LA BELLE MANOR CARE CENTER

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to ensure ceiling vents were free of a buildup of dust and debris. The facility census was 43. Observation on 02/04/19 between 10:20 A.M. and 3:46 P.M., showed the following: -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the southeast hall clean utility room was covered with a thick layer of dust; -The ceiling vent in the oxygen storage room was covered with a thick layer of dust; -The ceiling vent in the southeast hall dirty utility room was covered with a thick layer of dust; -The ceiling vent in the southeast shower room was covered with a thick layer of dust; -Two ceiling vents in the south dining area were covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the social services office was covered with a thick layer of dust; -The ceiling vent in the south nurse’s bathroom was covered with a thick layer of dust; -The ceiling vent in the south nurse’s station medication room was covered with a thick layer of dust; -The ceiling vent in the laundry/housekeeping office was covered with a thick layer of dust; -The ceiling vent in the central hall storage room was covered with a thick layer of dust; -The ceiling vent in the employee breakroom was covered with a thick layer of dust; -The ceiling vent in the north nurse’s bathroom was covered with a thick layer of dust; -A ceiling vent in the north dining area was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the beauty shop was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of dust; -Two ceiling vents in the north shower room were covered with a thick layer of dust; -The ceiling vent in the north dirty utility room was covered with a thick layer of dust;

(X4) ID PREFIX TAG

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

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure housekeeping and
maintenance services were provided to ensure ceiling vents were free of a buildup of dust
and debris. The facility census was 43.
Observation on 02/04/19 between 10:20 A.M. and 3:46 P.M., showed the following:
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the southeast hall clean utility room was covered with a thick layer
of dust;
-The ceiling vent in the oxygen storage room was covered with a thick layer of dust;
-The ceiling vent in the southeast hall dirty utility room was covered with a thick layer
of dust;
-The ceiling vent in the southeast shower room was covered with a thick layer of dust;
-Two ceiling vents in the south dining area were covered with a thick layer of dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the social services office was covered with a thick layer of dust;
-The ceiling vent in the south nurse’s bathroom was covered with a thick layer of dust;
-The ceiling vent in the south nurse’s station medication room was covered with a thick
layer of dust;
-The ceiling vent in the laundry/housekeeping office was covered with a thick layer of
dust;
-The ceiling vent in the central hall storage room was covered with a thick layer of dust;
-The ceiling vent in the employee breakroom was covered with a thick layer of dust;
-The ceiling vent in the north nurse’s bathroom was covered with a thick layer of dust;
-A ceiling vent in the north dining area was covered with a thick layer of dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the beauty shop was covered with a thick layer of dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-The ceiling vent in the bathroom in room [ROOM NUMBER] was covered with a thick layer of
dust;
-Two ceiling vents in the north shower room were covered with a thick layer of dust;
-The ceiling vent in the north dirty utility room was covered with a thick layer of dust;

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: 265646

If continuation sheet
Page 1 of 11

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 1) -Eight ceiling vents in the laundry room were covered with a thick layer of dust; -A ceiling vent in the service corridor was covered with a thick layer of dust; -The ceiling vent in the janitor’s closet in the service corridor was covered with a thick layer of dust. During interview on 02/06/19 at 2:26 P.M., the maintenance supervisor said maintenance was responsible for ensuring the ceiling vents were clean. He said staff checked the vents monthly. He was not aware the ones found during the inspection needed cleaning. During interview on 02/06/19 at 3:41 P.M., the administrator said she expected the ceiling vents to be clean and dust free.
	F 0659 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Provide care by qualified persons according to each resident’s written plan of care. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff were trained and available to provide Cardiopulmonary Resuscitation (CPR) (the manual application of chest compressions and ventilation’s to persons in [MEDICAL CONDITION], done in an effort to maintain viability until advanced help arrives) when transporting residents who requested to be full code, in the facility van. Three residents (Resident #6, Resident #9, and Resident #31) of 12 sampled residents, who were a full code, were transported multiple times by facility transporters who were not certified to perform CPR. The facility failed to ensure certified staff was in the building at all times to provide CPR if needed to full code residents. The facility hired Licensed Practical Nurse (LPN) G on [DATE] and allowed him/her to work multiple shifts with an expired CPR certificate. The facility census was 43. 1. Review of the facility’s policy, undated, Cardiopulmonary Resuscitation, showed the following: -Facility staff will provide care according to the resident’s wishes and physician orders; -CPR will be attempted for any resident who is found to have no palatable pulse and/or no discernible respirations unless there is a written physician order [REDACTED]. -CPR is a technique for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilatory action. CPR is defined as artificial respiration accompanied by external cardiac compressions; -DNR code status: physician order [REDACTED]. -Full Code: if resident is not breathing and or does not have a pulse, CPR is to be initiated. 2. Review of the facility’s undated transportation policy showed it was the facility’s policy to provide the residents with transportation to physician appointments as the van/bus was available. Review of the list of full code residents provided by the director of nurses (DON), undated, showed 26 residents with a full code order/status. 3. During an interview on [DATE] at 10:20 A.M., the administrator said that all licensed facility staff were CPR certified but the transporters were not. They found out through other facilities that the transporters needed to be CPR certified. 4. Review of LPN G’s CPR card showed the LPN’s CPR card expired (YEAR). Review of LPN G’s work schedule supplied by the DON showed the following: – LPN G started working for the facility on [DATE]; -[DATE] LPN G worked from 5:00 P.M. to 10:00 P.M. (five hours) without any other staff

(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)
-Eight ceiling vents in the laundry room were covered with a thick layer of dust;
-A ceiling vent in the service corridor was covered with a thick layer of dust;
-The ceiling vent in the janitor’s closet in the service corridor was covered with a thick
layer of dust.
During interview on 02/06/19 at 2:26 P.M., the maintenance supervisor said maintenance was
responsible for ensuring the ceiling vents were clean. He said staff checked the vents
monthly. He was not aware the ones found during the inspection needed cleaning.
During interview on 02/06/19 at 3:41 P.M., the administrator said she expected the ceiling
vents to be clean and dust free.

F 0659

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care by qualified persons according to each resident’s written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff were trained and
available to provide Cardiopulmonary Resuscitation (CPR) (the manual application of chest
compressions and ventilation’s to persons in [MEDICAL CONDITION], done in an effort to
maintain viability until advanced help arrives) when transporting residents who requested
to be full code, in the facility van. Three residents (Resident #6, Resident #9, and
Resident #31) of 12 sampled residents, who were a full code, were transported multiple
times by facility transporters who were not certified to perform CPR. The facility failed
to ensure certified staff was in the building at all times to provide CPR if needed to
full code residents. The facility hired Licensed Practical Nurse (LPN) G on [DATE] and
allowed him/her to work multiple shifts with an expired CPR certificate. The facility
census was 43.
1. Review of the facility’s policy, undated, Cardiopulmonary Resuscitation, showed the
following:
-Facility staff will provide care according to the resident’s wishes and physician orders;
-CPR will be attempted for any resident who is found to have no palatable pulse and/or no
discernible respirations unless there is a written physician order [REDACTED].
-CPR is a technique for the purpose of oxygenating the brain and heart until appropriate
medical treatment can restore normal heart and ventilatory action. CPR is defined as
artificial respiration accompanied by external cardiac compressions;
-DNR code status: physician order [REDACTED].
-Full Code: if resident is not breathing and or does not have a pulse, CPR is to be
initiated.
2. Review of the facility’s undated transportation policy showed it was the facility’s
policy to provide the residents with transportation to physician appointments as the
van/bus was available.
Review of the list of full code residents provided by the director of nurses (DON),
undated, showed 26 residents with a full code order/status.
3. During an interview on [DATE] at 10:20 A.M., the administrator said that all licensed
facility staff were CPR certified but the transporters were not. They found out through
other facilities that the transporters needed to be CPR certified.
4. Review of LPN G’s CPR card showed the LPN’s CPR card expired (YEAR).
Review of LPN G’s work schedule supplied by the DON showed the following:
– LPN G started working for the facility on [DATE];
-[DATE] LPN G worked from 5:00 P.M. to 10:00 P.M. (five hours) without any other staff

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0659 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 2) that were CPR certified; -[DATE] LPN G worked from 10:00 P.M. to 6:00 A.M. (eight hours) without any other staff that were CPR certified; -[DATE] LPN G worked from 10:00 P.M. to 6:00 A.M. (eight hours) without any other staff that were CPR certified; -[DATE] LPN G worked from 5:00 P.M. to 10:00 P.M. (five hours) without any other staff that were CPR certified. During interview on [DATE] at 7:50 A.M. the DON said LPN G worked [DATE], [DATE], [DATE], and [DATE] without current CPR certified and without any other CPR certified staff in the building. 5. Review of Resident #6’s physician orders [REDACTED]. -[DIAGNOSES REDACTED]. -admission date of [DATE]; -Code status: full code. Review of the the facility’s transportation schedule report showed the facility transported the resident in the facility van to appointments out of town on [DATE], [DATE], [DATE], [DATE] and [DATE]. 6. Review of Resident #9’s physician orders [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Code status: full code. Review of the facility’s transportation schedule report showed the facility provided transportation of the resident in the facility van to appointments on [DATE] and [DATE]. 7. Review of Resident #31’s physician’s orders [REDACTED]. -admission date of [DATE]; -[DIAGNOSES REDACTED]. -Code status: full code. Review of the facility’s transportation schedule report showed the the facility provided transportation for the resident to an appointment on [DATE]. 6. During interview on [DATE] at 10:11 A.M., the transporter said the following: -He/she was hired in ,[DATE] as the transporter to take residents to and from physician appointments and occasionally to the store; -He/she had been CPR certified back in 2010 or 2011 and it was different process back then; -He/she would call 911 if a resident was non-responsive; -He/she might check a resident’s pulse before performing CPR; -He/she never had to perform CPR on a real person before. During interview on [DATE] 10:36 A.M., the administrator said all the licensed staff were CPR certified. She just found out that staff that transported the residents also needed to be CPR certified.
	F 0661 Level of harm – Potential for minimal harm Residents Affected – Many	Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a comprehensive discharge summary and recapitulation of stay for one resident (Resident #48), in a review

(X4) ID PREFIX TAG

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

F 0659

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
that were CPR certified;
-[DATE] LPN G worked from 10:00 P.M. to 6:00 A.M. (eight hours) without any other staff
that were CPR certified;
-[DATE] LPN G worked from 10:00 P.M. to 6:00 A.M. (eight hours) without any other staff
that were CPR certified;
-[DATE] LPN G worked from 5:00 P.M. to 10:00 P.M. (five hours) without any other staff
that were CPR certified.
During interview on [DATE] at 7:50 A.M. the DON said LPN G worked [DATE], [DATE], [DATE],
and [DATE] without current CPR certified and without any other CPR certified staff in the
building.
5. Review of Resident #6’s physician orders [REDACTED].
-[DIAGNOSES REDACTED].
-admission date of [DATE];
-Code status: full code.
Review of the the facility’s transportation schedule report showed the facility
transported the resident in the facility van to appointments out of town on [DATE],
[DATE], [DATE], [DATE] and [DATE].
6. Review of Resident #9’s physician orders [REDACTED].
-admission date of [DATE];
-[DIAGNOSES REDACTED].
-Code status: full code.
Review of the facility’s transportation schedule report showed the facility provided
transportation of the resident in the facility van to appointments on [DATE] and [DATE].
7. Review of Resident #31’s physician’s orders [REDACTED].
-admission date of [DATE];
-[DIAGNOSES REDACTED].
-Code status: full code.
Review of the facility’s transportation schedule report showed the the facility provided
transportation for the resident to an appointment on [DATE].
6. During interview on [DATE] at 10:11 A.M., the transporter said the following:
-He/she was hired in ,[DATE] as the transporter to take residents to and from physician
appointments and occasionally to the store;
-He/she had been CPR certified back in 2010 or 2011 and it was different process back
then;
-He/she would call 911 if a resident was non-responsive;
-He/she might check a resident’s pulse before performing CPR;
-He/she never had to perform CPR on a real person before.
During interview on [DATE] 10:36 A.M., the administrator said all the licensed staff were
CPR certified. She just found out that staff that transported the residents also needed to
be CPR certified.

F 0661

Level of harm – Potential for minimal harm

Residents Affected – Many

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a comprehensive
discharge summary and recapitulation of stay for one resident (Resident #48), in a review

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0661 Level of harm – Potential for minimal harm Residents Affected – Many	(continued… from page 3) of three closed records, and one additional resident (Resident #100). The facility census was 43. 1. During interview on 2/11/19 at 1:48 P.M., the Director of Nursing (DON) said the facility did not have a discharge or recapitulation policy. 2. Review of Resident #48’s medical record showed the following: -admitted to the facility on [DATE]; -discharged home with family member on 11/26/18. Staff sent all medications with the resident’s family member; -The medical record contained no discharge summary or recapitulation of stay. 3. Review of Resident #100’s medical record showed the following: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -discharged home 6/29/18; -The medical record contained no discharge summary or recapitulation of stay. 4. During interview on 2/6/19 at 4:36 P.M., the DON said the following: -The charge nurse is responsible for completing discharge summaries; -The staff just found out they needed to complete a summary of residents’ stays; -The staff have not been completing discharge summaries or recapitulation of the residents’ stay. -Resident #48 was a respite care resident for the holidays and she was not aware staff needed to complete a recapitulation summary for respite care residents.
	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 personnel , subject to physician orders and the resident’s advance directives. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Surveyor: Lene, Tammy Based on interview and record review, the facility failed to ensure the medical record accurately and consistently indicated resident code status for two residents (Resident #6 and #46) in a review of 12 sampled residents. The facility census was 43. 1. Review of the facility policy Cardiopulmonary Resuscitation dated [DATE], showed the following: -Staff will provide care according to the resident’s wishes and physician’s orders; -When appropriate, CPR will be initiated by facility staff and continued until paramedics/EMT (emergency medical technician) arrives to relieve facility staff and take over the CPR procedure; -Staff will attempt CPR for any resident who is found to have no palpable pulse and/or no discernible respirations unless there is a written physician’s order to the contrary and a written, signed DO Not Resuscitate (DNR) order; -CPR is a technique for the purpose of oxygenating the brain and heart until appropriate definitive medical treatment can restore normal heart and ventilator action. CPR is defined as artificial respiration accompanied by external cardiac compressions; -DNR Code Status-physician’s order Do Not Resuscitate, which means not to use CPR in the event of cessation of breathing and/or pulse; -Full Code-If resident is not breathing and/or does not have a pulse, CPR is to be initiated and emergency policies and procedures followed; -Code status will be obtained from the resident’s physician for each resident upon

(X4) ID PREFIX TAG

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

F 0661

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 3)
of three closed records, and one additional resident (Resident #100). The facility census
was 43.
1. During interview on 2/11/19 at 1:48 P.M., the Director of Nursing (DON) said the
facility did not have a discharge or recapitulation policy.
2. Review of Resident #48’s medical record showed the following:
-admitted to the facility on [DATE];
-discharged home with family member on 11/26/18. Staff sent all medications with the
resident’s family member;
-The medical record contained no discharge summary or recapitulation of stay.
3. Review of Resident #100’s medical record showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-discharged home 6/29/18;
-The medical record contained no discharge summary or recapitulation of stay.
4. During interview on 2/6/19 at 4:36 P.M., the DON said the following:
-The charge nurse is responsible for completing discharge summaries;
-The staff just found out they needed to complete a summary of residents’ stays;
-The staff have not been completing discharge summaries or recapitulation of the
residents’ stay.
-Resident #48 was a respite care resident for the holidays and she was not aware staff
needed to complete a recapitulation summary for respite care residents.

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
personnel , subject to physician orders and the resident’s advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Surveyor: Lene, Tammy
Based on interview and record review, the facility failed to ensure the medical record
accurately and consistently indicated resident code status for two residents (Resident #6
and #46) in a review of 12 sampled residents. The facility census was 43.
1. Review of the facility policy Cardiopulmonary Resuscitation dated [DATE], showed the
following:
-Staff will provide care according to the resident’s wishes and physician’s orders;
-When appropriate, CPR will be initiated by facility staff and continued until
paramedics/EMT (emergency medical technician) arrives to relieve facility staff and take
over the CPR procedure;
-Staff will attempt CPR for any resident who is found to have no palpable pulse and/or no
discernible respirations unless there is a written physician’s order to the contrary and a
written, signed DO Not Resuscitate (DNR) order;
-CPR is a technique for the purpose of oxygenating the brain and heart until appropriate
definitive medical treatment can restore normal heart and ventilator action. CPR is
defined as artificial respiration accompanied by external cardiac compressions;
-DNR Code Status-physician’s order Do Not Resuscitate, which means not to use CPR in the
event of cessation of breathing and/or pulse;
-Full Code-If resident is not breathing and/or does not have a pulse, CPR is to be
initiated and emergency policies and procedures followed;
-Code status will be obtained from the resident’s physician for each resident upon

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 4) admission; -Code status will be updated on the resident’s chart when/if changed; -When a resident is found to be unresponsive: staff will call for help using call system or verbally alerting other staff on duty; -Verify code status (full code or DNR). If code status is not known and cannot be immediately determined, assume full code; -Initiate emergency procedures. Example, call 911, physician, obtain equipment, etc.; -If a resident is a full code, a staff person initiates CPR according to current BLS (basic life support) guidelines and a second person acts as a messenger to assist first staff person; -Messenger ensures Code Blue is announced overhead and emergency personnel and physician is notified; -CPR will continue until emergency personnel arrive and take over the process. 2. Review of the resident listing report supplied by the Director of Nursing (DON) on [DATE] at 3:25 P.M. showed the following: -Resident #6 was a full code; -Resident #46 was a full code. 3. Review of Resident #6’s medical record showed an outside the hospital DNR request dated [DATE] showed the resident requested to have a DNR put into place and did not want staff performing CPR. Review of the resident’s face sheet showed DNR highlighted. Review of the resident’s physician orders (POS) dated [DATE] showed CPR, indicating the resident was a full code. Review of the resident’s care plan last updated [DATE], showed the resident’s code status was not addressed on the care plan. Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed the following: -admission date of [DATE]; -Cognitively intact; -Understood others and made self understood; -[DIAGNOSES REDACTED]. Observation on [DATE] to [DATE] of the resident’s hard chart showed a green sticker indicating the resident was a full code. Review of the resident’s POS dated [DATE] showed CPR, indicating the resident was a full code. Observation on [DATE], at 12:33 P.M., of the resident’s door showed a red sticker on his/her name tag, indicating DNR status. 3. Review of Resident #46’s hard chart showed a red sticker indicating the resident was a DNR. Review of the resident’s care plan last updated [DATE], showed the resident’s code status was not addressed. Record review of the resident’s quarterly MDS dated [DATE], showed the following: -admission date of [DATE]; -Cognition intact; -[DIAGNOSES REDACTED]. Review of the resident’s physician orders (POS) on the electronic medical record (EMR) dated (MONTH) 2019, showed the code status was blank. Observation on [DATE] at 2:30 P.M. of the resident’s door showed a green sticker on his/her name tag indicating full code status.

(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 4)
admission;
-Code status will be updated on the resident’s chart when/if changed;
-When a resident is found to be unresponsive: staff will call for help using call system
or verbally alerting other staff on duty;
-Verify code status (full code or DNR). If code status is not known and cannot be
immediately determined, assume full code;
-Initiate emergency procedures. Example, call 911, physician, obtain equipment, etc.;
-If a resident is a full code, a staff person initiates CPR according to current BLS
(basic life support) guidelines and a second person acts as a messenger to assist first
staff person;
-Messenger ensures Code Blue is announced overhead and emergency personnel and physician
is notified;
-CPR will continue until emergency personnel arrive and take over the process.
2. Review of the resident listing report supplied by the Director of Nursing (DON) on
[DATE] at 3:25 P.M. showed the following:
-Resident #6 was a full code;
-Resident #46 was a full code.
3. Review of Resident #6’s medical record showed an outside the hospital DNR request dated
[DATE] showed the resident requested to have a DNR put into place and did not want staff
performing CPR.
Review of the resident’s face sheet showed DNR highlighted.
Review of the resident’s physician orders (POS) dated [DATE] showed CPR, indicating the
resident was a full code.
Review of the resident’s care plan last updated [DATE], showed the resident’s code status
was not addressed on the care plan.
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated [DATE] showed the following:
-admission date of [DATE];
-Cognitively intact;
-Understood others and made self understood;
-[DIAGNOSES REDACTED].
Observation on [DATE] to [DATE] of the resident’s hard chart showed a green sticker
indicating the resident was a full code.
Review of the resident’s POS dated [DATE] showed CPR, indicating the resident was a full
code.
Observation on [DATE], at 12:33 P.M., of the resident’s door showed a red sticker on
his/her name tag, indicating DNR status.
3. Review of Resident #46’s hard chart showed a red sticker indicating the resident was a
DNR.
Review of the resident’s care plan last updated [DATE], showed the resident’s code status
was not addressed.
Record review of the resident’s quarterly MDS dated [DATE], showed the following:
-admission date of [DATE];
-Cognition intact;
-[DIAGNOSES REDACTED].
Review of the resident’s physician orders (POS) on the electronic medical record (EMR)
dated (MONTH) 2019, showed the code status was blank.
Observation on [DATE] at 2:30 P.M. of the resident’s door showed a green sticker on
his/her name tag indicating full code status.

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0678 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 5) 5. During interview on [DATE] at 5:54 A.M., Certified Nurse Aide (CNA) C said he/she finds out a resident’s code status by looking at the computer under the Kardex by the resident’s name. During interview on [DATE] at 5:56 A.M., CNA D said he/she knows resident code status from the stickers on the resident’s hard chart and the sticker on the outside of the resident’s room on their picture. The stickers should match, with red dot sticker being DNR and the green dot sticker being full code. The code status is also in the resident’s EMR charted by the allergies [REDACTED]. During an interview on [DATE] at 9:45 A.M. Licensed Practical Nurse (LPN) A said the following: -He/she had worked at the facility long enough to know the residents’ code status; -A green dot on the resident name plate on the door and resident’s chart meant the resident was a full code; -A red dot on the resident’s name plate on the door and spine of the chart meant the resident was DNR; -He/she would also look at the EMR top right corner which tells the resident code status but he/she didn’t always have a computer available. During an interview on [DATE] at 6:11 A.M. LPN E said the following: -He/she would look for the red or green dot outside on the spine of the resident’s chart to know the resident’s code status; -If the resident had a green dot it meant the resident was a full code; -If the resident’s chart had a red dot on the outside spine it meant the resident was a DNR; -He/she would also check the resident’s face sheet for the code status. During an interview on [DATE] at 7:50 A.M. the DON said the following; -The facility has full code and DNR residents in the building; -The facility did not have a policy for the red and green dot system for resident code status; -The admitting nurse was responsible for getting the resident’s wishes for code status from the resident and/or the resident’s guardian and the physician; -Each resident should have a red or green dot on the spine of their hard chart indicating code status; -A red dot meany the resident was a DNR and a green dot meant the resident was a full code; -The dots outside the residents’ rooms were not used anymore because they were too hard to keep up with; -He/she was not sure why some of the residents have dots outside their door on their name plate and some do not because they have not used that system for at least a year; -She expected staff to refer to the resident’s spine of their hard chart, face sheet, and POS for code status; -If there was no code status indicated, the resident is a full code; -She would expect the resident’s POS, face sheet, and chart to all match on code status.
	F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Ensure medication error rates are not 5 percent or greater. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the

(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 5)
5. During interview on [DATE] at 5:54 A.M., Certified Nurse Aide (CNA) C said he/she finds
out a resident’s code status by looking at the computer under the Kardex by the resident’s
name.
During interview on [DATE] at 5:56 A.M., CNA D said he/she knows resident code status from
the stickers on the resident’s hard chart and the sticker on the outside of the resident’s
room on their picture. The stickers should match, with red dot sticker being DNR and the
green dot sticker being full code. The code status is also in the resident’s EMR charted
by the allergies [REDACTED].
During an interview on [DATE] at 9:45 A.M. Licensed Practical Nurse (LPN) A said the
following:
-He/she had worked at the facility long enough to know the residents’ code status;
-A green dot on the resident name plate on the door and resident’s chart meant the
resident was a full code;
-A red dot on the resident’s name plate on the door and spine of the chart meant the
resident was DNR;
-He/she would also look at the EMR top right corner which tells the resident code status
but he/she didn’t always have a computer available.
During an interview on [DATE] at 6:11 A.M. LPN E said the following:
-He/she would look for the red or green dot outside on the spine of the resident’s chart
to know the resident’s code status;
-If the resident had a green dot it meant the resident was a full code;
-If the resident’s chart had a red dot on the outside spine it meant the resident was a
DNR;
-He/she would also check the resident’s face sheet for the code status.
During an interview on [DATE] at 7:50 A.M. the DON said the following;
-The facility has full code and DNR residents in the building;
-The facility did not have a policy for the red and green dot system for resident code
status;
-The admitting nurse was responsible for getting the resident’s wishes for code status
from the resident and/or the resident’s guardian and the physician;
-Each resident should have a red or green dot on the spine of their hard chart indicating
code status;
-A red dot meany the resident was a DNR and a green dot meant the resident was a full
code;
-The dots outside the residents’ rooms were not used anymore because they were too hard to
keep up with;
-He/she was not sure why some of the residents have dots outside their door on their name
plate and some do not because they have not used that system for at least a year;
-She expected staff to refer to the resident’s spine of their hard chart, face sheet, and
POS for code status;
-If there was no code status indicated, the resident is a full code;
-She would expect the resident’s POS, face sheet, and chart to all match on code status.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 6) medication error rate was less than five percent. Twenty-six opportunities were observed with five medication errors, resulting in a medication error rate of 19.23 percent. The facility census was 43. 1. Review of the facility’s policy, Medication Pass Times, implemented 7/1/13, showed the following: -Purpose was to ensure medications were administered as ordered in a safe and effective manner that meets standards of practice according to Centers for Medicare and Medicaid Service’s guidelines; -Time frame for the evening medication pass was 3:00 P.M. to 6:00 P.M., and the time frame for the bedtime (HS) pass was 7:00 P.M. to 10:00 P.M. 2. Review of the facility’s policy Eye Drop Administration, revised (MONTH) 2011, showed the following: -Administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner; -Tilt the resident’s head slightly back; -With a gloved finger, gently pull down lower eyelid to form a pouch while instructing the resident to look up. Place other hand against the resident’s forehead to steady; -Hold inverted medication bottle between the thumb and index finger, press gently, and instill prescribed number of drops into the pouch near outer the corner of the resident’s eye; -If resident blinks or a drop lands on the resident’s cheek, repeat administration. 3. Review of Resident #101’s physician order, dated 2/4/19, showed an order for [REDACTED]. Observation on 2/5/19 at 11:35 A.M., showed the resident lay in bed with the head of his/her bed slightly elevated. Licensed Practical Nurse (LPN) A did not tilt the resident’s head back before he/she instilled one drop of the [MEDICATION NAME] B solution into the resident’s right eye. LPN A did not instill the eye drop into a pouch in the resident’s lower lid but instilled the drop into the corner of the eye. The drop immediately rolled out of the resident’s eye and down the resident’s cheek. LPN A wiped the drop from the resident’s face. LPN A did not instill another eye drop into the resident’s eye. During interview on 2/13/19 at 1:17 P.M. and on 2/21/19 at 11:10 A.M., LPN A said he/she was rushed and nervous and knew right away, he/she did not administer the eye drop correctly. He/she was to instill the drop by making a pouch in the lower eyelid. He/she should have re-administered the eye drop to the resident. During interview on 2/21/19 at 10:58 A.M., the director of nursing (DON) said she expected staff to re-administer the eye drop if it immediately rolled out of the resident’s eye upon administration. Staff was to make a pouch in the lower eye lid to instill the eye drop. 4. Review of Resident #37’s physician orders, dated 2/6/19, showed the following: -[MEDICATION NAME] (a natural hormone that helps maintain daily cycle of sleep and wakefulness) 5 milligram (mg), administer one tablet at bedtime for sleeplessness; -[MEDICATION NAME] (antidepressant) 30 mg, administer one tablet at bedtime for chronic depression. Review of the resident’s electronic Medication Administration Record [REDACTED] -[MEDICATION NAME] 5 mg, give one tablet at bedtime for sleeplessness; -[MEDICATION NAME] 30 mg, give one tablet at bedtime for chronic depression; -These medications were on the list of medications for staff to administer to the resident during the 1700 (5:00 P.M.) medication pass.

(X4) ID PREFIX TAG

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

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
medication error rate was less than five percent. Twenty-six opportunities were observed
with five medication errors, resulting in a medication error rate of 19.23 percent. The
facility census was 43.
1. Review of the facility’s policy, Medication Pass Times, implemented 7/1/13, showed the
following:
-Purpose was to ensure medications were administered as ordered in a safe and effective
manner that meets standards of practice according to Centers for Medicare and Medicaid
Service’s guidelines;
-Time frame for the evening medication pass was 3:00 P.M. to 6:00 P.M., and the time frame
for the bedtime (HS) pass was 7:00 P.M. to 10:00 P.M.
2. Review of the facility’s policy Eye Drop Administration, revised (MONTH) 2011, showed
the following:
-Administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective
manner;
-Tilt the resident’s head slightly back;
-With a gloved finger, gently pull down lower eyelid to form a pouch while instructing the
resident to look up. Place other hand against the resident’s forehead to steady;
-Hold inverted medication bottle between the thumb and index finger, press gently, and
instill prescribed number of drops into the pouch near outer the corner of the resident’s
eye;
-If resident blinks or a drop lands on the resident’s cheek, repeat administration.
3. Review of Resident #101’s physician order, dated 2/4/19, showed an order for
[REDACTED].
Observation on 2/5/19 at 11:35 A.M., showed the resident lay in bed with the head of
his/her bed slightly elevated. Licensed Practical Nurse (LPN) A did not tilt the
resident’s head back before he/she instilled one drop of the [MEDICATION NAME] B solution
into the resident’s right eye. LPN A did not instill the eye drop into a pouch in the
resident’s lower lid but instilled the drop into the corner of the eye. The drop
immediately rolled out of the resident’s eye and down the resident’s cheek. LPN A wiped
the drop from the resident’s face. LPN A did not instill another eye drop into the
resident’s eye.
During interview on 2/13/19 at 1:17 P.M. and on 2/21/19 at 11:10 A.M., LPN A said he/she
was rushed and nervous and knew right away, he/she did not administer the eye drop
correctly. He/she was to instill the drop by making a pouch in the lower eyelid. He/she
should have re-administered the eye drop to the resident.
During interview on 2/21/19 at 10:58 A.M., the director of nursing (DON) said she expected
staff to re-administer the eye drop if it immediately rolled out of the resident’s eye
upon administration. Staff was to make a pouch in the lower eye lid to instill the eye
drop.
4. Review of Resident #37’s physician orders, dated 2/6/19, showed the following:
-[MEDICATION NAME] (a natural hormone that helps maintain daily cycle of sleep and
wakefulness) 5 milligram (mg), administer one tablet at bedtime for sleeplessness;
-[MEDICATION NAME] (antidepressant) 30 mg, administer one tablet at bedtime for chronic
depression.
Review of the resident’s electronic Medication Administration Record [REDACTED]
-[MEDICATION NAME] 5 mg, give one tablet at bedtime for sleeplessness;
-[MEDICATION NAME] 30 mg, give one tablet at bedtime for chronic depression;
-These medications were on the list of medications for staff to administer to the resident
during the 1700 (5:00 P.M.) medication pass.

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 7) Observation on 2/5/19 at 4:05 P.M., showed Certified Medication Technician (CMT) B reviewed the resident’s eMAR, which highlighted medications to be administered for the 5:00 medication pass. CMT B administered the [MEDICATION NAME] 5 mg and [MEDICATION NAME] 30 mg to the resident during the evening medication pass scheduled for 5:00 P.M. per the eMAR. (Both medications were ordered to be given at bedtime.) 5. Review of Resident #1’s physician’s orders [REDACTED]. -[MEDICATION NAME] (anticonvulsant) 100 mg, administer one tablet at bedtime; -Donepezil (cognition-enhancing medication) 10 mg, administer one tablet at bedtime. Review of the resident’s eMAR showed [MEDICATION NAME] and donepezil were scheduled for the evening medication pass (5:00 P.M.), however, the eMAR showed the medications were ordered to be administered at bedtime. Observation on 2/5/19 at 4:15 P.M. showed CMT B administered the [MEDICATION NAME] 100 mg and donepezil 10 mg to the resident during the evening medication pass. (Both medications were ordered to be given at bedtime.) 6. During interview on 2/13/18 at 1:56 P.M., CMT B said he/she followed the eMAR when administering medications. The eMAR said the medications for Resident #1 and Resident #37 were to be given during the 5:00 P.M. medication pass. 7. During interviews on 2/11/19 at 1:48 P.M. and on 2/13/19 at 2:09 P.M., the DON said the following: -The nurse, who receives a physician’s orders [REDACTED]. The nurse on the next shift was to review the new order and eMAR to ensure it was correct; -Staff were to administer Resident #1 and Resident #37’s bedtime medications no earlier than 7:00 P.M. Staff administering bedtime medications at 4:00 P.M. or 5:00 P.M. was too early; -Staff were to administer medications ordered specifically at HS as listed on the physician’s orders [REDACTED].>-She expected staff to follow physician’s orders [REDACTED].
	F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the range hood was free of an accumulation of debris, and failed to ensure a ceiling-mounted ventilation unit was free of a buildup of debris. The facility census was 43. 1. Record review of the dietician’s reports, dated 11/14/18 and 1/23/19, showed the following kitchen inspection recommendations/comments: -11/14/18: Clean entire air conditioning vent and replace filter regularly, gets dirty quickly; -1/23/19: HVAC vent/filter needs to be replaced and attached correctly. Observation on 2/4/19 at 11:26 AM and on 2/5/19 at 10:46 A.M. showed a ceiling-mounted air conditioning ventilation unit in the kitchen was positioned over metal countertops and the steamtable. The unit was supported by metal supports and bars that had a heavy accumulation of dark-colored dust and debris. Portions of cut-up orange swimming pool noodles and black electrical tape covered the ends of the metal bars that held the ventilation unit up over the food preparation counter and recipe book area. There areas were also covered in dark fuzzy debris. The long metal spiral bolts that attached to the

(X4) ID PREFIX TAG

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

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
Observation on 2/5/19 at 4:05 P.M., showed Certified Medication Technician (CMT) B
reviewed the resident’s eMAR, which highlighted medications to be administered for the
5:00 medication pass. CMT B administered the [MEDICATION NAME] 5 mg and [MEDICATION NAME]
30 mg to the resident during the evening medication pass scheduled for 5:00 P.M. per the
eMAR. (Both medications were ordered to be given at bedtime.)
5. Review of Resident #1’s physician’s orders [REDACTED].
-[MEDICATION NAME] (anticonvulsant) 100 mg, administer one tablet at bedtime;
-Donepezil (cognition-enhancing medication) 10 mg, administer one tablet at bedtime.
Review of the resident’s eMAR showed [MEDICATION NAME] and donepezil were scheduled for
the evening medication pass (5:00 P.M.), however, the eMAR showed the medications were
ordered to be administered at bedtime.
Observation on 2/5/19 at 4:15 P.M. showed CMT B administered the [MEDICATION NAME] 100 mg
and donepezil 10 mg to the resident during the evening medication pass. (Both medications
were ordered to be given at bedtime.)
6. During interview on 2/13/18 at 1:56 P.M., CMT B said he/she followed the eMAR when
administering medications. The eMAR said the medications for Resident #1 and Resident #37
were to be given during the 5:00 P.M. medication pass.
7. During interviews on 2/11/19 at 1:48 P.M. and on 2/13/19 at 2:09 P.M., the DON said the
following:
-The nurse, who receives a physician’s orders [REDACTED]. The nurse on the next shift was
to review the new order and eMAR to ensure it was correct;
-Staff were to administer Resident #1 and Resident #37’s bedtime medications no earlier
than 7:00 P.M. Staff administering bedtime medications at 4:00 P.M. or 5:00 P.M. was too
early;
-Staff were to administer medications ordered specifically at HS as listed on the
physician’s orders [REDACTED].>-She expected staff to follow physician’s orders
[REDACTED].

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation, interview, and record review, the facility failed to ensure the
range hood was free of an accumulation of debris, and failed to ensure a ceiling-mounted
ventilation unit was free of a buildup of debris. The facility census was 43.
1. Record review of the dietician’s reports, dated 11/14/18 and 1/23/19, showed the
following kitchen inspection recommendations/comments:
-11/14/18: Clean entire air conditioning vent and replace filter regularly, gets dirty
quickly;
-1/23/19: HVAC vent/filter needs to be replaced and attached correctly.
Observation on 2/4/19 at 11:26 AM and on 2/5/19 at 10:46 A.M. showed a ceiling-mounted air
conditioning ventilation unit in the kitchen was positioned over metal countertops and the
steamtable. The unit was supported by metal supports and bars that had a heavy
accumulation of dark-colored dust and debris. Portions of cut-up orange swimming pool
noodles and black electrical tape covered the ends of the metal bars that held the
ventilation unit up over the food preparation counter and recipe book area. There areas
were also covered in dark fuzzy debris. The long metal spiral bolts that attached to the

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 8) supports and ran up into the ceiling also were covered in dusty and debris. White PVC piping and black wiring underneath the unit had a buildup of dark fuzzy debris. Observation on 2/5/19 at 10:46 A.M. showed Dietary Staff A removed frozen chicken livers from plastic bags under the ceiling mounted air conditioning ventilation unit. Three small empty steamtable pans sat underneath the unit and were not covered. Two open bags of frozen chicken livers sat underneath the air conditioning unit. During an interview on 2/5/19 at 10:55 A.M., the dietary manager said dietary staff cleaned the air conditioning ventilation unit monthly. The unit cleaning was not listed on the daily, weekly or monthly cleaning lists for December. The unit cleaning was listed on the (MONTH) monthly cleaning log, but the task had not been documented as being completed for (MONTH) and was left blank. She was unable to provide documentation to show when the unit had been cleaned previously. During an interview on 2/5/19 11:36 A.M., the maintenance supervisor said dietary staff was responsible for cleaning the air conditioning ventilation unit in the kitchen. Maintenance staff changed the filters in the kitchen on a monthly basis. During an interview on 2/5/19 at 12:17 P.M., the dietary manager said staff should prepare food at the end of the food preparation metal counter that doesn’t have the air conditioning unit over the top. She was aware the dietician had concerns with the cleanliness of the unit. The dietician reviewed her report with dietary staff at the end of the visit, so dietary had been made aware of the dirty unit. The dietician also emailed her reports to the assistant dietary manager. 2. Observations on 2/4/19 at 10:48 A.M. and on 2/4/19 at 2:26 P.M. showed the range hood in the kitchen had a buildup of fuzzy, stringy dark-colored debris on the baffle filters and the fire suppression piping and nozzles. Observation on 2/4/19 at 3:15 P.M. of the kitchen range hood showed the filters were covered with a moderate amount of clear grease and debris. During an interview on 2/4/19 at 2:27 P.M., the dietary manager said maintenance staff was responsible for cleaning the baffle filters monthly. An outside vendor professionally cleaned the range hood a few months ago. During an interview on 2/5/19 at 8:18 A.M., the maintenance supervisor said he cleaned the baffle filters monthly.
	F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	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 offer and vaccinate eligible residents with the pneumococcal vaccines as indicated by the current Centers for Disease Control (CDC) guidelines, for three residents (Residents #1, #25, and #37), in a review of 12 sampled residents. The facility census was 43. 1. Review of the undated facility policy Pneumonia Policy and Procedure, showed the following: -Encourage all residents to receive the pneumonia vaccine, if indicated; -Educate residents, family and/or responsible party on the risk versus benefits of receiving the pneumonia vaccine; -The facility will provide educational material along with consent forms to residents, family and/or responsible party and the consent form will be signed prior to the resident receiving the pneumonia vaccine;

(X4) ID PREFIX TAG

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

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 8)
supports and ran up into the ceiling also were covered in dusty and debris. White PVC
piping and black wiring underneath the unit had a buildup of dark fuzzy debris.
Observation on 2/5/19 at 10:46 A.M. showed Dietary Staff A removed frozen chicken livers
from plastic bags under the ceiling mounted air conditioning ventilation unit. Three small
empty steamtable pans sat underneath the unit and were not covered. Two open bags of
frozen chicken livers sat underneath the air conditioning unit.
During an interview on 2/5/19 at 10:55 A.M., the dietary manager said dietary staff
cleaned the air conditioning ventilation unit monthly. The unit cleaning was not listed on
the daily, weekly or monthly cleaning lists for December. The unit cleaning was listed on
the (MONTH) monthly cleaning log, but the task had not been documented as being completed
for (MONTH) and was left blank. She was unable to provide documentation to show when the
unit had been cleaned previously.
During an interview on 2/5/19 11:36 A.M., the maintenance supervisor said dietary staff
was responsible for cleaning the air conditioning ventilation unit in the kitchen.
Maintenance staff changed the filters in the kitchen on a monthly basis.
During an interview on 2/5/19 at 12:17 P.M., the dietary manager said staff should prepare
food at the end of the food preparation metal counter that doesn’t have the air
conditioning unit over the top. She was aware the dietician had concerns with the
cleanliness of the unit. The dietician reviewed her report with dietary staff at the end
of the visit, so dietary had been made aware of the dirty unit. The dietician also emailed
her reports to the assistant dietary manager.
2. Observations on 2/4/19 at 10:48 A.M. and on 2/4/19 at 2:26 P.M. showed the range hood
in the kitchen had a buildup of fuzzy, stringy dark-colored debris on the baffle filters
and the fire suppression piping and nozzles.
Observation on 2/4/19 at 3:15 P.M. of the kitchen range hood showed the filters were
covered with a moderate amount of clear grease and debris.
During an interview on 2/4/19 at 2:27 P.M., the dietary manager said maintenance staff was
responsible for cleaning the baffle filters monthly. An outside vendor professionally
cleaned the range hood a few months ago.
During an interview on 2/5/19 at 8:18 A.M., the maintenance supervisor said he cleaned the
baffle filters monthly.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 offer and vaccinate eligible
residents with the pneumococcal vaccines as indicated by the current Centers for Disease
Control (CDC) guidelines, for three residents (Residents #1, #25, and #37), in a review of
12 sampled residents. The facility census was 43.
1. Review of the undated facility policy Pneumonia Policy and Procedure, showed the
following:
-Encourage all residents to receive the pneumonia vaccine, if indicated;
-Educate residents, family and/or responsible party on the risk versus benefits of
receiving the pneumonia vaccine;
-The facility will provide educational material along with consent forms to residents,
family and/or responsible party and the consent form will be signed prior to the resident
receiving the pneumonia vaccine;

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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


	F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 9) -If a resident, staff, family and/or responsible party refuses pneumonia vaccine, other than for allergy to vaccination, and/or the resident has previously been vaccinated, further education will be provided and documented. The facility policy did not address following the current CDC guidelines for administering the pneumococcal vaccinations. 2. 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) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23): -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. 3. Review of Resident #1’s immunization record showed the following: -The resident received the pneumococcal conjugate vaccine (PCV13) on 12/31/16; -Consent status: historically. (The resident did not receive this vaccine in the facility.) Review of the resident’s face sheet, showed the following: -He/she was admitted to the facility on [DATE]; -The resident was over age 65. Review of the resident’s medical record showed no evidence a current pneumococcal vaccine consent form or educational information was provided to the resident and/or his/her representative. Further review showed no evidence staff offered or administered the PPSV23 vaccine to the resident. During interview on 2/21/19 at 9:56 A.M., the resident’s guardian said the resident was admitted to the facility from a residential care facility. The guardian signed the pneumonia consent and told the facility to give the pneumonia vaccine as long as the record showed it was required at this time. He/she expected the facility to follow the guidelines for administration of the pneumococcal vaccine. During interview on 2/21/19 at 10:50 A.M., the director of nursing (DON) said the facility did not offer the pneumococcal vaccine when the resident was admitted since the resident had the PCV13 vaccine in the hospital in (YEAR). 4. Review of Resident #25’s face sheet, showed the following: -He/she was admitted to the facility on [DATE]; -The resident was over age 65. Review of the resident’s influenza and pneumococcal vaccine consent form, dated 10/12/16, showed the following: -The resident’s guardian gave consent for the resident to receive the pneumococcal vaccination; -The consent form did not provide information related to the PCV13 and PPSV23

(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 – Some

(continued… from page 9)
-If a resident, staff, family and/or responsible party refuses pneumonia vaccine, other
than for allergy to vaccination, and/or the resident has previously been vaccinated,
further education will be provided and documented.
The facility policy did not address following the current CDC guidelines for administering
the pneumococcal vaccinations.
2. 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) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23,
[MEDICATION NAME] 23):
-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.
3. Review of Resident #1’s immunization record showed the following:
-The resident received the pneumococcal conjugate vaccine (PCV13) on 12/31/16;
-Consent status: historically. (The resident did not receive this vaccine in the
facility.)
Review of the resident’s face sheet, showed the following:
-He/she was admitted to the facility on [DATE];
-The resident was over age 65.
Review of the resident’s medical record showed no evidence a current pneumococcal vaccine
consent form or educational information was provided to the resident and/or his/her
representative. Further review showed no evidence staff offered or administered the PPSV23
vaccine to the resident.
During interview on 2/21/19 at 9:56 A.M., the resident’s guardian said the resident was
admitted to the facility from a residential care facility. The guardian signed the
pneumonia consent and told the facility to give the pneumonia vaccine as long as the
record showed it was required at this time. He/she expected the facility to follow the
guidelines for administration of the pneumococcal vaccine.
During interview on 2/21/19 at 10:50 A.M., the director of nursing (DON) said the facility
did not offer the pneumococcal vaccine when the resident was admitted since the resident
had the PCV13 vaccine in the hospital in (YEAR).
4. Review of Resident #25’s face sheet, showed the following:
-He/she was admitted to the facility on [DATE];
-The resident was over age 65.
Review of the resident’s influenza and pneumococcal vaccine consent form, dated 10/12/16,
showed the following:
-The resident’s guardian gave consent for the resident to receive the pneumococcal
vaccination;
-The consent form did not provide information related to the PCV13 and PPSV23

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

PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265646

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LA BELLE MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1002 CENTRAL
LA BELLE, MO 63447

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 – Some	(continued… from page 10) vaccinations. Review of the resident’s medical record showed no evidence staff provided educational material regarding the PPSV23 and PCV13 pneumococcal vaccinations to the resident and/or his/her representative. Further review showed no evidence staff administered the pneumococcal vaccine to the resident after the guardian gave consent on 10/12/16. During interview on 2/21/19 at 10:10 A.M., the resident’s guardian said he/she would have consented to administering the pneumonia vaccine to the resident upon admission. He/she expected the facility to follow the guidelines for administering the pneumococcal vaccine. During interview on 2/21/19 at 10:50 A.M., the DON said even though the resident’s pneumococcal vaccination consent form was dated 10/12/16, she didn’t think staff administered the pneumococcal vaccine to the resident. She thought it was probably overlooked. 5. Review of Resident #37’s face sheet, showed the following: -He/she was admitted to the facility on [DATE]; -The resident was over age 65. Review of the resident’s influenza and pneumococcal vaccine consent form, dated 9/24/18, showed the following: -The resident’s responsible party gave consent for the resident to receive the pneumococcal vaccination; -The consent form did not provide information related to the PCV13 and PPSV23 vaccinations. Review of the resident’s medical record showed no evidence staff provided educational material regarding the PPSV23 and PCV13 pneumococcal vaccinations to the resident and/or his/her representative. Further review showed no evidence the resident received the pneumococcal vaccination after his/her responsible party gave consent on 9/24/18. During interview on 2/21/19 at 10:15 A.M., the resident’s responsible party said he/she was not sure if he/she signed a consent for the pneumonia vaccine but would have given consent for the facility to administer the pneumonia vaccine to the resident. He/she was not sure if the resident received the pneumonia vaccine. During interview on 2/21/19 at 10:50 A.M., the DON said staff had not yet administered the pneumococcal vaccine to the resident. 6. During interview on 2/11/19 at 1:48 P.M., the DON said the following: -The facility only administered the PCV13 pneumococcal vaccine to residents at this time; -She had to review all the residents and their pneumococcal vaccination status, and was administering the PCV13 to the residents in alphabetical order. Staff had not yet administered the PCV13 vaccination to all the residents who provided consent; -Staff did not administer the PPSV23 pneumococcal vaccination to any residents, including Resident #1; -She was just learning the CDC guidelines for the pneumococcal vaccines.

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