MARYMOUNT MANOR

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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

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

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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

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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

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;

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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

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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

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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

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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:

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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:

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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;

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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;

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

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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: