FOUR SEASONS LIVING CENTER

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265149

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

09/07/2018

NAME OF PROVIDER OF SUPPLIER

FOUR SEASONS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

2800 HIGHWAY TT
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility staff failed to update the plan of care with changes in the resident’s needs for six residents (Resident #2, #76, #95, #123, and #161). The facility census was 227. 1. The facility did not provide direction to staff in regards to when to review and revise each resident’s plan of care to ensure his/her needs were identified and met. 2. Review of Resident #2’s, Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Independent for bed mobility, transfers, toileting, and dressing; -Required supervision with set up assistance of one staff for eating; and -Independently walks in room, and in the corridor. Review of the resident’s physician’s orders [REDACTED]. Review of the resident’s care plan, dated 5/28/18, showed staff did not update the care plan to direct staff on the care needed with the improvement to the resident’s mobility and functional status. 3. Review of Resident #76’s Quarterly MDS, a federally mandated assessment, dated 06/26/18, showed staff assessed the resident as: -Moderate cognitive impairment; -Independent with all Activities of Daily Living, except bathing and eating; -Limited physical assistance of one person for bathing; -Supervision with set up assistance of one staff for eating; -Always continent of bowel and bladder; -[DIAGNOSES REDACTED]. -Assessed to have no pain or falls. Review of the resident’s POS, dated 8/15/18 to 9/14/18, showed the resident went to the wound clinic on 09/05/18 for an open area, just below the left great toe over the joint area. The resident returned with a new order: -Cleanse wound with wound cleanser; -Apply silver [MEDICATION NAME] (antibacterial wound dressing) to the wound base and cover with foam; -Wrap with kerlix; -Change dressing daily and as needed. Review of the care plan, dated 07/20/18, showed staff did not provide direction for care of the wound on the foot below the left great toe. 4. Review of Resident #95’s, Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Independent for bed mobility, transfers, toileting, and dressing; -Independently walks in room, and in the corridor; -Fall with major injury; -No bed alarm addressed. Review of the resident’s care plan, showed staff did not update the care plan to direct staff on the care needed with identification of the resident’s bed alarm or risk for falls. Observation on 09/05/18 at 10:04 A.M., showed the resident in room with a bed alarm in place. The resident turned the bed alarm off and went to the bathroom with no assistance

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to update the
plan of care with changes in the resident’s needs for six residents (Resident #2, #76,
#95, #123, and #161). The facility census was 227.
1. The facility did not provide direction to staff in regards to when to review and revise
each resident’s plan of care to ensure his/her needs were identified and met.
2. Review of Resident #2’s, Quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Cognitively Intact;
-Independent for bed mobility, transfers, toileting, and dressing;
-Required supervision with set up assistance of one staff for eating; and
-Independently walks in room, and in the corridor.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s care plan, dated 5/28/18, showed staff did not update the care
plan to direct staff on the care needed with the improvement to the resident’s mobility
and functional status.
3. Review of Resident #76’s Quarterly MDS, a federally mandated assessment, dated
06/26/18, showed staff assessed the resident as:
-Moderate cognitive impairment;
-Independent with all Activities of Daily Living, except bathing and eating;
-Limited physical assistance of one person for bathing;
-Supervision with set up assistance of one staff for eating;
-Always continent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Assessed to have no pain or falls.
Review of the resident’s POS, dated 8/15/18 to 9/14/18, showed the resident went to the
wound clinic on 09/05/18 for an open area, just below the left great toe over the joint
area. The resident returned with a new order:
-Cleanse wound with wound cleanser;
-Apply silver [MEDICATION NAME] (antibacterial wound dressing) to the wound base and cover
with foam;
-Wrap with kerlix;
-Change dressing daily and as needed.
Review of the care plan, dated 07/20/18, showed staff did not provide direction for care
of the wound on the foot below the left great toe.
4. Review of Resident #95’s, Quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Cognitively Intact;
-Independent for bed mobility, transfers, toileting, and dressing;
-Independently walks in room, and in the corridor;
-Fall with major injury;
-No bed alarm addressed.
Review of the resident’s care plan, showed staff did not update the care plan to direct
staff on the care needed with identification of the resident’s bed alarm or risk for
falls.
Observation on 09/05/18 at 10:04 A.M., showed the resident in room with a bed alarm in
place. The resident turned the bed alarm off and went to the bathroom with no assistance

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265149

If continuation sheet
Page 1 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265149

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

09/07/2018

NAME OF PROVIDER OF SUPPLIER

FOUR SEASONS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

2800 HIGHWAY TT
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 1) from staff. During an interview on 09/06/18 at 5:43 P.M., LPN C said the resident has fallen twice in the last six months and has a bed alarm. The resident is supposed to let staff know when he/she gets out of bed, but he/she turns the alarm off. 5. Review of Resident #123’s, Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely Cognitively Impaired; -Requires extensive assistance of one staff members for bed mobility, transfer, walking, dressing, hygiene, and toileting; -Requires supervision and set up for dining; -Frequently incontinent of bladder and bowel; -Bed rail used daily; -Bed alarm not used; -Received antipsychotic, antidepressant, and diuretic for seven of seven look back days. Review of the resident’s POS dated 8/15/18 to 9/14/18 showed the resident with an order for [REDACTED].>Review of the resident’s care plan, dated 4/4/17, showed staff did not update the care plan to direct staff on the care needed with identification of the resident’s bed rail. Further review showed staff did not update the care plan to direct staff to provide extensive assistance with ADLs. Review showed staff did not update the care plan to direct staff that the resident is frequently incontinent of bowel and bladder. 6. Review of Resident #161’s, Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Independent for bed mobility, transfers, toileting, and dressing; -Required supervision with set up assistance of one staff for eating; -Independently walks in room, and in the corridor; and 161 -Smokes per facility smoke schedule. Review of the resident’s POS (physician’s orders [REDACTED].>Review of the resident’s care plan, dated 2/01/18, showed staff did not update the care plan to direct staff on the care needed with oxygen use. Additional review showed staff did not update the care plan with identification of the resident’s oxygen use and smoking regimen. 7. During an interview 9/7/18 at 2:42 P.M., the DON (Director of Nursing) said he/she expects the MDS (Minimum Data Set) coordinators to update the care plans with any new event such as a fall, bruise, etc. and with each review. When staff receive new orders, they are expected to notify the MDS Coordinator so he/she can update the care plan timely. The MDS Coordinator also attends morning meetings when department heads review any resident updates. Falls, special alarms, and wounds are some of the things that should be on the residents’ care plans.
	F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
from staff.
During an interview on 09/06/18 at 5:43 P.M., LPN C said the resident has fallen twice in
the last six months and has a bed alarm. The resident is supposed to let staff know when
he/she gets out of bed, but he/she turns the alarm off.
5. Review of Resident #123’s, Quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severely Cognitively Impaired;
-Requires extensive assistance of one staff members for bed mobility, transfer, walking,
dressing, hygiene, and toileting;
-Requires supervision and set up for dining;
-Frequently incontinent of bladder and bowel;
-Bed rail used daily;
-Bed alarm not used;
-Received antipsychotic, antidepressant, and diuretic for seven of seven look back days.
Review of the resident’s POS dated 8/15/18 to 9/14/18 showed the resident with an order
for [REDACTED].>Review of the resident’s care plan, dated 4/4/17, showed staff did not
update the care plan to direct staff on the care needed with identification of the
resident’s bed rail. Further review showed staff did not update the care plan to direct
staff to provide extensive assistance with ADLs. Review showed staff did not update the
care plan to direct staff that the resident is frequently incontinent of bowel and
bladder.
6. Review of Resident #161’s, Quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Cognitively Intact;
-Independent for bed mobility, transfers, toileting, and dressing;
-Required supervision with set up assistance of one staff for eating;
-Independently walks in room, and in the corridor; and 161
-Smokes per facility smoke schedule.
Review of the resident’s POS (physician’s orders [REDACTED].>Review of the resident’s
care plan, dated 2/01/18, showed staff did not update the care plan to direct staff on the
care needed with oxygen use. Additional review showed staff did not update the care plan
with identification of the resident’s oxygen use and smoking regimen.
7. During an interview 9/7/18 at 2:42 P.M., the DON (Director of Nursing) said he/she
expects the MDS (Minimum Data Set) coordinators to update the care plans with any new
event such as a fall, bruise, etc. and with each review. When staff receive new orders,
they are expected to notify the MDS Coordinator so he/she can update the care plan timely.
The MDS Coordinator also attends morning meetings when department heads review any
resident updates. Falls, special alarms, and wounds are some of the things that should be
on the residents’ care plans.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265149

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

09/07/2018

NAME OF PROVIDER OF SUPPLIER

FOUR SEASONS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

2800 HIGHWAY TT
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 2) NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on [MEDICAL CONDITION] medications required for two residents (Residents #106, and #186) and failed to ensure that as needed (PRN) [MEDICAL CONDITION] medication orders were limited to 14 days unless specific duration and clinical rationale were provided for one resident (Resident #106). Staff also failed to obtain an appropriate [DIAGNOSES REDACTED].#20, and #72). The facility census was 227. 1. Review of the facility’s [MEDICAL CONDITION] and Antipsychotic Medication Policy, dated (MONTH) 28, (YEAR) showed: -PRN (as needed) medications may only be extended longer than 14 days with physician documentation explaining why it is appropriate to extend the medication; -For all [MEDICAL CONDITION] medication, nursing and physician should evaluate efficacy of routine medications and adjust as needed. 2. Review of Resident #20’s MDS, dated [DATE], showed the resident’s [DIAGNOSES REDACTED].>- Depression – Anxiety Disorder – [MEDICAL CONDITION] (other than [MEDICAL CONDITION]) – TBI ([MEDICAL CONDITION]) Review of the resident’s physician’s orders [REDACTED]. 3. Review of Resident #72’s MDS, a federally mandated resident assessment, dated 6/26/18, showed resident [DIAGNOSES REDACTED]. Review of resident’s physician’s orders [REDACTED]. 4. Review of Resident #106’s quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 7/12/18, showed staff assessed the resident as: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Staff assessed mood as moderate mood indicators; -Physical behaviors no behaviors. Review of the resident’s care plan, dated 10/12/17, showed it directed staff: -Monitor for adverse reactions; -Obtain labs as ordered and report to the physician; and -Observe for changes in mood/behavior and report to the physician. Review of the resident’s POS, dated 8/15/18 to 9/14/18, showed staff obtained a physician’s orders [REDACTED]. Review of the resident’s Medication Administration Record [REDACTED]. Further review showed the order did not contain a stop date of 14 days or less or a rationale for the continued use for either the [MEDICATION NAME] or the [MEDICATION NAME]. 5. Review of Resident #106’s quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Staff assessed mood-moderate mood indicators; -Did not display behaviors. Review of the resident’s care plan, dated 10/12/17, showed it directed staff: -Monitor for adverse reactions; -Obtain labs as ordered and report to the physician; and -Observe for changes in mood/behavior and report to the physician. Review of the resident’s POS, dated 8/15/18 to 9/14/2018, showed staff obtained a physician’s orders [REDACTED].

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to perform Gradual Dose
Reductions (GDRs) on [MEDICAL CONDITION] medications required for two residents (Residents
#106, and #186) and failed to ensure that as needed (PRN) [MEDICAL CONDITION] medication
orders were limited to 14 days unless specific duration and clinical rationale were
provided for one resident (Resident #106). Staff also failed to obtain an appropriate
[DIAGNOSES REDACTED].#20, and #72). The facility census was 227.
1. Review of the facility’s [MEDICAL CONDITION] and Antipsychotic Medication Policy, dated
(MONTH) 28, (YEAR) showed:
-PRN (as needed) medications may only be extended longer than 14 days with physician
documentation explaining why it is appropriate to extend the medication;
-For all [MEDICAL CONDITION] medication, nursing and physician should evaluate efficacy of
routine medications and adjust as needed.
2. Review of Resident #20’s MDS, dated [DATE], showed the resident’s [DIAGNOSES
REDACTED].>- Depression
– Anxiety Disorder
– [MEDICAL CONDITION] (other than [MEDICAL CONDITION])
– TBI ([MEDICAL CONDITION])
Review of the resident’s physician’s orders [REDACTED].
3. Review of Resident #72’s MDS, a federally mandated resident assessment, dated 6/26/18,
showed resident [DIAGNOSES REDACTED].
Review of resident’s physician’s orders [REDACTED].
4. Review of Resident #106’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 7/12/18, showed staff assessed the resident as:
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
-Staff assessed mood as moderate mood indicators;
-Physical behaviors no behaviors.
Review of the resident’s care plan, dated 10/12/17, showed it directed staff:
-Monitor for adverse reactions;
-Obtain labs as ordered and report to the physician; and
-Observe for changes in mood/behavior and report to the physician.
Review of the resident’s POS, dated 8/15/18 to 9/14/18, showed staff obtained a
physician’s orders [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED]. Further review
showed the order did not contain a stop date of 14 days or less or a rationale for the
continued use for either the [MEDICATION NAME] or the [MEDICATION NAME].
5. Review of Resident #106’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
-Staff assessed mood-moderate mood indicators;
-Did not display behaviors.
Review of the resident’s care plan, dated 10/12/17, showed it directed staff:
-Monitor for adverse reactions;
-Obtain labs as ordered and report to the physician; and
-Observe for changes in mood/behavior and report to the physician.
Review of the resident’s POS, dated 8/15/18 to 9/14/2018, showed staff obtained a
physician’s orders [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265149

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

09/07/2018

NAME OF PROVIDER OF SUPPLIER

FOUR SEASONS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

2800 HIGHWAY TT
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 3) Review of the resident’s MAR indicated [REDACTED]. Staff documented all as given daily. Review of the resident’s medical record showed it did not contain any pharmacy recommendations or physician approved gradual dosage reductions for the last year. 6. Review of Resident #186’s Annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Staff assessed mood-minimal mood indicators; -Physical behaviors no behaviors; Review of the resident’s care plan, dated 8/10/17, showed it directed staff: -Monitor for adverse reactions; -[DIAGNOSES REDACTED]. -No documented behaviors. Review of the resident’s POS, dated 8/15/18 to 9/14/18, showed staff obtained a physician’s orders [REDACTED]. Review of the resident’s MAR indicated [REDACTED]. Staff documented they administered the medication daily. Review of the resident’s medical record showed it did not contain any pharmacy recommendations or physicians approved gradual dosage reductions for the last year. 7. During an interview on 9/07/18 at 2:42 P.M., the Director of Nursing (DON) said the pharmacy reviews the residents’ charts for GDR recommendations or other medication recommendations, then he/she is responsible to send them to the physician and track them.
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	Provide and implement an infection prevention and control program. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility staff failed to develop and implement policies and procedures for the inspection, testing and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire’s Disease (LD). Facility staff also failed to properly provide care in a way to prevent the spread of bacteria during the provision of care for five residents (Residents #85, #124, #152, #198 and #232). Furthermore staff failed to serve resident meals in a way to prevent the spread of bacteria for residents. The facility census was 227. 1. Review of the facility’s building maintenance, inspection and testing records, showed the records did not contain documentation of a water management program to monitor the facility’s water systems for the growth of waterborne pathogens and prevent LD. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
Review of the resident’s MAR indicated [REDACTED]. Staff documented all as given daily.
Review of the resident’s medical record showed it did not contain any pharmacy
recommendations or physician approved gradual dosage reductions for the last year.
6. Review of Resident #186’s Annual MDS, dated [DATE], showed staff assessed the resident
as:
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
-Staff assessed mood-minimal mood indicators;
-Physical behaviors no behaviors;
Review of the resident’s care plan, dated 8/10/17, showed it directed staff:
-Monitor for adverse reactions;
-[DIAGNOSES REDACTED].
-No documented behaviors.
Review of the resident’s POS, dated 8/15/18 to 9/14/18, showed staff obtained a
physician’s orders [REDACTED].
Review of the resident’s MAR indicated [REDACTED]. Staff documented they administered the
medication daily.
Review of the resident’s medical record showed it did not contain any pharmacy
recommendations or physicians approved gradual dosage reductions for the last year.
7. During an interview on 9/07/18 at 2:42 P.M., the Director of Nursing (DON) said the
pharmacy reviews the residents’ charts for GDR recommendations or other medication
recommendations, then he/she is responsible to send them to the physician and track them.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures for the inspection, testing and maintenance of the facility water
systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak
of Legionnaire’s Disease (LD). Facility staff also failed to properly provide care in a
way to prevent the spread of bacteria during the provision of care for five residents
(Residents #85, #124, #152, #198 and #232). Furthermore staff failed to serve resident
meals in a way to prevent the spread of bacteria for residents. The facility census was
227.
1. Review of the facility’s building maintenance, inspection and testing records, showed
the records did not contain documentation of a water management program to monitor the
facility’s water systems for the growth of waterborne pathogens and prevent LD.
2. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification
(S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at
risk. Those at risk include persons who are at least [AGE] years old, smokers, or those
with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression.
Outbreaks have been linked to poorly maintained water systems in buildings with large or
complex water systems including hospitals and long-term care facilities. Transmission can
occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and
decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265149

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

09/07/2018

NAME OF PROVIDER OF SUPPLIER

FOUR SEASONS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

2800 HIGHWAY TT
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 4) growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In (YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. During an interview on 09/06/18 at 11:27 A.M., the administrator said the facility does not have policies and procedures for the inspection, testing, and maintenance of the facility’s water systems related to LD. The administrator said the facility’s corporation stated they will develop these policies and procedures if one of their facilities admits a resident with LD, but said the corporation does not currently have the policies and procedures. 3. Review of the facility’s Handwashing Policy, dated (MONTH) 6 (YEAR), showed staff is directed to wash their hands after handling items potentially contaminated with a resident’s blood, body fluids, exertions and secretions. Review of the facility’s Peri-Care Policy, dated (MONTH) (YEAR), showed it did not contain direction for the staff in regards to when it is appropriate to change gloves and wash their hands during perineal care. 4. Observation on 09/05/18 at 12:12 P.M., showed Restorative Aide (RA) J cleaned tea from the floor, picked up the soiled linen with his/her hands and placed in the hamper. RA J did not wash his/her hands before he/she continued to pass resident’s drinks and meal trays. During an interview on 9/7/18 at 2:00 P.M., RA K said during dining tasks if any staff’s hands get visually soiled, they are to wash them. RA K said that staff are expected to sanitize after every tray pass. Observation on 09/05/18 at 2:44 P.M., showed Certified Nurse Assistant (CNA) A did not clean Resident #198 from front to back during incontinent care. Additionally, he/she did not change his/her gloves before he/she cleaned the resident’s front perineal area with his/her contaminated gloves or before he/she touched the clean sheet and pad. Observation on 09/06/18 at 10:58 A.M., showed CNA B and CNA G provided catheter care to Resident #152. CNA G did not wash his/her hands after he/she touched the resident’s

(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 – Many

(continued… from page 4)
growth in building water systems that reduce the risk of growth and spread of Legionella
and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies
and procedures to reduce the risk of growth and spread of Legionella and other
opportunistic pathogens in building water systems. An industry standard calling for the
development and implementation of water management programs in large or complex building
water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by
American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In
(YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this
ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html).
Environmental, clinical, and epidemiological considerations for healthcare facilities are
described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management
implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,
nontuberculous mycobacteria, and fungi) could grow and spread in the facility water
system;
-Implement a water management program that considers the ASHRAE industry standard and the
CDC toolkit, and includes control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for
pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the
results of testing and corrective actions taken when control limits are not maintained.
During an interview on 09/06/18 at 11:27 A.M., the administrator said the facility does
not have policies and procedures for the inspection, testing, and maintenance of the
facility’s water systems related to LD. The administrator said the facility’s corporation
stated they will develop these policies and procedures if one of their facilities admits a
resident with LD, but said the corporation does not currently have the policies and
procedures.
3. Review of the facility’s Handwashing Policy, dated (MONTH) 6 (YEAR), showed staff is
directed to wash their hands after handling items potentially contaminated with a
resident’s blood, body fluids, exertions and secretions.
Review of the facility’s Peri-Care Policy, dated (MONTH) (YEAR), showed it did not contain
direction for the staff in regards to when it is appropriate to change gloves and wash
their hands during perineal care.
4. Observation on 09/05/18 at 12:12 P.M., showed Restorative Aide (RA) J cleaned tea from
the floor, picked up the soiled linen with his/her hands and placed in the hamper. RA J
did not wash his/her hands before he/she continued to pass resident’s drinks and meal
trays.
During an interview on 9/7/18 at 2:00 P.M., RA K said during dining tasks if any staff’s
hands get visually soiled, they are to wash them. RA K said that staff are expected to
sanitize after every tray pass.
Observation on 09/05/18 at 2:44 P.M., showed Certified Nurse Assistant (CNA) A did not
clean Resident #198 from front to back during incontinent care. Additionally, he/she did
not change his/her gloves before he/she cleaned the resident’s front perineal area with
his/her contaminated gloves or before he/she touched the clean sheet and pad.
Observation on 09/06/18 at 10:58 A.M., showed CNA B and CNA G provided catheter care to
Resident #152. CNA G did not wash his/her hands after he/she touched the resident’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265149

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

09/07/2018

NAME OF PROVIDER OF SUPPLIER

FOUR SEASONS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

2800 HIGHWAY TT
SEDALIA, MO 65301

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 – Many	(continued… from page 5) catheter and tubing or before he/she left the resident’s room. Observation on 09/06/18 at 11:42 A.M., showed Licensed Practical Nurse (LPN) C provided suprapubic catheter (tube surgically inserted into the bladder to drain urine) care for Resident # 232. The LPN wiped around the insertion cite multiple times with the same area of the gauze, and wiped the resident’s open wound multiple times with the same area of gauze during wound care. Additionally, the LPN placed dry gauze into the resident’s open wound after he/she touched the skin around the wound and used his/her finger to place the packing to the resident’s hip wound. Observation on 9/6/18 at 11:47 A.M., showed CNA I and CNA H entered Resident #85’s room to provide incontinence care. Further observation showed CNA H cleansed the resident’s buttocks. Additional observation showed the CNA then touched the resident’s clean brief, sheet, and package of wipes with the same soiled gloves. Observation on 09/06/18 at 5:26 P.M., showed LPN C touched Resident #124’s medications with his/her bare hands during medication administration. 5. During an interview on 09/07/18 at 2:00 P.M., LPN E said staff are expected to spray cleanser on the gauze pad and clean the wound using a different area of the gauze with each wipe when they cleanse a wound. Staff should clean a suprapubic catheter with a circular motion and use a clean area of the cloth or gauze with each wipe. Staff should wipe front to back when they provide incontinence care, and the cloth or wipe should not touch the resident anywhere before staff use it to clean the resident’s perineal area. Staff should change their dirty gloves and wash their hands before touching the resident or their belongings. When staff provide wound care, they are expected to use a q-tip to pack a wound and not their finger, the packing material should be placed directly into the wound, and the packing material should not touch the skin area on the outside of the wound. Staff should wash their hands after they touch a resident’s catheter bag and tubing, and before they leave the room. During an interview on 09/07/18 at 2:17 P.M., CNA F said when staff clean around a suprapubic catheter, they are expected to use a new wipe for each wipe and during any care the wipe should not touch anything before staff use it to clean a resident. When providing incontinence care to female residents, staff should wipe from front to back and change their gloves and wash their hands before they continue to touch the resident or their belongings. Staff should wash their hands after they touch a resident’s belongings or catheter bag and when they leave a resident’s room.

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