Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Immediately tell the resident, the resident’s doctor, and a family member of situations
(injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the physician of a
change in condition for one resident (Resident #40), in a review of 15 sampled residents.
The facility census was 43.
1. Review of the facility policy Change in a Resident’s Condition or Status, last revised
5/17, showed: The nurse will notify the resident’s attending physician or physician on
call when there has been a significant change in the resident’s physical/ emotional/
mental condition; need to alter the resident’s medical treatment significantly and with
the need to transfer the resident to a hospital. A significant change of condition is a
major decline or improvement in the resident’s status that will not normally resolve
itself without intervention by staff or by implementing standard disease-related clinical
interventions and/or impacts more than one area of the resident’s health. Prior to
notifying the physician or healthcare provider, the nurse will make detailed observations
and gather relevant and pertinent information for the provider. Except in medical
emergencies, notifications will be made within 24 hours of a change occurring in the
resident’s medical/mental condition or status.
2. Review of Resident #40’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument to be completed by the facility, dated 1/20/19, showed the
following:
-Speech clear;
-Usually made self understood and understood others;
-Independent with bed mobility, transfers, ambulation in room and corridor and toilet use;
-Walker for ambulation.
-Occasionally incontinent of bladder and bowel.
Review of the resident’s nurse’s notes, dated 2/23/19 at 10:26 P.M., showed the resident
was very agitated this shift. He/she was trying to get out the front door before supper;
several times almost falling out of his/her wheelchair. The resident was getting physical
and trying to hit staff and started swearing. PRN [MEDICATION NAME] (anti-anxiety
medication) 0.5 milligram (mg) given intramuscularly (IM) to decrease agitation.
Review of a Change of Condition Report from facility staff to the physician, dated 2/23/19
at 10:13 P.M., showed needing order for a urinalysis (UA). The resident’s urine is very
cloudy and the resident has had mental status changes. Would like to get as soon as
possible (ASAP).
Review of a document titled Event Report (provided by the physician) dated 2/23/19 to
2/26/19, showed the following:
-Office received faxes (four total) for Resident #40 requesting a UA ASAP because patient
was having mental status changes. Fax sent 2/23/19 at 10:13 P.M. 2/23/19 was a Saturday.
The office was closed over the weekend.
-On 2/26/19 at 11:42 A.M., called the Director of Nursing (DON) and reported the issue and
the physician should have been called. Director of Nursing (DON) stated he/she was
addressing the issue.
Review of nurse’s notes showed the following:
-On 2/26/19 at 10:59 A.M., a new order was received to obtain UA and CT Scan (X-ray image)
for [DIAGNOSES REDACTED].
-On 2/26/19 at 9:00 P.M., the resident is confused and has a problem getting right words
to express himself/herself. There has been a change in the resident’s physical/mental
status. The resident required two staff to assist with his/her transfer tonight and did

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
not walk. The resident used a wheelchair as his/her main mode of travel. Total care
patient. UA due in the morning and CAT scan on Friday.
Review of the resident’s nurses’ notes, dated 2/27/19 at 2:00 A.M., showed UA obtained via
straight catheter (a thin, sterile tube inserted into the bladder to drain urine from the
body). Resident experienced pain and had 500 cc residual, cloudy, purulent, yellow urine
with a strong odor.
Review of a UA report, dated 2/27/19, showed the following:
-Leukocytes (white blood cells) – moderate (normal is negative);
-Protein – trace (normal is negative);
-Glucose – greater than/equal to 000 (normal 0-0.8 millimoles(mmol)/Liter/L);
-Blood – moderate (normal is negative);
-White blood cells (WBCs) – too numerous to count (normal is none);
-Red blood cells (RBC) – 15-20 (normal is none);
-Bacteria – 4+ (normal is none).
Review of the resident’s nurse’s notes, dated 2/28/19 at 9:00 A.M., showed the physician
was in the facility. New order for Keflex (antibiotic) 500 mg three times daily for five
days.
Review of the urine culture report, dated 3/1/19, showed the following:
-Yeast greater than 100,000 colony forming unit (CFU)/milliliter(ml) after two day
incubation.
-2/28/19, give 1 gram (gm) [MEDICATION NAME] (antibiotic) IM one time at bedtime.
During interview on 4/11/19 at 2:20 P.M., the resident’s physician said the following:
-He/she was only in his/her office on Tuesdays and Thursdays;
-His/her office (which is closed on Saturday) received a fax, dated 2/23/19, requesting a
UA for the resident ASAP;
-His/her first opportunity to address the fax would have been 2/26/19, which he/she did
and gave the order for the UA;
-He/she would have expected staff (who felt the resident needed a UA ASAP) to call him/her
as he/she was always available to them;
-He/she would not expect staff to fax an ASAP UA request (for a resident with mental
status changes) to a closed office.
During interview on 4/23/19 at 2:55 P.M., Licensed Practical Nurse (LPN) G said the
following:
-Staff should not send a fax requesting lab work for a resident ASAP (due to change in
condition) to a physician office which is closed;
-He/she should have phoned the physician and the order would have been given at that time.
During interview on 4/12/19 at 5:05 P.M. and 4/23/19 at 2:00 P.M., the director of nursing
said the following:
-He/she would not expect nursing staff to send a fax requesting an ASAP UA to a closed
physician clinic. He/she expected staff to call and get the order;
-He/she would have expected staff to ask the physician for the needed UA on 2/25/19 when
staff spoke with the physician regarding the resident’s [MEDICATION NAME]. (Record review
showed staff received a telephone order regarding the resident’s [MEDICATION NAME] on
2/25/19.)

F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to provide a copy of the
transfer notice to a representative of the Office of the State Long-Term Care Ombudsman
for six residents (Residents #40, #39, #9, #41, #33, and #36), in a review of 15 sampled
residents and one additional resident (Resident #29) who were transferred to the hospital.
The facility census was 43.
1. During interview on 4/11/19 at 4:30 P.M. the Administrator said the facility did not
have a policy regarding notification of the Office of the State Long-Term Care Ombudsman
of resident discharges and transfers from the facility.
2. Review of Resident #39’s medical record showed the following:
-He/She was originally admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfers.
3. Review of Resident #33’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
4. Review of Resident 9’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
5. Review of Resident #29’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer on 4/9/19.
6. Review of Resident #40’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer from the facility.
7. Review of Resident #41’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer from the facility.
8. Review of Resident #36’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer from the facility.
9. During interview on 4/11/19 at 4:25 P.M. the Administrator said the facility only
notified the State Ombudsman’s office of 30 day notices issued to residents. The facility
did not notify the State Ombudsman’s office of all resident transfers and discharges.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform residents and/or legal
representatives of their bed hold protocol at the time of transfer for six residents
(Residents #40, #39, #9, #41, #33, and #36), in a review of 15 sampled residents and one
additional resident (Resident #29) who were transferred to the hospital. The facility
census was 43.
1. Review of the facility Bed Hold Policy dated 1/13/16 and located in the facility
admission packet showed the following:
If a resident was away over night (at hospital, home or other place) and if the beds were
full enough that another resident was wanting a bed, the facility would charge $20.00 per
night to guarantee a hold on the bed until the resident returned. If the resident
preferred not to pay the bed hold fee, the facility would place the resident on a waiting
list. The previous residents received highest priority on the waiting list and would have
first chance at an available bed subject to appropriate placement. If a Medicaid
resident’s hospitalization or therapeutic leave ended while no bed was available, the
facility would admit them to the next available bed as required by regulation.
2. Review of Resident #39’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal
representative of the facility’s bed hold policy at the time of transfer.
3. Review of Resident #33’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal
representative of the facility’s bed hold policy at the time of transfer.
4. Review of Resident #9’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal
representative of the facility’s bed hold policy at the time of transfer.
5. Review of Resident #40’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal
representative of the facility’s bed hold policy at the time of transfer.
6. Review of Resident #41’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal
representative of the facility’s bed hold policy at the time of transfer.
7. Review of Resident #36’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 4)
representative of the facility’s bed hold policy at the time of transfer.
8. Review of Resident #29’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facilty for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the resident or his/her legal
representative of the facility’s bed hold policy at the time of transfer.
9. During interview on 4/11/19 at 4:00 P.M the Social Services Designee said the
following:
-He/She reviewed the facility bed hold policy with the resident and his/her legal
representative at the time of admission to the facility;
-He/She did not provide the resident or his/her legal representative the facility’s bed
hold policy at the time of transfer verbally or in writing;
-The facility did not have a policy about informing the resident or legal representative
in writing at the time of transfer of the facility’s bed hold policy.
10. During interview on 4/11/19 at 4:30 P.M. the Business Office Manager said he/she did
not provide the resident or legal representative notification of the facility bed hold
policy either verbally or in writing at the time of transfer out of the facility. He/She
was unaware the facility should provide the bed hold policy in writing at the time of
transfer.
11. During interview on 4/11/19 at 4:25 P.M. the Administrator said the Social Services
Designee reviewed the facility bed hold policy with the resident or legal representative
at the time of admission. If the bed hold policy was reviewed again at the time of
transfer, the Business Office Manager would provide the information.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to complete a
significant change in status assessment (SCSA) Minimum Data Set (MDS; a federally mandated
assessment instrument required to be completed by facility staff) for five residents
(Residents #6, #19, #33, #37, and #39) in a review of 15 sampled residents, within 14 days
after the facility determined, or should have determined, there had been a significant
change in the resident’s physical or mental condition which had an impact on more than one
area of the resident’s health status and required interdisciplinary review and/or revision
of the care plan. The facility census was 43.
1. During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said he/she followed the
Resident Assessment Instrument (RAI) 3.0 manual while completing residents’ MDS.
2. Review of the Long Term Care Facility RAI User’s Manual, version 3.0 showed a
significant change is a decline or improvement in a resident’s status that:
-Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, is not self-limiting;
-Impacts more than one area of the resident’s health status;
-Requires interdisciplinary review and/or revision the care plan.
The Manual also showed a Significant Change in Resident Status (SCSA) is appropriate if
there is a consistent pattern of changes, with either two or more areas of decline, or two
or more areas of improvement. This may include two changes within a particular domain
(e.g., two areas of ADL decline or improvement).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
Guidelines for determining significant change in resident status included the following:
-Any decline in an ADL physical functioning area where a resident is newly coded as 3, 4,
or 8;
-Resident’s incontinence pattern changes from 0 or 1 to 2, 3, or 4;
-Emergence of a pressure ulcer at Stage II or higher, when no pressure ulcers were
previously present at Stage II or higher;
-Emergence of an unplanned weight loss problem (5% change in 30 days or 10% change in 180
days).
3. Review of Resident#39’s quarterly MDS dated [DATE] showed the following:
-The resident’s cognition was moderately impaired;
-He/she required extensive assistance of one staff with bed mobility, transfers, walking
in and out of his/her room, and locomotion on and off of the unit;
-He/she required limited assistance of one staff with personal hygiene.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-His/her cognition improved from moderately impaired to intact;
-He/she required limited assistance of one staff with bed mobility, transfers, and
locomotion on and off of the unit;
-He/she required extensive assistance of one staff with personal hygiene;
-He/she only ambulated in his/her room once or twice with assist of one staff and did not
ambulate out of his/her room.
Review of the resident’s quarterly MDS dated [DATE] showed the following when compared to
the previous quarterly MDS dated [DATE]:
-The resident’s cognition improved from moderately impaired to intact;
-The resident improved in bed mobility, transfers and locomotion on and off the unit from
extensive assist to limited assist;
-The resident declined in personal hygiene from limited assist to extensive assist;
-The resident declined in ambulation from extensive assist to only ambulated in his/her
room once or twice with assist of one staff and did not ambulation out of his/her room;
-The resident’s assessment met the criteria for significant change in status.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-His/her cognition declined and now was mildly impaired;
-He/she showed a decline in ADLs and now required extensive assistance of two staff with
bed mobility and transfers;
-Ambulation in his/her room did not occur;
-He/she now required extensive assistance of one staff on and off of the unit.
Review of the resident’s quarterly MDS dated [DATE] showed the following when compared to
the previous quarterly dated 12/16/18 showed the following:
-The resident’s cognition declined from intact to moderately impaired;
-The resident declined in bed mobility and transfers from limited assist to extensive
assist;
-The resident declined in ambulation in his/her room from only occurred once or twice with
staff assist to did not occur;
-The resident’s assessment met the criteria for a significant change in status.
Observation of the resident on 4/09/19 at 12:26 P.M showed he/she sat in his/her room with
his/her left arm in an immobilizer during lunch. He/she was not eating and said his/her
arm hurt too bad to eat. He/she wore oxygen and rubbed his/her left arm.
4. Review of Resident #33’s quarterly MDS dated [DATE] showed the following:
-He/She required extensive physical assistance of two staff with transfers;
-He/She required limited assistance of one staff with eating;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-He/She was frequently incontinent of bladder;
-He/She was always continent of bowel.
Review of the resident’s quarterly MDS dated [DATE] showed the following declines in
his/her condition:
-He/She was now physically dependent on two staff for all transfers;
-He/She was now dependent on one staff to assist with eating;
-He/She was now always incontinent of bladder;
-He/She was now always incontinent of bowel.
The resident’s quarterly MDS dated [DATE] showed the following when compared to the
previous quarterly MDS dated [DATE]:
-The resident declined in transfers from extensive assist to totally dependent;
-The resident declined in eating from limited assist to totally dependent;
-The resident declined in continence from frequently incontinent of bladder to always
incontinent of bladder and always continent of bowel to always incontinent of bowel;
-The resident’s assessment met the criteria for significant change in status.
During an interview on 4/12/19 at 12:05 P.M., Certified Nurse Aide (CNA) A said the
following:
-The resident had declined in transfer status;
-The resident used to be a two person stand up transfer and now required the Hoyer lift
for transfers since he/she returned from the hospital a few months ago;
-Three or four months ago, the resident was able to use the toilet, but now is always
incontinent of bowel and bladder;
-The resident did not move around and required staff to turn and reposition him/her.
5. Review of Resident #6’s quarterly MDS dated [DATE] showed the following:
-Severely impaired cognition;
-Walking in room did not occur;
-Required limited assistance of one staff member with locomotion on the unit;
-Required limited assistance of one staff member with dressing;
-Required set up help with eating;
-Not steady, only able to stabilize with staff assistance with moving from seated to
standing position and moving on and off the toilet;
-Weight 94 pounds.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Moderately impaired cognition;
-Walking in room occurred once or twice;
-Independent with locomotion on the unit, dressing and eating;
-Weight 109 pounds.
The resident’s quarterly MDS dated [DATE] showed the following when compared to the
previous quarterly MDS dated [DATE]:
-The resident improved in cognition from severe to moderately impaired cognition;
-The resident improved in walking in room from did not occur to occurred once or twice;
-The resident improved in locomotion on the unit and with dressing from required limited
assistance of one staff member to independent;
– The resident improved in eating from required set up help to independent;
-14 percent weight gain in three months;
-The resident’s assessment met the criteria for significant change in status.
Observation of the resident from 4/9/19 through 4/12/19 showed the resident transferred
him/herself to the wheelchair, propelled him/herself down the hallway to the dining room,
ate independently, brushed his/her own teeth and hair without staff assistance and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
transferred with staff assistance to the toilet.
During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said the resident had
improved in status and needed a significant change MDS for improvement.
6. Review of Resident #19’s quarterly MDS dated [DATE] showed the following:
-He/She required extensive assistance of two staff with toileting;
-He/She was frequently incontinent of bowel and bladder;
-He/She weighed 188 pounds.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-He/She was totally dependent on two or more staff with toileting;
-He/She was always incontinent of bowel and bladder;
-His/Her weight was 170 pounds (18 pound weight loss since previous assessment).
The resident’s quarterly MDS dated [DATE] showed the following when compared to the
previous quarterly MDS dated [DATE];
-The resident declined from extensive assist to totally dependent with toileting;
-The resident’s continence declined from frequently incontinent to always incontinent of
both bladder and bowel;
-10.4% weight loss in three months;
-The resident’s assessment met the criteria for significant change.
7. Review of Resident #37’s quarterly MDS dated [DATE] showed the following:
-Required extensive assistance of one staff member with bed mobility, dressing, eating,
and personal hygiene;
-No functional limitation in range of motion of upper and lower extremities.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Required total assistance of two staff members with bed mobility and dressing;
-Required total assistance of one staff member with eating and personal hygiene;
-Functional limitation in range of motion with impairment of one upper extremity and both
lower extremities.
The resident’s quarterly MDS dated [DATE] showed the following when compared to the
previous quarterly MDS dated [DATE];
-The resident declined from extensive assistance of one staff member to total assistance
of two staff members with bed mobility and dressing;
-The resident declined from extensive assistance to total assistance of one staff member
with eating and personal hygiene;
-The resident declined from no functional limitation in range of motion of upper and lower
extremities to functional limitation in range of motion with impairment of one upper
extremity and both lower extremities;
-The resident’s assessment met the criteria for significant change in status.
Observation of the resident from 4/9/19 through 4/12/19 showed the resident required two
staff members and total assistance with bed mobility, dressing and toileting. The resident
was incontinent and wore incontinence briefs. Staff transferred the resident to a
wheelchair with a gait belt. The resident was unsteady and had limited weight bearing
during the transfer. He/she required one staff member total assistance to propel the
wheelchair to the dining room and required total assistance with eating.
During interview on 4/11/19 at 12:10 P.M. the MDS Coordinator said the resident had
declined in status and needed a significant change MDS for decline.
8. During an interview on 4/12/49 at 5:00 P.M., the Director of Nursing said the
following:
-He/she expected the MDS Coordinator to follow the RAI process and follow the guidelines
of when to complete a MDS when a resident has had a significant change in their status;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-He/she would expect a MDS for a significant change be completed if changes in a
resident’s status triggered for one.

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 ensure two residents
(Resident #36 and #37) with a mental disorder had a DA-124 Level I screen (used to
evaluate for the presence of psychiatric conditions to determine if a preadmission
screening/resident review (PASARR) level II screen is required) as required, in a review
of 15 sampled residents. The facility census was 43.
1. Record review of the Missouri Department of Health and Senior Services (DHSS) guide
titled, PASARR Desk Reference, dated 3/3/08, showed:
-The PASARR is a federally mandated screening process for any person for whom placement in
a Medicaid Title (XIX) certified bed is being sought. This is a Level I screening
(completion of the DA124C form).
-A Level II assessment is completed on those persons identified at Level I who are known
or suspected to have a serious mental illness (such as [MEDICAL CONDITION], dementia,
[MEDICAL CONDITION], etc., MR or related MR condition to determine the need for
specialized service (completion of the DA124A/B form). The facility responsible for
completing the DA124A/B and/or DA124C forms is also responsible for submitting completed
form(s) to DHSS, Division of Regulation and Licensure, Section for Long Term Care
Regulation, Central Office Medical Review Unit (COMRU);
-PASARR screening is required: To assure appropriate placement of persons known or
suspected of having a mental impairment;
-To assure that the individual needs of mentally impaired persons can be and are being met
in the appropriate placement environment;
-To be compliant with the OBRA/PASARR federal requirements, see 42 CFR 483.Subpart C; and
-To assure Title XIX funds are expended appropriately and in accordance with Legislative
intent.
2. Review of Resident #37’s Annual Minimum Data Set (MDS), a federally mandated assessment
tool required to be completed by facility staff, dated 9/24/18 showed the following:
-[DIAGNOSES REDACTED].
-Received antipsychotic medications for the past seven days;
-Received antidepressant medications for the past seven days;
-Received antipsychotic medications on a routine basis;
-No documentation that a PASARR was completed for the resident.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-[DIAGNOSES REDACTED].
-Received antipsychotic medications for the past seven days;
-Received antidepressant medications for the past seven days;
-Received antipsychotic medications on a routine basis;
-No documentation that a PASARR was completed for the resident.
Review of the resident’s care plan updated 3/27/19 showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
-The resident received [MEDICAL CONDITION] medications that could have side effects. Staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY 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 9)
should monitor for drowsiness and dizziness.
Review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
-[MEDICATION NAME] (anti depressant medication) 40 milligrams (mg) daily at 7:00 A.M. for
major [MEDICAL CONDITION];
-[MEDICATION NAME] (antipsychotic medication) 25 mg two times daily at 7:00 A.M. and 8:00
P.M. for [MEDICAL CONDITION] disorder.
Review of the resident’s medical record showed no PASARR screening (Level I or II).
3. Review of Resident #36’s Admission MDS, dated [DATE] showed the following:
-[DIAGNOSES REDACTED].
-Received antipyschotic medications the past seven days;
-Received antidepressant medications the past seven days;
-Received antipsychotic medications on a routine basis;
-No documentation that a PASARR was completed for the resident.
Review of the resident’s Significant change MDS, dated [DATE] showed the following:
-[DIAGNOSES REDACTED].
-Received antipyschotic medications the the past seven days;
-Received antianxiety medications for the past five days;
-Received antidepressant medications for the past seven days;
-Received antipsychotic medications on a routine basis;
-No documentation that a PASARR was completed for the resident.
Review of the resident’s care plan dated 3/21/19 showed the following:
-Resident admitted on [DATE];
-[DIAGNOSES REDACTED].
-Problem: I take medications which can cause side effects such as drowsiness or dizziness.
Monitor me closely after giving me these medications.
Review of the Resident’s POS, dated (MONTH) 2019 showed the following:
-Amitriptylline 50 mg po daily at 7:00 P.M. for major [MEDICAL CONDITION];
-[MEDICATION NAME] 60 mg po daily at 8:00 P.M. for [MEDICAL CONDITION] disorder;
-[MEDICATION NAME] 25 mg po daily at 7:00 A.M. for major [MEDICAL CONDITION];
-[MEDICATION NAME] 0.5 mg po PRN (as needed) two times daily for anxiety disorder.
Review of the resident’s medical record showed no PASARR screening.
4.During interview on 4/12/19 at 10:50 A.M. the MDS coordinator said residents admitted
with a serious mental illness should have a PASARR completed prior to admission. He/She
was responsible for entering the PASARR information into the resident’s MDS. Resident #37
and #36 did not have a PASARR completed as required.
During interview on 4/11/19 at 4:25 P.M. the administrator said residents’ PASARR reports
should be in the medical record as required.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to follow
professional standards when administering eye drops for two residents (Residents #31 and
#35) in a review of 15 sampled residents. The facility census was 43.
1. Review of the facility policy, Instillation of Eye Drops, last revised 1/14 showed the
following: The purpose of this procedure is to provide guidelines for instillation of eye

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
drops to treat medical conditions, eye infections and dry eyes.
-Staff was to wash and dry hands thoroughly (if treating both eyes, wash and dry before
each eye)
-Put on gloves;
-If the resident is sitting up, tilt his/her head backward slightly;
-Gently pull the lower lid down. Instruct the resident to look up.
-Drop the medication into the lower eyelid;
-Instruct the resident to slowly close his/her eyelid to allow for even distribution of
the eye drops;
-Instruct the resident not to blink or squeeze the eyelid shut which forces medicine out
of the eye;
-Remove gloves and discard. Wash and dry hands thoroughly.
2. Review of the [MEDICATION NAME] opthalmic (eye medication used to treat ([MEDICAL
CONDITION]) (a group of eye conditions which can cause [MEDICAL CONDITION]))
manufacturer’s guidelines, dated 7/18 showed while looking up, gently squeeze the dropper
so that a single drop falls into the pocket made by the lower eyelid. Remove your index
finger from the eyelid, close your eye for two to three minutes and tip head down as
though looking at the floor. Try not to blink or squeeze your eyelids.
3. Review of the [MEDICATION NAME] opthalmic (beta-blocker eye medication used to treat
[MEDICAL CONDITION]) manufacturer’s guidelines, dated 11/07 showed gently close the eye
after administration of the drop, do not blink. Keep the eyes closed and apply pressure to
the inner corner of the eye with your finger for one to two minutes to allow the medicine
to be absorbed by the eye.
4. Review of Resident #31’s physicians order sheets (POS) dated 4/19 showed the following:
-[DIAGNOSES REDACTED].>-[MEDICATION NAME] 0.2% opthalmic- one drop both eyes two times
daily for [MEDICAL CONDITION] (5/25/18);
-[MEDICATION NAME] ophthalmic drops 0.5% one drop to both eyes two times daily (5/25/18).
Observation on 4/9/19 at 3:45 P.M. in the resident’s room showed the following:
-The resident sat in his/her wheelchair;
-Certified Medication Technician (CMT) I entered the resident’s room, handed the resident
a Kleenex and administered [MEDICATION NAME] one drop into each eye;
-CMT I did not instruct the resident to close his/her eyes for two to three minutes or
hold pressure to the lacrimal duct.
Observation on 4/9/19 at 4:00 P.M. in the resident’s room showed the following:
-CMT I entered the resident’s room, handed the resident a Kleenex and administered
[MEDICATION NAME] one drop into each eye;
-CMT did not instruct the resident to close his/her eyes or hold pressure to the lacrimal
duct.
5. Review of Resident #35’s Physician Order Sheet (POS), dated 4/19 showed the following:
-[DIAGNOSES REDACTED].>-[MEDICATION NAME] 0.2% eye drops- one drop both eyes three
times daily for [MEDICAL CONDITION] (9/14/17);
-[MEDICATION NAME] ophthalmic 0.5% apply to both eyes two times daily for open angle
[MEDICAL CONDITION] with borderline findings (9/14/17).
Observation on 4/9/19 at 3:52 P.M. in the resident’s room showed the following:
-The resident lay in bed;
-CMT I entered the resident’s room, administered [MEDICATION NAME] one drop into each eye
and patted the resident’s eyes momentarily;
-CMT I did not instruct the resident to close his/her eyes for two to three minutes or
hold pressure to the lacrimal duct.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
Observation on 4/9/19 at 4:05 P.M. in the resident’ room showed the following:
-CMT I entered the resident’s room, administered [MEDICATION NAME] one drop into each eye;
-CMT I did not instruct the resident to close his/her eyes or hold pressure to the
lacrimal duct.
During interview on 4/12/19 at 4:25 P.M. CMT I said the following:
-He/she had been taught to pull the lower lid of the eye down and administer the drop in
the corner and hold pressure for 30 seconds or if the resident was able, instruct them to
do so;
-He/she forgot to hold pressure after administering the eye drops.
During interview on 4/12/19 at 5:05 P.M the Director of Nursing (DON) said he/she would
expect staff to hold pressure to the lacrimal duct for at least one minute after a
medicated eye drop was given.

F 0689

Level of harm – Actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to monitor the
effectiveness of current fall interventions, failed to modify the interventions as
necessary to prevent further falls, and failed to consistently implement fall
interventions for four residents (Residents #31, #39, #40, and #41), in a review of 15
sampled residents, who had a history of [REDACTED]. The facility census was 43.
1. Review of the facility policy Falls-Clinical Protocol, dated (MONTH) (YEAR), showed the
following:
-Assessment and Recognition section;
-The physician would help identify individuals with a history of falls and risk factors
for falling. Staff would ask the resident and the caregiver or family about a history of
falling. The staff and physician would document in the medical record a history of one or
more recent falls. While many falls were isolated individual incidents, a few individuals
fall repeatedly. Those individuals often have an identifiable underlying cause;
-In addition, the nurse should assess and document/report the resident’s vital signs,
recent injury, especially fracture or head injury, musculoskeletal function, observing for
change in normal range of motion, weight bearing, change in cognition or level of
consciousness, neurological status, pain, frequency and number of falls since last
physician visit, precipitating factors, details on how fall occurred, all current
medications, especially those associated with dizziness or lethargy and all active
diagnosis;
-The staff and practitioner would review each resident’s risk factors for falling and
document in the medical record;
-The physician would identify medical conditions affecting fall risk and the risk for
significant complications of falls;
-The staff would evaluate and document falls that occur while the individual was in the
facility. When and where it happened, any observations of the events, etc.;
-Falls should be categorized as those that occurred while trying to rise from a sitting or
lying to an upright position, those that occurred while upright and attempting to ambulate
and other circumstances such as sliding out of a chair or rolling from a low bed to the
floor;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 12)
-Falls should also be identified as witnessed or unwitnessed events;
-For an individual who had fallen, the staff and practitioner would begin to try to
identify possible causes within 24 hours of the fall;
-If the cause of the fall was unclear, or if a fall may have a significant medial cause,
or if the individual continues to fall despite attempted interventions, a physician would
review the situation and help further identify causes and contributing factors;
-Based on the preceding assessment, the staff and physician would identify pertinent
interventions to try to prevent subsequent falls and to address the risks of clinically
significant consequences of falling;
-If underlying causes could not be readily identified or corrected, staff would try
various relevant interventions, based on assessment of the nature or category of falling,
until falling reduces or stops or until a reason was identified for its continuation;
-The staff would follow up on any fall with associated injury until the resident was
stable and delayed complications such as late fracture or subdural hematoma had been ruled
out or resolved;
-The staff and physician would monitor and document the individual’s response to
interventions intended to reduce falling or the consequences of falling. Frail elderly
individuals were often at greater risk for serious adverse consequences of falls. Risks of
serious adverse consequences could sometimes be minimized even if falls could not be
prevented;
-If interventions had been successful in fall prevention, the staff would continue with
current approaches and would discuss periodically with the physician whether these measure
were still needed;
-If the individual continued to fall, the staff and physician would re-evaluate the
situation and reconsider possible reasons for the resident’s falling and also reconsider
the current interventions;
-As needed, after an appropriately thorough review, the physician would document any
uncorrectable risk factors and underlying causes.
2. Review of Resident’s #39’s care plan, dated 7/2/18, showed the following:
-The resident had a personal history of falls and took medications that could increase
fall risk;
-He/she would not have any serious injuries due to falls;
-Encourage him/her to ask for help with all transfers;
-He/she took medications that could cause dizziness and drowsiness which could lead to
falls. Monitor him/her after administering these medications;
-Keep his/her call light within reach at all times.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
to be completed by the facility, dated 9/25/18, showed the following:
-The resident’s cognition was moderately impaired;
-He/she required extensive assistance from one staff with bed mobility, transfers, walking
in and out of his/her room, and locomotion on and off of the unit and toilet use;
-He/she was frequently incontinent of bladder and always continent of bowel;
-He/she used a walker and wheelchair;
-He/she was not steady and was only able to stabilize with human assistance with changing
from seating to standing potion, walking, turning around and facing opposite direction
while walking, transferring on and off of the toilet, surface to surface transfers, and
transfers between bed to chair or wheelchair;
-He/she had one fall with minor injury and one fall with major injury since previous
assessment (6/28/18).
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 13)
Review of the resident’s fall risk assessment, dated 10/17/18, showed the following:
-He/she had one to two falls within the past three months;
-He/she was chair-bound;
-He/she had problems with balance while standing and walking;
-He/she had decreased muscular coordination;
-He/she had a change in gait pattern when walking through a doorway;
-He/she required the use of an assistive device such as a wheelchair, walker, or cane;
-He/she took one or two medications that could cause lethargy (weakness) and confusion;
-He/she had one or two predisposing diseases that could cause falls;
-His/her total fall risk score was 12, which indicated the resident was at high risk for
falls.
Review of the resident’s nursing notes, dated 11/18/18 at 3:57 P.M., showed the following:
-The resident was observed in the hallway on his/her bottom scooting across the floor;
-He/she told staff he/she was trying to transfer himself/herself to the wheelchair from
the recliner without wearing shoes;
-He/she was encouraged to use his/her call light for assistance and to wear shoes or grip
socks during transfers.
Review of the resident’s care plan showed a hand written intervention, dated 11/18/18,
that instructed staff to educate the resident to ask for assistance when transferring
himself/herself. (This intervention was identified on the resident’s care plan prior to
the resident’s fall on 11/18/18.)
Review of the resident’s nursing notes, dated 11/20/18 at 7:30 P.M., showed the following:
-The resident was observed sitting on the floor beside his/her bed;
-He/she told staff he/she was getting up from the bed and the bed was not locked and slid
out from under him/her.
Review of the resident’s care plan showed an intervention was added on 11/20/18 to educate
the resident to ask for assistance with transfers to bed so staff can ensure the brakes
were locked. (Staff identified the intervention for the resident to ask for assistance
with transfers on the resident’s care plan on 7/2/18 and after the resident fell on
[DATE].)
Review of the resident’s nursing notes, dated 12/15/18 at 1:00 A.M., showed the following:
-The resident was observed on the floor in his/her room;
-The resident was lying on his/her right side in front of his/her recliner with his/her
wheelchair nearby;
-He/she was not wearing grip socks;;
-The resident told staff he/she was trying to go to the bathroom when his/her feet slid
out from under him/her and he/she landed on his/her bottom.
Review of the resident’s Post Fall Huddle Guide Form, dated 12/15/18, showed the
following:
-The resident was at risk for falls;
-The resident had not fallen in the past four weeks (documentation showed the resident
fell on [DATE]);
-The resident had brittle bones;
-The resident was going to the bathroom at the time of the fall;
-Staff was caring for other residents at the time of the fall;
-The resident had not fallen recently, but every fall was basically because the resident
was hurting and was weak;
-Changes made to the resident’s care plan to decrease the risk of future falls included
the resident needed to wear grip socks when self-transferring or have the resident use
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 14)
his/her call light and ask for assistance with transfers. (Staff documented in the nurses
notes on 11/18/18, they encouraged the resident to wear grip socks after he/she fell while
not wearing the socks on 11/18/18.)
Review of the resident’s care plan showed an intervention was added on 12/17/18 to educate
the resident to use his/her call light for assistance with transfers. (The interventions
to encourage the resident to use his/her call light and to encourage the resident to ask
for assistance with transfers were identified on the resident’s care plan on 7/2/18 and
after the resident fell on [DATE] and 11/20/18.)
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-His/her cognition was intact;
-He/she required limited assistance from one staff with transfers and locomotion on and
off of the unit;
-He/she required extensive assistance of one staff with toileting;
-He/she walked in his/her room once or twice with assist from one staff;
-He/she did not ambulate out of his/her room;
-He/she was frequently incontinent of bladder and always continent of bowel;
-He/she used a walker and wheelchair;
-He/she was not steady and was only able to stabilize with human assistance with changing
from seating to standing potion, walking, turning around and facing opposite direction
while walking, transferring on and off of the toilet, surface to surface transfers, and
transfers between bed to chair or wheelchair;
-He/she had one fall with minor injury and one fall with major injury since previous
assessment (6/28/18);
-He/she had impairment with one side of his/her lower extremities during range of motion
(ROM);
-He/she had two non-injury falls and one minor injury fall since previous assessment.
Review of the resident’s Care Plan Conference Summary, dated 12/26/18, showed he/she was
at high risk for falls due to trying to do things for himself/herself. (There was no
evidence staff evaluated or modified current interventions to prevent the resident from
falling.)
Review of the facility’s fall investigation, dated 1/25/19, showed the resident was found
on the floor in front of his/her wheelchair in his/her room on 1/25/19 at 4:50 P.M. The
resident stated he/she was transferring himself/herself from the recliner to the
wheelchair when he/she slipped and fell on to the floor.
Review of the resident’s Post Fall Huddle Guide Form, dated 1/25/19, showed the following:
-The resident was transferring himself/herself from the recliner to wheelchair;
-Root cause of the fall: the resident did not use his/her call light to ask for
assistance;
-Changes to the resident’s care plan to decrease the risk of further falls included to
remind the resident the importance of using call light to get help while transferring.
Review of the resident’s care plan showed an intervention was added on 1/25/19 to educate
the resident to use his/her call light for assistance with transfers. (The interventions
to encourage the resident to use his/her call light and to encourage the resident to ask
for assistance with transfers were identified on the resident’s care plan on 7/2/18 and
after the resident fell on [DATE], 11/20/18, and 12/17/18.)
Review of the facility’s fall investigation, dated 1/30/19, showed the following:
-On 1/30/19 at 11:55 P.M., the resident was getting himself/herself out of bed without
wearing socks, slid down the side of the bed, and landed on the floor;
-Intervention put into place to prevent further incidents included educating the resident
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 15)
of the need for grip socks at all times that shoes were not on.
Review of the resident’s Post Fall Huddle Guide Form, dated 1/30/19, showed the following:
-The resident was trying to get out of bed without his/her shoes on;
-Root cause of the fall: the resident did not use his/her call light to ask for assistance
and he/she was not wearing shoes or gripper socks at the time of the incident;
-Changes made to the resident’s care plan to decrease the risk of future falls included
the resident needed to wear grip socks when self-transferring or have the resident use
his/her call light and ask for assistance with transfers;
-System problem that needed to be communicated to other departments included to be sure to
place non-grip socks on the resident at bedtime.
Review of the resident’s care plan showed an intervention was added on 1/30/19 to educate
the resident of the need for grip socks at all times that shoes were not on. (Staff
documented they provided education to the resident after he/she fell when not wearing grip
socks on 11/18/18 and 12/15/18.)
Review of the facility’s fall investigation, dated 2/1/19, showed the following:
-On 2/1/19 at 3:00 P.M., the resident slipped and fell on to the floor in his/her room
while trying to transfer himself/herself from the recliner to the wheelchair;
-Intervention put into place to prevent further incidents included to re-educate the
resident to use the call light for assistance with transfers.
Review of the resident’s Post Fall Huddle Guide Form, dated 2/1/19, showed the following:
-He/she was taking himself/herself to the bathroom from the recliner;
-Root cause of the fall: the resident slipped when he/she tried to get up;
-There were no changes to the resident’s care plan that would decrease the risk for future
falls;
-The facility was unable to develop interventions to prevent further falls.
Review of the resident’s care plan showed an intervention was added on 2/1/19 to educate
the resident to use his/her call light for assistance with transfers. (The interventions
to encourage the resident to use his/her call light and to encourage the resident to ask
for assistance with transfers were identified on the resident’s care plan on 7/2/18 and
after the resident fell on [DATE], 11/20/18, 12/15/18, and 1/25/19.)
Review of the facility’s fall investigation, dated 2/14/19, showed the following:
-On 2/14/19 at 1:15 P.M., the resident was found lying on the floor in his/her room. The
resident could not remember what had happened;
-Intervention to prevent further incident included to educate the resident to use call
light when needing to transfer.
Review of the resident’s Post Fall Huddle Guide Form, dated 2/14/19, showed the following:
-The resident was found lying on the floor on his/her right side and he/she could not tell
staff what he/she was doing;
-Root cause of the fall: the resident complained of having a headache and nausea with
vomiting before lunch. He/she was being treated for [REDACTED].
-The resident had a room at the end of the hall and could not always be heard when he/he
asked for help;
-Intervention that could be made to decrease risk for future falls included moving the
resident closer to the nurse’s station and to check on him/her more frequently;
-Remind the resident to use the call light when he/she wanted to get up.
Review of the resident’s care plan showed an intervention was added on 2/14/19 to educate
the resident to use his/her call light for assistance with transfers. (The interventions
to encourage the resident to use his/her call light and to encourage the resident to ask
for assistance with transfers were identified on the resident’s care plan on 7/2/18 and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 16)
after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, and 2/1/19.)
Review of the resident’s nursing notes, dated 2/24/19 at 6:36 P.M., showed the following:
-The resident was observed on the floor lying on his/her back between the bed and
recliner;
-The resident told staff he/she was trying to get up to change into his/her night clothes;
-He/she pushed away from his/her sink with brakes not in the locked position;
-Re-educated resident on the importance of using call light for assistance and to make
sure the brakes were in the locked position if he/she was going to self-transfer.
Review of the resident’s Post Fall Huddle Guide Form, dated 2/24/19, showed the following:
-There were no changes made to the care plan that could decrease the resident’s risk for
future falls;
-Interventions that could be made to decrease the risk for future falls or injuries was to
move resident to a room that was closer to the nurse’s station;
-Due to resident’s frequent fall history, he/she needed to be closer to the nurse’s
station;
-Fall could have possibly been prevented.
Review of the resident’s care plan showed an intervention was added on 2/24/19 to educate
the resident to use his/her call light for assistance with transfers and ensuring grip
socks were on, and wheelchair brakes were locked.
(Staff identified the interventions to encourage the resident to use his/her call light
and to encourage the resident to ask for assistance with transfers on the resident’s care
plan on 7/2/18 and after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19,
and 2/14/19. Staff also provided education to the resident after he/she fell when not
wearing grip socks on 11/18/18, 12/15/18, and 1/30/19.)
Review of the facility’s fall investigation, dated 2/25/19, showed the following:
-On 2/25/19 at 10:20 A.M , the resident was found sitting on the floor in front of his/her
recliner;
-Intervention to prevent further falls included educating the resident to use call light
for assistance when he/she needed to get up.
Review of the resident’s Post Fall Huddle Guide Form, dated 2/25/19, showed the following:
-The resident was transferring himself/herself;
-Root cause of the fall: the resident did not ask for help
-Need to consult PT/OT about mobility/positioning/seating (no documentation was found the
resident received PT/OT consult);
-Changes made to the resident’s care plan to decrease the risk of future falls included
reminding the resident to use his/her call light when he/she wanted help.
Review of the resident’s care plan showed an intervention was added on 2/25/19 to educate
the resident to use his/her call light for assistance with transfers. (Staff identified
the interventions to encourage the resident to use his/her call light and to encourage the
resident to ask for assistance with transfers on the resident’s care plan on 7/2/18 and
after the resident fell on [DATE], 11/20/18, 12/15/18, 1/25/19, 2/1/19, 2/14/19 and
2/24/19.)
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-His/her cognition was mildly impaired;
-He/she required extensive assistance of two staff with bed mobility, transfers,
ambulation, and locomotion off of the unit, and toilet use;
-His/her ROM was limited on one side of both upper and lower extremities;
-He/she used a walker and wheelchair;
-He/she was occasionally incontinent of bladder and always continent of bowel;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265816

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SCHUYLER COUNTY NURSING HOME

STREET ADDRESS, CITY, STATE, ZIP

1306 US HIGHWAY 63
QUEEN CITY, MO 63561

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 17)
-He/she was not steady and was only able to stabilize with human assistance with changing
from seating to standing potion, walking, turning around and facing opposite direction
while walking, transferring on and off of the toilet,