Original Inspection report

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify each resident of certain balances and convey resident funds upon discharge,
eviction, or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to ensure timely notification
of balance letters to residents when the balance of the Medicaid residents’ trust fund
accounts exceeded $1,799.99, $200.00 less than the SSI resource limit. This deficient
practice had the potential to affect all residents that received Medicaid services. The
census was 91.
1. Review of a 7/1/17, Department of Social Services memo, showed the following:
-The Department of Social Services has increased the resident resource limit to $2,000.00
for an individual;
-Previous notification to the resident at $799.99 and above is now notification to be
given at $1,799.99 and above or the resident may lose eligibility for Medicaid or
Supplemental Security Income (SSI).
2. Review of the facility’s Residents Funds Letter policy showed, anytime a resident fund
is over $1799, the book keeper will send out a letter to the resident or responsible party
to inform them they need to spend down some of their finances. The Medicaid regulation for
any resident to qualify must have less than $1099.99.
3. Review of Resident #301’s balance reports, showed the following:
-As of 1/31/18, the resident had $3520.24 in his/her account;
-As of 2/28/18, the resident had $3520.24 in his/her account;
-As of 3/31/18, the resident had $3520.24 in his/her account;
-As of 4/30/18, the resident had $3520.24 in his/her account.
4. Review of Resident #302’s balance reports, showed the following:
-As of 1/31/18, the resident had $2241.32 in his/her account;
-As of 2/28/18, the resident had $3886.32 in his/her account;
-As of 3/31/18, the resident had $3886.32 in his/her account;
-As of 4/30/18, the resident had $3886.82 in his/her account.
5. Review of Resident #68’s balance reports, showed the following:
-As of 2/28/18, the resident had $4242.57 in his/her account;
-As of 3/31/18, the resident had $4262.74 in his/her account;
-As of 4/30/18, the resident had $3145.6 in his/her account.
6. Review of Resident #20’s balance reports, showed the following:
-As of 1/31/18, the resident had $4615.22 in his/her account;
-As of 2/28/18, the resident had $5703.60 in his/her account;
-As of 3/31/18, $4200 was returned to MoHealth Net Recovery.
7. During an interview on 5/24/18 at 12:15 P.M. and 4:00 P.M., the bookkeeper/accountant
in charge of resident funds said he/she does not send out spend down letters. For the last
four months, he/she sent out one letter total, but should have sent out nine total. He/She
does not have a system to review the residents’ balance and ensure the letters are sent
out in a timely manner. The bookkeeper said typically, he/she will only send out the first
month the account is over $1799, and does not send another in following months when the
account is not spent down. The bookkeeper said he/she called Resident #68 and Resident
#20’s responsible parties, but he/she did not follow it up with a letter. Resident #301
was discharged from the facility on 11/28/16, and Resident #302 was discharged on [DATE].
He/She notified the State that the residents no longer live at the facility, but has not
heard anything back regarding the money. To his/her knowledge, the residents’ money is
still sitting in their account waiting to be returned. He/She thinks there is a policy
regarding resident fund balances, but is not sure. The bookkeeper said he/she did not know

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
the letter had to be sent for balances over $1799 and did not know it had to be sent each
month the account is over $1799.
During an interview on 5/24/18 at 4:25 P.M., the Administrator said there is a policy
regarding resident account balances. The bookkeeper is responsible for reviewing accounts
and sending out the letters. He expects staff to send the letters monthly until the
accounts are spent down below $1799. Phone calls cannot substitute for the letters, but
could be used to supplement.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation and interview, the facility failed to ensure a comfortable and
homelike environment for five residents (Resident #17, #36, and #67, and #73). The
facility census was 91.
1. Observation on 5/21/18, at 10:05 P.M., showed Resident’s #17 and #36’s room in need of
repair. Observation showed the two walls from the residents’ door to the sink with long
black scratches, and the partial wall by the sink with the trim off and on the floor, that
exposed crumbled wall.
2. Observation on 5/22/18 at 12:00 P.M., 5/23/18 at 3:30 P.M., and 5/24/18 at 8:19 A.M.,
showed Resident #73’s chair rail, behind the head of the bed, was chipped and gouged with
unfinished wood exposed.
3. Review of Resident #67’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 02/25/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Independent with all Activities of Daily Living (ADLs), except supervision of one for
bathing.
Observation on 05/22/18 at 10:25 A.M., showed the shower for the resident to have a
section of at least four loose tile near the floor. The tiles were pulled away from the
wall and bowed outward. Observation showed grout missing in places and a black substance
in the spaces along the floor and between the tiles.
Observation on 05/24/18 at 03:58 P.M., showed the resident’s shower tiles remain loose on
the shower wall. Observation also showed black grout along bottom of shower where tile
connects to floor. Observation showed a pile of brown debris on the shower floor under the
loose tiles.
During an interview on 05/24/18 at 4:00 P.M., the resident said the tiles in the shower
have been coming loose for quite some time. The resident said he/she has complained about
the loose tiles and the black substance in the shower but no one has repaired it. The
resident said he/she is concerned it could be mold growing. The resident said a male
employee came into his/her room and pushed around on the loose tiles, causing the brown
debris to fall onto the shower floor on 5/23/18. The resident said no one had come to
clean up the mess.
4. During an interview on 5/24/18 at 6:50 P.M., Certified Medication Technician (CMT) G
said a Housekeeping/Maintenance form is to be filled out and turned in to maintenance if
staff see something needing repaired. The CMT said maintenance usually gets the repairs
done pretty quickly.
During an interview on 5/24/18 at 7:00 P.M., Licensed Practical Nurse (LPN) H said a

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
Housekeeping/Maintenance Work Request is to be completed if staff notice something in need
of repair. The LPN said one copy goes to maintenance and one copy remains at the nurse’s
station for follow up. The LPN said he/she was not aware of any loose tiles or black
substance in Resident #67’s shower. The LPN said the resident is very private and doesn’t
like people in his/her room.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to complete the federally
required comprehensive Minimum Data Set (MDS) assessments (a federally mandated
assessment) in a timely manner for six residents (Resident #1, #7, #16, #18, #21, #26, and
#27). The facility census was 91.
1. Review of the Resident Assessment Instrument (RAI) manual, dated (MONTH) (YEAR), showed
direction for facilities to complete the following assessments:
-The Admission MDS assessment is a comprehensive assessment for a new resident and, under
some circumstances, a returning resident that must be completed by the end of day 14,
counting the date of admission to the nursing home as day 1 if:
o this is the resident’s first time in this facility, OR
o the resident has been admitted to this facility and was discharged return not
anticipated, OR
o the resident has been admitted to this facility and was discharged return anticipated
and did not return within 30 days of discharge.
-The Annual MDS assessment is a comprehensive assessment for a resident that must be
completed on an annual basis (at least every 366 days) unless a Significant Change in
Status Assessment (SCSA) has been completed since the most recent comprehensive assessment
was completed. Its completion dates (MDS/(Care Area Assessment)CAA(s)/care plan) depend on
the most recent comprehensive and past assessments’ ARDs and completion dates.
o The Assessment Reference Date (ARD) must be set within 366 days after the ARD of the
previous Omnibus Budget Reconciliation Act (OBRA) comprehensive assessment (ARD of
previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of
the previous OBRA Quarterly or Significant Correction to Prior Quarterly assessment (ARD
of previous OBRA Quarterly assessment + 92 calendar days).
o The MDS completion date must be no later than 14 days after the ARD (ARD + 14 calendar
days). This date may be earlier than or the same as the CAA(s) completion date, but not
later than.
o The CAA(s) completion date must be no later than 14 days after the ARD (ARD + 14
calendar days). This date may be the same as the MDS completion date, but not earlier
than.
o The care plan completion date must be no later than 7 calendar days after the CAA(s)
completion date (CAA(s) completion date + 7 calendar days).
-The Significant Change In Status Assessment (SCSA) MDS is a comprehensive assessment for
a resident that must be completed when the Interdisciplinary team (IDT) has determined
that a resident meets the significant change guidelines for either major improvement or
decline. It can be performed at any time after the completion of an Admission assessment,
and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
determination was made that the resident had a significant change.
A significant change is a major decline or improvement in a resident’s status that:
o Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, the decline is not considered
self-limiting;
o Impacts more than one area of the resident’s health status; and
o Requires interdisciplinary review and/or revision of the care plan.
o When a resident’s status changes and it is not clear whether the resident meets the SCSA
guidelines, the nursing home may take up to 14 days to determine whether the criteria are
met.
o A SCSA is required to be performed when a terminally ill resident enrolls in a hospice
program (Medicare-certified or State-licensed hospice provider) or changes hospice
providers and remains a resident at the nursing home. The ARD must be within 14 days from
the effective date of the hospice election.
o The ARD must be less than or equal to 14 days after the IDT’s determination that the
criteria for a SCSA are met (determination date + 14 calendar days).
o The MDS completion date must be no later than 14 days from the ARD (ARD + 14 calendar
days) and no later than 14 days after the determination that the criteria for a SCSA were
met. This date may be earlier than or the same as the CAA(s) completion date, but not
later than.
o The CAA(s) completion date must be no later than 14 days after the ARD (ARD + 14
calendar days) and no later than 14 days after the determination that the criteria for a
SCSA were met. This date may be the same as the MDS completion date, but not earlier than
MDS completion.
o The care plan completion date must be no later than 7 calendar days after the CAA(s)
completion date (CAA(s) completion date + 7 calendar days).
2. Review of Resident #1’s MDS assessments showed:
-Discharge MDS assessment with an ARD of 2/5/18;
-Entry MDS assessment with an ARD of 5/2/18.
Review of the resident’s record showed it did not contain an admission assessment within
14 days of the admitted .
3. Review of Resident #7’s MDS assessments showed:
-Annual MDS with an ARD of 4/26/17;
-Quarterly MDS with an ARD of 1/8/18.
Review of the resident’s record showed it did not contain an annual assessment within 366
days of the previous annual assessment or within 92 days of the last quarterly assessment.
4. Review of Resident #16’s MDS assessments showed:
-Annual MDS with an ARD of 4/19/17;
-Quarterly MDS with an ARD of 1/19/18.
Review of the resident’s record showed it did not contain an annual assessment within 366
days of the previous annual assessment or within 92 days of the last quarterly assessment.
5. Review of Resident #18’s MDS assessments showed:
-Annual MDS with an ARD of 4/26/17;
-Quarterly MDS with an ARD of 1/16/18.
Review of the resident’s record showed it did not contain an annual assessment within 366
days of the previous annual assessment or within 92 days of the last quarterly assessment.
6. Review of Resident #21’s MDS assessments showed:
-Annual MDS with an ARD of 4/24/17;
-Quarterly MDS with an ARD of 1/16/18.
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
Review of the resident’s record showed it did not contain an annual assessment within 366
days of the previous annual assessment or within 92 days of the last quarterly assessment.
7. Review of Resident #26’s MDS assessments showed:
-Discharge return anticipated with an ARD of 4/19/18;
-Entry with an ARD of 5/2/18.
Review of the resident’s chart showed the resident admitted on [DATE] with hospice
services.
Further review showed the facility staff did not complete a SCSA within 14 days of
initiation of hospice services.
8. Review of Resident #27’s MDS assessments showed staff completed assessments of the
resident on the following dates:
-Annual assessment 05/03/17;
-Quarterly assessment 07/27/17;
-Quarterly assessment 10/27/17;
-Quarterly assessment 01/23/18.
Review showed staff did not complete an Annual assessment with an ARD of not later than
04/24/18, which is 92 days from the last ARD of 01/23/18.
9. During an interview on 5/24/18, at 3:35 P.M., the MDS Coordinator (MDSC) A said he/she
is about two months behind because he/she works the floor as a charge nurse when the
facility is short staffed.
During an interview on 5/24/18, at 4:30 P.M., the director of nursing (DON) said he/she
expects staff to complete resident MDSs according to the RAI manual.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assure that each resident’s assessment is updated at least once every 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure they assessed
residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment
completed by staff, no less frequently than once every three months. This affected seven
residents (Resident #1, #7, #16, #18, #21, #26, and #76). The facility census was 91.
1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed staff are
directed as follows:
-The Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA)
non-comprehensive assessment for a resident that must be completed at least every 92 days
following the previous OBRA assessment of any type. It is used to track a resident’s
status between comprehensive assessments to ensure critical indicators of gradual change
in a resident’s status are monitored. As such, not all MDS items appear on the Quarterly
assessment. The Assessment Reference Date (ARD) must be not more than 92 days after the
ARD of the most recent OBRA assessment of any type.
-Assessment Completion refers to the date that all information needed has been collected
and recorded for a particular assessment type and staff have signed and dated that the
assessment is complete. For required Comprehensive assessments, assessment completion is
defined as completion of the CAA process in addition to the MDS items, meaning that the
registered nurse (RN) assessment coordinator has signed and dated both the MDS (Item
Z0500) and CAA(s) (Item V0200B) completion attestations. Since a Comprehensive assessment
includes completion of both the MDS and the CAA process, the assessment timing
requirements for a comprehensive assessment apply to both the completion of the MDS and

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
the CAA process.
-Assessment Completion date for quarterly MDS assessments, is ARD plus 14 calendar days;
-Transmission Date for quarterly MDS assessments, is Completion date plus 14 calendar
days.
Review of the facility’s MDS Policy, dated 01/03/18, showed the objective is to provide
the most accurate data in order to develop the most accurate MDS for each individual
resident in the facility. An MDS will be developed upon admission per Center for
Medicare/Medicaid Services (CMS) guidelines to ensure that there is a continuity of care
and is in accordance with the individual’s needs. The individual’s MDS will also be
updated with a significant change of condition. The MDS must be based upon the resident’s
assessment, the medication administration sheets, treatment administration sheets,
physician’s orders [REDACTED]. Staff that will participate in the collection of data of
the MDS is as follows: MDS Coordinator, Social Services Director, Activities Director,
Dietary Director, and Therapy Director.
2. Review of Resident #4’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
3. Review of Resident #12’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
4. Review of Resident #17’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
5. Review of Resident #19’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
6. Review of Resident #20’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
7. Review of Resident #22’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
8. Review of Resident #23’s MDS assessments showed a Quarterly MDS dated [DATE]. Review
showed the resident did not have a Quarterly MDS within 92 days of the last assessment.
9. Review of the MDS assessments for Resident #76 showed staff completed assessments of
the resident on the following dates:
-Annual assessment 03/15/17;
-Quarterly assessment 06/08/17;
-Quarterly assessment 08/31/17;
-Missing a quarterly assessment for 11/2017;
-Quarterly assessment 02/25/18.
Review showed staff did not complete a quarterly MDS assessment for 11/2017. The quarterly
assessment with an ARD of 02/25/18 should have been an annual assessment.
10. Review of Resident #97’s MDS assessments showed a Significant Change in Status
Assessment, dated 1/11/18. Review showed the resident did not have a Quarterly MDS within
92 days of the last assessment.
11. During an interview on 5/24/18, at 3:35 P.M., the MDS Coordinator (MDSC) A said he/she
is about two months behind because he/she works the floor as a charge nurse when the
facility is short staffed.
During an interview on 5/24/18, at 4:30 P.M., the director of nursing (DON) said he/she
expects staff to complete resident MDSs according to the RAI manual.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Encode each resident’s assessment data and transmit these data to the State within 7
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
days of assessment.

Based on interview and record review, facility staff failed to transmit required Minimum
Data Sets (MDS) assessments for thirteen residents (Resident #15, #24, #26, #27, #28, #31,
#32, #36, #37, #38, #40, #73, and #80) of 19 sampled resident and thirteen additionally
sampled resident’s (Resident #303, #304, #305, #306, #307, #308, #309, #310, #311, #312,
#313, #314, #315, and #316). The facility census was 91.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, directs
assessments are to be submitted as follows:
-Comprehensive assessments must be transmitted electronically within 14 days of the Care
Plan Completion Date (V0200C2 + 14 days).
-All other MDS assessments must be submitted within 14 days of the MDS Completion Date
(Z0500B + 14 days).
-Transmitting Data: Submission files are transmitted to the QIES ASAP system using the
Centers for Medicare and Medicaid Services (CMS) wide area network. Providers must
transmit all sections of the MDS 3.0 required for their State-specific instrument,
including the Care Area Assessment (CAA) Summary (Section V) and all tracking or
correction information. Transmission requirements apply to all MDS 3.0 records used to
meet both federal and state requirements. Care plans are not required to be transmitted.
– Assessment Transmission: Comprehensive assessments must be transmitted electronically
within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS
assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14
days).
– Tracking Information Transmission: For Entry and Death in Facility tracking records,
information must be transmitted within 14 days of the Event Date (A1600 + 14 days for
Entry records and A2000 + 14 days for Death in Facility records).
-Submission Confirmation Page: The initial feedback generated by the CMS MDS Assessment
Submission and Processing System (ASAP) after an MDS data file is electronically
submitted. This page acknowledges receipt of the submission file, but does not examine the
file for any warnings and/or errors. Warnings and/or errors are provided on the Final
Validation Report.
-Final Validation Report (FVR) A report generated after the successful submission of MDS
3.0 assessment data. This report lists all of the residents for whom assessments have been
submitted in a particular submission batch, and displays all errors and/or warnings that
occurred during the validation process. An FVR with a submission type of production is a
facility’s documentation for successful file submission. An individual record listed on
the FVR marked as accepted is documentation for successful record submission.
2. Further review of the RAI manual showed, Transmittal requirements:
Within 14 days after a facility completes a resident’s assessment, a facility must
electronically transmit encoded, accurate, and complete MDS data to the CMS System,
including the following:
-Admission assessment;
-Annual assessment;
-Significant change in status assessment;
-Significant correction of prior full assessment;
– Significant correction of prior quarterly assessment;
– Quarterly review;
– A subset of items upon a resident’s transfer, reentry, discharge, and death;

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
– Background (face-sheet) information, for an initial transmission of MDS data on resident
that does not have an admission assessment.
3. Review of the facility’s CMS Submission Report, MDS 3.0 Final Validation, dated 3/6/18,
showed the following:
-22 records processed;
-Resident #25’s Quarterly MDS with an ARD date of 1/23/18, Submission Date of 3/6/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B (Date
RN assessment coordinator signed as complete) of 1/23/18;
-Resident #303 Entry MDS with an ARD date of 12/27/17, Submission Date of 3/6/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B (Date RN
assessment coordinator signed as complete) of 12/27/17;
-Resident #304’s Quarterly MDS with an ARD date of 1/23/18, Submission Date of 3/6/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/23/18;
-Resident #304’s Discharge return anticipated MDS with an ARD date of 1/29/18, Submission
Date of 3/6/18, Warning Record Submitted Late-the submission date is more than 14 days
after ZO500 B of 1/29/18;
-Resident #304’s Entry MDS with an ARD date of 2/02/18, Submission Date of 3/6/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B (Date RN
assessment coordinator signed as complete) of 2/02/18;
-Resident #305’s Discharge return anticipated MDS with an ARD date of 1/24/18, Submission
Date of 3/6/18, Warning Record Submitted Late-the submission date is more than 14 days
after ZO500 B of 1/24/18;
-Resident #305’s Entry MDS with an ARD date of 1/25/18, Submission Date of 3/6/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 1/25/18;
-Resident #306’s Discharge return not anticipated MDS with an ARD date of 10/27/17,
Submission Date of 3/6/18, Warning Record Submitted Late-the submission date is more than
14 days after ZO500 B of 11/7/17;
-Resident #307’s Annual MDS with an ARD date of 1/28/18, Submission Date of 3/6/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/28/18;
-Resident #28’s Quarterly MDS with an ARD date of 1/24/18, Submission Date of 3/6/18,
Warning Assessment completed Late-prior record ARD within 92 days of the submitted record
could not be found; Warning Record Submitted Late-the submission date is more than 14 days
after ZO500 B of 2/7/18;
-Resident #26’s Annual MDS with an ARD date of 1/23/18, Submission Date of 3/6/18, Warning
Assessment Completed Late- An OBRA comprehensive assessment with the CAA is due every year
a prior record with an ARD within 366 days could not be found; Warning Record Submitted
Late-the submission date is more than 14 days after ZO500 B of 1/23/18;
-Resident #308’s Admission MDS with an ARD date of 11/25/17, Submission Date of 3/6/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
11/25/17;
-Resident #24’s Quarterly MDS with an ARD date of 1/21/18, Submission Date of 3/6/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/21/18;
-Resident #80’s Significant Change in Status (SCSA) MDS with an ARD date of 12/23/17,
Submission Date of 3/6/18, Warning Record Submitted Late-the submission date is more than
14 days after ZO500 B of 12/23/17;
-Resident #309’s Entry MDS with an ARD date of 2/9/18, Submission Date of 3/6/18, Warning
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 2/9/18;
-Resident #27’s Quarterly MDS with an ARD date of 1/23/18, Submission Date of 3/6/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/23/18.
4. Review of the facility’s CMS Submission Report, MDS 3.0 Final Validation, dated
3/19/18, showed the following:
-31 records processed;
-Resident #310’s SCSA MDS with an ARD date of 2/9/18, Submission Date of 3/19/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 2/20/18;
-Resident #32’s Quarterly MDS with an ARD date of 1/23/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/23/18;
-Resident #37’s SCSA MDS with an ARD date of 2/1/18, Submission Date of 3/19/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 2/1/18;
-Resident #311’s Annual MDS with an ARD date of 1/28/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/28/18;
-Resident #73’s Entry MDS with an ARD date of 2/2/18, Submission Date of 3/19/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 2/2/18;
-Resident #73’s Discharge return anticipated unplanned MDS with an ARD date of 2/9/18,
Submission Date of 3/19/18, Warning Record Submitted Late-the submission date is more than
14 days after ZO500 B of 2/23/18;
-Resident #73’s Entry MDS with an ARD date of 2/10/18, Submission Date of 3/19/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 2/10/18;
-Resident #38’s Quarterly MDS with an ARD date of 2/4/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
2/4/18;
-Resident #36’s Quarterly MDS with an ARD date of 1/28/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/28/18;
-Resident #313’s Admission MDS with an ARD date of 12/3/17, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
12/3/17;
-Resident #314’s Quarterly MDS with an ARD date of 1/23/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/23/18;
-Resident #315’s Quarterly MDS with an ARD date of 1/23/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/23/18;
-Resident #31’s Quarterly MDS with an ARD date of 1/9/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
1/9/18;
-Resident #309’s Admission MDS with an ARD date of 2/16/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
2/22/18;
-Resident #40’s Annual MDS with an ARD date of 2/11/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
2/11/18;
-Resident #15’s Discharge MDS with an ARD date of 2/19/18, Submission Date of 3/19/18,
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
2/19/18;
-Resident #15’s Entry MDS with an ARD date of 2/22/18, Submission Date of 3/19/18, Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B of 2/22/18;
-Resident #316’s Admission MDS with an ARD date of 11/7/17, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
11/7/17;
-Resident #316’s Quarterly MDS with an ARD date of 2/4/18, Submission Date of 3/19/18,
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B of
2/4/18.
5. Review of the facility’s CMS Submission Report, MDS 3.0 Final Validation, dated
3/19/18, showed the facility submitted seven records, and five of the seven records said
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B.
6. Review of the facility’s CMS Submission Report, MDS 3.0 Final Validation, dated
3/27/18, showed the facility submitted 21 records, and 17 of the 21 records said Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B.
7. Review of the facility’s CMS Submission Report, MDS 3.0 Final Validation, dated
3/28/18, showed the facility submitted 10 records, and 9 of the 10 records said Warning
Record Submitted Late-the submission date is more than 14 days after ZO500 B.
8. Review of the facility’s CMS Submission Report, MDS 3.0 Final Validation, dated
3/29/18, showed the facility submitted three records, and one of the three records said
Warning Record Submitted Late-the submission date is more than 14 days after ZO500 B.
The facility records did not contain Validation Reports from 3/30/18-5/24/18.11.
9. During an interview on 5/24/18, at 3:35 P.M., the MDS Coordinator (MDSC) A said he/she
is about two months behind because he/she works the floor as a charge nurse when the
facility is short staffed.
During an interview on 5/24/18, at 4:06 P.M., the MDSC B said that MDSC A completes the
long term resident’s MDS’s and he/she completes the Medicare skilled assessments. He/She
said administration is aware that the MDS’s have been behind. MDSC B said he/she submits
the MDS assessments to CMS weekly.
During an interview on 5/24/18, at 4:30 P.M., the director of nurse (DON) said he/she
expects staff to complete and submit resident MDS’s according to the RAI manual.

F 0642

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure a qualified health professional conducts resident assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide a registered nurse
(RN) to coordinate the Resident Assessment Instrument (RAI) process, and provide an RN
signature at the completion of the each Minimum Data Set (MDS) assessment for eleven
resident’s (Resident #1, #4, #10, #12, #13, #15, #16, #31, #66, #69, and #97). The
facility census is 91.
1. Review of the Resident Assessment Instrument (RAI) manual, dated (MONTH) (YEAR),
directs facilities:
-The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR
483.20 (b)(1)(xviii), (g), and (h) require that:
(1) the assessment accurately reflects the resident’s status
(2) a registered nurse conducts or coordinates each assessment with the appropriate

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0642

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
participation of health professionals
(3) the assessment process includes direct observation, as well as communication with the
resident and direct care staff on all shifts.
-An individual licensed as a registered nurse by the State Board of Nursing and employed
by a nursing facility, and is responsible for coordinating and certifying completion of
the resident assessment instrument.
2. Review of Resident # 1’s Admission MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500 (Signature of RN Assessment Coordinator Verifying Assessment
Completion).
Review of the resident’s Discharge MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
3. Review of Resident # 4’s Quarterly MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
4. Review of Resident # 10’s Significant Change in Status Assessment (SCSA) MDS, dated
[DATE], showed it did not contain a RN signature for item ZO500.
5. Review of Resident # 12’s Quarterly MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
6. Review of Resident # 13’s Admission MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
7. Review of Resident # 15’s Quarterly MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
8. Review of Resident # 16’s Quarterly MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
9. Review of Resident # 31’s Annual MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
10. Review of Resident # 66’s SCSA MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
11. Review of Resident # 69’s SCSA MDS, dated [DATE], showed it did not contain a RN
signature for item ZO500.
12. Review of Resident # 97’s Significant Change in Status Assessment, dated 1/11/18,
showed it did not contain a RN signature for item ZO500.
13. During an interview on 5/24/18, at 3:35 P.M., the MDS Coordinator (MDSC) A said he/she
completes the MDS assessments and takes them to be signed by an RN. He/She said he/she
didn’t get the assessments signed because he/she is behind.
During an interview on 5/24/18, at 4:30 P.M., the director of nurses (DON) said he/she
expects staff to complete residents’ MDS assessments according to the RAI manual. He/She
said the MDSC brings the MDS assessments that need signatures to the RN working or the
DON. He/She said there is not an RN who coordinates the process.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, and record review the facility failed to complete Level I
pre-admission screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition
for one resident (Resident #25 ) and failed to send Level I pre-admission for Mental
Illness/Mental [MEDICAL CONDITION] or related condition screening to initiate a new Level
II screening that requires completion of the Preadmission Screening and Resident 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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
(PASARR) for one resident with Mental [MEDICAL CONDITION] (Resident #99) out of 7 sampled
residents. The facility census was 91.
1. Review of the facility’s policy DA 124 C (Form number for the Level I pre-admission
screening for Mental Illness/Mental [MEDICAL CONDITION] or related condition) Policy,
revised 5/29/18, showed the policy directs the staff to obtain the DA 124 C for residents
upon admission. It will be the responsibility of the social worker, Medicaid specialist
and nursing to complete the required forms and send them to Central Office Medical Review
Unit (COMRU) as required.
2. Review of Resident #25’s quarterly MDS, dated [DATE], showed:
-admission date of [DATE];
-No information for Preadmission Screening and Resident Review (PASARR);
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
During an interview on 5/24/18 at 10:19 A.M., the Medicaid Consultant said she was unable
to find any DA-124 level I screen or PASARR for the resident. Resident #25 does not have
the screenings, because he/she is a private pay resident.
3. Review of Resident #99’s, Significant Change in Status Assessment (SCSA) MDS, dated
[DATE], showed staff documented:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-The resident had not been evaluated by Level II Preadmission Screening and Resident
Review for resident’s with a serious mental illness and/or mental [MEDICAL CONDITION] or a
related condition;
-Rejects care;
-Mild depression;
-Did not contain resident or staff interview for Activities (Section F);
-Extensive assistance of one staff member for dressing, and personal hygiene;
-Dependent on one staff member for locomotion off the unit;
-Dependent on two or more staff members for bed mobility, transfers, toilet use, and
bathing;
-Antipsychotic, and antidepressant medication daily.
Review of the resident’s Level One Nursing Facility Pre-admission Screening for Mental
Illness/Mental [MEDICAL CONDITION] or related condition, dated 11/15/14, showed the
resident’s [DIAGNOSES REDACTED].
Review of the resident’s records showed the facility did not obtain the resident’s Level
II screening.
Review of the Department of Health and Senior Services (DHSS) database showed the
resident’s last Level II screening performed on 9/10/04. The screening did not reflect the
resident’s current condition.
Review of the resident’s Care Plan, dated 3/11/18, directed the staff the resident is
combative with care. Review showed to approach the resident in a calm manner, and redirect
him/her as needed when providing care. The Care Plan did not show information provided
from a Level II PASARR.
During an interview on 5/23/18, at 10:30 A.M., the Medicaid Consultant said the facility
does not have a Level II screening for the resident.
During an interview on 05/24/18 12:13 PM COMRU staff member said the resident should have
a PASARR for his admission on 6-7-17 and he/she needs a current one done. The COMRU 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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
member said the last one for this resident was done on 9/10/04, with mental [MEDICAL
CONDITION] [DIAGNOSES REDACTED]. The COMRU staff member said the resident’s Level II
screen shows inactive in the system.
During an interview on 5/24/18, at 4:19 P.M., the MDS Coordinator (MDSC) A said the Social
Services Director (SSD) fills out the section of the MDS about the PASARR, and is
responsible to include information from the Level II PASARR on the resident’s care plan.
During an interview on 5/24/18, at 4:25 P.M., the SSD said he/she does not have a copy of
a Level II PASARR for resident #99. He/She would include the information on the MDS and
Care plan if a resident had a Level II PASARR.
4. During an interview on 5/24/18 at 10:19 A.M., the facility’s Medicaid Consultant
responsible for residents’ DA124C, said the DA124C is only completed for Medicaid
residents. Private pay and insurance paid residents do not have a DA124C. There are
currently ten private pay residents and two Medicare A residents. None of them have a
completed DA124C on file. She was not aware that the DA124C was based on the bed
certification. She thought it was based on the resident’s payment source. She did not know
the DA124C had to be updated if the resident had a significant change. She did not know
what kind of change would warrant a new DA124C.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility staff failed to complete
a comprehensive care plan with measurable goals and interventions addressing all aspects
of the residents’ needs for six residents (Resident #61, #76, #80, #92, #98, and #99). The
facility’s census was 91.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, showed the
facility must develop a comprehensive care plan for each resident that includes measurable
objectives and timetables to meet a resident’s medical, nursing, and mental and
psychosocial needs that are identified in the comprehensive assessment. The comprehensive
care plan is an interdisciplinary communication tool. The services that are to be
furnished to attain or maintain the resident’s highest practicable physical, mental, and
psychosocial well-being and any services that would otherwise be required but are not
provided due to the resident’s exercise of rights including the right to refuse treatment.
The Care Area Assessments (CAA)’s provide a link between the Minimum Data Set (MDS), a
federally mandated assessment tool, completed by facility staff, and care planning. The
care plan should be revised on an ongoing basis to reflect changes in the resident and the
care that the resident is receiving.
2. Review of the Care Plan Section Responsibility policy dated 08/17/17, shows the
objective is for the facility to perform quality of care that applies to all treatment and
care provided to facility residents. Based on the comprehensive assessment of a resident,
the facility must ensure that residents receive treatment and care in accordance with
professional standards of practice, the comprehensive person-centered care plan, and the
resident’s choices. A care plan will be developed upon admission per CMS guidelines. It
will be updated quarterly, and annually per CMS guidelines to ensure that there is a
continuity of care, and is in accordance with the individual’s needs. Care plan will also

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
be updated with a significant change of condition. The care plan must be based upon the
resident assessment, choices, and advance directives, if any. As the resident’s status
changes, the facility, attending practitioner, and the resident representative, to the
extent possible, must review and/or revise care plan goals and treatment choices.
Residents who are admitted to the facility will receive an initial plan in accordance with
the physician’s orders [REDACTED]. Any family input is welcomed and will be accumulated,
and updated as needed.
3. Review of Resident #61’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 2/18/18, showed the facility assessed the resident as:
-Severe cognitive impairment;
-Limitations in two lower extremities.
Review of the resident’s care plan, updated 5/8/18, showed the care plan did not contain
direction to staff on range of motion/contracture care.
4. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment, dated
02/25/18, showed staff assessed the Resident #76 as:
-Severe cognitive impairment;
-Total physical assistance of two plus persons for transfers;
-Extensive physical assistance of one person for bed mobility, locomotion, dressing, and
bathing;
-Limited physical assistance of one person for eating, toileting, and personal hygiene;
-Limited range of motion on one side for upper and lower extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Pain medications as needed;
-Two non-injury falls and two injury falls during the look back period;
-Skin intact;
-During the seven day look back period took seven days of antianxiety medication;
-No restraints or alarms.
Review of the care plan dated 05/26/17, showed the care plan did not address the resident
eating at a bedside table in front of the nurse’s station. The care plan did not provide
direction for the staff when the resident refused to eat or displayed behaviors, such as
pushing the plate or table away. The care plan also showed the resident to have limited
range of motion for the upper and lower extremities on one side and a history of falls.
The care plan did not provide direction for staff to provide restorative nursing care.
Observation on 5/22/18, at 12:55 P.M., showed the resident sat in his/her wheelchair with
a bedside table in front of him/her at the nurses station. Observation showed staff served
the resident his/her lunch at the nurses station.
Observation on 5/24/18, at 12:52 P.M., showed the resident sat in his/her wheelchair with
a bedside table in front of him/her at the nurses station. Observation showed staff served
the resident his/her lunch at the nurses station.
During an interview on 05/24/18 at 04:21 P.M., the Director of Nursing (DON) said Resident
#76’s knees are tight and the resident has a potential for contractures but is not on a
restorative program. The DON said the resident can be combative. The DON expects the CNAs
to provide passive range of motion but does not know if this happens regular basis. The
DON expects direction for restorative care to be on the care plan. The DON also said the
resident does not eat well in the main dining room. The DON said the resident becomes
easily agitated and eats much better in a small, quiet setting. The DON expects direction
for staff to assist the resident to eat at the nurses station and how to redirect the
resident’s behaviors during meals to be on the care plan.
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
5. Review of Resident #80’s Quarterly MDS, dated [DATE], showed the staff assessed the
resident as follows:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Mild depression;
-Dependent on one staff member for locomotion, eating, and personal hygiene;
-Dependent on two or more staff members for bed mobility, transfers, dressing, toilet use,
and bathing;
-Functional limitation in range of motion to both upper and both lower extremities;
-Did not receive Restorative Nursing Program;
-Antidepressant medication daily;
-Diuretic medication 3 out of 7 days, and an opioid one out of seven days.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Care Plan, dated 12/28/17, directed staff:
-Resident has pain related to arthritis and contractures;
-Place rolled up washcloths in the residents hands.
The care plan did not include direction to the staff to prevent further or worsening of
contractures.
Observation on 5/21/18, at 10:00 P.M., showed the resident with contractures in both
hands. Additional observation did not show any splint or rolls in the resident’s hands.
Observation 5/22/18, at 2:18 P.M., showed the resident in bed. Observation showed the
resident did not have splints, or wash clothes rolled in the resident’s hands.
Observation on 5/23/18, at 11:00 A.M., showed the resident in his/her wheelchair at the
nurse’s desk. Observation showed the resident did not have splints, or wash clothes rolled
in the resident’s hands.
During an interview on 5/23/18, at 2:00 P.M., CNA D said he/she does not know if the
resident is on a Restorative Nursing program or what they do for the resident’s
contractured hands.
6. Review of Resident #92’s MDS, dated [DATE], showed facility staff assessed the resident
as follows:
-Severe cognitive impairment;
-Impairment in range of motion in one lower extremity.
Review of the resident’s care plan, updated 5/2/18, showed the care plan did not contain
direction to staff on range of motion/contracture care.
7. Review of Resident #98’s significant change MDS, a federally mandated assessment, dated
03/10/18, showed facility staff assessed the resident as:
-Severely cognitively impaired;
-Extensive physical assistance of two persons for bed mobility, transfers, and bathing;
-Extensive physical assistance of one person for dressing, toileting, and personal
hygiene;
-Limited physical assistance of one person for eating and locomotion;
-Impaired range of motion of bilateral lower extremities;
-Always incontinent of bladder and bowel;
-[DIAGNOSES REDACTED].
-Two non-injury falls;
-One Stage II pressure ulcer identified on 12/22/17;
-During the seven day look back period took seven days of antipsychotic medication;
-Hospice.
Review of the resident’s care plan, dated 03/09/18, showed the care plan did not contain
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
direction to staff for hospice care.
8. Review of Resident #99’s, Significant Change in Status Assessment (SCSA) MDS, dated
[DATE], showed staff assessed the resident as follows:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-The resident had not been evaluated by Level II Preadmission Screening and Resident
Review for resident’s with a serious mental illness and/or mental [MEDICAL CONDITION] or a
related condition;
-Rejects care;
-Mild depression;
-Did not contain resident or staff interview for Activities (Section F);
-Extensive assistance of one staff member for dressing, and personal hygiene;
-Dependent on one staff member for locomotion off the unit;
-Dependent on two or more staff members for bed mobility, transfers, toilet use, and
bathing;
-Antipsychotic, and antidepressant medication daily.
Review of the resident’s Care Plan, dated 3/11/18, directed the staff the resident is
combative with care. Review showed to approach the resident in a calm manner, and redirect
him/her as needed when providing care. The Care Plan did not show information provided
from a Level II PASARR, why the resident sits at the nurses station for meals, or any
information about aggression towards other residents.
Observation on 5/22/18, at 12:55 P.M., showed the resident sat in his/her wheelchair with
a bedside table in front of him/her at the nurses station. Observation showed staff served
the resident his/her lunch at the nurses station.
Observation on 5/24/18, at 12:52 P.M., showed the resident sat in his/her wheelchair with
a bedside table in front of him/her at the nurses station. Observation showed staff served
the resident his/her lunch at the nurses station.
During an interview on 5/22/18, at 1:19 P.M., licensed practical nurse (LPN) F said that
the resident does not sit in the dining room for meals because he/she is combative with
other residents.
9. During an interview on 5/2418 at 2:26 P.M., the Assistant Director of Nursing (ADON)
said the residents range of motion limitations should be on the care plan and he/she is
not sure why they are not there.
During an interview on 5/24/18, at 4:30 P.M., the director of nurse (DON) said he/she
expects staff to complete a comprehensive care plan according to the RAI manual. He/She
said all the care needs of the resident should be included in the care plan.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review facility staff failed to provide an
ongoing program of activities designed to meet the residents’ interest for five residents
(Resident’s # 31, #73, #80, #97, and #99) out of 19 sampled resident’s. This also had the
potential to affect all residents who received one-on-one activities. Facility census was
91.
1. Review of the facility’s policy One on One Activities, dated 5/29/18, showed the policy
directed the staff to:

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Provide a one-on-one program for resident who are room/bed bound, who refuse to
participate in scheduled activities, diagnosed with [REDACTED].
-The activity department will meet once a week to discuss and determine what activity is
suitable, stimulating, challenging and appropriate for each resident, and document in the
one-on-one activity book that is kept in the activity department;
-The notes will be documented and should coordinate with the quarterly notes that are kept
in the resident’s charts;
-The program will also be part of the resident’s care plan.
2. Review of Resident #31’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 4/41/8, showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Very important to participate in religious services/practices;
-Somewhat important to the resident to listen to the music he/she likes, be around
animals, participate in group activities, and participate in his/her favorite activities.
Resident’s care plan, dated 5/21/18, showed staff were directed to:
-Encourage and invite the resident to activities daily;
-Assist when wanting to attend;
-Will have a monthly calendar of activities.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), showed no
activities attended.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), showed no
activities attended.
Review of the resident’s Record of One-to-one Activities, dated (MONTH) (YEAR) through
(MONTH) (YEAR), showed staff did not document any one on one activities for the resident.
3. Review of Resident #73’s significant change MDS, dated [DATE], showed staff assessed
the resident as follows:
-admission date of [DATE];
-BIMS of 11 out of 15;
-Preferred the activities of music, doing things with groups of people, going outside to
get fresh air when the weather is good, and participating in religious services;
-Required total dependence of two staff for transfers;
-Ambulated with a wheelchair;
-Required limited assistance for locomotion on and off unit;
-[DIAGNOSES REDACTED].
-Had pain but it has not interfered with sleeping or day-to-day activities;
-On hospice.
Review of the resident’s care plan, last reviewed on 4/27/18, showed:
-Problem start date of 2/21/18;
-Problem: the resident prefers to stay in his/her room and watch television. The resident
has declined. The resident refuses to attend activities;
-Goal: the resident will attend one small group activity a month when feeling up to
attending. The resident will respond to simple conversation when visiting one-to-one;
-Approach: the resident will be invited to the activities. The resident will have a
monthly calendar of activities. Staff will visit one-to-one when the resident does not
want to attend activities. The resident has been admitted to hospice.
During an interview on 5/23/18 at 12:05 P.M., the resident said he/she does not get up in
his/her wheelchair, because it causes him too much pain. He/she cannot be in the Hoyer or
other lift due to pain. The nurses give him/her pain medication, but it does not work for
him. His/her legs do not work. He/she gets bored and lonely. He/she does not watch
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
television. He/she does not go to activities, because he cannot get up.
Observation of the resident on 5/24/18 at 8:19 A.M., showed the resident sat in bed and
ate breakfast. The head of the resident’s bed was elevated to 80 degrees, and the resident
was feeding himself/herself. A pillow was positioned under the left side of the resident’s
head so that the resident leaned towards the right as he/she ate. CNA D sat in a chair in
the left corner of the resident’s room and watched television. The chair in which the CNA
sat was positioned behind and to the left of the resident so he/she could not see the CNA
while he/she ate breakfast. The CNA did not talk to the resident while he ate.
Review of the one-to-one activity binder, showed the resident participated in an activity
on 1/18/18. The activity was balloon volleyball. The resident hit the balloon with the
activity staff and another person. No other activities for the resident were recorded in
the binder.
Review of the group activity binder, showed the resident did not participate in any group
activity during the month of (MONTH) or May.
During an interview on 5/24/18 at 3:20 P.M., the Director of Nursing (DON) said the
resident experienced a decline in condition after a personal relationship ended. He/she
became depressed and sickly. He/she moved to the skilled nursing facility (SNF) where
he/she continued to decline and is now on hospice. He/she does not like to leave his/her
room, but he/she gets one-to-one activities. The one-to-one activities are in the
resident’s care plan. The DON did not know how often one-to-one activities are conducted.
She knows the resident really likes the therapy dog, and he/she likes when people talk to
him/her. The one-to-one activities are good for his spirits and mood.
During an interview on 5/24/18 at 3:30 P.M., the Activity Director said the resident gets
one-to-one activities. There are no entries in his/her one-to-one activity record since
January, (YEAR), but there should be multiple entries in his/her record. She knows he/she
was invited to the Veteran activity last month. That should be documented on the record.
There should definitely be more than one activity documented on his record since January.
She is aware of the resident’s broken engagement, depression, and hospice. He/she would
benefit from the one-to-one activity, and it would be good for his/her psychosocial
well-being. She attends the resident’s care plan meetings and is aware one-to-one
activities are in his/her care plan. She knows what types of activities the resident likes
because there is an assessment in his/her chart. She confirmed there was no assessment in
the resident’s chart. She said it was her fault. The assessment should have been put in
there.
During an interview on 5/24/18 at 4:25 P.M., the Administrator said the resident has been
depressed since his/her broken engagement. He/she has slowly declined and is now on
hospice. The resident should get a one-to-one activity at least one or more times a week.
It would benefit him/her greatly to receive these. The resident enjoys conversations with
people.
4. Review of Resident #80’s Quarterly MDS, dated [DATE], showed the staff assessed the
resident as follows:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Mild depression;
-Dependent on one staff member for locomotion, eating, and personal hygiene;
-Dependent on two or more staff members for bed mobility, transfers, dressing, toilet use,
and bathing;
-Functional limitation in range of motion to both upper and both lower extremities;
-Antidepressant medication daily.
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
Review of the resident’s Significant Change in Status Assessment (SCSA) MDS, dated [DATE],
showed the staff documented the resident enjoys listening to music.
Resident’s care plan, dated 12/23/17, showed staff were directed to:
-Invite and assist the resident to scheduled activities when he/she is up;
-Will watch movies in his/her room;
-Will have a monthly calendar of activities.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), did not
contain staff documentation of the resident’s attendance at any activity.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), showed the
staff documented the resident attended a movie on 5/6/18.
Review of the resident’s Record of One-to-one Activities, dated (MONTH) (YEAR) through
(MONTH) (YEAR), did not contain staff documentation of any one on one activities for the
resident.
5. Review of Resident #97’s SCSA, dated 1/11/18, showed staff assessed the resident as
follows;
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].>-Moderate depression;
-Wandering four to six days;
-Enjoys being around animals;
-Extensive assistance of one staff member for bed mobility, transfers, locomotion,
dressing, eating, and hygiene;
-Extensive assistance of two staff members for toilet use, and bathing.
Resident’s care plan, dated 1/16/18, showed staff were directed to:
-Encourage and invite the resident to activities daily;
-Resident’s enjoys pets, and religious activities;
-Assist when wanting to attend;
-Will have a monthly calendar of activities.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), did not
contain staff documentation of the resident’s attendance at any activity.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), showed the
staff documented the resident attended spiritual/religious on 5/8/18, and 5/22/18.
Review of the resident’s Record of One-to-one Activities, dated (MONTH) (YEAR) through
(MONTH) (YEAR), did not contain staff documentation of any one on one activities for the
resident.
6. Review of Resident #99’s, Significant Change in Status Assessment (SCSA) MDS, dated
[DATE], showed staff assessed the resident as follows:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Mild depression;
-Did not contain resident or staff interview for Activities (Section F);
-Extensive assistance of one staff member for dressing, and personal hygiene;
-Dependent on one staff member for locomotion off the unit;
-Dependent on two or more staff members for bed mobility, transfers, toilet use, and
bathing;
-Antipsychotic, and antidepressant medication daily.
Review of the resident’s care plan, dated 3/11/18, showed staff were directed to:
-Staff will visit resident and have simple conversation about baseball;
-Encourage to attend one large activity such a music once a month.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), did not
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
contain staff documentation of the resident’s attendance at any activity.
Review of the resident’s Individual Resident Activities, dated (MONTH) (YEAR), did not
contain staff documentation of the resident’s attendance at any activity.
Review of the resident’s Record of One-to-one Activities, dated (MONTH) (YEAR) through
(MONTH) (YEAR), did not contain staff documentation of any one on one activities for the
resident.
7. During an interview on 5/24/18 at 3:30 P.M., the Activity Director said there are three
activity staff: herself, one full time, and one part time. They document activities in two
different notebooks: a group activity book and a one-to-one activity book. If the resident
comes to a group activity then a dash is put in the activity box for the specific date. If
a resident is offered and participates/declines a one-to-one activity then it is noted in
the one-to-one activity book. In the one-to-one activity book, the following is noted: the
date, the activity, and the resident’s response. There should be an entry for each
activity offered. If there is no entry than she cannot be certain the resident was offered
a one-to-one activity. She does not have a list of residents who receive one-to-one
activities. She just goes over the census and sees who does not attend group. That is how
they decide who gets one-to-one. There is no schedule for one-to-one activity. They just
fit it in whenever they can get to it. It could be 2-3 x/wk or not at all. Ideally,
one-to-one activities should be conducted 2-3 times a week. Minimally, one-to-one
activities should be 1-2 times a week.
8. During an interview on 5/24/18 at 4:25 P.M., the Administrator said he would expect
care plans to be followed. He would expect one-to-one activity to occur at least one time
a week. The staff meet every day to discuss each resident. The Activity Director is at
this meeting and at the care plan meeting. She should be aware which residents have
one-to-one activities. She should make a list and have a schedule. She should document if
it is done and if it is refused. If a resident consistently refuses the one-to-one
activities then she should mention it at the daily meeting.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, facility staff failed to provide
restorative nursing services as ordered by the physician for one resident (Resident #61)
with limitations in range of motion (ROM). Facility failed to provide restorative nursing
services to prevent a decline in resident’s range of motion, ability to perform activities
of daily living (ADL’s) and mobility for four residents (Resident #76, #80, #92, and #98).
The facility census was 91.
1. Review of the facility’s policy Restorative Therapy, dated 9/2017, directs the staff:
-Restorative therapy will be to achieve the highest level of functioning for the
individual;
-Restorative orders are generally two times a week unless otherwise ordered;
-All orders will be reviewed monthly by the Director of Nursing (DON) or clinical managers
to reassess the appropriateness of the restorative therapy program.
2. Review of the facility’s policy Range of Motion (ROM) Exercises, dated 5/4/15, showed
the policy directed staff to:

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Prevent contractures (tightening of the muscles related to immobility that can cause
inability to move a joint, pressure ulcers, pain, and limit the resident’s ability to
function);
-Gives direction on how to provide ROM for the neck, shoulders, elbow, wrist, fingers,
hip, knee, ankle, and toes.
The facility’s policies do not contain direction for how resident’s with contractures, or
with potential for contractures will receive services to maintain or prevent worsening of
the resident’s current function.
3. Review of Resident #61’s Minimum Data Set, a federally mandated assessment tool, dated
2/18/18, showed facility staff assessed the resident as follows:
-Severe cognitive impairment;
-Range of motion (ROM) impairment in two lower extremities;
-No ROM impairment in the upper extremities;
-Did not receive restorative therapy in the last seven calendar days.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Nursing rehab/Restorative plan of care, dated (MONTH) (YEAR),
showed staff documented restorative nursing was administered on the 2 nd, 11 th, 18 th,
and 1st.
Further review of the resident’s Nursing rehab/Restorative plan of care, dated (MONTH)
(YEAR), showed staff did not document they administered restorative therapy twice a week
as ordered.
Review of the resident’s POS, dated (MONTH) (YEAR), showed the physician ordered
restorative therapy twice a week to maintain functional mobility as tolerated, ordered on
[DATE].
Review of the resident’s Nursing rehab/Restorative plan of care, dated (MONTH) (YEAR),
showed staff documented they administered restorative nursing on the 2 nd, 9th, 16 th, and
19 th.
Further review of the resident’s Nursing rehab/Restorative plan of care, dated (MONTH)
(YEAR), showed staff did not document they administered restorative therapy twice a week
as ordered.
Review of the resident’s care plan, updated 5/8/18, showed no direction for staff for
limitations in range of motion or restorative therapy program.
During an interview on 5/24/18 at 2:26 P.M., the Assistant Director of Nursing (ADON) said
the facility was short staffed in (MONTH) and the restorative aid was pulled to the floor
and restorative therapy was not done.
4. Review of Resident #76’s admission Minimum Data Set (MDS), a federally mandated
assessment, dated 02/25/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-Total physical assistance of two plus persons for transfers;
-Extensive physical assistance of one person for bed mobility, locomotion, dressing, and
bathing;
-Limited physical assistance of one person for eating, toileting, and personal hygiene;
-Limited range of motion on one side for upper and lower extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Pain medications as needed;
-Two non-injury falls and two injury falls during the look back period;
-Skin intact;
-During the seven day look back period took seven days of antianxiety medication;
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-No restraints or alarms.
Review of the care plan dated 05/26/17, showed staff documented the resident had limited
range of motion for the upper and lower extremities on one side and a history of falls.
The care plan did not provide direction for staff to provide restorative nursing care.
Review of the Physician order [REDACTED].
Review of the resident’s chart showed staff did not document a restorative nursing plan to
maintain the resident’s current functional status.
5. Review of Resident #80’s Quarterly MDS, dated [DATE], showed the staff documented:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Mild depression;
-Dependent on one staff member for locomotion, eating, and personal hygiene;
-Dependent on two or more staff members for bed mobility, transfers, dressing, toilet use,
and bathing;
-Functional limitation in range of motion to both upper and both lower extremities;
-Did not receive Restorative Nursing Program, or therapy.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Care Plan, dated 12/28/17, showed the care plan directed staff:
-Resident has pain related to arthritis and contractures;
-Place rolled up washcloths in the resident’s hands.
The care plan did not include direction to provide restorative therapy to prevent
worsening of ROM limitations in the resident’s upper and lower extremities.
Review of the resident’s record showed it did not contain Restorative Nursing plan or
documentation.
Observation on 5/21/18, at 10:00 P.M., showed the resident with contractures in both
hands. Additional observation did not show any splint or rolls in the resident’s hands.
Observation 5/22/18, at 2:18 P.M., showed the resident in bed. Observation showed the
resident did not have splints, or wash clothes rolled in the resident’s hands.
Observation on 5/23/18, at 11:00 A.M., showed the resident in his/her wheelchair at the
nurse’s desk. Observation showed the resident did not have splints, or wash clothes rolled
in the resident’s hands.
During an interview on 5/23/18, at 2:00 P.M., CNA D said he/she does not know if the
resident is on a Restorative Nursing program or what they do for the resident’s contracted
hands.
6. Review of Resident #92’s MDS, dated [DATE], showed staff documented the resident as:
-Severe cognitive impairment;
-ROM impairment in one lower extremity;
-No ROM impairment in upper extremities;
-Did not receive restorative therapy in the last seven calendar days.
Review of the resident’s care plan, dated 5/2/18, showed the plan directed staff to do the
following:
-Required assistance of one staff for transfers;
-Continue to work with therapy Physical Therapy (PT)/Occupational therapy (OT) as of
(MONTH) 12 th;
-Follow OT/PT/ST recommendations;
-Resident had a left [MEDICAL CONDITION].
Review of the resident’s medical record showed the resident did not receive restorative
nursing services.
During an interview on 5/24/18 at 2:26 P.M., the ADON said that the resident has issues
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
with range of motion since his/her [MEDICAL CONDITION]. Staff usually refer them to
therapy for splints but didn’t think about referring the resident to therapy or
restorative therapy for his/her limitations in range of motion.
7. Review of Resident #98’s significant change MDS, a federally mandated assessment, dated
03/10/18, showed facility staff assessed the resident as:
-Severely cognitively impaired;
-Extensive physical assistance of two persons for bed mobility, transfers, and bathing;
-Extensive physical assistance of one person for dressing, toileting, and personal
hygiene;
-Limited physical assistance of one person for eating and locomotion;
-Impaired range of motion of bilateral lower extremities;
-Always incontinent of bladder and bowel;
-[DIAGNOSES REDACTED].
-Two non-injury falls;
-One Stage II pressure ulcer identified on 12/22/17;
-During the seven day look back period took seven days of antipsychotic medication;
-Hospice.
Review of the care plan dated 03/09/18, showed the resident requires extensive assistance
with Activities of Daily Living (ADLs) due to dementia and weakness and has a history of
falls. The care plan does not provide direction for staff to maintain current functional
status by providing restorative nursing care such as passive range of motion.
Review of the Physician order [REDACTED].
Review of the resident’s chart showed staff did not document a restorative nursing plan to
maintain the resident’s current functional status.
8. During an interview on 5/24/18, at 3:00 P.M., the Assistant Director of Nursing (ADON)
said he/she oversees the Restorative nursing program. He/She said he/she does not think
about how to maintain ability for resident’s with contractures, or include them in the
Restorative Nursing program. He/She said the facility only has two Restorative aides so
they have to limit who is on the Restorative Nursing program. The ADON said to maintain
current ability and prevent further contractures Restorative nursing would do a program
for range of motion. He/She was not aware resident’s with contractures should be on a
restorative program. He/She said the following resident’s current condition includes:
-Resident #27 had a resting hand splint and he/she does not know if the resident currently
does or if he/she is on a Restorative program;
-Resident #76 had a [MEDICAL CONDITION] last year, does not walk anymore, and is not on a
Restorative program;
-Resident #80 has hand contractures and foot drop, and is not on a Restorative program;
-Resident #92 had a fracture and a decline, and is not on a Restorative program;
-Resident #98 cannot straighten legs during care, and is not on a Restorative program.
The ADON said he/she could not find policy on maintaining ADL’s and functional abilities
or preventing comorbidities from worsening contractures.
During an interview on 5/24/18, at 4:19 P.M., the MDS Coordinator (MDSC) A said the
following:
-Resident #61–is on restorative, he/she does not think about putting restorative on the
care plan;
-Resident #76 leg muscles are tight with a potential for contractures, he/she might do
passive ROM;
-Resident #80 hands are contracted, the washcloths should be on the care plan, and he/she
do not know about his/her feet;
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-Resident #92 ambulated before his/her fracture and is no longer able to, he/she does not
know if he/she has a restorative plan;
-Resident #98 has range of motion issues in his/her knees, he/she does not know why not
the facility is not doing ROM.
During an interview on 5/24/18, at 4:30 P.M., the DON said the ADON oversees Restorative
nursing. He/She said the ADON and MDSC are expected to coordinate restorative nursing
information for the MDS and care plan.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview the facility failed to complete
individual entrapment assessments, measures for additional monitoring for resident’s at
risk for entrapment that have bed rails, and obtain informed consent for the use of bed
rails for ten resident’s (Resident #27, #32, #38, #59, #66,#73, #80, #95, #98, and #99)
out of 19 sampled residents. The facility census was 91.
1. Review of the facility’s policy Side Rail Guidelines, dated 5/19/17, showed it directed
staff:
-Bed rails may be used to aide in turning and repositioning while in bed;
-Providing a hand-hold for getting in or out of bed.
The facility’s policy did not contain an individual resident assessment for risk of
entrapment, additional safety measures if bed rails are used on a resident at risk for
entrapment, or informed consent from the resident’s or the resident’s responsible party on
the risk or benefits of using bed rails.
2. Review of Resident #27’s quarterly MDS, a federally mandated assessment, dated
01/23/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Requires total physical assistance of two plus persons for bed mobility, transfers, and
bathing;
-Requires total physical assistance of one person for locomotion, dressing, eating,
toileting, and personal hygiene;
-Impaired range of motion for bilateral upper and lower extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-No restraints.
Review of the resident’s Side Rail Evaluation Screen dated 04/20/18, showed the following:
-Resident should use half side rails bilaterally to attain or maintain his/her highest
practical level;
-Did not include an assessment of the resident’s entrapment risk.
Review of the resident’s record did not contain a consent for the use of bed rails, or
education of the resident’s representative of the risk and benefits for the use of bed
rails.
3. Review of Resident #32’s significant change MDS, dated [DATE], showed the following:
-Understood/understands;

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-BIMS of 3 out of 15, severe cognitive impairment;
-Requires extensive assistance for bed mobility;
-Total dependence for transfers;
-No functional limitation in range of motion of upper extremities;
-Functional limitation in range of motion on one side of lower extremities;
-[DIAGNOSES REDACTED].
-On hospice;
-Bed rails not used.
Review of the resident’s Side Rail Evaluation Screen dated 1/23/18, showed the following:
-Resident should use bilateral quarter side rails to attain or maintain his/her highest
practical level;
-Did not include an assessment of the resident’s entrapment risk;
-Alternatives used and effectiveness not listed.
Review of the resident’s care plan, last reviewed on 5/23/18, did not discuss the use of
side rails or grab bars.
Review of the resident’s POS, dated 5/1/18 through 5/31/18, showed no order for side rails
or grab bars.
Review of the resident’s record did not contain a consent for the use of bed rails, or
education of the resident’s representative of the risk and benefits for the use of bed
rails.
Observation on 5/22/18 at 12:00 noon and 5/24/18 at 2:45 P.M., showed the resident laid in
bed with bilateral half side rails up.
4. Review of Resident #38’s quarterly MDS, a federally mandated assessment, dated
02/04/18, showed the following:
-Severe cognitive impairment;
-Total physical assistance of two persons for bathing;
-Extensive physical assistance of two persons for bed mobility, transfers, and toileting;
-Extensive physical assistance of one person for locomotion, dressing, and personal
hygiene;
-Independent with set up help for eating;
-Impaired range of motion for bilateral lower extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-During the seven day look back period took an antipsychotic for seven days and an
antidepressant for seven days;
-No restraints.
Review of the resident’s Side Rail Evaluation Screen dated 04/20/18, showed the following:
-Resident should use quarter side rails bilaterally to attain or maintain his/her highest
practical level;
-Did not include an assessment of the resident’s entrapment risk.
Review of the resident’s record did not contain a consent for the use of bed rails, or
education of the resident’s representative of the risk and benefits for the use of bed
rails.
5. Review of Resident #59’s annual MDS, dated [DATE], showed the following:
-Understood/understands;
-BIMS of 14 out of 15, cognitively intact;
-Requires extensive assistance for bed mobility and transfers;
-No functional limitation in range of motion of extremities;
-[DIAGNOSES 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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-Bed rails not used.
Review of the resident’s Side Rail Evaluation Screen dated 8/3/17, showed the following:
-Resident should use bilateral grab bars to attain or maintain his/her highest practical
level;
-Did not include an assessment of the resident’s entrapment risk;
-Alternatives used and effectiveness not listed.
Review of the resident’s care plan, last reviewed on 4/11/18, showed the following:
-Problem start date 1/28/18;
-Problem: Resident requires extensive assist with bed mobility;
-Goal: Utilize approaches to help meet resident’s needs;
-Approach: Use grab bars x 2 to assist with bed mobility.
Review of the resident’s POS, dated 5/1/18 through 5/31/18, showed an undated order for
bilateral half grab bars for positioning and mobility.
Review of the resident’s record did not contain a consent for the use of bed rails, or
education of the resident’s representative of the risk and benefits for the use of bed
rails.
Observation on 5/22/18 at 12:10 P.M., 5/23/18 at 3:30 P.M., and 5/24/18 at 8:19 A.M.,
showed the resident laid in bed with bilateral grab rails up.
6. Review of Resident #66’s quarterly MDS, a federally mandated assessment, dated
12/24/17, showed the following:
-Cognitively impaired;
-Extensive physical assistance of two persons for transfers and toileting;
-Extensive physical assistance of one person for bed mobility, dressing, personal hygiene,
and bathing;
-Limited physical assistance of one person for locomotion;
-Set up help and supervision for eating;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-[DIAGNOSES REDACTED].
-Receives pain medication as needed for occasional pain;
-During the seven day look back period took an antipsychotic for seven days and a diuretic
for seven days;
-During the look back period, had two non-injury falls;
-No restraints.
Review of the resident’s Side Rail Evaluation Screen, dated 03/06/18, showed the
following:
-Resident should use grab bars on one side to attain or maintain his/her highest practical
level;
-Did not include an assessment of the resident’s entrapment risk.
Review of the resident’s record showed it did not contain a consent for the use of bed
rails, or education of the resident’s representative of the risk and benefits for the use
of bed rails.
7. Review of Resident #73’s significant change MDS, dated [DATE], showed the following:
-Understood/understands;
-BIMS of 11 out of 15, moderate cognitive impairment;
-Requires extensive assistance for bed mobility;
-Total dependence for transfers;
-No functional limitation in range of motion of extremities;
-[DIAGNOSES 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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-On hospice;
-Bed rails not used.
Review of the resident’s Side Rail Evaluation Screen dated 2/22/18, showed the following:
-Resident should use half side rails to attain or maintain his/her highest practical
level;
-Did not include an assessment of the resident’s entrapment risk;
-Alternatives used and effectiveness not listed.
Review of the resident’s care plan, last reviewed on 4/27/18, showed it did not address
the use of side rails or grab bars.
Review of the resident’s POS, dated 5/1/18 through 5/31/18, showed an undated order for
half side rails (grab bars) for positioning and mobility. The order was crossed out and
discontinued on 4/30/18.
Review of the resident’s record showed it did not contain a consent for the use of bed
rails, or education of the resident’s representative of the risk and benefits for the use
of bed rails.
Observation on 5/22/18 at 12:05 P.M., 5/23/18 at 3:32 P.M., and 5/24/18 at 2:45 P.M.,
showed the resident laid in bed with bilateral half side rails up.
During an interview on 5/24/18 at 3:20 P.M., the Director of Nursing (DON), said if a
physician’s orders [REDACTED]. In the case of side rails, nurses should let the
maintenance staff know the side rails have been discontinued and need to be removed.
Maintenance should go and remove the side rails. She confirmed the resident is lying in
bed with the side rails up. She said the side rails should not be on the bed.
8. Review of Resident #80’s Quarterly MDS, dated [DATE], showed the staff documented:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Mild depression;
-Dependent on one staff member for locomotion, eating, and personal hygiene;
-Dependent on two or more staff members for bed mobility, transfers, dressing, toilet use,
and bathing;
-Functional limitation in range of motion to both upper and both lower extremities;
-Did not receive Restorative Nursing Program.
Review of the resident’s Side Rail Evaluation Screen dated 12/23/17, showed the following:
-Resident should use side rails bilaterally to attain or maintain his/her highest
practical level with bolster mattress.
-Did not include an assessment of the resident’s entrapment risk.
Further review showed the side rail safety check blank on the assessment.
Review of the resident’s Care Plan, dated 12/23/17, showed it directed the staff the
resident has pain related to arthritis and contractures. The care plan did not contain
information about mattress bolsters, the resident’s use of bed rails, or safety measures
to reduce the risk of entrapment.
Review of the resident’s record did not contain a consent for the use of bed rails, or
education of the resident’s representative of the risk and benefits for the use of bed
rails.
Observation on 5/21/18, at 10:00 P.M., showed the resident in bed with a bolster mattress
and full bed rails extending from the resident’s head to his/her feet.
9. Review of Resident #95’s Quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-Extensive assistance of one staff member for dressing, and personal hygiene;
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
-Extensive assistance of two staff members for bed mobility, toilet use, and bathing;
-Dependent of two staff members for transfers;
-Functional Limitation in range of motion of one upper extremity and both lower
extremities.
Review of the resident’s Side Rail Evaluation Screen dated 12/23/17, showed the following:
-Resident should use half side rails bilaterally to attain or maintain his/her highest
practical level with bolster mattress.
-Did not include an assessment of the resident’s entrapment risk.
Further review showed the side rail safety check blank on the assessment.
Review of the resident’s Care Plan, dated 12/10/17, showed it directed the staff the
resident to use grab bars to assist with bed mobility.
Review of the resident’s Side Rail Evaluation Screen dated 3/20/18, showed the following:
-Resident should use two quarter side rails bilaterally to attain or maintain his/her
highest practical level;
-Did not include an assessment of the resident’s entrapment risk.
Review of the resident’s record showed it did not contain a consent for the use of bed
rails, or education of the resident’s representative of the risk and benefits for the use
of bed rails.
Observation on 5/21/18, at 10:23 P.M., showed the resident in his/her bed with his/her
eyes closed. The resident’s upper bed rails in a raised position.
During an interview on 5/23/18, at 2:33 P.M., the resident said he/she didn’t know why
he/she had the bed rails. He/She said he/she cannot turn, or really use them.
10. Review of Resident #98’s significant change MDS, a federally mandated assessment,
dated 12/24/17, showed staff assessed the resident as follows:
– Severe cognitive impairment;
-Extensive physical assistance of two persons for bed mobility, transfers, and bathing;
-Extensive physical assistance of one person for dressing, toileting, and personal
hygiene;
-Limited physical assistance of one for locomotion and eating;
-Impaired range of motion for bilateral lower extremities;
-Two non-injury falls during the look back period;
-During the seven day look back period took an antipsychotic for seven days;
-Hospice;
-No restraints.
Review of the resident’s Side Rail Evaluation Screen, dated 09/07/17, showed the
following:
-Resident should use grab bars on one side to attain or maintain his/her highest practical
level;
-Did not include an assessment of the resident’s entrapment risk.
Review of the resident’s record did not contain a consent for the use of bed rails, or
education of the resident’s representative of the risk and benefits for the use of bed
rails.
11. Review of Resident #99’s, Significant Change in Status Assessment (SCSA) MDS, dated
[DATE], showed staff assessed the resident as follows:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Rejects care;
-Extensive assistance of one staff member for dressing, and personal hygiene;
-Dependent on one staff member for locomotion off the unit;
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
-Dependent on two or more staff members for bed mobility, transfers, toilet use, and
bathing;
-Antipsychotic, and antidepressant medication daily.
Review of the resident’s Care Plan, dated 3/11/18, directed the staff the resident to use
padded 1/2 side rails for protection related to [MEDICAL CONDITION] and to assist with bed
mobility.
Review of the resident’s Side Rail Evaluation Screen dated 5/24/18, showed the following:
-Resident should use half side rails bilaterally to attain or maintain his/her highest
practical level;
-Did not include an assessment of the resident’s entrapment risk.
Review of the resident’s record showed it did not contain a consent for the use of bed
rails, or education of the resident’s representative of the risk and benefits for the use
of bed rails.
Observation on 05/21/18, at 10:10 P.M., showed the resident in his/her bed. Observation
showed bed rails in the raised position from the resident’s chest to his/her knees. The
rail on the resident’s left side of the bed had a cushion hanging on one side, the right
side did not have a pad on the bed rail. Further observation showed the resident did not
utilize the bed rail when staff turned him/her.
12. During an interview on 5/24/18, at 4:00 P.M., the director of nursing (DON) said
he/she thought the measurements of the bed rails accounted for the entrapment assessment,
and the facility does not have a consent form they use for bed rail use.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to obtain stop dates of 14
days or less on PRN (as needed) [MEDICAL CONDITION] medications (a chemical substance that
changes brain function and results in alterations in perception, mood, consciousness or
behavior), or specify conditions present to administer the medication for three residents
(Resident #80, #98, and #99) out of 19 sampled residents. The facility census was 91.
1. Review of the facility’s policy [MEDICAL CONDITION] Medications, dated (MONTH) (YEAR),
showed the policy directed staff:
-Physicians and psychiatric consultants will use [MEDICAL CONDITION] medications
appropriately working with the interdisciplinary team to ensure appropriate use,
evaluation and monitoring.
-The facility will comply with state and federal regulations related to the use of
psychopharmacological medications in the long-term care facility to include regular review
for continued need, appropriate dosage, side effects, risks and/or benefits;
-Gradual dose reductions must be attempted for two separate quarters with at least one
month between attempts;
-Gradual dose reductions must be attempted annually thereafter or as the resident’s
clinical condition warrants unless clinically contraindicated;
-Acceptable [DIAGNOSES REDACTED].
-Behavioral monitoring completed every shift and documented on the behavior charting;

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
-Behavior and adverse reactions reviewed in interdisciplinary team with interventions and
recommendations will be forwarded to physicians and/or psychiatric consultants;
-[MEDICAL CONDITION] medication use, [DIAGNOSES REDACTED].
2. Review of Resident #80’s Quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 3/20/18, showed the staff assessed the resident as follows:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-Mild depression;
-Antidepressant medication daily.
Review of the resident’s Quarterly [MEDICAL CONDITION] Medication Assessment, dated
5/9/17, showed:
-Antidepressants: [MEDICATION NAME];
-Antianxiety: [MEDICATION NAME];
-Psychiatrist reviewed medications 3/30/17.
Review of the resident’s physician’s orders [REDACTED].
The physicians order did not contain a stop date of 14 days or less.
Review of the resident’s chart showed staff did not document monitoring for adverse
effects or side effects of the [MEDICAL CONDITION] medications.
3. Review of Resident #98’s significant change MDS, a federally mandated assessment, dated
03/10/18, showed facility staff assessed the resident as:
-Severely cognitively impaired ;
-Extensive physical assistance of two persons for bed mobility, transfers, and bathing;
-Extensive physical assistance of one person for dressing, toileting, and personal
hygiene;
-Limited physical assistance of one person for eating and locomotion;
-Impaired range of motion of bilateral lower extremities;
-Always incontinent of bladder and bowel;
-[DIAGNOSES REDACTED].
-Two non-injury falls;
-One Stage II pressure ulcer identified on 12/22/17;
-During the seven day look back period took seven days of antipsychotic medication;
-Hospice.
Review of the resident’s care plan, dated 03/09/18, showed the care plan did not address
the use of the antianxiety medication.
Review of the resident’s Physician order [REDACTED]. The order did not contain a specific
indication for use or a stop date of 14 days or less.
4. Review of Resident #99’s, Significant Change in Status Assessment (SCSA) MDS, dated
[DATE], showed staff documented:
-Severely impaired cognition;
-[DIAGNOSES REDACTED].
-The resident had not been evaluated by Level II Preadmission Screening and Resident
Review for resident’s with a serious mental illness and/or mental [MEDICAL CONDITION] or a
related condition;
-Rejects care;
-Mild depression;
-Antipsychotic, and antidepressant medication daily;
-Gradual dose reduction has not been attempted, physician documented GDR as clinically
contraindicated 10/30/17.
Review of the resident’s physician’s 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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
-[MEDICATION NAME] (medication for anxiety) 2 mg every day at bedtime for anxiety;
-[MEDICATION NAME] (medication for hallucinations and delusion) 1.5 mg twice daily call
physician if oversedated (The medication did not have an indication);
-[MEDICATION NAME] (medication for depression) 15 mg every day at bedtime;
-[MEDICATION NAME] ([MEDICAL CONDITION] medication that can cause sedation) 150 mg twice
daily;
-[MEDICATION NAME] (medication for anxiety) 1 mg every 4 hours PRN for restlessness and
prior to shower or bath (the medication order did not contain a stop date) ordered
4/10/18;
-[MEDICATION NAME] 1 mg/ml gel apply 1 ml syringe at pulse point every 4 hours for
agitation PRN (the medication order did not contain a stop date) ordered 5/1/18 and is a
duplicate therapy for the previous [MEDICATION NAME] order.
Review of the resident’s Quarterly [MEDICAL CONDITION] Medication Assessment, dated
2/17/18, showed:
-[MEDICAL CONDITION]: [MEDICATION NAME], and Respiridone;
-Antidepressants: [MEDICATION NAME];
-Psychiatrist reviewed medications 10/17/17.
Review of the resident’s chart showed staff did not document they monitored for adverse
effects or side effects of the [MEDICAL CONDITION] medications.
Observation on 5/22/18, at 1:20 P.M., showed the resident had involuntary lip smacking (a
possible side effect of [MEDICAL CONDITION] medications.
5. During an interview on 5/23/18, at 9:56 A.M., licensed practical nurse (LPN) E said
he/she did not know if staff are expected to obtain stop dates for PRN orders for [MEDICAL
CONDITION] medication.
During an interview on 5/24/18, at 4:30 P.M., the director of nursing (DON) said that
resident’s are monitored for behaviors just by what is in the nurses notes, behaviors and
psychosocial needs should be on the care plan, and the staff monitor for side effects
monthly. He/She said antipsychotics are supposed to have a 14 day stop date.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, record review, and interview the facility staff failed to prepare
the pureed food according to the nutritionally calculated recipe, serve the nutritionally
correct portion sizes, held pureed food hot longer than two hours, and failed to reheat
the pureed food in a manner to prevent infections for six resident (Resident #23, #25,
#43, #48, #92, and #100). The facility census was 91.
1. Review of the facility’s Pureed Food Guidelines, undated, direct staff on the
following:
-Entrees: 3 ounces (oz) cooked or 1/2 cup cooked (ground) per serving; 1/2 slice of bread
per serving; Broth same as the type of meat; place bread, then food to be pureed in
blender or food processor, begin with 1/2 cup of liquid, puree, then continue to alternate
adding liquid and pureeing until the product is the correct consistency;
-Vegetables cooked: 1/2 cup of cooked vegetable per serving; 1/2 slice of bread per
serving; melted margarine; Place bread, then food to be pureed in the blender or food
processor, begin with 1/2 cup melted margarine or liquid; puree, then continue to

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
alternate adding liquid and pureeing until product is correct consistency;
-The consistency of the pureed food should not be thinner than pudding or thicker than
mashed potatoes;
-After pureeing place the food in a steam table pan, cover with foil, and reheat to above
165 degrees.
2. Review of the facility’s Menu for 5/23/18 lunch meal, showed the menu directed the
staff to serve residents with a pureed diet:
-1/2 cup pureed pork with pureed bread;
-1/2 cup sweet potatoes;
-1/2 cup pureed vegetable blend with pureed bread;
-1/2 cup lemon pudding with topping.
Review of the facility’s Menu for 5/24/18 lunch meal, showed the menu directed the staff
to serve residents with a pureed diet:
-1 cup of pureed roast beef; with
-1/4 cup of gravy with pureed bread;
-1/2 cup of whipped potatoes; with
-1/2 cup gravy;
-1/2 cup of green beans with pureed bread;
-1/2 cup of pureed strawberry shortcake.
3. Review of Resident #23’s Physicians Orders, dated 5/1/18-5/31/18, showed the physician
directed the staff to serve the resident a pureed diet.
Review of Resident #25’s Physicians Orders, dated 5/1/18-5/31/18, showed the physician
directed the staff to serve the resident a pureed diet.
Review of Resident #43’s Physicians Orders, dated 5/1/18-5/31/18, showed the physician
directed the staff to serve the resident a pureed diet.
Review of Resident #48’s Physicians Orders, dated 5/1/18-5/31/18, showed the physician
directed the staff to serve the resident a pureed diet.
Review of Resident #92’s Physicians Orders, dated 5/1/18-5/31/18, showed the physician
directed the staff to serve the resident a pureed diet.
Review of Resident #100’s Physicians Orders, dated 5/1/18-5/31/18, showed the physician
directed the staff to serve the resident a pureed diet.
4. Observation on 5/23/18, at 9:15 A.M., showed Cook C placed eight pieces of bread, and
eleven #8 1/2 cup scoops of diced pork roast, and an unmeasured amount of broth into the
blender and blended. He/She took the blended food out of the blender and placed in a steam
table pan and covered with plastic wrap and foil and placed into the oven set at 200
degrees. The staff did not prepare the pureed pulled pork according to the facility’s
Pureed Food Guidelines, held the food hot more than two hours, and did not rapid reheat
the pureed food to 165 degrees.
During an interview on 5/23/18, at 09:21 A.M., Cook C said that he/she already pureed the
vegetables for lunch, and lunch starts at 12:30 P.M
Observation on 5/23/18, at 12:37 P.M., showed Cook C prepared the plates for Residents
#23, #25, #43, #48, #92, and #100. The staff served #8 1/2 cup gray scoop pureed meat, #8
1/2 cup gray scoop of pureed sweet potato, and #8 1/2 cup gray spoon of the puree
vegetable.
5. During an interview on 5/24/18, at 8:58 A.M., Cook C said he/she prepares the pureed
food for lunch before 9:00 A.M. He/She said he/she places a piece of bread, a serving of
the food item, and broth or water for most all of the pureed food.
Observation on 5/24/18, at 9:00 A.M., showed Cook C placed five pieces of bread into the
blender, 10 #8 1/2 cup gray spoons of green beans, 1/2 cup of butter and blended. He/She
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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
took the blended food out of the blender and placed in a steam table pan and covered with
plastic wrap and foil and placed into the oven set at 200 degrees for the meal at 12:30
P.M The staff did not prepare the green beans according to the facility’s Pureed Food
Guidelines, held the food hot more than two hours, and did not rapid reheat the pureed
food to 165 degrees.
Observation on 5/24/18, at 9:11 A.M., showed Cook C placed five pieces of bread in the
blender to make 10 servings, 10 slices of roast beef, 1/2 cup beef broth, and blended.
He/She took the blended food out of the blender and placed in a steam table pan and
covered with plastic wrap and foil and placed into the oven set at 200 degrees for the
meal at 12:30 P.M The staff did not prepare the roast beef according to the facility’s
Pureed Food Guidelines, held the food hot more than two hours, and did not rapid reheat
the pureed food to 165 degrees.
During an interview on 5/24/18, at 9:16 A.M., Cook C said he/she keeps the prepared pureed
food in the oven until the meal. He/She gets it done early to make sure he/she gets done.
6. During an interview on 5/24/18, at 11:43 A.M., Cook C said he/she does not know how
long to hold hot pureed food, or about rapid reheating of pureed food to 165 degrees that
maintains for 15 seconds. He/She said he/she places the pureed food in the oven at 200
degrees and then takes it down to serve. He/she said hot meat like beef has to be at 165,
no one ever told him/her what specific temperature the any of the food is supposed to be.
During an interview on 5/24/18, at 11:47 A.M., the Dietary Manager (DM) said that staff
are expected to prepare food according to the Pureed Food Guidelines. He/She said the
staff place the broth and a slice of bread for each serving into the blender, and blend
until the food gets to the right consistency. He/She said one cook then puts the food into
the steamer and the other cook puts the prepared pureed food in the oven. He/She said
he/she does not know how long the pureed food can be kept hot. The other cook prepares the
pureed food right before the meal but Cook C prepares the pureed food earlier.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures for the inspection, testing and maintenance of the facility water
systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak
of Legionnaire’s Disease (LD). The facility census was 91.
1. Review of the facility’s building maintenance, inspection and testing records, showed
the records did not contain documentation of a water management program to monitor the
facility’s water systems for the growth of waterborne pathogens and prevent LD.
During an interview on 05/22/18 at 12:25 P.M., the Maintenance Director said he/she did
not have policies and procedures for the inspection, testing and maintenance of the
facility water systems and did not know of the requirement to have a water management
program to prevent the growth of waterborne pathogens.
During an interview on 05/23/18 at 11:40 A.M., the administrator said the facility did not
have policies and procedures for the inspection, testing and maintenance of the facility
water systems and he/she did not know of the requirement to develop a water management
program to prevent the growth of waterborne pathogens.
Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification
(S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:

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:

265140

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

NAME OF PROVIDER OF SUPPLIER

MARYMOUNT MANOR

STREET ADDRESS, CITY, STATE, ZIP

313 AUGUSTINE RD, PO BOX 600
EUREKA, MO 63025

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 33)
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at
risk. Those at risk include persons who are at least [AGE] years old, smokers, or those
with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression.
Outbreaks have been linked to poorly maintained water systems in buildings with large or
complex water systems including hospitals and long-term care facilities. Transmission can
occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and
decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial
growth in building water systems that reduce the risk of growth and spread of Legionella
and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies
and procedures to reduce the risk of growth and spread of Legionella and other
opportunistic pathogens in building water systems. An industry standard calling for the
development and implementation of water management programs in large or complex building
water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by
American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In
(YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this
ASHRAE Standard(https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html).
Environmental, clinical, and epidemiological considerations for healthcare facilities are
described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management
implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,
nontuberculous mycobacteria, and fungi) could grow and spread in the facility water
system;
-Implement a water management program that considers the ASHRAE industry standard and the
CDC toolkit, and includes control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for
pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the
results of testing and corrective actions taken when control limits are not maintained.