LINCOLN COUNTY NURSING & REHAB

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0570 Level of harm – Potential for minimal harm Residents Affected – Some	Assure the security of all personal funds of residents deposited with the facility. Based on record review and interview, the facility failed to maintain a surety bond sufficient (an amount equal to at least one and one half times the average monthly balance of the resident’s personal funds including petty cash), to ensure protection of the resident funds. The facility census was 77. 1. Record review of the facility’s resident trust fund bank statement for the period of (MONTH) (YEAR)-February (YEAR) showed an average monthly balance of $24,937.44. Calculation showed the facility required bond amount of $37,500.00 to cover the deposited money of the residents. Record review of the facility’s current surety bond showed the facility held a bond in the amount of $35,000.00. During interview on 3/29/18 at 5:41 P.M., the Financial Consultant with System Service said he/she did not know the bond amount and did not have a copy of bond. Record review of the bond received from the facility on 3/30/18 showed the bond amount of $35,000.00.
	F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Develop and implement policies and procedures to prevent abuse, neglect, and theft. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to implement a comprehensive procedure for background screenings for five employees ( Dietary Aide B, Nurse Assistant (NA) C, Certified Nurse Assistant (CNA) D , Licensed Practical Nurse (LPN) S and the Director of Nursing (DON) in a review of nine employee files. The facility census was 77. 1. Record review of the facility’s policy dated (MONTH) (YEAR), Abuse Prohibition Protocol Manual showed the following: -To assure that everything possible is being done to prevent abuse; -The facility has implemented the following: -Screening of potential employees. 2. Record review of the facility’s policy dated (MONTH) 2012, Employee Screening Guidelines Abuse Prohibition Protocol Manual showed the following: -This facility is to thoroughly screen potential employees for a history of abuse, neglect, mistreatment of [REDACTED]. -Applicant must sign a Criminal Background Check form and a Division of Aging Employee Disqualification list form; -Prior to offering employment, verify that the applicant is not on the Division of Aging Employee List. 3. Record review of the DON’s employee file showed the following: -Hire date 2/26/18; -No Family Care Safety Registry (FCSR); -No Criminal Back Ground check completed (CBC). Record review of Dietary Aide B’s employee file showed the following: -Hire date 3/5/18; -No Family Care Safety Registry; -No Criminal Back Ground check completed. Record review of NA C’s employee file showed the following: -Hire date 2/26/18;

(X4) ID PREFIX TAG

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

F 0570

Level of harm – Potential for minimal harm

Residents Affected – Some

Assure the security of all personal funds of residents deposited with the facility.

Based on record review and interview, the facility failed to maintain a surety bond
sufficient (an amount equal to at least one and one half times the average monthly balance
of the resident’s personal funds including petty cash), to ensure protection of the
resident funds. The facility census was 77.
1. Record review of the facility’s resident trust fund bank statement for the period of
(MONTH) (YEAR)-February (YEAR) showed an average monthly balance of $24,937.44.
Calculation showed the facility required bond amount of $37,500.00 to cover the deposited
money of the residents.
Record review of the facility’s current surety bond showed the facility held a bond in the
amount of $35,000.00.
During interview on 3/29/18 at 5:41 P.M., the Financial Consultant with System Service
said he/she did not know the bond amount and did not have a copy of bond.
Record review of the bond received from the facility on 3/30/18 showed the bond amount of
$35,000.00.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to implement a comprehensive
procedure for background screenings for five employees ( Dietary Aide B, Nurse Assistant
(NA) C, Certified Nurse Assistant (CNA) D , Licensed Practical Nurse (LPN) S and the
Director of Nursing (DON) in a review of nine employee files. The facility census was 77.
1. Record review of the facility’s policy dated (MONTH) (YEAR), Abuse Prohibition Protocol
Manual showed the following:
-To assure that everything possible is being done to prevent abuse;
-The facility has implemented the following:
-Screening of potential employees.
2. Record review of the facility’s policy dated (MONTH) 2012, Employee Screening
Guidelines Abuse Prohibition Protocol Manual showed the following:
-This facility is to thoroughly screen potential employees for a history of abuse,
neglect, mistreatment of [REDACTED].
-Applicant must sign a Criminal Background Check form and a Division of Aging Employee
Disqualification list form;
-Prior to offering employment, verify that the applicant is not on the Division of Aging
Employee List.
3. Record review of the DON’s employee file showed the following:
-Hire date 2/26/18;
-No Family Care Safety Registry (FCSR);
-No Criminal Back Ground check completed (CBC).
Record review of Dietary Aide B’s employee file showed the following:
-Hire date 3/5/18;
-No Family Care Safety Registry;
-No Criminal Back Ground check completed.
Record review of NA C’s employee file showed the following:
-Hire date 2/26/18;

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: 265433

If continuation sheet
Page 1 of 13

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0607 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 1) -No Nurse Assistant Registry check completed Record review of CNA D’s employee file showed the following: -Hire date 3/5/18; -No Nurse Assistant Registry check completed. Record review of LPN S’ s employee file showed the following; -Hire date 3/5/18; -No Employee Disqualification List verification completed (EDL). During interview on 3/29/18 at 3:15 P.M. the Corporate Business Administrator said the Background Checks, Nurse Registry, EDL and Family Care Registry, should be in the employee files. During interview on 3/29/18 at 4:40 P.M. and 4/4/18 at 11:35 A.M. and on 4/4/18 at 2:30 P.M. the administrator said the following: -The business office manager is responsible for the completion of the CBC, EDL and the Nurse Aide Registry checks on all new employees; – The past business office manager was responsible for all parts of the background check including the CBC, EDL, FCSR and the Nurse Aide registry; -She did not know why the CBC, EDL and the Nurse Aide Registry Checks were not completed.
	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Ensure services provided by the nursing facility meet professional standards of quality. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow physician’s orders for six residents (Residents #6, #12, #15, #32, #64 and #176) in a review of 18 sampled residents. Staff failed to follow physician orders for two residents (Resident #6 and Resident #15), by failing to apply and monitor [MEDICATION NAME]es (medication used for moderate to severe pain) as ordered. Staff failed to provide [MEDICAL CONDITION] (direct airway through an incision in the trachea) care for one resident (Resident #32), failed to give [MEDICATION NAME] (pain medication) as ordered for one resident (Resident #176), failed to obtain laboratory tests as ordered by the physician for one resident (Residents #64) and failed to follow up with the resident’s physician after a medication change for one resident (Resident #6). The facility census was 77. 1. Review of the facility policy Physician Orders dated (MONTH) (YEAR) showed the following: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be written and maintained in chronological order. 2. Review of the facility policy for [MEDICAL CONDITION] Care from the Nursing Guidelines Manuel dated (MONTH) (YEAR), showed the following: -A [MEDICAL CONDITION] is an artificial opening into the trachea for the insertion of a tube to facilitate passage of air into the lungs or to evacuate secretions; -The purpose is to maintain a patent airway, to evacuate secretions and to prevent and/or reduce infection; -Explain process to resident and place the resident in semi-fowlers position unless medially contraindicated; -Open sterile catheter using aseptic technique; -Pour peroxide and sterile water or saline in basin (50/50 mixture);

(X4) ID PREFIX TAG

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

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-No Nurse Assistant Registry check completed
Record review of CNA D’s employee file showed the following:
-Hire date 3/5/18;
-No Nurse Assistant Registry check completed.
Record review of LPN S’ s employee file showed the following;
-Hire date 3/5/18;
-No Employee Disqualification List verification completed (EDL).
During interview on 3/29/18 at 3:15 P.M. the Corporate Business Administrator said the
Background Checks, Nurse Registry, EDL and Family Care Registry, should be in the employee
files.
During interview on 3/29/18 at 4:40 P.M. and 4/4/18 at 11:35 A.M. and on 4/4/18 at 2:30
P.M. the administrator said the following:
-The business office manager is responsible for the completion of the CBC, EDL and the
Nurse Aide Registry checks on all new employees;
– The past business office manager was responsible for all parts of the background check
including the CBC, EDL, FCSR and the Nurse Aide registry;
-She did not know why the CBC, EDL and the Nurse Aide Registry Checks were not completed.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow
physician’s orders for six residents (Residents #6, #12, #15, #32, #64 and #176) in a
review of 18 sampled residents. Staff failed to follow physician orders for two residents
(Resident #6 and Resident #15), by failing to apply and monitor [MEDICATION NAME]es
(medication used for moderate to severe pain) as ordered. Staff failed to provide [MEDICAL
CONDITION] (direct airway through an incision in the trachea) care for one resident
(Resident #32), failed to give [MEDICATION NAME] (pain medication) as ordered for one
resident (Resident #176), failed to obtain laboratory tests as ordered by the physician
for one resident (Residents #64) and failed to follow up with the resident’s physician
after a medication change for one resident (Resident #6). The facility census was 77.
1. Review of the facility policy Physician Orders dated (MONTH) (YEAR) showed the
following:
-Current lists of orders must be maintained in the clinical record of each resident to
avoid confusion and errors;
-Orders must be written and maintained in chronological order.
2. Review of the facility policy for [MEDICAL CONDITION] Care from the Nursing Guidelines
Manuel dated (MONTH) (YEAR), showed the following:
-A [MEDICAL CONDITION] is an artificial opening into the trachea for the insertion of a
tube to facilitate passage of air into the lungs or to evacuate secretions;
-The purpose is to maintain a patent airway, to evacuate secretions and to prevent and/or
reduce infection;
-Explain process to resident and place the resident in semi-fowlers position unless
medially contraindicated;
-Open sterile catheter using aseptic technique;
-Pour peroxide and sterile water or saline in basin (50/50 mixture);

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 2) -Put gloves on; -Unlock inner cannula of [MEDICAL CONDITION], remove and soak in basin of peroxide 50/50 mixture solution; -Remove dressing and discard, clean skin around [MEDICAL CONDITION] with applicators and peroxide 50/50 mixture solution. Remove all exudate and drainage. Do not allow any solution to enter outer [MEDICAL CONDITION] or [MEDICAL CONDITION] opening; -Clean inner cannula well with applicators. Rinse well with sterile saline or water and drain on sterile 4×4 gauze; -Suction before inserting inner cannula. Insert inner cannula and lock into place; -Dressing may be formed by folding 4×4 gauze in half lengthwise and folding to a V. This is then fitted around the [MEDICAL CONDITION]; -Remove gloves and discard all disposable equipment in a plastic bag; -Position resident comfortably with call light within reach. 3. Review of Drugs.com showed the following: -[MEDICATION NAME] is a narcotic medication used for severe pain that does not go away; -Misuse of narcotic medication can cause addiction, overdose, or death; -Only one patch should be applied at a time, if the the patch does not seem adequate a higher dosage or alternate pain treatment may be needed; -Serious, life threatening respiratory depression may occur even when used as recommenced. 4. Review of Resident #12’s annual Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by staff, dated 2/13/18 showed the following: -Severe cognitive impairment; -Dependent on two or more staff for transfers; -Speech unclear; -Received scheduled pain medication in the last five days; -Did not have pain at time of assessment. Review of the resident’s physician orders (POS) dated 3/26/18 to 4/25/18, showed the following: -[DIAGNOSES REDACTED]. Most common symptom is pain and stiffness), and [MEDICAL CONDITION] (damage to or disease affecting nerves. The nerves become damaged which impair sensation and movement. Causing pain, tingling, numbness, and weakness); -[MEDICATION NAME] 12 micrograms (mcg)/hour (hr.), one patch topically; -Change patch every three days; -[MEDICATION NAME] (a medicine used to treat pain and fever) 325 milligrams (mg) one tablet ever four hours as needed (PRN). Review of the resident’s Medication Administration Record [REDACTED] -The last day staff documented administration of the resident’s [MEDICATION NAME] was 3/17/18 at 6:00 A.M.; -Staff circled [MEDICATION NAME] administration on 3/20/18, 3/23/18, 3/26/18 and 3/28/18 at 6:00 A.M., indicating staff did not administer the [MEDICATION NAME] to the resident; -On 3/20/18 staff documented on the back of the resident’s MAR indicated [REDACTED]. Staff placed a call to the pharmacy to get a refill; -On 3/23/18 staff documented on the back of the resident’s MAR indicated [REDACTED]. Staff called the pharmacy and the pharmacy was waiting on a script. Review of the resident’s medical record dated 3/20/18 to 3/28/18 showed staff failed to document any communication with the pharmacy and failed to notify the resident’s physician regarding the resident’s [MEDICATION NAME]es not administered or available from pharmacy. Observation on 3/28/18 at 4:12 P.M. showed the following:

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-Put gloves on;
-Unlock inner cannula of [MEDICAL CONDITION], remove and soak in basin of peroxide 50/50
mixture solution;
-Remove dressing and discard, clean skin around [MEDICAL CONDITION] with applicators and
peroxide 50/50 mixture solution. Remove all exudate and drainage. Do not allow any
solution to enter outer [MEDICAL CONDITION] or [MEDICAL CONDITION] opening;
-Clean inner cannula well with applicators. Rinse well with sterile saline or water and
drain on sterile 4×4 gauze;
-Suction before inserting inner cannula. Insert inner cannula and lock into place;
-Dressing may be formed by folding 4×4 gauze in half lengthwise and folding to a V. This
is then fitted around the [MEDICAL CONDITION];
-Remove gloves and discard all disposable equipment in a plastic bag;
-Position resident comfortably with call light within reach.
3. Review of Drugs.com showed the following:
-[MEDICATION NAME] is a narcotic medication used for severe pain that does not go away;
-Misuse of narcotic medication can cause addiction, overdose, or death;
-Only one patch should be applied at a time, if the the patch does not seem adequate a
higher dosage or alternate pain treatment may be needed;
-Serious, life threatening respiratory depression may occur even when used as recommenced.

4. Review of Resident #12’s annual Minimum Data Sheet (MDS), a federally mandated
assessment instrument completed by staff, dated 2/13/18 showed the following:
-Severe cognitive impairment;
-Dependent on two or more staff for transfers;
-Speech unclear;
-Received scheduled pain medication in the last five days;
-Did not have pain at time of assessment.
Review of the resident’s physician orders (POS) dated 3/26/18 to 4/25/18, showed the
following:
-[DIAGNOSES REDACTED]. Most common symptom is pain and stiffness), and [MEDICAL CONDITION]
(damage to or disease affecting nerves. The nerves become damaged which impair sensation
and movement. Causing pain, tingling, numbness, and weakness);
-[MEDICATION NAME] 12 micrograms (mcg)/hour (hr.), one patch topically;
-Change patch every three days;
-[MEDICATION NAME] (a medicine used to treat pain and fever) 325 milligrams (mg) one
tablet ever four hours as needed (PRN).
Review of the resident’s Medication Administration Record [REDACTED]
-The last day staff documented administration of the resident’s [MEDICATION NAME] was
3/17/18 at 6:00 A.M.;
-Staff circled [MEDICATION NAME] administration on 3/20/18, 3/23/18, 3/26/18 and 3/28/18
at 6:00 A.M., indicating staff did not administer the [MEDICATION NAME] to the resident;
-On 3/20/18 staff documented on the back of the resident’s MAR indicated [REDACTED]. Staff
placed a call to the pharmacy to get a refill;
-On 3/23/18 staff documented on the back of the resident’s MAR indicated [REDACTED]. Staff
called the pharmacy and the pharmacy was waiting on a script.
Review of the resident’s medical record dated 3/20/18 to 3/28/18 showed staff failed to
document any communication with the pharmacy and failed to notify the resident’s physician
regarding the resident’s [MEDICATION NAME]es not administered or available from pharmacy.
Observation on 3/28/18 at 4:12 P.M. showed the following:

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 3) -Licensed Practical Nurse (LPN) K checked the resident’s back and chest; -LPN K put a [MEDICATION NAME] 12 mcg patch between the resident’s shoulder blades behind his/her neck. During interview on 3/28/18 at 4:12 P.M. LPN K said the following: -The resident had been without [MEDICATION NAME]es; -The resident’s [MEDICATION NAME]es just came in from pharmacy; -The staff that work nights normally put the [MEDICATION NAME]es on the residents at 6:00 A.M., but since the resident had been without his/her pain patch he/she applied one to the resident. During an interview on 3/29/18 at 11:26 A.M. LPN F said the following: -The resident was without the [MEDICATION NAME] for pain from 3/20/18 to 3/28/18; -The resident was hard to assess for pain because the resident could not verbalize pain; -He/she was not sure if the resident had increased pain without the patch; -The night charge nurse normally fills out a form when resident medications were getting low or out and faxes the form to the pharmacy for refill; -The day charge nurse follows up with the pharmacy; -The facility had been having difficulty getting medications from the pharmacy. During interview on 3/29/18 at 2:25 P.M. Physician I said the following: -He was the medical director and the resident’s physician; -The resident going six to eight days without his/her [MEDICATION NAME] was too long; -He would of expected staff to contact the resident’s physician within 48 hours of medication not being available to notify the physician and get an alternative plan for pain control; -He expected staff to follow all physician orders. 5. Review of Resident #15’s significant change MDS dated [DATE], showed the following: -The resident was cognitively intact; -Dependent on staff for bed mobility, dressing, and toileting; -[DIAGNOSES REDACTED]. -The resident had frequent pain; -The resident rated his/her pain a 10 on scale of one to 10 with ten being the worst pain. Review of the resident’s re-admission POS dated (MONTH) (YEAR), showed the following: -[DIAGNOSES REDACTED]. -[MEDICATION NAME] 12 mcg/hr one patch topically; -Change patch every three days; -Two nurses to sign and destroy the removal of old patch; -[MEDICATION NAME] 325 mg one tablet ever four hours as needed PRN; -[MEDICATION NAME] (narcotic pain medication used for moderate to severe pain) 100 mg /five milliliters (ml) take 0.25 ml every three hours PRN; -Hospice 3/18/18. Review of the resident’s MAR indicated [REDACTED] -[MEDICATION NAME] 12 mcg one patch every three days; -Staff documented they applied the resident’s [MEDICATION NAME] on 3/18/18 at 6:00 A.M.; -Staff documented on 3/21/18 (when the [MEDICATION NAME] should have been changed), that a [MEDICATION NAME] was not available to apply as ordered. There was no documentation two nurses removed the patch that was applied on 3/18/18; -Staff documented applying a [MEDICATION NAME] on 3/24/18 at 6:00 A.M. Staff failed to document two nurses removed and destroyed the patch that was applied on 3/18/18; -Staff documented they applied a [MEDICATION NAME] on the resident on 3/26/18 (two days

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Licensed Practical Nurse (LPN) K checked the resident’s back and chest;
-LPN K put a [MEDICATION NAME] 12 mcg patch between the resident’s shoulder blades behind
his/her neck.
During interview on 3/28/18 at 4:12 P.M. LPN K said the following:
-The resident had been without [MEDICATION NAME]es;
-The resident’s [MEDICATION NAME]es just came in from pharmacy;
-The staff that work nights normally put the [MEDICATION NAME]es on the residents at 6:00
A.M., but since the resident had been without his/her pain patch he/she applied one to the
resident.
During an interview on 3/29/18 at 11:26 A.M. LPN F said the following:
-The resident was without the [MEDICATION NAME] for pain from 3/20/18 to 3/28/18;
-The resident was hard to assess for pain because the resident could not verbalize pain;
-He/she was not sure if the resident had increased pain without the patch;
-The night charge nurse normally fills out a form when resident medications were getting
low or out and faxes the form to the pharmacy for refill;
-The day charge nurse follows up with the pharmacy;
-The facility had been having difficulty getting medications from the pharmacy.
During interview on 3/29/18 at 2:25 P.M. Physician I said the following:
-He was the medical director and the resident’s physician;
-The resident going six to eight days without his/her [MEDICATION NAME] was too long;
-He would of expected staff to contact the resident’s physician within 48 hours of
medication not being available to notify the physician and get an alternative plan for
pain control;
-He expected staff to follow all physician orders.
5. Review of Resident #15’s significant change MDS dated [DATE], showed the following:
-The resident was cognitively intact;
-Dependent on staff for bed mobility, dressing, and toileting;
-[DIAGNOSES REDACTED].
-The resident had frequent pain;
-The resident rated his/her pain a 10 on scale of one to 10 with ten being the worst pain.

Review of the resident’s re-admission POS dated (MONTH) (YEAR), showed the following:
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] 12 mcg/hr one patch topically;
-Change patch every three days;
-Two nurses to sign and destroy the removal of old patch;
-[MEDICATION NAME] 325 mg one tablet ever four hours as needed PRN;
-[MEDICATION NAME] (narcotic pain medication used for moderate to severe pain) 100 mg
/five milliliters (ml) take 0.25 ml every three hours PRN;
-Hospice 3/18/18.
Review of the resident’s MAR indicated [REDACTED]
-[MEDICATION NAME] 12 mcg one patch every three days;
-Staff documented they applied the resident’s [MEDICATION NAME] on 3/18/18 at 6:00 A.M.;
-Staff documented on 3/21/18 (when the [MEDICATION NAME] should have been changed), that a
[MEDICATION NAME] was not available to apply as ordered. There was no documentation two
nurses removed the patch that was applied on 3/18/18;
-Staff documented applying a [MEDICATION NAME] on 3/24/18 at 6:00 A.M. Staff failed to
document two nurses removed and destroyed the patch that was applied on 3/18/18;
-Staff documented they applied a [MEDICATION NAME] on the resident on 3/26/18 (two days

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 4) after they applied the patch on 3/24/28 not three days) at 6:00 A.M. Staff documented they removed the resident’s patch at 6:00 A.M. Observation on 3/27/18 at 10:09 A.M. during the resident’s shower showed the resident had a [MEDICATION NAME] 12 mcg patch dated 3/18/18 on his/her right upper arm and a [MEDICATION NAME] 12 mcg patch dated 3/26/18 on his her right upper chest. CNA M washed over both patches with soap and water. Observation on 2/27/18 at 2:56 P.M. showed the following: -Licensed Practical Nurse (LPN) F entered the resident’s room; -LPN F looked at the resident’s chest and right arm and noted two [MEDICATION NAME] 12 mcg patches; -LPN F removed one [MEDICATION NAME] 12 mcg patch from the resident’s right upper arm dated 3/18/18; -LPN F asked the Director of Nursing (DON) to sign and observe destruction of the [MEDICATION NAME] 12 mcg patch he/she removed from the resident’s right upper arm; -LPN F and the DON destroyed the [MEDICATION NAME]. During interview on 2/27/18 at 2:58 P.M. LPN F said the following: -The resident should not have two patches on at one time; -He/she was not sure how the patch got missed; -There was no order on the MAR indicated [REDACTED]. During an interview on 3/29/18 at 11:26 A.M. LPN F said the following: -He/she was the charge nurse working and found the resident with two patches; -He/she did not do anything different for the resident when he/she found two patches on the resident; -He/she did not contact the resident’s physician and notify of the resident having two patches (therefore medication exceeded the ordered dose); -He/she would not normally notify the physician about a resident receiving too much medication or not getting the medication; -If the resident was having any side affects that he/she noticed he/she would send the resident to the emergency room ; -He/she would contact the physician if the resident needed a new script from the pharmacy. During interview on 3/29/18 at 2:25 P.M. Physician I said the following: -He was the medical director for the facility; -He expected staff to follow all physician orders; -The resident having two [MEDICATION NAME] 12 mcg patches put the resident at low risk for sedation; -A higher dose of [MEDICATION NAME] could lead to serious issues, even death. During an interview on 3/29/18 at 3:59 P.M. Physician J said the following: -He/she was the resident’s physician; -He expected staff to follow physician orders; -[MEDICATION NAME] was used for the resident’s pain; -The resident having two [MEDICATION NAME]es on when one patch was ordered was an obvious problem and he would have expected for staff to notify him; -The resident having two [MEDICATION NAME] 12 mcg patches on at the same time could cause the resident to be sedated. 6. Review of Resident #32’s care plan dated 12/27/17, showed the following: -He/she has a [MEDICAL CONDITION]; -He/she does not require oxygen. Review of the resident’s re-admission orders [REDACTED].

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
after they applied the patch on 3/24/28 not three days) at 6:00 A.M. Staff documented they
removed the resident’s patch at 6:00 A.M.
Observation on 3/27/18 at 10:09 A.M. during the resident’s shower showed the resident had
a [MEDICATION NAME] 12 mcg patch dated 3/18/18 on his/her right upper arm and a
[MEDICATION NAME] 12 mcg patch dated 3/26/18 on his her right upper chest. CNA M washed
over both patches with soap and water.
Observation on 2/27/18 at 2:56 P.M. showed the following:
-Licensed Practical Nurse (LPN) F entered the resident’s room;
-LPN F looked at the resident’s chest and right arm and noted two [MEDICATION NAME] 12 mcg
patches;
-LPN F removed one [MEDICATION NAME] 12 mcg patch from the resident’s right upper arm
dated 3/18/18;
-LPN F asked the Director of Nursing (DON) to sign and observe destruction of the
[MEDICATION NAME] 12 mcg patch he/she removed from the resident’s right upper arm;
-LPN F and the DON destroyed the [MEDICATION NAME].
During interview on 2/27/18 at 2:58 P.M. LPN F said the following:
-The resident should not have two patches on at one time;
-He/she was not sure how the patch got missed;
-There was no order on the MAR indicated [REDACTED].
During an interview on 3/29/18 at 11:26 A.M. LPN F said the following:
-He/she was the charge nurse working and found the resident with two patches;
-He/she did not do anything different for the resident when he/she found two patches on
the resident;
-He/she did not contact the resident’s physician and notify of the resident having two
patches (therefore medication exceeded the ordered dose);
-He/she would not normally notify the physician about a resident receiving too much
medication or not getting the medication;
-If the resident was having any side affects that he/she noticed he/she would send the
resident to the emergency room ;
-He/she would contact the physician if the resident needed a new script from the pharmacy.

During interview on 3/29/18 at 2:25 P.M. Physician I said the following:
-He was the medical director for the facility;
-He expected staff to follow all physician orders;
-The resident having two [MEDICATION NAME] 12 mcg patches put the resident at low risk for
sedation;
-A higher dose of [MEDICATION NAME] could lead to serious issues, even death.
During an interview on 3/29/18 at 3:59 P.M. Physician J said the following:
-He/she was the resident’s physician;
-He expected staff to follow physician orders;
-[MEDICATION NAME] was used for the resident’s pain;
-The resident having two [MEDICATION NAME]es on when one patch was ordered was an obvious
problem and he would have expected for staff to notify him;
-The resident having two [MEDICATION NAME] 12 mcg patches on at the same time could cause
the resident to be sedated.
6. Review of Resident #32’s care plan dated 12/27/17, showed the following:
-He/she has a [MEDICAL CONDITION];
-He/she does not require oxygen.
Review of the resident’s re-admission orders [REDACTED].

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 5) Review of the resident’s Treatment Administration Record (TAR) dated 2/23/18-2/25/18 showed the following: -Trach care daily and PRN; -Hydrogen peroxide solution 3% topically once daily; -There was no documentation staff [MEDICAL CONDITION] as ordered Review of the resident’s POS dated 2/26/18 through 3/25/18 showed an order for [REDACTED]. Review of the resident’s TAR dated 2/26/18 through 3/25/18 showed the following: -There was no order on the TAR [MEDICAL CONDITION] daily; -There was no order on the TAR for hydrogen peroxide daily; -There was no documentation staff [MEDICAL CONDITION] as ordered. During interview on 3/28/18 at 1:07 P.M. the hospital Nurse Practitioner (NP) U said: -The resident had lots of sputum suctioned from his/her [MEDICAL CONDITION] when he/she arrived at the hospital; -The inner cannula had hard crusted brown sputum in the cannula. During interview on 3/28/18 at 3:12 P.M., LPN E said: -The resident had a [MEDICAL CONDITION]; -Trach care was done every shift, suctioned at least once a shift and PRN; -He/she did not use [MEDICAL CONDITION] kit; -He/she cleaned [MEDICAL CONDITION] with soap and water; -He/she put a new inner cannula in every time he/she [MEDICAL CONDITION]; -He/she would suction the resident and then suction normal saline though suction tubing to clean and then put the package back to reuse. During interview on 3/29/18 at 4:52 P.M., LPN H said: -Trach care was completed once a shift; -He/she only suctioned one time, the resident received a breathing treatment and would cough up and didn’t need to be suctioned; -He/she never changed the inner cannula and never cleaned it; -He/she never received any training [MEDICAL CONDITION]; -He/she did not feel comfortable [MEDICAL CONDITION]. 7. Review of Resident #64’s quarterly MDS dated [DATE] showed the [DIAGNOSES REDACTED]. Review of resident’s physician’s orders dated 2/20/18 showed the following: -Decrease Losartan (medication used to treat high blood pressure) to 50 milligrams (mg), daily; -Complete blood count (CBC) (a blood test used to evaluate overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection, and [MEDICAL CONDITION]), and basic metabolic panel (BMP), (a panel of eight tests that shows the status of a person’s metabolism) in two weeks. Review of the resident’s medical records dated showed no documentation the CBC and the BMP were completed as ordered. During interview on 3/27/2018 at 9:45 A.M. LPN H said the following: -He/she was not able to locate results of lab work for the resident; -He/she called the physician’s office who reported they did not receive the results of the ordered labs; -He/she said the physician’s office said the last labs received were on 2/7/2018 and they should have received new lab results on 3/7/2018. 8. Review of resident #6’s care plan last reviewed 5/11/17 showed the following: -[DIAGNOSES REDACTED]. -Resident will be prescribed the lowest effective dose of medication; -Assess and record effectiveness of drug treatment, monitor and report signs of sedation,

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
Review of the resident’s Treatment Administration Record (TAR) dated 2/23/18-2/25/18
showed the following:
-Trach care daily and PRN;
-Hydrogen peroxide solution 3% topically once daily;
-There was no documentation staff [MEDICAL CONDITION] as ordered
Review of the resident’s POS dated 2/26/18 through 3/25/18 showed an order for [REDACTED].
Review of the resident’s TAR dated 2/26/18 through 3/25/18 showed the following:
-There was no order on the TAR [MEDICAL CONDITION] daily;
-There was no order on the TAR for hydrogen peroxide daily;
-There was no documentation staff [MEDICAL CONDITION] as ordered.
During interview on 3/28/18 at 1:07 P.M. the hospital Nurse Practitioner (NP) U said:
-The resident had lots of sputum suctioned from his/her [MEDICAL CONDITION] when he/she
arrived at the hospital;
-The inner cannula had hard crusted brown sputum in the cannula.
During interview on 3/28/18 at 3:12 P.M., LPN E said:
-The resident had a [MEDICAL CONDITION];
-Trach care was done every shift, suctioned at least once a shift and PRN;
-He/she did not use [MEDICAL CONDITION] kit;
-He/she cleaned [MEDICAL CONDITION] with soap and water;
-He/she put a new inner cannula in every time he/she [MEDICAL CONDITION];
-He/she would suction the resident and then suction normal saline though suction tubing to
clean and then put the package back to reuse.
During interview on 3/29/18 at 4:52 P.M., LPN H said:
-Trach care was completed once a shift;
-He/she only suctioned one time, the resident received a breathing treatment and would
cough up and didn’t need to be suctioned;
-He/she never changed the inner cannula and never cleaned it;
-He/she never received any training [MEDICAL CONDITION];
-He/she did not feel comfortable [MEDICAL CONDITION].
7. Review of Resident #64’s quarterly MDS dated [DATE] showed the [DIAGNOSES REDACTED].
Review of resident’s physician’s orders dated 2/20/18 showed the following:
-Decrease Losartan (medication used to treat high blood pressure) to 50 milligrams (mg),
daily;
-Complete blood count (CBC) (a blood test used to evaluate overall health and detect a
wide range of disorders, including [MEDICAL CONDITION], infection, and [MEDICAL
CONDITION]), and basic metabolic panel (BMP), (a panel of eight tests that shows the
status of a person’s metabolism) in two weeks.
Review of the resident’s medical records dated showed no documentation the CBC and the
BMP were completed as ordered.
During interview on 3/27/2018 at 9:45 A.M. LPN H said the following:
-He/she was not able to locate results of lab work for the resident;
-He/she called the physician’s office who reported they did not receive the results of the
ordered labs;
-He/she said the physician’s office said the last labs received were on 2/7/2018 and they
should have received new lab results on 3/7/2018.
8. Review of resident #6’s care plan last reviewed 5/11/17 showed the following:
-[DIAGNOSES REDACTED].
-Resident will be prescribed the lowest effective dose of medication;
-Assess and record effectiveness of drug treatment, monitor and report signs of sedation,

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 6) [MEDICATION NAME] (used primarily to treat tremor symptoms associated with [MEDICAL CONDITION]), and/or extrapyramidal (a group of symptoms that can occur in people taking antipsychotic medications) symptoms; -Exhibits socially inappropriate disruptive behavioral symptoms; -Frequently yells out and will cry if he/she does not get attention promptly. Review of the resident’s quarterly MDS dated [DATE] showed the following: -[DIAGNOSES REDACTED]. -Severe memory impairment; -Moderately dependent on decision making; -Little or no interest in doing things; -Trouble falling asleep. Review of the resident’s physician’s order dated 2/27/2018 showed the following: -Discontinue (DC) current [MEDICATION NAME] order of 50 milligrams by mouth three times a day (used to treat certain mental/mood conditions such as [MEDICAL CONDITIONS] disorder, sudden episodes [MEDICAL CONDITION] depression associated with [MEDICAL CONDITION] disorder); -Start [MEDICATION NAME] 50 mg by mouth morning and 5:00 P.M.; -Call in one week with update. Review of the resident’s nurse’s notes showed no documentation staff updated the physician on the change in [MEDICATION NAME]. During interview on 3/27/2018 at 10:00 A.M. LPN H said the following: -He/she was not able to locate an entry in the resident’s nurse’s notes of an update to the physician for the resident; -He/she would expect a nurse to write in the resident’s nurse’s notes that a follow up with physician was completed; -He/she called the physician’s office on 3/27/18 at 10:15 A.M. who reported they received no follow up for the [MEDICATION NAME] change. 8. Review of Resident #176’s admission orders [REDACTED]. Review of the resident’s POS, dated 3/12/18, showed the following: -[MEDICATION NAME] 50 mg take two tablets by mouth once daily at 8:00 A.M.; -[MEDICATION NAME] 50 mg one tablet by mouth every six hours during the day PRN. Review of the resident’s MAR indicated [REDACTED] -[MEDICATION NAME] 50 mg two tablets by mouth daily at 8:00 A.M.; -[MEDICATION NAME] 50 mg one tablet by mouth every six hours PRN; -The resident received two PRN doses on 3/22/18 and 4/17/18. The facility failed to correctly transcribe the physician’s order for [MEDICATION NAME] to be scheduled every six hours during the day instead of PRN. During interview on 3/29/18 at 10:46 A.M., the resident said: -He/she had taken [MEDICATION NAME] scheduled for about a year due to back pain; -He/she was admitted to facility on 3/12/18 after back surgery; -He/she never asked for PRN dose of [MEDICATION NAME]; -There were times he/she could have used extra [MEDICATION NAME]. 9. During interview on 3/29/2018 at 4:30 P.M. the DON said the following: -Any nurse that goes in the chart should follow through with the physician’s orders; -She expected physician’s orders be followed; -Would expect orders to be checked every shift and processed; -She expected staff to notify the physician if the resident’s ordered pain medication was not available and if the resident had two [MEDICATION NAME]es on when one pain patch was ordered;

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
[MEDICATION NAME] (used primarily to treat tremor symptoms associated with [MEDICAL
CONDITION]), and/or extrapyramidal (a group of symptoms that can occur in people taking
antipsychotic medications) symptoms;
-Exhibits socially inappropriate disruptive behavioral symptoms;
-Frequently yells out and will cry if he/she does not get attention promptly.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-[DIAGNOSES REDACTED].
-Severe memory impairment;
-Moderately dependent on decision making;
-Little or no interest in doing things;
-Trouble falling asleep.
Review of the resident’s physician’s order dated 2/27/2018 showed the following:
-Discontinue (DC) current [MEDICATION NAME] order of 50 milligrams by mouth three times a
day (used to treat certain mental/mood conditions such as [MEDICAL CONDITIONS] disorder,
sudden episodes [MEDICAL CONDITION] depression associated with [MEDICAL CONDITION]
disorder);
-Start [MEDICATION NAME] 50 mg by mouth morning and 5:00 P.M.;
-Call in one week with update.
Review of the resident’s nurse’s notes showed no documentation staff updated the physician
on the change in [MEDICATION NAME].
During interview on 3/27/2018 at 10:00 A.M. LPN H said the following:
-He/she was not able to locate an entry in the resident’s nurse’s notes of an update to
the physician for the resident;
-He/she would expect a nurse to write in the resident’s nurse’s notes that a follow up
with physician was completed;
-He/she called the physician’s office on 3/27/18 at 10:15 A.M. who reported they received
no follow up for the [MEDICATION NAME] change.
8. Review of Resident #176’s admission orders [REDACTED].
Review of the resident’s POS, dated 3/12/18, showed the following:
-[MEDICATION NAME] 50 mg take two tablets by mouth once daily at 8:00 A.M.;
-[MEDICATION NAME] 50 mg one tablet by mouth every six hours during the day PRN.
Review of the resident’s MAR indicated [REDACTED]
-[MEDICATION NAME] 50 mg two tablets by mouth daily at 8:00 A.M.;
-[MEDICATION NAME] 50 mg one tablet by mouth every six hours PRN;
-The resident received two PRN doses on 3/22/18 and 4/17/18.
The facility failed to correctly transcribe the physician’s order for [MEDICATION NAME] to
be scheduled every six hours during the day instead of PRN.
During interview on 3/29/18 at 10:46 A.M., the resident said:
-He/she had taken [MEDICATION NAME] scheduled for about a year due to back pain;
-He/she was admitted to facility on 3/12/18 after back surgery;
-He/she never asked for PRN dose of [MEDICATION NAME];
-There were times he/she could have used extra [MEDICATION NAME].
9. During interview on 3/29/2018 at 4:30 P.M. the DON said the following:
-Any nurse that goes in the chart should follow through with the physician’s orders;
-She expected physician’s orders be followed;
-Would expect orders to be checked every shift and processed;
-She expected staff to notify the physician if the resident’s ordered pain medication was
not available and if the resident had two [MEDICATION NAME]es on when one pain patch was
ordered;

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 7) -She expected two licensed nurses to dispose of used [MEDICATION NAME]; -She expected staff to check and document placement of a [MEDICATION NAME] shiftily. During interview on 3/28/2018 at 4:50 P.M. the administrator said the following: -At times, the resident’s chart is shut before the physician’s orders are processed; -The facility recognized a problem with physician orders being missed by staff and they were working on process to prevent the issue; -She expected staff to follow the physician orders. During an interview on 3/29/18 at 2:25 P.M. Physician I said the following: -He was the medical director for the facility; -He expected staff to notify him within 48 hours if a resident was not getting his/her medication as ordered; -He expected staff to notify him if a resident received too much medication; -He expected staff to follow all physician orders. See MO 9
	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Provide care and assistance to perform activities of daily living for any resident who is unable. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided scheduled showers for two residents (Resident #39 and Resident #176) in a sample of 18 residents who were unable to complete their own activities of daily living (ADL). The facility census was 77. 1. Review of the facility’s Tub Bath and Shower Bath policy, dated (MONTH) (YEAR), showed the following: -The shower is a bath of choice for many of the residents because of their poor mobility; -Let the resident choose which type of bath to take if not specified in the care plan. 2. Review of Resident #39’s quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff dated 1/6/18 showed the following: -Brief Interview of Mental Status (BIMS) of 13, indicating the resident was cognitively intact; -No rejection of care; -Required extensive assistance of one staff for personal hygiene and bathing. Review of the resident’s care plan last updated 2/12/18 showed the resident required limited to extensive assistance with all ADLs except independent with eating. Review of the facility’s hand written,undated shower schedule for the resident showed the staff were to give the resident a shower on Tuesdays and Fridays of every week. Review of the certified nursing assistant (CNA’s) documentation of the shower schedule sheet provided by the facility for (MONTH) (YEAR), showed the staff only provided three showers for the resident from 3/1/18 through 3/28/18. Staff last documented giving the resident a shower on 3/20/18. Staff failed to give the resident a shower for eight days from 3/20/18 to 3/28/18. Review of the resident’s medical record from 3/1/18 to 3/28/18 showed staff did not document any resident rejection of care. Observation on 3/26/18 at 4:00 P.M. showed the resident’s hair was oily with white flakes in his/her hair. During interview on 3/26/18 at 4:00 P.M. the resident said the following:

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-She expected two licensed nurses to dispose of used [MEDICATION NAME];
-She expected staff to check and document placement of a [MEDICATION NAME] shiftily.
During interview on 3/28/2018 at 4:50 P.M. the administrator said the following:
-At times, the resident’s chart is shut before the physician’s orders are processed;
-The facility recognized a problem with physician orders being missed by staff and they
were working on process to prevent the issue;
-She expected staff to follow the physician orders.
During an interview on 3/29/18 at 2:25 P.M. Physician I said the following:
-He was the medical director for the facility;
-He expected staff to notify him within 48 hours if a resident was not getting his/her
medication as ordered;
-He expected staff to notify him if a resident received too much medication;
-He expected staff to follow all physician orders.
See MO 9

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided scheduled showers for two residents (Resident #39 and Resident #176) in a sample
of 18 residents who were unable to complete their own activities of daily living (ADL).
The facility census was 77.
1. Review of the facility’s Tub Bath and Shower Bath policy, dated (MONTH) (YEAR), showed
the following:
-The shower is a bath of choice for many of the residents because of their poor mobility;
-Let the resident choose which type of bath to take if not specified in the care plan.
2. Review of Resident #39’s quarterly Minimum Data Sheet (MDS), a federally mandated
assessment instrument completed by facility staff dated 1/6/18 showed the following:
-Brief Interview of Mental Status (BIMS) of 13, indicating the resident was cognitively
intact;
-No rejection of care;
-Required extensive assistance of one staff for personal hygiene and bathing.
Review of the resident’s care plan last updated 2/12/18 showed the resident required
limited to extensive assistance with all ADLs except independent with eating.
Review of the facility’s hand written,undated shower schedule for the resident showed the
staff were to give the resident a shower on Tuesdays and Fridays of every week.
Review of the certified nursing assistant (CNA’s) documentation of the shower schedule
sheet provided by the facility for (MONTH) (YEAR), showed the staff only provided three
showers for the resident from 3/1/18 through 3/28/18. Staff last documented giving the
resident a shower on 3/20/18. Staff failed to give the resident a shower for eight days
from 3/20/18 to 3/28/18.
Review of the resident’s medical record from 3/1/18 to 3/28/18 showed staff did not
document any resident rejection of care.
Observation on 3/26/18 at 4:00 P.M. showed the resident’s hair was oily with white flakes
in his/her hair.
During interview on 3/26/18 at 4:00 P.M. the resident said the following:

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 8) -He/she depended on staff to give him/her a shower; -He/she normally received one shower a week but would like at least like to have two showers a week; -He/she was supposed to get showers on Tuesdays and Fridays; -Staff had not given the resident a shower for at least five days; -Staff gave the resident his/her showers when staff felt like it; -He/she felt dirty; -He/she liked to be clean. Observation from 3/27/18 to 3/29/18 showed the resident’s hair was oily with white flakes in his/her hair. During interview on 3/29/18 at 9:45 A.M. the resident said staff had not given him/her a shower from 3/20/18 to 3/29/18. He/she was scheduled to get a shower on 3/29/18 but had not received one yet. 3. Review of Resident #176’s admission MDS, dated [DATE], showed the following: -BIMS score of nine, indicating cognition moderately impaired; -No rejection of care; -Limited assistance of one staff for personal hygiene; -Extensive assistance of one staff for bathing. Review of the resident’s care plan dated 3/26/18, showed the following: -The resident will be clean, dry and odor free; -Provide assistance of one staff for toileting and hygiene as needed; -The care plan did not address bathing. During interview on 3/26/18 at 1:15 P.M., the resident’s family member said the resident was not receiving showers twice a week. Review of the CNA’s documentation of the shower schedule sheet provided by the facility for (MONTH) (YEAR), showed the resident did not receive a shower from 3/12/18 through 3/28/18. (The resident was admitted to the facility on [DATE]). During interview on 3/27/18 at 8:45 A.M., the resident said: -He/she has only had one shower since he/she was admitted on [DATE]; -He/she did not get a shower on 3/22/18 or 3/26/18. During interview on 3/28/18 at 2:45 P.M., the resident said: -He/she did not get a shower today; -He/she took a sponge bath at the sink in his/her room; -He/she would like to have two showers a week. 4. During interview on 3/28/18 at 1:30 P.M., CNA M said the following: -He/she was scheduled to provide showers for the residents 3/28/18; -He/she was pulled the floor to work and was not able to give the residents showers as scheduled; -He/she was the normal shower aide that provided showers for the residents, but was often pulled to the floor to work; -When he/she wasn’t able to give showers to the residents as scheduled, evening shift would provide showers if they had enough staff; -If the residents do not get a shower as scheduled, the resident would wait until the next shower day; -On 3/27/18 he/she was not able to complete Resident #39’s shower because he/she was working the floor. During interview on 3/28/18 at 1:58 P.M., CNA L said the following: -He/she was responsible for giving showers to the residents on the halls CNA M wasn’t responsible for completing;

(X4) ID PREFIX TAG

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

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-He/she depended on staff to give him/her a shower;
-He/she normally received one shower a week but would like at least like to have two
showers a week;
-He/she was supposed to get showers on Tuesdays and Fridays;
-Staff had not given the resident a shower for at least five days;
-Staff gave the resident his/her showers when staff felt like it;
-He/she felt dirty;
-He/she liked to be clean.
Observation from 3/27/18 to 3/29/18 showed the resident’s hair was oily with white flakes
in his/her hair.
During interview on 3/29/18 at 9:45 A.M. the resident said staff had not given him/her a
shower from 3/20/18 to 3/29/18. He/she was scheduled to get a shower on 3/29/18 but had
not received one yet.
3. Review of Resident #176’s admission MDS, dated [DATE], showed the following:
-BIMS score of nine, indicating cognition moderately impaired;
-No rejection of care;
-Limited assistance of one staff for personal hygiene;
-Extensive assistance of one staff for bathing.
Review of the resident’s care plan dated 3/26/18, showed the following:
-The resident will be clean, dry and odor free;
-Provide assistance of one staff for toileting and hygiene as needed;
-The care plan did not address bathing.
During interview on 3/26/18 at 1:15 P.M., the resident’s family member said the resident
was not receiving showers twice a week.
Review of the CNA’s documentation of the shower schedule sheet provided by the facility
for (MONTH) (YEAR), showed the resident did not receive a shower from 3/12/18 through
3/28/18. (The resident was admitted to the facility on [DATE]).
During interview on 3/27/18 at 8:45 A.M., the resident said:
-He/she has only had one shower since he/she was admitted on [DATE];
-He/she did not get a shower on 3/22/18 or 3/26/18.
During interview on 3/28/18 at 2:45 P.M., the resident said:
-He/she did not get a shower today;
-He/she took a sponge bath at the sink in his/her room;
-He/she would like to have two showers a week.
4. During interview on 3/28/18 at 1:30 P.M., CNA M said the following:
-He/she was scheduled to provide showers for the residents 3/28/18;
-He/she was pulled the floor to work and was not able to give the residents showers as
scheduled;
-He/she was the normal shower aide that provided showers for the residents, but was often
pulled to the floor to work;
-When he/she wasn’t able to give showers to the residents as scheduled, evening shift
would provide showers if they had enough staff;
-If the residents do not get a shower as scheduled, the resident would wait until the next
shower day;
-On 3/27/18 he/she was not able to complete Resident #39’s shower because he/she was
working the floor.
During interview on 3/28/18 at 1:58 P.M., CNA L said the following:
-He/she was responsible for giving showers to the residents on the halls CNA M wasn’t
responsible for completing;

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 9) -He/she was pulled to the floor because the facility did not have enough staff; -He/she would not be able give all residents scheduled a shower due to helping on the floor. During interview on 3/29/18 at 4:40 P.M. the Director of Nurses (DON) said the following: -She expected staff to complete showers as scheduled and needed; -There were times when showers were not being completed due to staffing.
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Provide and implement an infection prevention and control program. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional practices during personal care for one resident (Resident #39) in a review of 18 sampled residents and for two additional residents (Resident #72 and Resident #200). The facility census was 77. 1. Review of the Nurse Assistant in a Long-term Care Facility, 2001 Revision edition, regarding hand washing and use of gloves, showed the following: -Wash hands before and after glove use and after contact with any waste or contaminated material; -Gloves should be worn when contact is likely with the following: anybody opening, blood, all moist body fluids, mucous membranes (nose, mouth, etc.), non-intact skin (pressure ulcers, skin tears), dressings, used tissues or wipes, surfaces or items contaminated with blood or body fluids, specimen containers being transported; -Use gloves when doing mouth care, perineal care, skin care, and other procedures involving body fluids; -Gloves do not eliminate the need to wash your hands; they just provide a barrier between you and potentially infectious microorganisms; -Never touch unnecessary articles in the room or one’s face, hair, contact lens, or glasses when wearing gloves. 2. Review of the facility’s undated Handwashing policy showed the following: -The purpose is to decrease the risk of transmission of infection by appropriate handwashing; -Handwashing is generally considered the most important single procedure for preventing nosocomial infections; -Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects; -Although antiseptics and other handwashing agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the handwashing technique followed. 3. Review of the facility’s undated Infection Control policy, showed the following: -Wear gloves when it is likely that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus,or items/surfaces soiled with these substances); -Gloves should be changed and hands washed between residents; -Remember: Gloves are not a cure-all. They reduce the likelihood of contaminating the

(X4) ID PREFIX TAG

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

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-He/she was pulled to the floor because the facility did not have enough staff;
-He/she would not be able give all residents scheduled a shower due to helping on the
floor.
During interview on 3/29/18 at 4:40 P.M. the Director of Nurses (DON) said the following:
-She expected staff to complete showers as scheduled and needed;
-There were times when showers were not being completed due to staffing.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure nursing
staff washed their hands and changed soiled gloves after each direct resident contact and
when indicated by professional practices during personal care for one resident (Resident
#39) in a review of 18 sampled residents and for two additional residents (Resident #72
and Resident
#200). The facility census was 77.
1. Review of the Nurse Assistant in a Long-term Care Facility, 2001 Revision edition,
regarding hand washing and use of gloves, showed the following:
-Wash hands before and after glove use and after contact with any waste or contaminated
material;
-Gloves should be worn when contact is likely with the following: anybody opening, blood,
all moist body fluids, mucous membranes (nose, mouth, etc.), non-intact skin (pressure
ulcers, skin tears), dressings, used tissues or wipes, surfaces or items contaminated with
blood or body fluids, specimen containers being transported;
-Use gloves when doing mouth care, perineal care, skin care, and other procedures
involving body fluids;
-Gloves do not eliminate the need to wash your hands; they just provide a barrier between
you and potentially infectious microorganisms;
-Never touch unnecessary articles in the room or one’s face, hair, contact lens, or
glasses when wearing gloves.
2. Review of the facility’s undated Handwashing policy showed the following:
-The purpose is to decrease the risk of transmission of infection by appropriate
handwashing;
-Handwashing is generally considered the most important single procedure for preventing
nosocomial infections;
-Antiseptics control or kill microorganisms contaminating skin and other superficial
tissues and are sometimes composed of the same chemicals that are used for disinfection of
inanimate objects;
-Although antiseptics and other handwashing agents do not sterilize the skin, they can
reduce microbial contamination depending on the type and the amount of contamination, the
agent used, the presence of residual activity and the handwashing technique followed.
3. Review of the facility’s undated Infection Control policy, showed the following:
-Wear gloves when it is likely that hands will be in contact with mucous membranes,
non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral
secretions, sputum, vomitus,or items/surfaces soiled with these substances);
-Gloves should be changed and hands washed between residents;
-Remember: Gloves are not a cure-all. They reduce the likelihood of contaminating 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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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 – Some	(continued… from page 10) hands, but hands should be washed after removal of gloves; -Wash hands often, always between resident’s care and after any contact with body substances or contaminated materials. 4. Review of the facility’s blood glucometer (a medical device used to determine the approximate amount of sugar in the blood) disinfecting policy dated (MONTH) (YEAR), showed the following: -Purpose: to prevent spread of infection; -Equipment: approved wipes with 10% bleach or comparable product; -Wash hands, put on gloves, provide clean field in which to place glucometer (a paper towel works well for this); -Clean the glucometer prior to use with approved 10% bleach or comparable product, place on clean field and let air dry. Do not touch the clean field with gloves including the test port. The glucometer may be wrapped in another 10% bleach wipe and stored; -Remove gloves and wash hands. 5. Review of Resident #39’s quarterly Minimum Data Sheet (MDS), a federally mandated assessment instrument completed by facility staff dated 1/6/18 showed the following: -Brief Interview of Mental Status (BIMS) of 13, indicating the resident was cognitively intact; -Required extensive assistance of one staff for personal hygiene and toileting; -Urinary catheter; -Always continent of bowel. Review of the resident’s care plan last updated 2/12/18 showed the following: -The resident required limited to extensive assistance from staff with all activities of daily living (ADL); -Urinary catheter. Observation on 3/28/18 at 6:04 A.M. showed the following: -The resident lay in bed; -Certified Nursing Assistant (CNA) P entered the resident’s room and without washing his/her hands applied gloves; -CNA P removed the resident’s feces soiled incontinency brief; -CNA P cleaned the resident’s rectum, buttocks and perineal area; -With the same soiled gloves, CNA P applied a clean incontinency brief, pulled the resident’s clean pants to the resident’s knees and assisted the resident to a sitting position on the side of the bed; -With the same soiled gloves, CNA P touched the resident’s hands, arms and back; -With the same soiled gloves, CNA P placed the gait belt (canvas belt placed around the resident’s waist to assist with ambulation, transfer, and positioning in a chair) around the resident’s waist and transferred the resident to the wheelchair; -With the same soiled gloves, CNA P opened the resident’s bedside table, removed a brush from the top drawer and combed the resident’s hair touching the resident’s face; -Without removing his/her soiled gloves or washing his/her hands, CNA P picked up the resident’s dirty linens, placed them in a bag, tied the bag and walked down the hall to the dirty utility room. With the same soiled gloves, CNA P turned the door knob to open the door and placed the dirty linens in the bin; -CNA P removed his/her soiled gloves and without washing his/her hands, walked down the hall into the resident’s room; -Without washing his/her hands, CNA P removed two incontinency pads from the clean linen cart and placed them on the resident’s bed; During interview on 3/28/18 at 6:43 A.M. CNA P said the following:

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
hands, but hands should be washed after removal of gloves;
-Wash hands often, always between resident’s care and after any contact with body
substances or contaminated materials.
4. Review of the facility’s blood glucometer (a medical device used to determine the
approximate amount of sugar in the blood) disinfecting policy dated (MONTH) (YEAR), showed
the following:
-Purpose: to prevent spread of infection;
-Equipment: approved wipes with 10% bleach or comparable product;
-Wash hands, put on gloves, provide clean field in which to place glucometer (a paper
towel works well for this);
-Clean the glucometer prior to use with approved 10% bleach or comparable product, place
on clean field and let air dry. Do not touch the clean field with gloves including the
test port. The glucometer may be wrapped in another 10% bleach wipe and stored;
-Remove gloves and wash hands.
5. Review of Resident #39’s quarterly Minimum Data Sheet (MDS), a federally mandated
assessment instrument completed by facility staff dated 1/6/18 showed the following:
-Brief Interview of Mental Status (BIMS) of 13, indicating the resident was cognitively
intact;
-Required extensive assistance of one staff for personal hygiene and toileting;
-Urinary catheter;
-Always continent of bowel.
Review of the resident’s care plan last updated 2/12/18 showed the following:
-The resident required limited to extensive assistance from staff with all activities of
daily living (ADL);
-Urinary catheter.
Observation on 3/28/18 at 6:04 A.M. showed the following:
-The resident lay in bed;
-Certified Nursing Assistant (CNA) P entered the resident’s room and without washing
his/her hands applied gloves;
-CNA P removed the resident’s feces soiled incontinency brief;
-CNA P cleaned the resident’s rectum, buttocks and perineal area;
-With the same soiled gloves, CNA P applied a clean incontinency brief, pulled the
resident’s clean pants to the resident’s knees and assisted the resident to a sitting
position on the side of the bed;
-With the same soiled gloves, CNA P touched the resident’s hands, arms and back;
-With the same soiled gloves, CNA P placed the gait belt (canvas belt placed around the
resident’s waist to assist with ambulation, transfer, and positioning in a chair) around
the resident’s waist and transferred the resident to the wheelchair;
-With the same soiled gloves, CNA P opened the resident’s bedside table, removed a brush
from the top drawer and combed the resident’s hair touching the resident’s face;
-Without removing his/her soiled gloves or washing his/her hands, CNA P picked up the
resident’s dirty linens, placed them in a bag, tied the bag and walked down the hall to
the dirty utility room. With the same soiled gloves, CNA P turned the door knob to open
the door and placed the dirty linens in the bin;
-CNA P removed his/her soiled gloves and without washing his/her hands, walked down the
hall into the resident’s room;
-Without washing his/her hands, CNA P removed two incontinency pads from the clean linen
cart and placed them on the resident’s bed;
During interview on 3/28/18 at 6:43 A.M. CNA P said the following:

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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 – Some	(continued… from page 11) -He/she normally applied gloves when he/she entered a resident’s room; -He/she removed his/her gloves and washed his/her hands after providing care and prior to leaving a resident’s room; -He/she did not normally change gloves after perineal care; -He/she normally only changed gloves if they were visibly soiled; -He/she only washed his/her hands after removing gloves not prior to applying gloves; -He/she should have removed gloves and washed hands prior to touching clean items. 6. Review of Resident #72’s quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident’s care plan last updated 3/6/18 showed the resident required supervision of staff for all ADLs. Review of the resident’s physician order [REDACTED]. -The resident’s [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is on the skin it is transferred by contact); -Staff were to check the resident’s blood sugars at 7:00 A.M., 12:00 P.M. and 5:00 P.M. Observation on 3/28/18 at 4:02 P.M. showed the following: -Registered Nurse (RN) K with ungloved hands used a lancet (a small, broad, two-edged surgical knife or blade with a sharp point) to puncture the resident’s ring finger and placed a drop of blood on the glucometer strip; -With ungloved hands, RN K removed the strip containing the blood and threw the strip in the trash; -With soiled hands, RN K applied pressure with a cotton ball to the resident’s finger to stop the bleeding; -With soiled hands, RN K opened the Medication Administration Record [REDACTED]. During interview on 3/29/18 at 5:06 P.M., RN K said the following: -The facility had two to three glucometer’s in the building that staff used to take the residents’ blood sugars; -He/she never cleaned the glucometers prior or after performing an blood sugar check on a resident; -He/she did not know if he/she should clean the glucometer machine or not; -He/she never wore gloves when performing an blood sugar check on a resident because he/she could not get a good grip with gloves on; -He/she knew he/she should probably wear gloves but preferred not to; -He/she did not have access to washing his/her hands when performing blood sugar checks or during medication pass so he/she did not wash his/her hands; -He/she did use hand sanitizer about every other blood sugar check; -He/she did not use hand sanitizer with every blood sugar check because his/her hands were dry and cracking. 7. Review of Resident #200’s quarterly MDS dated [DATE] showed the following: -The resident BIMS of 14, indicating the resident was cognitively intact; -The resident required extensive assistance of one staff for bed mobility, dressing, transfers, toilet and bathing; -The resident required limited assistance of one staff for personal hygiene; -The resident was frequently incontinent of bowel and bladder. Review of the resident’s care plan last updated 3/7/18 showed the following: -Required assistance from staff for all ADLs; -Incontinent of bladder; -Required staff to provide incontinence care after each incontinent episode. Observation on 3/28/18 at 5:16 A.M. showed the following:

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-He/she normally applied gloves when he/she entered a resident’s room;
-He/she removed his/her gloves and washed his/her hands after providing care and prior to
leaving a resident’s room;
-He/she did not normally change gloves after perineal care;
-He/she normally only changed gloves if they were visibly soiled;
-He/she only washed his/her hands after removing gloves not prior to applying gloves;
-He/she should have removed gloves and washed hands prior to touching clean items.
6. Review of Resident #72’s quarterly MDS dated [DATE] showed the resident was cognitively
intact.
Review of the resident’s care plan last updated 3/6/18 showed the resident required
supervision of staff for all ADLs.
Review of the resident’s physician order [REDACTED].
-The resident’s [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is on the skin it is transferred
by contact);
-Staff were to check the resident’s blood sugars at 7:00 A.M., 12:00 P.M. and 5:00 P.M.
Observation on 3/28/18 at 4:02 P.M. showed the following:
-Registered Nurse (RN) K with ungloved hands used a lancet (a small, broad, two-edged
surgical knife or blade with a sharp point) to puncture the resident’s ring finger and
placed a drop of blood on the glucometer strip;
-With ungloved hands, RN K removed the strip containing the blood and threw the strip in
the trash;
-With soiled hands, RN K applied pressure with a cotton ball to the resident’s finger to
stop the bleeding;
-With soiled hands, RN K opened the Medication Administration Record [REDACTED].
During interview on 3/29/18 at 5:06 P.M., RN K said the following:
-The facility had two to three glucometer’s in the building that staff used to take the
residents’ blood sugars;
-He/she never cleaned the glucometers prior or after performing an blood sugar check on a
resident;
-He/she did not know if he/she should clean the glucometer machine or not;
-He/she never wore gloves when performing an blood sugar check on a resident because
he/she could not get a good grip with gloves on;
-He/she knew he/she should probably wear gloves but preferred not to;
-He/she did not have access to washing his/her hands when performing blood sugar checks or
during medication pass so he/she did not wash his/her hands;
-He/she did use hand sanitizer about every other blood sugar check;
-He/she did not use hand sanitizer with every blood sugar check because his/her hands were
dry and cracking.
7. Review of Resident #200’s quarterly MDS dated [DATE] showed the following:
-The resident BIMS of 14, indicating the resident was cognitively intact;
-The resident required extensive assistance of one staff for bed mobility, dressing,
transfers, toilet and bathing;
-The resident required limited assistance of one staff for personal hygiene;
-The resident was frequently incontinent of bowel and bladder.
Review of the resident’s care plan last updated 3/7/18 showed the following:
-Required assistance from staff for all ADLs;
-Incontinent of bladder;
-Required staff to provide incontinence care after each incontinent episode.
Observation on 3/28/18 at 5:16 A.M. showed the following:

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:

265433

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LINCOLN COUNTY NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1145 EAST CHERRY STREET, PO BOX 130
TROY, MO 63379

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

	(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 12) -CNA O entered the resident’s room; -The resident lay on his/her back in his/her bed; -The resident told CNA O that he/she was incontinent of urine; -With gloved hands, CNA O removed the resident’s urine saturated incontinency brief; -CNA O provided perineal care; -With the same soiled gloves, CNA O applied a clean incontinency brief, touching the resident’s right thigh, upper back and stomach; -With the same soiled gloves, CNA O straightened the resident’s shirt, repositioned the resident’s pillow under the resident’s head while touching the resident’s face, handed the resident his/her television remote, covered the resident with a clean sheet, held the resident’s coffee cup from the top and moved the coffee cup on the resident’s bedside table. During interview on 3/28/18 at 7:08 A.M. CNA O said the following: -He/she normally washed hands when he/she entered a resident’s room, after removing gloves, and when they become soiled; -He/she normally wore gloves prior to providing care for a resident; -He/she normally changed gloves after providing perineal care or when the gloves became soiled; -He/she forgot to change his/her gloves after providing incontinency care for the resident. 8. During interview on 3/29/18 at 4:40 P.M. the Director Of Nursing (DON) said the following: -She expected staff to wash hands prior to resident care,when they become soiled, with change of gloves, and after providing care for a resident; -She expected staff to wear gloves when in contact with bodily fluids such as blood, prior to cares; -She expected staff to change gloves when they became soiled and after perineal care; -She expected staff to use Sani wipes (disinfectant wipe) to clean the glucometer’s after use and between use.

SWOPE RIDGE GERIATRIC CENTER

SWEET SPRINGS VILLA

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SUNSET HILLS HEALTH AND REHABILITATION CENTER

LINCOLN COUNTY NURSING & REHAB

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