, 3/12/19, 3/19/19, 4/2/19, 4/12/19, 4/19/19, 4/26/19, 4/30/19, 5/3/19,
5/7/19, 5/10/19, 5/14/19, 5/17/19, 5/24/19, 5/28/19 and 6/4/19.
Observation on 06/10/19 at 5:10 P.M. showed the following:
-The resident sat in a chair in the dining room;
-The resident had unshaven facial hair resembling stubble;
-The resident had a white film-like substance on his/her teeth.
Observation on 06/11/19 at 11:30 A.M. showed the following:
-The resident sat in a chair the dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 06/12/19 at 10:45 A.M. showed the following:
-The resident sat on his bed in his/her room;
-The resident had unshaven facial hair resembling stubble;
-The resident had a white film-like substance on his/her teeth.
During interview on 6/13/19 at 1:39, the resident’s guardian/family member said the
following:
-Oral care was not completed;
-The resident had $5800 worth of dental work completed in (MONTH) 2019 due to the staff
not completing oral care and the resident would not initiate oral care;
-The resident had to take Tylenol ([MEDICATION NAME]) before every meal to be able to eat
due to build up of residue on his/her teeth. He/she couldn’t eat;
-The resident does not shave him/herself and he/she would want to be shaved daily.
8. Review of Resident #11’s care plan last reviewed on 3/19/19 showed the following:
-The resident required staff reminders and supervision with bathing, and hygiene related
to impaired thought process;
-The resident was incontinent of urine and required staff to toilet at times;
-Staff were to provide appropriate equipment for resident to groom self.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-The resident was cognitively intact;
-The resident was independent with personal hygiene and bathing;
-The resident was occasionally incontinent of bowel and bladder;
-The resident refused care 4-6 times a week but not daily.
Observation on 6/9/19 at 1:00 P.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
-The resident had an approximately one inch long gray hair on his/her chin.
Observation on 6/10/19 at 2:00 P.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-The resident had an approximately one inch long gray hair on his/her chin.
Observation on 6/11/19 at 5:29 A.M. and 2:05 P.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
-The resident had an approximately one inch long gray hair on his/her chin.
Observation on 6/12/19 at 10:54 A.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
-The resident had an approximately one inch long gray hair on his/her chin.
Observation on 6/13/19 at 10:15 A.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled.
During interview on 6/13/19 at 10:15 A.M. the resident said the following:
-His/Her family member came yesterday evening and shaved him/her;
-He/She liked to be shaved and did not like facial hair;
-He/She had asked the staff to shave him/her but they never had time.
During an interview on 6/13/19 at 10:42 A.M. CNA K said the following:
-He/She was on light duty and was responsible for shaving the residents;
-He/She had not shaved the resident because he/she ran out of time;
-The resident liked to be shaved;
-The resident required staff to shave him/her.
During an interview on 6/13/19 at 10:28 A.M. Registered Nurse (RN) M said the following:
-The staff had to shave the resident;
-The resident preferred his/her facial hair waxed but the facility didn’t wax the
resident’s facial hair any longer;
-The resident required staff assistance to be shaved.
9. Record review of Resident #16’s significant change MDS, dated [DATE], showed the
following:
-Cognition intact;
-Bathing very important;
-Always incontinent of bowel and bladder.
Record review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-No rejection of care;
-Required total assistance of two or more staff for dressing;
-Required total assistance of one staff for personal hygiene and bathing;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 6/6/19, showed the following:
-Requires assist with ADLs;
-Assist with bathing;
-Assist with dressing;
-Shower or bath two times per week;
-Supervise and assist the resident as needed while bathing/showering.
Review of the resident’s CNA care card located in the resident’s closet, undated, showed
the following:
-Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff;
-Dressing – assist of one staff;
-Bathing – shower with assist of one staff.
Record review of the facility’s shower assignment sheet showed the resident was to have a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
shower on Wednesday and Saturday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following:
-The resident’s last documented shower was on 5/31/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/7/19, 4/6/19, 4/10/19, 4/17/19, 5/4/19, 5/8/19, 5/25/19, 6/1/19, 6/5/19,
6/8/19 and 6/11/19;
-Resident refused a shower on 4/24/19 due to it was too late;
-Resident refused a shower on 5/1/19 due to he/she was already in bed.
Observation on 06/12/19 at 9:43 A.M. showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
Observation on 06/13/19 at 1:00 P.M. showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
During interview on 6/12/19 at 9:43 A.M., the resident said the following:
-Staff help him/her shave on shower days;
-Shower days are Wednesday and Saturday with the make-up day on Sunday, but if the
facility is short staffed showers do not get done on Sundays;
-It has been two weeks since he/she had a shower (review of the shower sheets show his
last shower was 5/31/19);
-He/She does not like the stubble of facial hair on his/her face.
10. Record review of Resident #25’s annual MDS, dated [DATE], showed the following:
-Cognition intact;
-Bathing somewhat important;
-Frequently incontinent of bowel and bladder.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-The resident’s cognition was moderately impaired;
-No rejection of care;
-Required extensive assist of one staff with transfers, dressing, personal hygiene and
bathing;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan last reviewed on 4/2/19 showed the following:
-The resident is limited in ability to transfer self, related-to visual impairment and
weakness:
-Instruct the resident in proper transfer techniques;
-Provide assistance for transferring;
-The resident experiences bladder incontinence related to visual impairment and need of
assistance for transfers.
Review of the resident’s CNA care card located in the resident’s closet, undated, showed
the following:
-Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff;
-Dressing – assist of one staff;
-Bathing – shower with assist of one staff.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following:
-The resident’s last documented shower was on 6/2/19;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/7/19, 3/14/19, 3/18/19, 3/21/19, 4/1/19, 4/4/19, 4/15/19, 4/22/19, 4/25/19,
4/29/19, 5/2/19, 5/6/19, 5/13/19, 5/16/19, 5/20/19, 5/30/19, 6/3/19, 6/6/19 and 6/10/19;
-Resident refused his/her shower on 3/28/19, 4/8/19, 4/23/19 due to it was too late.
11. Record review of Resident #29’s significant change MDS, dated [DATE], showed the
following:
-Cognition severely impaired;
-No rejection of care;
-Prefers showers;
-Requires total assist of one staff with dressing, personal hygiene and bathing;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan last reviewed on 6/9/19 showed the following:
-When the resident wakes for the day, assist with morning cares;
-Assist as needed with oral care;
-Requires extensive with activities of daily living (ADLs) related-to [MEDICAL CONDITION]
and cognitive impairment;
-Shower two times per week. Check finger and toenails;
-Provide pericare after toileting and after episodes of incontinence.
Review of the resident’s CNA care card located in the resident’s closet, undated, showed
the following:
-Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff;
-Dressing – assist of one staff;
-Bathing – shower with assist of one staff on Wednesday and Saturday.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following:
-The resident’s last documented shower was on 6/4/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 4/1/19, 4/4/19, 4/8/19, 4/15/19, 4/22/19, 4/25/19, 4/29/19, 5/2/19, 5/6/19,
5/9/19, 5/13/19, 5/23/19, 6/6/19 and 6/10/19.
Observation on 06/10/19 at 4:30 P.M. showed the following:
-The resident sat in his/her wheelchair in the dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 06/12/19 at 10:00 A.M. showed the following:
-The resident sat in a chair in the day room;
-The resident had unshaven facial hair resembling stubble.
12. Review of Resident #37’s quarterly MDS dated [DATE] showed the following:
-The resident’s cognition was severely impaired;
-The resident was dependent on two staff for transfers;
-The resident was dependent on one staff with dressing, toilet use, personal hygiene, and
bathing;
-The resident was always incontinent of bowel and bladder;
-There was no documentation provided regarding the resident’s dental/oral status.
Review of the resident’s care plan last reviewed on 4/17/19 showed the following:
-The resident was totally dependent on staff for all ADLs;
-The resident was incontinent of urine and wore an adult brief;
-There was no documentation to show the resident’s bathing schedule and/or his/her
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
preferences.
Review of the resident’s undated CNA Care Card located in the resident’s room showed the
following:
-The resident required assistance of one staff with brushing his/her teeth, combing
his/her hair, peri-care, and shaving;
-The resident was to receive a shower with assistance of one staff on Mondays and
Thursdays;
-The resident was incontinent of bowel and bladder and required assistance of one staff
with post-incontinence care.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 4/1/19 to
4/30/19 showed the resident’s showers scheduled on Mondays and Thursdays. There was no
documentation to show the resident received showers on 4/2/19, 4/8/19, 4/11/19, 4/18/19,
4/22/19, 4/25/19, and 4/29/19. Staff documented that the resident received showers on
4/3/19 and 4/14/19 during this time frame.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 5/19/19 to
5/31/19 showed the resident’s showers scheduled on Mondays and Thursdays. There was no
documentation to show the resident received showers on 5/2/19, 5/6/19, 5/9/19, 5/16/19,
5/27/19, and 5/30/19. Staff documented that the resident received showers on 5/13/19,
5/19/19, 5/22/19, and 5/25/19 during this time frame.
Review of resident’s Physician order [REDACTED].
Review of the resident’s skin monitoring/comprehensive CNA shower reviews dated 6/1/19 to
6/13/19 showed the resident’s showers scheduled on Mondays and Thursdays. There was no
documentation to show the resident received showers on 6/6/19, 6/10/19, and 6/13/19. Staff
documented that the resident received a shower on 6/2/19 during this time frame.
Observation of the resident on 6/9/19 at 1:45 P.M. showed the following:
-The resident sat in front of the nurse’s station with an orange colored substance on
his/her shirt, pants, and wheelchair;
-The resident had visible facial hair noted on his/her chin;
-The resident had a strong urine odor.
Observation on 6/11/19 at 5:30 A.M. showed the resident lay in bed with his/her eyes
closed. A strong urine odor was noted in his/her room.
Observation on 6/11/19 at 7:40 AM showed the following:
-CNA D was assisting the resident up for the day;
-The resident’s teeth had a white film on them;
-The resident had visible facial hair on his/her chin;
-CNA D failed to offer/provide oral care before assisting the resident to the dining room
for breakfast.
During an interview on 6/11/19 at 7:45 A.M., CNA D said it was difficult to complete
resident’s showers due to the facility’s staffing shortage.
Observation of the resident on 6/12/19 at 10:26 A.M. showed the following:
-The resident sat in his/her wheelchair in the day area;
-His/Her teeth had a white film on them;
-The resident had visible facial hair noted on his/her chin;
-The resident’s hair appeared greasy and unkempt.
13. Record review of Resident #41’s significant change MDS, dated [DATE], showed the
following:
-Cognition intact;
-Bathing very important;
-Frequently incontinent of bowel and bladder.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Cognition intact;
-No rejection of care;
-Required supervision and setup help for bathing;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan last reviewed on 6/9/19 showed the following:
-The resident is mostly independent with ADLs. Needs assist with showering and shaving;
-Assist the resident with ADLs.
Review of the resident’s CNA care card located in the resident’s closet, dated 6/26/18,
showed the following:
-Personal hygiene – brush teeth and comb hair independently;
-Personal hygiene – shave with assist;
-Dressing – independent;
-Bathing – shower independently with assist on Monday and Thursday.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Wednesday and Saturday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through (MONTH) 11, 2019, showed the following:
-The resident’s last documented shower was on 6/1/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/2/19, 3/9/19, 4/6/19, 4/10/19, 4/13/19, 4/17/19, 4/24/19, 4/27/19, 5/4/19,
5/8/19, 5/18/19, 5/25/19, 5/29/19, 6/5/19 and 6/8/19.
Observation on 06/9/19 at 2:22 P.M. showed the following:
-The resident sat on his/her bed in his/her room;
-The resident had unshaven facial hair resembling stubble.
Observation on 6/11/19 at 1:30 P.M. showed the resident walked in the hallway with
unshaven facial hair resembling stubble.
During interview on 6/9/19 at 2:22 P.M., the resident said he/she did a lot of care for
him/herself but required staff help with bathing and shaving.
14. During an interview on 6/11/19 at 7:45 A.M., CNA D said it was difficult to complete
residents’ showers due to the facility’s staffing shortage.
During an interview on 6/11/19 at 4:00 P.M., restorative aide (RA) RA/CNA A said the
following:
-Residents should be assisted with oral care twice a day;
-Morning ADL cares should include oral hygiene, brushing resident’s teeth, shaving
residents if needed, washing their faces, and combing hair;
-Women should be shaved as well as men if they want facial hair removed.
During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan Coordinator said the
following:
-Oral hygiene should be offered/provided every morning, before residents go to bed, and as
needed if staff noted a film on the resident’s teeth;
-He/She would expect CNAs to follow the CNA Manual;
-He/She would expect CNAs to follow the CNA guidelines when providing perineal care for
both male and female residents;
-He/She expected all areas of the perineum to b

F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide basic life support, including CPR, prior to the arrival of emergency medical
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
personnel , subject to physician orders and the resident’s advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff were properly
trained in cardiopulmonary resuscitation (CPR-process of providing rescue ventilation and
chest compressions to maintain circulation of blood) and subject to accepted professional
guidelines, by allowing staff to certify/recertify for CPR online. The facility identified
32 residents as full code status (CPR required in the event of cardiac or respiratory
arrest). The facility census was 57.
1. Review of the facility’s CPR policy dated (MONTH) (YEAR) showed the following:
-CPR certification must be designed for healthcare providers to be acceptable;
-On-line only first aid and CPR are not accepted;
-The course should be face to face or a hybrid course that includes hands-on skills
practice assessment from a certified instructor prior to certification.
2. Review of Registered Nurse (RN) B’s personnel file showed the employee’s CPR
certification was an online course only without hands-on practice or in person skills
portion. The employee’s hire date was [DATE].
During an interview on [DATE] at 4:01 P.M. RN B said the following:
-He/She had been employed for three years;
-He/She took a online CPR course last time and it did not require hands on training.
3. Review of Licensed Practical Nurse (LPN) I ‘s personnel file showed the employee’s
certification was online course only without hands-on practice or in person skills
portion. The employee’s hire date was [DATE].
During an interview on [DATE] at 12:53 P.M. LPN I said he/she took a online CPR course
last time and it did not require hands on training.
4. During an interview on [DATE] at 11:20 A.M. the administrator said the following:
-She was responsible for tracking employee CPR certifications;
-The facility offered CPR classes once a year;
-If an employee cannot make a CPR class they are allowed to take an online course;
-She was not sure if the online courses included hands on or face to face component;
-She was not aware the regulations required CPR certification to have a hands on or skills
portion;
-She had difficulty keeping up with staff certifications and getting a copy of the staff
CPR certifications because the staff get the card and often failed to bring her a copy.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed provide evidence
interventions were reviewed, evaluated and/or modified following falls to reduce the risk
for further falls for two residents (Residents #32 and #53), in a review of 15 sampled
residents. The facility also failed to implement interventions identified on the
resident’s care plan to prevent falls for one resident (Resident #4). The facility census
was 57.
1. Review of the facility’s fall champion program policy, last updated in (MONTH) (YEAR),

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
showed the following:
-Each community would appoint a fall champion to assist in the oversight and monitoring of
the community’s fall prevention program;
-Anyone who scored a ten or more on the fall risk assessment would be considered at risk
for falls;
-Admissions who scored a ten or more would be placed on the falling star program for two
weeks and would be removed from the program if the resident did not fall within those two
weeks;
-The Fall Champion was responsible for ensuring a falling star was on the resident’s name
plate and any equipment such as wheelchairs or walkers;
-Every event report would be taken to a morning stand up meeting along with the resident’s
chart for review by the interdisciplinary (IDT) team after the primary portion of the
stand-up meeting was done;
-Review of the resident’s events included review of nurse’s notes, neurological checks,
interventions that were put into place, and surrounding circumstances that occurred prior
to the resident’s fall;
-Staff was to document the IDT note in the nurse’s note as to what happened, what was in
place, and what was being done as well as any other information pertinent to prevention of
future falls;
-The resident’s care plans and care cards would be updated with writing FALL RISK in
capital letters on the top of the care card and highlight in yellow to bring attention to
the risk;
-Weekly, the fall champion would monitor the falling star program to ensure that starts
were placed on doors and equipment;
-The IDT team would meet weekly and discuss the facility’s falls and the interventions put
into place along with the effectiveness;
-The fall champions would collaborate with the MDS Coordinator to ensure the resident’s
care plan was updated as necessary.
2. Review of the facility’s undated policy for the Falling Star Program showed the
following:
-If a star was next to the resident’s name located on the door, this indicated the
resident as at high risk for falling;
-When walking down the hall, peek in on those residents to make sure they are not in a
position to fall, they have their call light within reach, etc.;
-Encourage the residents to keep their doors open unless the resident preferred otherwise.

3. Review of Resident #32’s [NAME]s Hopkins Fall Risk Assessment Tool, dated 3/27/19,
showed the resident was at high risk for falling.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment to be
completed by the facility for a significant change, dated 4/4/19, showed the following:
-The resident’s cognition was severely impaired;
-The resident required extensive assistance from one staff for bed mobility and transfers;
-The resident did not walk and required the use of a wheelchair for mobility;
-The resident was not steady and was only able to transfer from seated to standing
position and surface-to-surface with human assistance;
-There were no falls documented since the previous comprehensive assessment (1/20/19).
Review of the facility’s event report, recorded on 4/17/19, showed the following:
-The resident was observed on the floor next to his/her bed on 4/16/19 at 2:30 P.M.;
-The resident was sitting in his/her chair just prior to the fall;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-Interventions implemented to prevent further falls included to not leave the resident in
his/her room alone;
-Staff documented the interventions were effective;
-Staff documented the care plan was reviewed.
Review of the resident’s care plan showed no documentation regardings the resident’s fall
on 4/16/19, including interventions to prevent further falls.
Review of the resident’s event report, dated 4/20/19, showed the following:
-The resident experienced an unwitnessed fall in his/her room on 4/19/19 at 10:30 P.M.;
-The resident was lying in his/her bed just prior to the fall;
-There were no preventative interventions implemented;
-Staff documented interventions were effective.
Review of the resident’s care plan showed no evidence staff re-evaluated current fall
interventions or implemented new interventions after the resident fell on [DATE].
Review of the resident’s event report, recorded on 4/20/19, showed the following:
-The resident experienced an unwitnessed fall in his/her room on 4/20/19 at 4:15 A.M.;
-The resident was lying in bed prior to the fall;
-The resident complained of mild pain to his/her left cheek and left shoulder;
-Preventative interventions implemented included placement of a fall mat;
-Staff documented interventions were effective;
-Staff documented the care plan was not reviewed.
Review of the resident’s care plan showed no documentation regarding the resident’s fall
on 4/20/19.
Review of the resident’s care plan, last reviewed on 4/24/19, showed the following:
-The resident was at risk for falls related to use of [MEDICAL CONDITION] medications;
-The resident liked to lay on the floor at times;
-The resident was instructed to seek assistance with getting up;
-The resident’s bed was to remain in the lowest position when the resident was unattended.
Review of the resident’s event report, dated 4/25/19, showed the following:
-The resident experienced an unwitnessed fall in his/her room;
-There was no documentation to show what the resident was doing just prior to the fall;
-There were no preventative interventions implemented.
Review of the resident’s care plan showed no evidence staff re-evaluated current fall
interventions or implemented new interventions to prevent further falls after the resident
fell on [DATE].
Review of the resident’s event report, dated 5/16/19, showed the following:
-The resident experienced an unwitnessed fall in his/her room on 5/16/19 at 1:30 A.M.;
-The resident was lying in bed prior to the fall;
-The resident suffered a 2 centimeter (cm) by 2 cm laceration to the left hip area;
-Preventative interventions implemented included to ensure the resident’s necessary items
were in reach;
-Staff documented the care plan was not reviewed.
Review of the resident’s care plan showed no documentation regarding the resident’s fall
on 5/16/19.
Review of the resident’s care plan, revised on 6/4/19, showed the following:
-The resident fell on [DATE], 4/19/19, 4/20/19, 4/22/19, and 4/24/19;
-The resident was found on the floor next to the bed during the falls;
-Falls occurred early morning or on the evening shift;
-On 5/16/19, the resident was found on the fall mat next to his/her bed;
-The resident was placed on the falling star program on 5/8/19.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
Observation on 6/11/19 at 5:30 A.M. showed the resident lay in bed in his/her room
unattended.
During an interview on 6/12/19 at 4:54 P.M., Certified Nurse Assistant (CNA) E said the
following:
-There was not enough staff to have someone stay with the resident when he/she was in
his/her room;
-The resident was in a high low bed but it did not go completely to the floor;
-He/she checked on the resident every chance he/she got;
-Staff has tried everything, but the resident continued to put himself/herself on the
floor and would not stay in bed.
During an interview on 6/13/19 at 10:30 A.M., Licensed Practical Nurse (LPN) I said the
following:
-The resident slid himself/herself on the floor because he/she liked to be on the floor;
-It was difficult to have staff with the resident while he/she was in his/her room,
especially due to the staffing the facility had at that time;
-Charge nurses were responsible for updating the resident’s care plans after falls.
4. Review of Resident #53’s significant change MDS, dated [DATE], showed the following:
-The resident had moderate cognitive impairment;
-Independent with transfers;
-Not stable during surface to surface transfers;
-[DIAGNOSES REDACTED].
-Had one fall without injury since admission and prior assessment.
Review of the resident’s care plan, approach date 3/14/19, showed the following:
-The resident was at risk for falls;
-The resident has limited range of motion to his/her left arm;
-The resident’s fall mat was removed due to increased independence.
Review of the resident’s event report, recorded on 4/22/19, showed the following:
-The resident was coming out of the bathroom and was seen trying to push the door with
his/her shoulder. The resident lost his/her balance and slid down the wall onto his/her
buttocks;
-Staff documented the interventions were effective;
-Staff did not document any interventions to be put in place following the fall;
-Staff documented the care plan was not reviewed.
Review of the resident’s care plan showed the following:
-The resident fell coming out of the bathroom on 4/22/19;
-No evidence staff re-evaluated current fall interventions or implemented new
interventions after the resident fell on [DATE].
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-The resident had moderate cognitive impairment;
-Independent with transfers;
-Used a cane or crutch;
-Independent with locomotion on and off the unit;
-Was not stable from surface to surface transfers;
-Had one fall without injury since admission and prior assessment on 1/24/19.
Review of the resident’s event report, recorded on 5/4/19, showed the following:
-Witnessed fall at 9:15 A.M.;
-The resident attempted to sit down in a chair in the sun room, misjudged, and fell to the
floor;
-Staff assisted the resident into the chair;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Staff will continue to monitor;
-Staff did not document if interventions were effective or interventions put in place to
prevent further falls.
Review of the resident’s care plan showed the following:
-The resident fell coming out of the bathroom on 5/4/19;
-Staff documented on 5/4/19 the resident had poor safety awareness and is easily agitated
during care;
-No evidence staff re-evaluated current fall interventions or implemented new
interventions after the resident fell on [DATE].
5. Review of Resident #4’s care plan, dated 8/13/16, showed the following:
-Resident at risk for falls related to poor safety awareness, use of [MEDICAL CONDITION]
medication, visual impairment, and gait/balance is unsteady at times;
-Keep pathways clear for him/her to ambulate;
-Attempt to identify reason for him/her wanting to get up, offer assistance as
appropriate;
-Continue to monitor for safety and provide assistance with ambulation;
-Encourage him/her to wear tennis shoes or non-skid socks when up.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-The resident had short and long-term memory problems;
-The resident required extensive assistance from one staff for bed mobility, transfers,
walking in room or corridor, locomotion on and off of the unit, dressing and toileting;
-The resident was not steady but was able to stabilize without staff assistance when
moving from seated to standing position, walking, turning around and facing the opposite
direction while walking, moving on and off toilet and surface to surface transfers;
-There were no falls documented since the previous comprehensive assessment (2/9/19).
Review of the resident’s [NAME]s Hopkins Fall Risk Assessment Tool, dated 5/17/19, showed
a score of 22, which indicated the resident was at high risk for falling.
Observation on 6/9/19 at 4:26 P.M., showed the staff assisted the resident to walk from
his/her room to the dining room. The resident wore regular socks without non-skid
grippers.
Observation on 6/9/19 at 4:33 P.M., showed the resident got up from his/her chair in the
dining room and walked to the exit door in his/her socked feet. Staff instructed the
resident to get away from the door. The DON assisted him/her to sit back down.
Observation on 6/9/19 at 4:52 P.M., showed the resident stood up and went to the exit door
again in his/her socked feet. The DON assisted him/her to sit down.
Observation on 6/9/19 at 4:55 P.M., showed the resident then stood again at the door.
Staff told the resident to get away from the door. The DON assisted the resident to walk
back into his/her room. The resident was not wearing shoes and did not wear non-skid
socks.
Observation on 6/13/19 at 2:10 P.M. showed the resident walked in the hall with socked
feet without non-skid grippers.
During interview on 6/13/19 at 2:35 P.M., CNA L said the following:
-Staff put non-skid socks and shoes on the resident to prevent falls;
-The resident does what he/she wants;
-The resident should wear non-skid socks all the time;
-The CNA assigned to getting the resident up for the day is responsible for putting
non-skid socks on the resident;
-The resident should have non-skid socks on and he/she doesn’t know why the resident
doesn’t.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
During interview on 6/13/19 at 2:38 P.M., LPN I said the CNAs should make sure the
resident wears the non-skid socks and they are on him/her when he/she gets up in the
morning.
During interview on 6/13/19 at 4:55 P.M., the Director of Nursing (DON) and MDS/care plan
coordinator said the following:
-Residents should wear non-skid socks when it is care planned;
-The nurse or CNA is responsible for making sure the residents wear no-skid socks.
6. During an interview on 6/12/19 at 4:44 P.M. and 6/13/19 at 4:55 P.M., the MDS/Care Plan
Coordinator said it was the charge nurses were responsible to review and update the
residents’ care plans after falls.The charge nurses had a difficult time coming up with
interventions. She and the administrator tried to review falls and make sure interventions
were put in to place. The interdisciplinary team (IDT) had not been meeting about falls as
they should due to being short staffed and not having a DON.
During an interview on 6/20/19 at 1:41 P.M., the MDS/Care Plan Coordinator said the
following:
-The charge nurse should put fall interventions in place and update the care plan at the
time a resident falls;
-The fall champion is normally the DON but the facility had been without a DON;
-The Administrator and Care plan/MDS Coordinator were trying to fill in as the fall
champion;
-The fall champion was in charge of making sure the fall interventions were appropriate
and put on the care plan along with making sure fall events were completed;
-After reviewing Resident #53’s interventions, he/she was not sure why there weren’t
interventions for each fall.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assess one
resident’s (Resident #14) [MEDICAL TREATMENT] arteriovenous (AV) shunt/fistula (access
used to artificially connect a vein with an artery, so that a higher blood flow is created
to allow blood to be pumped out of the body to an artificial kidney machine, and returned
to the body by tubes that connect the patient to the machine) daily and after he/she
returned from [MEDICAL TREATMENT] treatments in a review of 15 sampled residents. The
facility failed to include care of the resident’s [MEDICAL TREATMENT] shunt/fistula on the
resident’s care plan. The facility census was 57.
1. Review of the facility’s policy for care of a resident receiving [MEDICAL TREATMENT]
from the Nursing Guidelines Manual dated (MONTH) of (YEAR) showed the following:
-Purpose; to utilize the following guidelines to provide care for a resident that was
receiving [MEDICAL TREATMENT];
-Care of the AV Shunt/fistula/graft included to keep the area clean and dry, feel for
thrill sensation daily, inspect the access for redness, swelling or warmth, no blood
pressures should be taken or IV administration should be done in the arm of the access
site, avoid excessive pressure on the puncture site after [MEDICAL TREATMENT], watch for
bleeding after [MEDICAL TREATMENT], and monitor for signs of infection;
-Site to be checked every shift and dressing reapplied or reinforced as needed;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
-Site should be monitored for signs of infection;
-Nursing staff should check and document the thrill (important sound and indicator of how
well the [MEDICAL TREATMENT] fistula is functioning) daily;
-Staff should contact the physician if no thrill sensation is felt.
2. Review of the Resident #14’s physician’s orders [REDACTED].
Review of the resident’s significant change Minimum Data Set (MDS), a federally mandated
assessment to be completed by facility staff, dated 5/19/19 showed the following:
-The resident’s cognition was intact;
-The resident received [MEDICAL TREATMENT].
Review of the resident’s care plan last reviewed on 6/4/19 showed no documentation the
resident had a [MEDICAL TREATMENT] shunt/fistula.
Review of the resident’s undated certified nursing assistant (CNA) care card showed no
documentation regarding the resident’s [MEDICAL TREATMENT] shunt/fistula.
Observation on 6/10/19 at 4:43 P.M. showed the following:
-The resident returned from [MEDICAL TREATMENT] at approximately 3:00 P.M.;
-His/Her right arm was wrapped with a gauze dressing;
During interview on 6/10/19 at 11:12 AM. and 4:45 P.M., the resident said the following:
-He/She had a [MEDICAL TREATMENT] shunt/fistula located in his/her upper right arm;
-He/She received [MEDICAL TREATMENT] treatments every Monday, Wednesday, and Friday;
-Staff did not monitor his/her [MEDICAL TREATMENT] shunt daily or when he/she returned
from [MEDICAL TREATMENT] treatments;
-He/She had to leave a dressing on the [MEDICAL TREATMENT] shunt/fistula area after
his/her treatment to make sure that it did not bleed;
-Facility staff did not come down and assess his/her [MEDICAL TREATMENT] shunt /fistula
area when he/she returned from [MEDICAL TREATMENT].
Review of the resident’s medical record showed the following:
-There were no documented daily assessments of the resident’s [MEDICAL TREATMENT]
shunt/fistula;
-There was no documented assessment of the resident’s [MEDICAL TREATMENT] shunt/fistula
when he/she returned from [MEDICAL TREATMENT] on 6/10/19.
During an interview on 6/11/19 at 2:40 P.M., Licensed Practical Nurse (LPN) C said the
following:
-He/She was unaware of any specific documented assessments to monitor the resident’s
[MEDICAL TREATMENT] shunt/fistula;
-He/She never cared for a resident with a [MEDICAL TREATMENT] shunt/fistula and did not
know how to check for bruit (sound generated by turbulent blood flow in an artery due to
either an area of partial obstruction or high rate of blood flow through an unobstructed
artery);
-He/She had worked at the facility for two years and this resident was the first he/she
had cared for that required [MEDICAL TREATMENT].
During an interview on 6/13/19 at 10:30 A.M., LPN I said the following:
-He/She did not know what to assess for with a resident who had a [MEDICAL TREATMENT]
shunt/fistula;
-There was no specific assessment that was required;
-The facility and/or the [MEDICAL TREATMENT] center did not provide any education on how
to care for a resident with a [MEDICAL TREATMENT] shunt/fistula;
-The resident had the shunt/fistula for approximately two months and started [MEDICAL
TREATMENT] approximately one month ago.
During an interview on 6/3/19 at 11:54 A.M., LPN H said the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
-He/She just found out that there was a policy for [MEDICAL TREATMENT] residents;
-Staff had not been assessing the resident’s [MEDICAL TREATMENT] shunt/fistula;
-If the facility had a Director of Nursing (DON) to provide education maybe they would
have been doing them like they should have.
During an interview on 6/11/19 at 2:30 P.M., Registered Nurse (RN) B said the following:
-There were no specific assessments of the resident’s [MEDICAL TREATMENT] shunt/fistula
completed daily or when the resident returned from [MEDICAL TREATMENT];
-There should be a documented assessment, but that has been overlooked.
During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan coordinator said the
following:
-Residents who have [MEDICAL TREATMENT] shunts/fistulas should be assessed every day by
the charge nurse;
-Resident’s care plan and CNA care cards should include care of the resident’s [MEDICAL
TREATMENT] shunt/fistula;
-There had been no education provided to the staff regarding care/assessment of the
[MEDICAL TREATMENT] shunt/fistula.

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
sufficient nursing staff to meet residents’ needs for eleven residents (Residents #4, #11,
#16, #25, #29, #30, #31, #37, #40, #41, and #54), in a review of 15 sampled residents.
Staff failed to provide routine showers, shaving, and oral care to ensure good personal
hygiene and prevent body odors; and failed to provide restorative therapy when the
restorative aide (RA) was pulled to work as a certified nurse assistant (CNA) and was
unable to complete duties for the restorative therapy nursing program. The facility census
was 57.
1. During an interview on 6/13/19 at 11:18 A.M., the administrator said the facility did
not have a staffing policy.
2. During interview with the facility’s resident council on 6/10/19 at 9:36 A.M. showed
the following:
-Residents #5, #41, and #55 had to sometimes wait quite a while for call light to be
answered;
-Residents #10 and #41 said they have had to wait up to an hour for staff assistance;
-Resident #18 has had to go out of the room to find staff to assist his/her roommate, but
staff would not respond in a timely manner;
-Resident #18 said staffing was worse on the weekends;
-Resident #10 said wait time for assistance was worse at night;
-Resident #41 said wait time for assistance was worse during the evening shift;
-Resident #15 said wait time for assistance was worse after midnight;
-Resident #18 said the facility’s staffing was bad and they needed more certified nurse
assistants (CNAs).
3. Record review of Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 5/12/19, showed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 24)
the following:
-Required extensive assistance of one staff for bathing;
-Required total assistance of one staff for personal hygiene.
Review of the resident’s care plan, revised 5/24/19, showed the following:
-Assist as needed with oral care;
-Requires extensive assist with dressing, bathing, hygiene and bathing related to impaired
cognition and visual function;
-Shower two times per week.
Review of the resident’s undated certified nurse assistant (CNA) care card, located in the
resident’s closet, showed the following:
-Personal hygiene – brush teeth, comb hair, shave with assist of one staff;
-Bathing – shower with assist of one staff.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Tuesday and Friday evening shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for (MONTH) 2019 through 6/11/19, showed the following:
-The resident’s last documented shower was on 5/30/19;
-No documentation to show the resident had been shaved or care had been provided or
refused on 3/8/19, 3/12/19, 3/19/19, 4/2/19, 4/12/19, 4/19/19, 4/26/19, 4/30/19, 5/3/19,
5/7/19, 5/10/19, 5/14/19, 5/17/19, 5/24/19, 5/28/19 and 6/4/19.
Observation on 06/10/19 at 5:10 P.M. showed the following:
-The resident sat in a chair in the dining room;
-The resident had unshaven facial hair resembling stubble;
-The resident had a white film substance on his/her teeth.
Observation on 06/11/19 at 11:30 A.M. showed the following:
-The resident sat in a chair the dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 06/12/19 at 10:45 A.M. showed the following:
-The resident sat on his bed in his/her room;
-The resident had unshaven facial hair resembling stubble;
-The resident had a white film substance on his/her teeth.
4. Review of Resident #11’s care plan, last reviewed on 3/19/19, showed the following:
-The resident required staff reminders and supervision with bathing, and hygiene related
to impaired thought process;
-Staff was to provide appropriate equipment for resident to groom self.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-The resident was cognitively intact;
-The resident was independent with personal hygiene and bathing.
Observation on 6/9/19 at 1:00 P.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
-The resident had approximately 1 inch long gray hairs on his/her chin.
Observation on 6/10/19 at 2:00 P.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
-The resident had approximately 1 inch long gray hairs on his/her chin.
Observation on 6/11/19 at 5:29 A.M. and 2:05 P.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 25)
-The resident had approximately 1 inch long gray hairs on his/her chin.
Observation on 6/12/19 at 10:54 A.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled;
-The resident had approximately 1 inch long gray hairs on his/her chin.
Observation on 6/13/19 at 10:15 A.M. showed the following:
-The resident sat in his/her chair;
-The resident’s hair was oily and disheveled.
During interview on 6/13/19 at 10:15 A.M., the resident said the following:
-His/Her family member came yesterday evening and shaved him/her;
-He/She liked to be shaved and did not like facial hair;
-He/She had asked the staff to shave him/her but they never had time.
During an interview on 6/13/19 at 10:42 A.M., CNA K said the following:
-He/She was on light duty and was responsible for shaving the residents;
-He/She had not shaved the resident because he/she ran out of time;
-The resident liked to be shaved;
-The resident required staff to shave him/her.
During an interview on 6/13/19 at 10:28 A.M., Registered Nurse (RN) M said the following:
-The staff had to shave the resident;
-The resident preferred his/her facial hair waxed but the facility didn’t wax the
resident’s facial hair any longer;
-The resident required staff assistance to be shaved.
5. Record review of Resident #16’s quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-Required total assistance of one staff for personal hygiene and bathing.
Review of the resident’s care plan, revised 6/6/19, showed the following:
-Requires assist with ADLs;
-Assist with bathing;
-Assist with dressing;
-Shower or bath two times per week;
-Supervise and assist the resident as needed while bathing/showering.
Review of the resident’s CNA care card, located in the resident’s closet, undated, showed
the following:
-Personal hygiene- brush teeth, comb hair, peri care and shave with assist of one staff;
-Assist of one staff for dressing and showers.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Wednesday and Saturday evening shift.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for (MONTH) 2019 through 6/11/19, showed the following:
-The resident’s last documented shower was on 5/31/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/7/19, 4/6/19, 4/10/19, 4/17/19, 5/4/19, 5/8/19, 5/25/19, 6/1/19, 6/5/19,
6/8/19 and 6/11/19;
-Resident refused a shower on 4/24/19 due to it was too late;
-Resident refused a shower on 5/1/19 due to he/she was already in bed.
Observation on 06/12/19 at 9:43 A.M. showed the following:
-The resident sat in his/her wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
Observation on 06/13/19 at 1:00 P.M. showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 26)
-The resident sat in his/her wheelchair in his/her room;
-The resident had unshaven facial hair resembling stubble.
During interview on 6/12/19 at 9:43 A.M., the resident said the following:
-Staff help him/her shave on shower days;
-Shower days are Wednesday and Saturday with the make-up day on Sunday, but if the
facility is short staffed showers do not get done on Sundays;
-It has been two weeks since he/she had a shower (review of the shower sheets show his
last shower was 5/31/19);
-He/She does not like the stubble of facial hair on his/her face.
During interview on 6/9/19 at 1:38 P.M, the resident said he/she needed help toileting
this morning but he/she was told he/she needed to wait because they were short staffed and
only had one aide for the day. He/she likes to get up at 4:00 A.M., but staff told him/her
he/she had to stay in bed until 6:00 A.M. when the day shift arrived due to he/she was
passing medications and the other staff member was busy (only had two staff on the
schedule for the night shift).
6. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following:
-The resident received restorative therapy for passive range of motion (PROM – involves
assistance in moving a joint) two days out of the last seven;
-The resident received restorative therapy for walking four days out of the last seven.
Review of the resident’s care plan, last reviewed on 4/2/19, showed the following:
-The resident is limited in ability to transfer self related to visual impairment and
weakness:
-Restorative program three times weekly for PROM to upper body and ambulation;
-Instruct the resident in proper transfer techniques;
-Provide assistance for transferring.
-The resident experiences bladder incontinence related to visual impairment and need of
assistance for transfers.
Review of the resident’s undated Certified Nurse Aide (CNA) Care Card showed the
following:
-Restorative and nursing interventions for walk to dine, multi podus boots (used for those
at risk for plantar flexion contracture, foot drop, hip rotation and decubitus heel
ulcers) on as tolerated and AFO (ankle and foot orthoses brace) on while in wheelchair;
-Personal hygiene – brush teeth, comb hair, peri care and shave with assist of one staff;
-Dressing – assist of one staff;
-Bathing – shower with assist of one staff.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday evening shift.
Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed
staff documented the resident received restorative therapy one out of two days for active
range of motion (AROM – exercises the resident is able to perform independently) and
walking.
Review of the resident’s physician orders [REDACTED].
Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed the
following:
-Staff documented the resident received restorative therapy zero days out of 34 for PROM;
-Staff documented the resident received restorative therapy eight days out of 34 for
walking.
Review of the resident’s comprehensive CNA shower review documentation, provided by the
facility for (MONTH) 2019 through 6/11/19, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 27)
-The resident’s last documented shower was on 6/2/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/7/19, 3/14/19, 3/18/19, 3/21/19, 4/1/19, 4/4/19, 4/15/19, 4/22/19, 4/25/19,
4/29/19, 5/2/19, 5/6/19, 5/13/19, 5/16/19, 5/20/19, 5/30/19, 6/3/19, 6/6/19 and 6/10/19;
-Resident refused shower on 3/28/19, 4/8/19, 4/23/19 due to it was too late.
7. Review of Resident #30’s physician order, dated 3/27/19, showed the following:
-[DIAGNOSES REDACTED].
-Restorative aide three times a week for range of motion for upper extremities and lower
extremities.
Review of resident’s care plan, last reviewed 4/4/19, showed the following:
-The resident’s ability to perform activities of daily living (ADLs) was at risk for
deterioration due to weakness and [DIAGNOSES REDACTED].
-The resident required assistance of one staff with ADLs;
-The resident was to receive restorative therapy three times a week for neck support and
range of motion (ROM).
Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed
staff documented the resident received restorative therapy six days out of 12.
Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed
staff documented the resident received restorative therapy three days out of 12.
During an interview on 6/11/19 at 4:00 P.M., Restorative Aide (RA)/CNA A said the
following:
-The resident was supposed to receive restorative therapy three times a week;
-He/She was unable to provide therapy because he/she was pulled to work other areas and
tasks due to staff shortage;
-Not receiving restorative care could cause a decline.
8. Review of Resident #31’s care plan, last reviewed 4/4/19, showed the following:
-The resident’s ability to perform ADLs was at risk for deterioration due to weakness and
[DIAGNOSES REDACTED].
-The resident required assistance of one staff with ADLs;
-The resident was to receive restorative therapy three times a week for neck support and
range of motion (ROM).
Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed the
facility’s staff documented the resident received restorative therapy four days out of 12.
Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed
staff documented the resident received restorative therapy two days out of 12.
During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following:
-The resident was supposed to receive restorative therapy three times a week;
-He/She was unable to provide therapy because he/she was pulled to work other areas and
tasks due to staff shortage;
-The resident had declined within the last couple of weeks;
-The resident had orders to walk to dine, but it was not being done because he/she was
unable to walk with him/her.
9. Review of Resident #40’s care plan, last reviewed on 4/29/19, showed the following:
-The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION]
([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of
the body), weakness, impaired mobility, and unsteady balance;
-The resident was to receive restorative therapy three times a week with staff performing
PROM to all of the resident’s joints to improve and maintain the resident’s left upper
extremity range of motion;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 28)
-The resident was supposed to wear a resting hand splint (on his/her left hand).
Review of the resident’s undated CNA Care Card showed no documentation the resident
received restorative nursing services or that he/she was supposed to wear a hand splint.
Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed the
following:
-Staff documented the resident received restorative therapy six days out of 12;
-There was no documentation to show the resident refused to wear the left hand splint.
Review of the resident’s Restorative Nursing Report, dated 5/12/19 to 6/11/19, showed the
following:
-Staff documented the resident received restorative therapy one day out of 12;
-There was no documentation to show the resident refused to wear the left hand splint.
Observation on 6/09/19 at 4:00 P.M. showed the following:
-The resident sat in his/her wheelchair outside of his/her room. His/her head leaned to
the right side;
-The resident’s left hand was contracted;
-There was no splint on his/her left hand.
Observation on 6/10/19 at 8:59 A.M. showed the following:
-The resident sat in his/her wheelchair;
-The resident’s left hand and left foot were contracted;
– There was no splint on his/her left hand.
During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following:
-The resident was supposed to have restorative therapy three times a week, but he/she had
been pulled from his/her restorative nursing duties to perform care;
-He/She was also unable to complete restorative nursing duties because he/she took
residents to appointments, completed residents’ weights and vital signs, attended care
plan meetings, and updated CNA Care Cards;
-There was a second CNA trained to assist with restorative therapy, but he/she worked as a
CNA on the day shift and was unable to assist with restorative therapy;
-The resident was supposed to wear a brace to his/her left hand and he/she had tried, but
the resident refused to wear the brace.
10. Review of Resident #54’s annual MDS, dated [DATE], showed the following:
-The resident’s range of motion was impaired on one side of upper and lower extremities;
-The resident received restorative therapy three out of the previous seven days.
Review of the resident’s care plan, last updated on 6/9/19, showed the following:
-The resident required extensive assistance with ADLs related to [DIAGNOSES REDACTED].
-The resident was to wear a splint to his/her left hand to assist with contraction;
-The resident was to have restorative therapy three times a week for left upper extremity
range of motion and right upper extremity strength.
Review of the resident’s undated care card showed the following:
-The resident had left sided weakness;
-He/She was to have a splint applied in the morning and removed at night (no documentation
to show the type of splint the resident was to wear).
Review of the resident’s Restorative Nursing Report, dated 4/12/19 to 5/11/19, showed the
following:
-Staff documented the resident received restorative therapy six days out of 12;
-There was no documentation to show the resident refused wearing the left hand splint.
Review of the resident’s Restorative Nursing Report dated 5/12/19 to 6/11/19 showed the
following:
-Staff documented the resident received restorative therapy two days out of 12;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 29)
-There was no documentation to show the resident refused wearing the left hand splint.
Observation on 6/10/19 at 1:47 P.M. showed the following:
-The resident’s left hand was contracted;
-No splint on his/her left hand.
11. Record review of Resident #29’s significant change MDS, dated [DATE], showed the
resident requires total assist of one staff with personal hygiene and bathing.
Review of the resident’s care plan, last reviewed on 6/9/19, showed the following:
-When the resident wakes for the day, assist with morning cares;
-Assist as needed with oral care;
-Requires extensive with activities of daily living (ADLs) related-to [MEDICAL CONDITION]
and cognitive impairment;
-Shower two times per week.
Review of the resident’s CNA care card, located in the resident’s closet, undated, showed
the following:
-Personal hygiene – shave with assist of one staff;
-Bathing – shower with assist of one staff on Wednesday and Saturday.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Monday and Thursday day shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through 6/11/19, showed the following:
-The resident’s last documented shower was on 6/4/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 4/1/19, 4/4/19, 4/8/19, 4/15/19, 4/22/19, 4/25/19, 4/29/19, 5/2/19, 5/6/19,
5/9/19, 5/13/19, 5/23/19, 6/6/19 and 6/10/19.
Observation on 06/10/19 at 4:30 P.M. showed the following:
-The resident sat in his/her wheelchair in the dining room;
-The resident had unshaven facial hair resembling stubble.
Observation on 06/12/19 at 10:00 A.M. showed the following:
-The resident sat in a chair in the day room;
-The resident had unshaven facial hair resembling stubble.
12. Review of Resident #37’s quarterly MDS, dated [DATE], showed the following:
-The resident’s cognition was severely impaired;
-The resident was dependent on one staff with dressing, toilet use, personal hygiene, and
bathing;
-The resident was always incontinent of bowel and bladder.
Review of the resident’s undated CNA Care Card, located in the resident’s room, showed the
following:
-The resident required assistance of one staff with brushing his/her teeth, combing
his/her hair, peri-care, and shaving;
-The resident was to receive a shower with assistance of one staff on Mondays and
Thursdays;
-The resident was incontinent of bowel and bladder and required assistance of one staff
with post-incontinence care.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews, dated 4/1/19 to
4/30/19, showed the resident’s showers were scheduled on Mondays and Thursdays. There was
no documentation to show the resident received showers on 4/2/19, 4/8/19, 4/11/19,
4/18/19, 4/22/19, 4/25/19, and 4/29/19. Staff documented the resident received showers on
4/3/19 and 4/14/19 during this time frame.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews, dated 5/19/19
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 30)
to 5/31/19, showed the resident’s showers were scheduled on Mondays and Thursdays. There
was no documentation to show the resident received showers on 5/2/19, 5/6/19, 5/9/19,
5/16/19, 5/27/19, and 5/30/19. Staff documented the resident received showers on 5/13/19,
5/19/19, 5/22/19, and 5/25/19 during this time frame.
Review of the resident’s skin monitoring/comprehensive CNA shower reviews, dated 6/1/19 to
6/13/19, showed the resident’s showers were scheduled on Mondays and Thursdays. There was
no documentation to show the resident received showers on 6/6/19, 6/10/19, and 6/13/19.
Staff documented the resident received a shower on 6/2/19 during this time frame.
Observation on 6/9/19 at 1:45 P.M. showed the following:
-The resident sat in front of the nurse’s station with an orange colored substance on
his/her shirt, pants, and wheelchair;
-The resident had visible facial hair noted on his/her chin;
-The resident had a strong urine odor.
Observation on 6/11/19 at 5:30 A.M. showed the resident lay in bed with his/her eyes
closed. A strong urine odor was noted in his/her room.
Observation on 6/11/19 at 7:40 AM showed the following:
-CNA D was assisting the resident up for the day;
-The resident’s teeth had a white film on them;
-The resident had visible facial hair on his/her chin;
-CNA D did not offer or provide oral care before assisting the resident to the dining room
for breakfast.
During an interview on 6/11/19 at 7:45 A.M., CNA D said it was difficult to complete
resident’s showers due to the facility’s staffing shortage.
Observation resident on 6/12/19 at 10:26 A.M. showed the following:
-The resident sat in his/her wheelchair in the day area;
-His/Her teeth had a white film on them;
-The resident had visible facial hair noted on his/her chin;
-The resident’s hair appeared greasy and unkempt.
13. Review of Resident #41’s quarterly MDS, dated [DATE], showed the following:
-Cognition intact;
-Required supervision and setup help for bathing.
Review of the resident’s care plan, last reviewed on 6/9/19, showed the resident is mostly
independent with ADLs. The resident needs assist with showering and shaving.
Review of the resident’s CNA care card, located in the resident’s closet, dated 6/26/18,
showed the following:
-Personal hygiene-shave with assist;
-Bathing-shower independently with assist on Monday and Thursday.
Record review of the facility’s shower assignment sheet showed the resident was to have a
shower on Wednesday and Saturday evening shift.
Review of the resident’s comprehensive CNA shower review documentation provided by the
facility for (MONTH) 2019 through 6/11/19, showed the following:
-The resident’s last documented shower was on 6/1/19;
-No documentation to show the resident had been shaved or that cares had been provided or
refused on 3/2/19, 3/9/19, 4/6/19, 4/10/19, 4/13/19, 4/17/19, 4/24/19, 4/27/19, 5/4/19,
5/8/19, 5/18/19, 5/25/19, 5/29/19, 6/5/19 and 6/8/19.
Observation on 06/9/19 at 2:22 P.M. showed the following:
-The resident sat on his/her bed in his/her room;
-The resident had unshaven facial hair resembling stubble.
Observation on 6/11/19 at 1:30 P.M. showed the resident walked in the hallway with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 31)
unshaven facial hair resembling stubble.
During interview on 6/9/19 at 2:22 P.M., the resident said he/she did a lot of care for
him/herself but required staff help with bathing and shaving.
14. During interview on 6/13/19 at 4:55 P.M, the DON and MDS/care plan coordinator said
the facility is short staffed and when there are only two CNAs the department heads help
out to complete resident’s needs and cares.
Review of the daily staffing from 5/1/19 to 6/7/19 showed the following:
-The administrator worked the floor as a CMT/CNA 12 out 38 days;
-The night shift only had two staff for 24 days out of 38 days.
During an interview on 6/11/19 at 4:00 P.M., RA/CNA A said the following:
-He/She was unable to complete the resident’s restorative therapy the last couple of weeks
because he/she was pulled from his/her restorative nursing duties to provide resident
care;
-He/She was pulled from his/her restorative nursing duties to provide resident care at
least once or twice a week due to lack of staff.
During interview on 6/11/19 at 10:30 A.M., RA/CNA A said the following:
-He/She was working as a CNA today. There is a backup RA when he/she was not here but the
backup RA was off today;
-He/She was to do RA today but got pulled to the floor due to short staffed for CNAs;
-He/She has been pulled from RA to CNA a lot lately, like twice a week. He/She was hired
to be a RA and he/she feels like he/she is letting the residents down as they are not
getting what they are supposed to get for restorative;
-He/She felt like residents were declining as he/she was unable to do the restorative when
he/she gets pulled to the floor.
During an interview on 6/13/19 at 3:55 P.M., the MDS/Care Plan Coordinator said the
following:
-He/She would not expect the RA to be pulled from restorative duties to provide resident
care;
-The RA had been pulled from his/her restorative nursing duties to provide resident care
within the last month or two due to lack of staff.
During interview on 6/13/19 at 11:18 A.M., the Administrator said the following:
-The facility has had staffing issues since May;
-They have tried recruiting and have hired several staff but none stay;
-They use PPD (per patient day which is census times eight times seven divided by 40) to
get the total number of staff needed per shift;
-They do not use the facility assessment or acuity to staff the facility;
-She would prefer and according to the PPD they should have two to four licensed staff and
four to five CNAs on the day shift, and two licensed staff and four to five CNAs on the
evening shift, and one licensed staff and two to three CNAs on night shift;
-The facility had several night shifts that only had two staff members on the shift which
included one licensed nurse and one CNA/Nurse Aide (NA)/CMT;
-Staff was not able to get the residents shaved, clean under the finger nails, and showers
completed since the facility had been short staffed;
-She has worked the floor as a CMT and CNA to provide resident care.

F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
director of nurses on a full time basis.

Based on interview and record review, the facility failed to provide the services of a
registered nurse (RN), for at least eight consecutive hours per day seven days per week.
The facility census was 57.
1. During interview on 6/13/19, the Administrator said the facility did not have a policy
for RN coverage.
Review of the facility Time sheets – Daily Hours by Employee dated (MONTH) 5, 2019 to
(MONTH) 9, 2019 showed no RN worked from 6:00 A.M.-2:30 P.M. on Saturday and Sunday day
shift for at least eight consecutive hours on the following dates:
-March 9, 16 and 17;
-April 6 and 7;
-May 4, 5, 12, 18 and 19;
-June 8 and 9.
During interview on 6/10/19 at 4:10 P.M. and 6/13/19 at 4:55 P.M. the Director of Nurses
(DON) said the following:
-He works mainly Monday through Friday and no holidays or weekends except when he has to
cover a shift from a call in or if he is the manager on duty;
-He has worked one weekend since starting here and that was a couple weekends ago;
-The facility does not have RN coverage eight consecutive hours a day on the day shift;
-The facility should have RN coverage eight consecutive hours a day on the day shift;
-The facility does not have RN coverage seven days a week.
During an interview 6/13/19 on 11:18 A.M. the administrator said:
-The facility did not have a RN eight hours a day, seven days a week;
-The facility had been short staffed since the beginning (MONTH) 2019.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, the facility failed to serve food that was palatable
and at a safe and appetizing temperature. The facility census was 57.
During interview with the facility’s resident council on 6/10/19 at 9:36 A.M. showed the
following:
-Resident #10 said food was served cold;
-Resident #47 said food could be hotter.
Observations on 06/10/19 showed the following:
-At 11:09 A.M., staff prepared the first plate for the lunch meal. Staff continued to
serve residents from the steam table. The steam table contained chicken strips as the main
entree. The alternate meat choices were roast beef and cube steak, and the alternate
vegetable was peas;
-At 12:05 P.M., staff served the last meal tray;
-At 12:07 P.M., the test tray was received. The temperatures of the cube steak was 118
degrees Fahrenheit, the roast beef was 112 degrees Fahrenheit, the ground chicken was 82
degrees Fahrenheit, the chicken strips were 110 degrees Fahrenheit, and the peas were 118

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
degrees Fahrenheit.
During interview on 06/10/19 at 02:49 P.M., the dietary manager said staff only take the
temperatures of the food when they put the food on the steam table. She expected the food
to be served at 120 degrees Fahrenheit or above. She was not aware the serving
temperatures did not meet the 120 degree temperature.
During interview on 06/11/19 at 11:10 A.M., the administrator said she expected the food
temperatures to be at least 120 degrees Fahrenheit at the time of service.

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 nursing
staff washed their hands after each direct resident contact and when indicated by
professional standards of practice during personal care for three residents (Resident #24,
#37, and #40), in a review of 15 sampled residents; and failed to ensure soiled linens
were secured in plastic bags and not placed directly on the floor. The facility also
failed to maintain and implement a comprehensive infection control program designed to
help prevent the development and transmission of water-borne pathogens (a bacterium,
virus, or other microorganism that can cause disease) and failed to provide documented
assessments for such an outbreak. The facility census was 57.
1. Review of the facility policy Handwashing, dated (MONTH) (YEAR), showed the following:
-Purpose was to reduce transmission of organisms from resident to resident, nursing staff
to resident and resident to nursing staff;
-Equipment needed was soap, comfortably hot water and disposable hand towel;
-Turn on water and adjust temperature; soap hands well; rub hands briskly, paying
attention to areas between fingers and nails; rinse with hands lowered to allow soiled
water to drain directly into sink; do not splash water onto clothing and do not allow
hands to touch sink; use disposable hand towel to turn off faucet and dry hands well and
apply moisture barrier if desired.
2. Review of the facility policy, Gloves, dated (MONTH) (YEAR), showed the following:
-Wear gloves when it could be reasonably anticipated that hands would be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound
drainage, oral secretions, sputum, vomitus or items/surfaces soiled with these substances)
and or person with a rash. Gloves must be changed between residents and between contacts
with different body sites of the same resident;
-REMEMBER: Gloves were not a cure-all. They should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects.
Dirty gloves were worse than dirty hands, because microorganisms adhere to the surface of
a glove easier than to the skin on your hands, handling medical equipment and devices with
contaminated gloves was not acceptable;
-Use examination gloves for gloves for procedures involving contact with mucous membranes
and for other resident care or diagnostic procedures;
-Change gloves between contacts with different residents or with different body sites of
the same resident;
-Do no wash or disinfect surgical or examination gloves for reuse.
3. Review of the facility soiled linen policy, dated (MONTH) 2012, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 34)
-Do not shake or place linen directly on the floor;
-Staff was to place soiled linens saturated with moisture in a plastic bag and tie the end
in a knot;
-Place the bag in an approved laundry bag.
4. Review of Resident #24’s significant change MDS dated [DATE], showed the following:
-The resident’s cognition was moderately impaired;
-The resident was dependent on one staff for personal hygiene;
-The resident was always incontinent of bowel and bladder.
Review of the resident’s care plan, last reviewed on 4/29/19, showed the following:
-The resident required staff assistance with activities of daily living (ADLs);
-Required staff assistance with pericare after each incontinence episode.
Observation on 6/11/19 at 3:58 P.M. showed the following:
-The resident lay in bed;
-The resident was incontinent of bowel and bladder;
-The resident’s bedding was saturated in urine and had a yellow ring from the middle of
the resident’s back to his/her knees;
-Certified Nurse Assistant (CNA) L washed his/her hands and applied gloves;
-CNA L provided perineal care and removed the urine saturated sheets;
-With the same soiled gloves, CNA L put clean sheets on the urine saturated mattress. CNA
L did not clean the urine soiled mattress prior to placing clean sheets on the resident’s
bed. CNA L applied a clean incontinence brief on the resident, touched the resident’s
clean pants, socks, and dressed the resident. CNA L put the mechanical lift sling under
the resident turning the resident from side to side touching the resident’s clean clothes,
bare arm and neck.
During an interview on 6/12/19 at 5:10 P.M., CNA L said the following:
-The facility was short staffed which made staff rush with cares of the residents so they
can get to the next resident;
-He/she was in a hurry when caring for the resident and failed to clean the resident’s
urine saturated mattress before putting clean sheets on it.
5. Review of Resident #37’s quarterly MDS, dated [DATE], showed the following:
-The resident’s cognition was severely impaired;
-The resident was dependent on one staff for toilet use and personal hygiene;
-The resident was always incontinent of bowel and bladder.
Review of the resident’s undated CNA Care Card, located in the resident’s room, showed the
resident was incontinent of bowel and bladder, and required assistance from one staff with
post-incontinence care.
Observation on 6/11/19 at 7:40 A.M. showed the following:
-The resident was incontinent of bladder;
-CNA D wore gloves and removed the resident’s urine soiled pants and incontinence brief;
-CNA D grabbed the perineal wash off the bedside table with his/her contaminated gloves
and cleansed the resident’s perineal area;
-Without removing his/her gloves, CNA D placed a clean incontinence brief, pants, and a
Hoyer lift (mechanical full body lift) pad under the resident;
-CNA D removed his/her soiled gloves, and without washing his/her hands, exited the room
to obtain the Hoyer lift;
-CNA D returned to the room with the Hoyer lift.
During an interview on 6/13/19 at 2:08 P.M., CNA D said the following:
-He/she was supposed to wash his/her hands and change gloves when they became
contaminated;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 35)
-He/she should never touch clean items with contaminated gloves;
-He/she should wash his/her hands when he/she entered a resident’s room, before putting on
gloves, and after removing contaminated gloves;
-He/she did not know why he/she touched clean items with contaminated gloves/hands.
6. Review of Resident #40’s quarterly MDS, dated [DATE], showed the following:
-The resident’s cognition was moderately impaired;
-The resident was dependent on one staff with personal hygiene;
-The resident was always incontinent of bowel and bladder.
Review of the resident’s care plan, last reviewed on 4/29/19, showed the following:
-The resident was totally dependent on staff for all ADLs due to [MEDICAL CONDITION]
([MEDICAL CONDITION]/stroke) with left sided [MEDICAL CONDITION] (paralysis of one side of
the body), weakness, impaired mobility, and unsteady balance;
-Staff was to provide reminders and supervision as needed for all ADLs.
Review of the resident’s undated CNA Care Card showed the following the resident was
incontinent of bowel and bladder, and wore an incontinence brief.
Observation on 6/11/19 at 6:45 A.M. showed the following:
-CNA G entered the resident’s room and applied gloves without washing his/her hands;
-The Director of Nursing (DON) entered the resident’s room and applied gloves;
-The resident’s bed linens were saturated with urine;
-The resident was incontinent of large amount of feces;
-With gloved hands, CNA G removed feces from the resident’s rectal area;
-Without removing his/her gloves, CNA G obtained peri-wash spray from the resident’s
bedside table and sprayed it onto a towel to finish removing feces from the resident’s
buttocks. CNA G removed his/her gloves, and without washing his/her hands, he/she put on
new gloves and placed clean socks on the resident;
-The DON assisted with repositioning the resident and touched the soiled sheets with
his/her gloves;
-The DON removed his/her gloves, did not wash his/her hands, and exited the room (by
touching the resident’s door knob to open the door). He/she re-entered the resident’s
room, and without washing hands, put on new gloves;
-The DON assisted the resident with putting on his/her clean shirt and pants;
-The DON and CNA G tucked the resident’s incontinence brief under him/her and pulled it
through to fasten it;
-Feces was noted on the resident’s buttock;
-The DON obtained a wash cloth, cleansed the resident’s right buttock, and placed the
soiled linens directly on the floor beside the bed;
-The DON removed his/her gloves, and without washing his hands, he touched the door knob
and exited the room;
-The DON returned to the resident’s room with a clean Hoyer lift pad and put on gloves
without washing his hands;
-The DON and CNA G placed the Hoyer lift pad under the resident;
-Once the pad was under the resident, the DON removed his gloves and exited the room (by
opening the door with door knob) without washing hands;
-The DON returned to the room with the Hoyer lift and without washing hands, he connected
the Hoyer pad to the machine;
-CNA G operated the Hoyer lift by pushing the controls;
-CNA G and the DON transferred the resident to his/her wheelchair;
-The DON exited the room without washing his hands;
-CNA G removed his/her gloves and exited the resident’s room without washing his/her
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 36)
hands.
During an interview on 6/11/19 at 6:30 A.M., CNA G said the following:
-He/she was supposed to wash his/her hands before and after resident care, and before
exiting a resident’s room;
-He/she would remove gloves when cleaning up urine and feces, but he/she did not always
wash his/her hands between because there was too much going on and it was easier if he/she
just kept working when he/she provided post incontinence care;
-Soiled linens should not be placed on the floor and should be contained in a plastic bag;

-He/she should never touch clean surfaces with contaminated gloves and hands.
7. During an interview, on 6/13/19 at 3:55 P.M., the DON said the following:
-He expected staff to wash their hands prior to any contact with residents and any time
that gloves were switched out;
-He expected staff to clean urine saturated mattresses prior to making the bed;
-He expected staff to not place soiled linens on the floor if they were not in a plastic
bag;
-He expected staff not to touch clean surfaces with contaminated gloves.
8. Record review of the facility policy, Environmental Water Testing for Legionnaires
Disease, dated 6/6/18, showed the following:
-An assessment of the facility with equipment identified that utilized water sources;
-A document titled Areas of Concern, showed the ice machine and a dead-zone at bath tub
were identified;
-A Monthly Water Management Inspection Checklist, dated 7/12/17;
-A hand-drawn schematic/diagram of the facility equipment that utilized water and their
locations;
-An overview of Legionnaire’s disease (guidelines, detection and reporting, investigation,
decontamination of water source);
-A water management program to reduce legionella growth (policy, purpose and guidelines);
-A water supply policy;
-A water supply-disruption due to repairs or emergencies policy;
-The Infection Prevention, Control and Immunizations critical pathway;
-The Center for Clinical Standards and Quality/Quality, Safety and Oversight Group, S&
C Letter, dated (MONTH) 2, (YEAR);
-The CDC Guidelines toolkit, dated (MONTH) 5, (YEAR), Developing a Water Management
Program to Reduce Legionella Growth & Spread in Buildings;
-The ASHRAE guidelines, undated, Developing a Legionella Water Management Program
A blank documentation form for monthly water management inspection checklist and an annual
water management checklist.
The facility was unable to provide documentation that showed implementation of a
comprehensive water testing program.
During an interview on 6/10/19 at 2:40 P.M., the Maintenance Supervisor said the facility
used city water and the city conducted water testing on the water that came into the
building. The facility used a dual filtration system on the ice machine. He performed
monthly visual inspections of the ice machine. The facility did not have any water
fountains or hot tubs. The facility did have two showers and excess water went down the
drains and had a whirlpool tub that emptied into a floor drain. He had not conducted any
water testing or sampling and did not need to perform any testing that he was aware of.
During an interview on 6/11/19 at 1:40 P.M., the Maintenance Supervisor said he had only
conducted one visual inspection of devices that used water this year. Corporate staff told

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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 37)
him inspections only needed to be done annually. He implemented the Legionella program in
(MONTH) 2019. There was a 12-inch section of dead-end pipe attached to the whirlpool tub
drain and this area could be an issue. If water was run to the tub, the water should go
down the floor drain, but some water could possibly remain in the dead-end section. The
tub was only used every four or five months. The ice machine had an air gap and had an
open drainage and dual filtration system that emptied into the floor drain. Maintenance
staff cleaned and sanitized the unit annually. The Dietary Manager also cleaned the unit
monthly. He said the city came to the facility and pulled a water sample from the
handwashing sink in the kitchen once a year. The facility identified two areas of concern,
however, no water samples or testing had been conducted for these two areas nor had there
been testing of any other areas in the facility.
During an interview on 6/11/19 at 2:40 P.M., the Administrator said no water samples had
been tested and she was ultimately responsible for implementation and maintenance of the
program.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to vaccinate eligible residents
with the pneumococcal vaccines as indicated by the current Centers for Disease Control and
Prevention (CDC) guidelines, for one resident (Resident #24) in a review of 15 sampled
residents. The facility failed to provide education to residents and/or resident
representatives explaining the benefits of the vaccination for two residents (Resident #24
and Resident #54). The facility census was 57.
1. Review of the facility policy Immunizations dated (MONTH) (YEAR) showed the following:
-The resident’s physician would be consulted and determine the level of risk and need for
the vaccinations. A physician order was required to administer any medication/vaccine;
-Pneumococcal: PCV 13 and PPSV23;
-Pneumococcal vaccination in persons ages 65 and older unless contraindicated would be
administered according to the Centers for Disease Control (CDC) guidelines;
-Pneumococcal vaccination in persons ages under 65 would be administered according to the
CDC guidelines;
-Requirements to administer the vaccination included physician order, consent to receive
signed by resident and /or legal representative, information sheet included with the
consent to administer pneumococcal vaccines includes general information risks and side
effects and the resident would be monitored for fever for up to 72 hours.
2. Review of the facility’s Immunization: Consent or Refusal Form showed the following:
-The facility had provided the resident or responsible party information regarding the
risks and benefits of the pneumococcal vaccines. They had received the Centers for Disease
Control Vaccine information sheets on pneumococcal vaccines, which had allowed the
resident to be educated to the risks and benefits and given the opportunity to ask
questions and discuss any concerns and were making an informed decision regarding the
immunizations;
-If the resident or responsible party sign, the consent is given for the immunization to
be administered and they will not have to resign the form for the remainder of the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
resident’s stay at this facility. However, if there is a change in the decision to consent
for this immunization they may do so, but must notify the facility of this decision;
-General consent or refusal column;
-Consent or refusal column for Pneumococcal PPSV23 and Pneumococcal PCV13 vaccines;
-Last received date and location column;
-Signature of resident and/or responsible party column;
-Signature of witness column.
3. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time
for Adults, dated 11/30/15, showed the following:
-Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate
vaccine (PCV13, PREVNAR 13), a pneumococcal vaccine that is used to protect adults against
disease caused by the bacterium streptococcus pneumonia (pneumococcus) and 23-valent
pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23), an injection that
protects against 23 types of pneumococcal causing bacteria:
-One dose of PCV13 was recommended for adults [AGE] years or older who had not previously
received PCV13;
-One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of
previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was
given at age [AGE] years or older, no additional doses of PPSV23 should be administered;
-For those age [AGE] years or older who had not received any pneumococcal vaccines, or
those with unknown vaccination history, administer one dose of PCV13. Administer one dose
of PPSV23 at least one year later for most adults or at least eight weeks later for adults
with immunocompromising conditions;
-For those age [AGE] years or older who previously received one dose of PPSV23 and no
doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23
for all adults regardless of medical conditions.
4. During an interview on 6/7/19 at 2:39 P.M. the administrator said the Minimum Data Set
(MDS), /Care Plan Coordinator was responsible for monitoring and overseeing the residents’
flu and pneumonia vaccines.
5. Review of Resident #24’s thirty day prospective payment system (PPS) Minimum Data Set
(MDS), a federally mandated assessment to be completed by the facility staff, dated
3/29/19, showed the following:
-The resident’s cognition was moderately impaired for making daily decisions;
-The resident did not receive the pneumococcal vaccine;
-Staff did not offer the resident pneumococcal vaccine;
-Resident was over age 65.
Review of the resident’s physician orders dated 5/11/19 to 6/11/19 showed the following:
-[DIAGNOSES REDACTED].
-admitted [DATE].
Review of the resident’s immunization consent or refusal showed the following:
-The resident’s responsible party signed for the resident to have PPSV23 and PCV13 on
9/28/18;
-The resident had received PPSV23 on 11/27/07 in the physician’s office;
-The resident had not received PCV13.
Review of the resident’s medical record showed the following:
-The resident had a guardian;
-No documented consent to show the resident and/or the resident’s representative refused
the vaccination;
-No documentation the facility provided education regarding the benefits of the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
vaccination.
Review of the facility’s Preventative Health Care Report for pneumonia vaccinations dated
5/22/19 to 6/13/19 showed the resident was not included in the report and did not receive
the vaccine.
6. Review of Resident #54’s Preventative Medicine documentation showed the resident
received Prevnar 13 or PCV 13 on 2/7/17.
Review of the resident’s quarterly MDS, dated [DATE] showed the following:
-The resident’s cognition was moderately impaired for making daily decisions;
-The resident’s [DIAGNOSES REDACTED].
-The resident was up to date with pneumonia vaccine.
-The resident was over age 65.
Review of the resident’s physician orders dated 3/31/18 showed the resident’s [DIAGNOSES
REDACTED].
Review of the resident’s nursing progress notes dated 7/5/18 at 2:38 A.M. showed the
resident refused PPSV 23 vaccination.
Review of the resident’s medical record showed the following:
-No documented consent to show the resident and/or the resident’s representative refused
the vaccination;
-No documentation the facility provided education to explain the benefits of the
vaccination.
Review of the resident’s progress notes dated 4/30/2019 at 1:20 P.M. showed the resident
was started on [MEDICATION NAME] (oral antibiotic) 250 mg twice a day (BID) for [DIAGNOSES
REDACTED].
Review of the facility’s infection antibiotic control log date (MONTH) 2019 showed the
following:
-The resident was started on [MEDICATION NAME] on 4/6/19 for pneumonia;
-His/her symptom of shortness of breath started on 4/5/19;
-Antibiotic was completed on 4/18/19.
7. During an interview on 6/13/19 at 10:35 A.M., Licensed Practical Nurse (LPN) I said the
following:
-He/She did not know who was supposed to be monitoring the residents’ vaccinations;
-Education on vaccinations was provided to residents verbally;
-There was no written documentation provided to the residents regarding the vaccinations;
-The MDS/Care Plan Coordinator asked him/her a couple of weeks ago to make a list of
residents who needed to have the pneumonia vaccinations per the CDC guidelines. Residents
who were 65 and older, residents with certain [DIAGNOSES REDACTED].
-Resident #54 recently had pneumonia.
During an interview on 6/13/19 at 11:54 A.M., LPN H said the following:
-Nursing administration were supposed to provide education regarding the vaccinations when
consents were signed;
-Education was supposed to be reviewed prior to administration of the vaccinations;
-Usually the Director of Nursing (DON) monitors the immunizations, but since the current
DON was new to the facility, he/she thought the MDS/Care Plan Coordinator was overseeing
the immunizations.
During an interview on 6/13/19 at 2:21 P.M. the social service designee said the
following:
-She was not a nurse therefore she gave the resident’s/ resident’s responsible party the
pneumococcal CDC vaccine information statement at the time of admission but he/she did not
educate the residents;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265611

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

NAME OF PROVIDER OF SUPPLIER

SILEX COMMUNITY CARE

STREET ADDRESS, CITY, STATE, ZIP

111 DUNCAN MANSION ROAD
SILEX, MO 63377

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 40)
-She also made sure the resident or responsible party signed a consent/refusal for the
pneumococcal vaccine at the time of admission.
During an interview on 6/13/19 at 3:00 P.M. and 3:55 P.M. the MDS/Care Plan Coordinator
said the following:
-He/She was not responsible for monitoring residents’ vaccinations, including pneumonia;
-He/She only monitored vaccinations for MDS purposes;
-There was no specific staff designated to ensure residents received vaccinations;
-He/She would expect staff to supply the CDC immunization information for education
whether the resident/resident party consents or refuses the immunization;
-He/She expected staff to offer the pneumococcal vaccine on admission and as needed.
During an interview on 6/13/19 at 3:15 P.M., the DON said that he/she was unsure of the
facility’s policy regarding pneumonia vaccinations.
During an interview on 6/12/19 at 11:48 A.M. and 5:30 P.M. and 6/13/19 at 11:18 A.M. the
administrator said the following:
-She could not find any documentation that Resident #24 was offered or educated about the
pneumococcal vaccines. The resident/resident’s responsible parties had signed consents but
she was not sure why they were not given;
-She could not find any documentation that Resident #54 was educated about the
pneumococcal vaccines;
-The facility provided education information regarding the vaccinations upon admission and
she was not sure if the information was provided again at the time of the consent;
-She expected staff to get immunization consents upon admission and annually;
-She doesn’t have a medical background and therefore does not do any teaching for
immunizations;
-She would expect the staff to provide teaching to the residents and residents’
responsible parties;
-The DON is normally responsible for monitoring the flu and immunization vaccines but
because the facility did not have a DON for a period of time the care plan/MDS coordinator
was responsible;
-The MDS/Careplan coordinator was responsible for tracking and administration of
immunizations for the residents.
During an interview on 6/25/19 at 10:27 A.M. the medical director said the following:
-He/she expected staff to follow the CDC guidelines;
-He/she would expect staff to get a history, educated and offer the vaccine to the
resident/responsible party;
-Anyone with pneumonia or history of immunocompromised may need the PCV13 or PPSV23;
-He/She would expect staff to follow policy and guidelines they have discussed.