ESTATES OF SPANISH LAKE, THE

Based on observation and interview, the facility staff failed to ensure they provided a
safe, comfortable, and homelike environment when they had two areas which contained a
black mold-like substance. This affected all the residents who used the men’s shower room
on the first floor. The facility census was 94.
1. Observation on 6/25/18 at 1:02 P.M., showed a six by six inch area on the ceiling in
the men’s shower room on the first floor A hall. The area had the appearance that it had
been wet and water damaged. The area of the ceiling had sections that hung down as far as
one inch. A dark stain covered the whole area and a black mold-like substance overspread
several areas on the dark colored stain.
During an interview on 6/25/18 at 5:56 P.M., the Maintenance Director (MD) said he did not
know about the area in the men’s shower room. He did not always go into the shower room
and expected staff to let him know of issues like damage to the ceiling. He did not have
anything about the men’s shower room in his maintenance request logs (logs filled out by
staff). He did know of any incident that may have caused the damage to the ceiling.
2. Observation on 6/25/18, at 1:28 P.M., showed a two by three foot area under a
kitchen-like sink on the left side in the upstairs clean utility room. The area under the
sink appeared that it had been water damaged. A dark stain covered the whole area and a
black mold-like substance overspread several areas of the dark colored stain. The
kitchen-like sink had been affixed and could not flow into the left vat of the two vat
sink.
During an interview on 6/25/18, at the same time, the MD said:
– The faucet could not be moved and it could only flow into the vat on the right-hand
side;
– The dark area under the sink was not mold, it was sewage.
– He did not know about the area under the sink;
– He did not know what had happened to cause the damage to the wooden base of the cabinet
under the sink.

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Based on observation, interview and record review, the facility failed to follow their
abuse and neglect policy and send two staff members home when a resident accused them of
hitting him/her. This affected one of 26 sampled residents (Resident #90). The census was
94.
Review of Resident #90’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/1/18, showed the following:
-[DIAGNOSES REDACTED].
-Short/long term memory loss;
-Short tempered and easily annoyed;
-Verbal behavioral symptoms directed at others;
-Required limited staff assistance for bed mobility, transfers, dressing and toilet use;
-Required extensive staff assistance for personal hygiene and bathing.
Review of the resident’s care plan, updated 6/18/18, showed the following:

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Based on interview and record review, the facility failed to ensure comprehensive Minimum
Data Set (MDS), a federally mandated assessment instrument completed by facility staff,
assessments were completed and/or submitted timely as mandated by the Center for Medicare
and Medicaid (CMS). Of the 26 sampled residents, four had comprehensive MDSs due that had
not been completed and/or submitted timely. (Residents #5, #8, #192 and #193) The census
was 94.
1. Review of Resident #5’s MDS submission schedule, showed the following:
-Significant change in status MDS dated [DATE];
-No Annual MDS completed for 3/2018.
2. Review of Resident #8’s MDS submission schedule, showed the following:
-Admission MDS dated [DATE];
-No annual MDS completed for 3/2018.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure quarterly Minimum Data
Set (MDS), a federally mandated assessment instrument completed by facility staff,
assessments were completed and/or submitted timely as mandated by the Centers for Medicare
and Medicaid (CMS). Of the 26 sampled residents, six had quarterly MDSs due that had not
been completed and/or submitted timely. (Residents #5, #8, #57, #79, #81 and #192) The
census was 94.
1. Review of Resident #5’s MDS, submission schedule, showed the following:
-A quarterly MDS dated and submitted 12/23/17;
-An annual MDS due but not submitted by 3/23/18;
-No quarterly MDS completed and/or submitted as of 6/26/18.
2. Review of Resident #8’s MDS submission schedule, showed the following:
-A quarterly MDS dated and submitted on 12/24/17;
-An annual MDS due but not submitted by 3/24/17;;
-No quarterly MDS completed and/or submitted as of 6/26/18.
3. Review of Resident #57’s MDS submission schedule, showed the following:
-An annual MDS dated and submitted on 2/17/18;
-No quarterly MDS completed and/or submitted for 5/2018.
4. Review of Resident #79’s MDS submission schedule, showed the following:
-A quarterly MDS dated and submitted on 3/11/18;
-No quarterly MDS completed and/or submitted as of 6/26/18.
5. Review of Resident #81’s MDS submission schedule, showed the following:
-A significant change in status MDS dated and submitted on 9/13/17;
-A quarterly MDS dated and submitted on 12/14/17;

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Based on observation and interview, the facility failed to ensure resident computer
generated care plans, were printed and accessible in the care plan book at the nurse’s
station for the use of all nursing staff. This affected four of 26 sampled residents.
(Residents #8, #57, #79 and #193). The census was 94.
1. Review of Resident #8’s care plan, located in the facility computer system, and last
reviewed on 5/24/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: Activity of daily living ((ADL) bathing, grooming,
transfers, bed mobility, dressing, etc .) assistance required, [MEDICAL CONDITION] which
places the resident at risk for infection, DM, nutritional status, [MEDICAL
CONDITION];[MEDICAL CONDITION] smoking;
-Interventions to assist the resident included: Low concentrated sweets diet, determine
food preferences through one to one interview, encourage relaxation techniques, diet
supplements as ordered and range of motion exercises.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

2. Review of Resident #57’s care plan, located in the facility computer system, and last
reviewed on 6/5/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: ADL assistance required, HTN, falls, nutritional status –
at risk for weight loss, pain – due to knee contractures and [MEDICAL CONDITION]
-Interventions to assist the resident included: Provide resident with two person
assistance with bathing and transfers, monitor resident for unsafe transfers, offer foods
he/she enjoys and supplements, apply knee brace daily, administer pain medications as

3. Review of Resident #79’s care plan, located in the facility computer system, and last
reviewed on 3/14/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: ADL assistance required, smoking, nutritional status,
antidepressant medication daily, at risk for falling and behavioral symptoms – becomes
agitated easily;
-Interventions to assist the resident included: Chooses to eat in his/her room, monitor
resident’s mood, keep call light in reach, encourage resident to relocate to areas with
less stimuli if he/she seems over stimulated by noise, encourage resident to read books
and do puzzles and encourage resident to seek out staff members for one on one if he/she
is having issues with other residents.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

4. Review of Resident #193’s care plan, located in the facility computer system, and last
reviewed on 6/26/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: Smoking, falls, increased independence in bed mobility with
positioning devices, at risk for social isolation, HTN, history of [MEDICAL CONDITION],
chronic pain characterized as severe and incapacitating at times, history of depression
and becomes easily upset or agitated when he/she feels other people are acting obnoxiously
toward him/her;
-Interventions to assist the resident included: Provide reminders about supervised
smoking, close monitoring when ambulating, check positioning devices to ensure they are in
good repair, provide one on one visits for activities, enjoys playing music and cards,
provide alternative therapies for pain and encourage resident go to his/her room if
becoming anxious or angry.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

5. During an interview on 6/26/18 10:20 A.M., the Director of Nurses said care plans are
completed in the computer by the MDS/Care Plan Coordinator. After normal business hours,
the nurses do not have access to the computer system to view care plans. The care plans
should be printed after they are developed and placed in the care plan book at the nurse’s
station.

Based on observation and interview, the facility staff failed to ensure they kept
medication locked at all times. The facility census was 94.
1. Observation on 6/25/18, at 12:17 P.M., showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility staff failed to complete a
comprehensive discharge summary for one of three sampled residents selected for a closed
record review. (Resident #91) The census was 94.
Review of Resident #91’s face sheet, showed an admission date of [DATE] and a [DIAGNOSES
REDACTED].
Review of the resident’s social service notes, showed the following:
-1/11/18 at 3:43 P.M., Plans for discharge to another facility pending the ending results
from [MEDICAL CONDITION] treatment he/she is going through;
-3/20/18 at 11:54 A.M., spoke to the resident’s family member regarding the resident and
moving to a new facility. The family member said the physician would release the resident
if well enough to move within the next 10 days.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s discharge Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/4/18, showed the following:
-discharge date : 4/4/18;
-Moderate cognitive impairment;
-Limited assistance with transfers, walking in room, locomotion on and off unit, dressing
and toilet use;
-Supervision with eating and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s nurse’s notes, dated 4/4/18, showed the following:
-(No time noted) Informed today is the date for the resident to transfer to another
facility. The resident has oxygen per nasal cannula at two liters as needed, is continent
of bowl and bladder and denies any pain. Report was given to the nurse at the new
facility. Also received phone orders to send medications and narcotics per physician’s
orders [REDACTED].>-1:05 P.M., the resident was discharged to his/her family, to be
taken to the new facility. The resident’s medication were sent with the resident’s family.
The report was already given to the new facility.
Further review of the resident’s medical record, showed no comprehensive discharge summary
for the resident.
During an interview on 6/26/18 at 11:55 A.M., the administrator said the resident should
have had a complete comprehensive discharge summary which includes a summary of the
resident’s stay, a summary of services and medicare and medicaid history.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
processed the Registered Dietician’s recommendations in a timely manner for two of 26
sampled residents. In addition, the facility identified three residents as having a
gastrostomy tube. One was observed receiving tube feeding and did not receive the amount
of tube feeding ordered by the physician. (Residents #79, #57 and #195) The census was 94.
1. Review of Resident #79’s quarterly minimum data set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/11/18, showed the following:
-Adequate hearing and vision;
-Understood and understands;
-Clear speech – distinct intelligible words;
-Supervision and oversight required for eating;
-Weight of 145 pounds (lbs).
Review of the resident’s care plan, last revised on 3/14/18, showed the following:
-[DIAGNOSES REDACTED].
-No problems or interventions for a chronic hoarse throat or a steady gradual weight loss.
Review of the resident’s dietary notes, completed by the Registered Dietician (RD) on
4/11/18, showed a recommendation to discontinue the resident’s health shakes and begin Med
Pass (nutritional supplement) 120 cubic centimeters (cc) two times a day.
Review of the resident’s medication administration records (MAR)s, dated 4/1/18 through
4/30/18 and 5/1/18 through 5/31/18, showed staff documented the resident received health
shakes twice a day, but no order for Med Pass.
Review of the resident’s monthly weights, showed the following:
-12/17 – 149 lbs, 1/18 – 143 lbs, 2/18 – 144 lbs, 3/18 – 148 lbs, 4/18 – 143 lbs, 5/18 –
140 lbs and 6/18 – 137 lbs (this represents a 12 lb or 8.05% weight loss in the past six
months).
Review of the resident’s dietary notes, completed by the RD on 6/6/18, showed weight down
137.4 lbs, 9% in 180 days. Recommend to discontinue health shakes and begin Med Pass 120
cc three times a day.
Review of the resident’s MAR, dated 6/1/18 through 6/30/18, showed an the resident
continued to receive health shakes two times a day, but no order for Med Pass.
During an interview on 6/21/18 at 8:43 A.M., the resident said he/she had lost weight and
was concerned as to why. His/her appetite had been the same as always. He/she had been
having a throat problem since April. His/her throat is not sore, but his/her voice had
been hoarse. He/she does have an appointment later this month with a specialist. The
resident did not know if the problem with his/her voice had anything to do with his/her
weight loss but was suspicious it might.
Observation on 6/21/18 at 12:42 P.M., showed the resident received his/her lunch on a tray
and delivered to his/her room. The lunch tray had no health shake or Med Pass. During an
interview at that time, the resident said he/she does not get a supplement too often. When
he/she does get it, it comes on his/her meal tray. He/she did not get a health shake or
Med Pass on his/her lunch tray.
Observation on 6/22/18 at 8:06 A.M., showed dietary staff prepared the resident’s
breakfast tray and delivered it to his/her room. The breakfast tray had no health shake,
whole milk or Med Pass.
During an interview on 6/22/18 at 8:31 A.M., the resident said he did not receive whole
milk, health shake or Med Pass with breakfast.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have a current signed
[MEDICAL TREATMENT] contract for the one resident the facility identified as receiving
[MEDICAL TREATMENT]. (Resident #81) The census was 94.
Review of the facility administration records, showed a [MEDICAL TREATMENT] contract,
dated 10/31/13, with the previous name of the facility.
During an interview on 6/26/18 at 10:41 A.M., the Director of Operations said they could
not get a copy of the current [MEDICAL TREATMENT] contract. The previous contract had the
facility’s previous name. The administration has not been able to get a copy of the
current contract.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure physician’s addressed
pharmacy medication regimen reviews in a timely manner. Of the 26 residents sampled, two
had pharmacy medication regimen reviews, completed for more than 30 days, without a
physician response to the recommendation and one had a recommendation that was addressed
55 days after it was made. (Residents #5, #8 and #57) The census was 94.
1. Review of Resident #5’s consultant pharmacist’s medication review, dated 4/18/18,
showed the following recommendation:
-Resident is receiving duloxetine (anti-depressant) and aripiprazole (anti-psychotic used
to treat [MEDICAL CONDITION] and bi-polar disease) without appropriate indication for use,
please evaluate and update orders with specific indications for use;
-No physician response.
Review of the resident’s consultant pharmacist’s medication regimen review, dated 5/10/18,
showed the following recommendation:
-Resident has been on [MEDICATION NAME] (medication used to treat acid reflux (heart
burn)) 20 milligrams (mg) every day for greater than 12 weeks. Extended use increases the
risk of fractures and infections;
-Please consider the following: Discontinue (DC) therapy, new order for alternative agent
or medication to be continued at current dose;
-No physician response.
Review of the resident’s physician’s orders [REDACTED].
2. Review of Resident #8’s consultant pharmacist’s medication regimen review, dated
4/18/18, showed the following:
-The resident is currently on [MEDICATION NAME] (anti-psychotic) 4 mg at hour of sleep and
may be indicated for a gradual dose reduction. Please consider reducing to 3 mg at hour of
sleep and document behaviors;
-A handwritten note on the form showing to psych;
-No physician or psychiatrist response.
Review of the resident’s consultant pharmacist’s medication regimen review, dated 5/10/18,
showed the following:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to address one of
26 sampled resident’s dental needs. (Resident #9) The census was 94.
Review of Resident #9’s last transmitted quarterly Minimum Data Set (MDS), a federally
mandated instrument completed by facility staff, dated 12/24/17, showed the following:
-Severe cognitive impairment;
-Extensive assistance with bed mobility, transfers, locomotion on and off the unit and
dressing;
-[DIAGNOSES REDACTED].
-Oral/Dental status: blank.
Review of the resident’s revised care plan, dated 4/16/18, showed no documentation
regarding the resident oral care or dentures.
Review of the resident’s dietary progress note, dated 5/16/18, showed the resident had a
weight of 85 pounds, was on a regular diet and had no pressure wounds. The resident had
issues with loose dentures noted.
Observation on 6/21/18 at 9:02 A.M., showed the resident self propelled his/her wheelchair
down the hall. The resident had loose dentures.
During an interview on 6/21/18 at 2:30 P.M, the resident said his/her dentures are very
loose. While they do not keep him/her from eating, they are at times uncomfortable. The
dentures hang down and seem like they are going to fall out. It would help if they were
not so loose. The resident said he/she has said something to administration but nothing

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Based on observation, interview and record review, the facility failed to assess and
provide therapy services for one resident with a contracted closed hand. the sample was
26. (Resident #15) The census was 94.
Review of Resident #15’s last transmitted quarterly Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 12/29/17, showed the
following:
-No cognitive impairment;
-Total dependence with transfers;
-Extensive assistance with bed mobility, dressing, toilet use and personal hygiene;
-Limited assistance with locomotion on and off the unit;
-Functional limited range of motion to the upper and lower extremity on one side;
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
Observation of the resident on 6/21/17 at 7:47 A.M., showed his/her right hand was
contracted closed.
Review of the resident’s revised care plan, dated 3/13/18, showed no documentation
regarding the contracted right hand.
Review of the resident’s medical record, showed no documentation regarding an assessment
of the contracted right hand.
During an interview on 6/25/18 at 1:52 P.M., the resident said the no one has tried to put

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Based on interview and record review, the facility failed to have an administrator with an
active license issued by the Missouri Board of Nursing Home Administrators. The census was
94.
During an interview on [DATE] at 8:33 A.M. during the entrance conference, the Director of
Clinical Operations said administrator E was the administrator, and he/she was in route to
the facility at that time. Administrator E had been the administrator since [DATE].
During an interview on [DATE] at 11:38 A.M., administrator E said he/she had been the
administrator at the facility for a little over three months. On [DATE], his/her emergency
temporary license (issued by the Missouri Board of Nursing Home Administrators) had
expired. On [DATE], his/her title changed from administrator to Facility Manager and the
Regional Consultant assumed the role of administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide documentation showing
the quality assurance and assessment (QAA) committee met quarterly for a quality assurance
performance improvement (QAPI) meeting. For the last four quarterly meetings, the facility
could only provide proof the QAA committee met two times, and one of those two times, the
administrator signing the attendance record did not hold a valid administrator’s license.
The census was 94.
During an interview on [DATE] at 10:04 A.M., administrator F said he/she could only find
two of the last four QAPI committee meeting attendance records; [DATE] and [DATE].
Administrator E attended the meeting on [DATE] and signed attendance record as the
administrator. Administrator E’s emergence temporary license expired on [DATE], so a
licensed administrator did not attend that meeting. The administrator is responsible for