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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on record review and interview the facility staff failed to check the Certified
Nurses’ Assistant (CNA) Registry to ensure staff did not have a Federal Indicator (a
marker given by the federal government to individuals who have committed abuse/neglect),
for five of ten sampled staff, failed to complete a Criminal Background Check (CBC) for
four of ten sampled staff and failed to check the Employee Disqualification List (EDL) for
one of ten sampled staff. The facility census was 29.
1. Record review of the facility’s revised Applicant, Employee and Volunteer Background
Investigations policy revised on 10/05/11 showed:
– Each applicant for a position in the nursing home will complete a Request for Criminal
Record Check and Request for Consent to Employee Disqualification Check Consent form;
– This form will be completed after an employment application has been completed and
submitted but before a new hire starts working;
– Applicants may not start work until the criminal background check has been completed and
reviewed for eligibility, and the CNA Registry has been completed and found to be
acceptable.
– Licensed Practical Nurses (LPN’s) and Registered Nurses (RN’s) must be checked with the
State of Missouri Department of Professional Registration.
2. Review of the facility personnel records showed:
– Housekeeping Staff (HKS) A hired on 3/6/18. The facility did not complete a CBC and
checked the CNA registry on 3/8/18, two days after hire;
– LPN C hired on 2/16/18 and no documentation of a CBC;
– CNA D hired on 2/28/18 and no documentation of a CBC;
– CNA E hired on 10/2/18 and no documentation of a CNA Registry check;
– HKS F hired on 10/11/18 and no documentation of a CNA Registry check;
– CNA G hired on 10/5/18 and no documentation of a CNA Registry check;
– CNA H hired on 8/30/18 and no documentation of a CNA Registry check;
– HKS J hired on 9/18/18 and the CBC completed on 10/02/18, 14 days after hire and EDL
checked on 10/02/18, 14 days after hire.
During an interview on 12/12/18 at 1:15 P.M., LPN K said:
– Some of the registry checks were just missed;
– They are working to correct the problem.

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify the resident and the
resident’s representative in writing of a facility-initiated transfer nor did they notify
a representative of the Office of the state Long-Term Care Ombudsman when four residents
(Resident #4, #17, #19, and #79) of four sampled residents were transferred to the
hospital. The facility census was 29.
1. Record review of Resident #4’s nurses notes showed:
– On 5/17/18 the resident transferred to the hospital and returned to the facility on
[DATE];
– On 10/19/18 the resident transferred to the hospital and returned to the facility on

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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 1)
[DATE].
Review of the resident’s record showed no documentation of a letter notifying the resident
or the resident’s representative in writing of the reason for transfer nor notification of
the state Long-Term Care Ombudsman.
2. Record review of Resident #17’s nurses notes showed the resident transferred to the
hospital on [DATE] and returned to the facility on [DATE].
Review of the resident’s record showed no documentation of a letter notifying the resident
or the resident’s representative in writing of the reason for transfer nor notification of
the state Long-Term Care Ombudsman.
3. Record review of Resident #19’s nurses notes showed the resident transferred to the
hospital on [DATE] and returned to the facility on [DATE].
Review of the resident’s record showed no documentation of a letter notifying the resident
or the resident’s representative in writing of the reason for transfer nor notification of
the state Long-Term Care Ombudsman.
4. Record review of Resident #79’s nurses notes showed the resident transferred to the
hospital on [DATE] and did not return to the facility.
Review of the resident’s record showed no documentation of a letter notifying the resident
or the resident’s representative in writing of the reason for transfer nor notification of
the state Long-Term Care Ombudsman.
During an interview on 12/12/18 at 11:32 P.M., the Administrator said the facility has not
been notifying the resident or the resident’s representative in writing of the reason for
transfer and was not aware that they were supposed to notify the ombudsman.
Record review of the Transfer to Hospital Policy, dated (MONTH) 6, (YEAR), showed:
– Prior to discharge/transfer, the Social Service Director will notify the resident’s
family, next of kin or legal representative regarding transfer/discharge;
– Location of the transfer/discharge;
– Reason for the transfer discharge.

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 the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for four residents (Resident #4, #17, #19, and #79) of 4 sampled residents. The
facility census was 29.
1. Record review of Resident #4’s nurses notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
transfer on 10/19/18.
2. Record review of Resident #17’s nurse’s notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of

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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 2)
transfer on 11/15/18.
3. Record review of Resident #19’s nurse’s notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
transfer on 10/21/18.
4. Record review of Resident #79’s nurse’s notes showed the resident transferred to the
hospital on [DATE] and did not return to the facility.
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
transfer on 9/12/18.
During an interview on 12/12/18 at 11:00 A.M., the Administrator said the facility gives
the bed hold policy on admission, and management has been working on implementing this but
they just didn’t have it in place yet.
Record review of the Bed Hold Policy, dated (MONTH) 10, (YEAR) (Revised (MONTH) 27,
(YEAR)), showed:
– When a resident is admitted to the facility, they receive a copy of the bed hold policy;
– When a resident is discharged to the hospital, the facility will provide to the resident
or their legal representative, a copy of the bed hold policy.

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 screen resident’s for a
mental disorder or intellectual disability prior to admission for three residents
(Resident #14, #15, and #18) of four sampled residents. The census was 29.
1. Review of Resident #14’s medical record, showed:
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– No documentation of a Level I Preadmission Screening and Resident Review (PASARR), a
federal requirement to help ensure individuals are not inappropriately placed in a nursing
home for long term care.
2. Review of Resident #15’s medical record, showed:
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– No documentation of a Level I PASARR.
During an interview on 12/11/18 at 2:15 P.M., Licensed Practical Nurse (LPN) K said the
resident did not have a psychiatric [DIAGNOSES REDACTED].
During an interview on 12/11/18 at 2:20 P.M., the Director of Nursing (DON) said the
resident did not have a psychiatric diagnosis, private pay and would not require an
assessment.
During an interview on 12/12/18 at 11:15 A.M., the Administrator said the Level I
Screening did not get completed on this resident.
3. Review of Resident #18’s medical record, showed:
– admitted to the facility on [DATE];
– [DIAGNOSES REDACTED].
– No documentation of a Level I PASARR.

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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
During an interview on 12/12/18 at 9:46 A.M., the Administrator said she would expect the
assessments to be completed on all residents. The facility does not have the Level I
PASARR documentation available for these residents and is trying to obtain copies.
Record review of the facility’s policy on PASARR assessments and DA-124 A & B showed:
– The purpose of this policy is to utilize the PASARR to develop a plan of care that shows
continuity from previous history of behaviors and placement. This policy is to ensure that
a procedure is set up that communicates to the Social Services Director, MDS/Care Plan
Coordinator Case Manage and Director of Nursing issues and concerns that need to be
addressed in the plan of care for the resident to reach and maintain the resident’s
highest level of mental and psychosocial functioning;
– The PASSAR will be utilized as an instrument to assist the facility in maintaining as
much as possible, previous treatment modalities that were effective in the resident’s life
prior to placement at this facility;
– The PASARR will be a guide in developing an assessment that will assist in the
continuity of care and services in the best interest of the resident.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to develop comprehensive care
plans for three residents (Resident #4, #19, and #23) of 12 sampled residents. The
facility census was 29.
1. Record review of Resident #4’s physician’s orders [REDACTED].
– [MEDICATION NAME] (medication used to treat pain) 7.5 milligram (mg)/325 mg, take 1
tablet by mouth every six hours as needed for pain;
– [MEDICATION NAME] (medication to treat minor aches and pain, and reduces fever) 325 mg,
take two tablets 650 mg by mouth every six hours as needed for pain.
Review of the resident’s Medication Administration Record, [REDACTED]
– (MONTH) (YEAR), [MEDICATION NAME] given 11 times;
– (MONTH) (YEAR), [MEDICATION NAME] given 11 times.
During an interview on 12/11/18 at 3:50 P.M., the resident reported generalized pain and
takes pain medication.
Record review of the care plan did not address pain.
During an interview on 12/12/18 at 1:48 P.M., Licensed Practical Nurse (LPN) K said pain
should be care planned if a resident has pain and is getting pain medications.
During an interview on 12/12/18 at 2:48 P.M., the Administrator she would expect pain to
be addressed on the care plan.
2. Record review of Resident #19’s medical record showed the resident smokes with
supervision of staff.
Record review of the resident’s care plan did not address smoking.
During an interview on 12/10/18 at 1:49 P.M. Licensed Practical Nurse (LPN) K said the
resident smokes about two times a week, however does not always smoke every day.
3. Record review of Resident #23’s medical record showed the resident smokes with
supervision of staff.
Record review of the resident’s care plan did not address smoking.
During an interview on 12/10/18 at 1:53 P.M. LPN K said the resident smokes on scheduled

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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
smoke breaks with supervision.
During an interview on 12/12/18 at 9:20 A.M. LPN K said the care plans should reflect the
residents smoking.
During an interview on 12/12/18 2:45 P.M. the Administrator said she was completing care
plans until the first part of (MONTH) (YEAR) and just missed putting the smoking on the
residents’ care plans.
Record review of the facility’s policy (not dated) on Comprehensive Care Plans showed:
– The purpose of this policy is ensure the facility must develop 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;
– A Registered Nurse that has been designated by the facility administration will
coordinate each assessment with the appropriate participation of health professionals
otherwise known for the purposes of the MDS/care planning process;
– The care plan will be updated toward preventing declines in functioning, will reflect on
managing risk factors and building on resident’s strengths;
– All treatment objectives will be measurable and corroborate with the resident’s own
goals and wishes when appropriate.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

Based on interview and record review, the facility failed to update and revise care plans
with specific interventions tailored to meet individual needs for one resident (Resident
#25) out of 12 sampled residents. The facility census was 29.
1. Record review of Resident #25’s medical record showed the resident admitted to hospice
services on 11/07/18 for Alzheimer’s dementia (a progressive disease that destroys memory
and other important mental functions).
Record review of the resident’s care plan, revised on 8/22/18 showed the care plan did not
address the resident receiving hospice services.
During an interview on 12/12/18 at 9:20 A.M., Licensed Practical Nurse (LPN) K said the
care plan should reflect the resident receiving hospice services.
During an interview on 12/12/18 at 10:10 A.M., the Director of Nursing (DON) said the
hospice service should have been on the resident’s care plan.
During an interview on 12:12 P.M., the Administrator said she had been responsible for
completing the care plans until just recently and that position had been filled. She said
the resident had just been admitted to hospice and it was missed.
Record review of the facility’s Care Plan Policy, dated (MONTH) 6, (YEAR) showed:
– The facility will use the Resident Assessment Instrument User Manual as a reference to
help the Interdisciplinary Team to look at residents holistically, as individuals for whom
quality of life and quality of care are mutually significant and necessary;
– The care plan will be updated toward preventing declines in functioning, will reflect on
managing risk factors and building on resident’s strengths;
– The nurses meetings will review any pertinent information or changes in residents’
condition;
– During each meeting, the care plan team will meet and address changes in resident’s plan

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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
of care within 24 hours during the week and within 72 hours after the weekend.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide restorative services
for two residents (Resident #4 and #14) out of six residents. The facility census was 29.
1. Record review of Resident #4’s Significant Change Minimum Data Set (MDS), a federally
mandated assessment instrument, completed by facility staff, dated 6/7/18, showed:
– Extensive assistance of one staff member for bed mobility;
– Extensive assistance of two staff members for transfers;
– To walk in the room or the corridor did not occur;
– Locomotion on or off the unit did not occur;
– Use of a wheelchair for mobility;
– Impairment on one side to lower extremity.
Record review of Resident #4’s Physical Therapy documentation, dated 6/22/18, showed:
– [DIAGNOSES REDACTED].
– Therapy for bilateral extremity strengthening, safety and balance training;
– Resident received physical therapy 6/07/18 through 6/22/18;
– Discharge plan to remain in skilled facility with restorative nursing program.
Record review of the resident’s Restorative Care Program documentation, dated 6/20/18,
showed;
– Resident to receive restorative therapy five times per week, for three months, June,
(MONTH) and August;
– Therapy goal to maintain range of motion to bilateral lower extremities and standing
tolerance;
– No restorative sheet for (MONTH) or August.
Record review of the Progress notes showed:
– Restorative therapy for (MONTH) (YEAR) documented out of 20 opportunities for therapy 16
opportunities were missed;
– No progress notes for (MONTH) (YEAR), with 20 of 20 opportunities missed.
During an interview on 12/12/18 at 10:25 P.M., LPN K said they have had some problems with
the restorative program and just became aware that the documentation hasn’t been getting
done as it should.
2. Record review of Resident #14’s quarterly MDS, dated [DATE], showed:
– Extensive assistance of two staff members for bed mobility;
– Extensive assistance of two staff members for transfers;
– To walk in the room or the corridor did not occur;
– Locomotion on or off the unit with total assistance of one staff member;
– Use of a wheelchair for mobility;
– Impairment on one side to upper and lower extremities.
Record review of the resident’s quarterly MDS, dated [DATE], showed:
– Extensive assistance of one staff members for bed mobility;
– Extensive assistance of two staff members for transfers;
– To walk in the room or the corridor did not occur;
– Locomotion on or off the unit with total assistance of one staff member;

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:

265832

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

NAME OF PROVIDER OF SUPPLIER

SENATH SOUTH HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

300 EAST HORNBECK STREET, PO BOX 940
SENATH, MO 63876

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
– Use of a wheelchair for mobility;
– Impairment on one side to upper and lower extremities.
Record review of Physical Therapy documentation, dated 5/24/18, showed:
– [DIAGNOSES REDACTED].
– discharged from physical therapy on 5/24/18 with goal met;
– Recommend discharge from skilled services with restorative program.
Record review of Restorative Care Program documentation, showed:
– Restorative to maintain trunk control, posture, position and wheelchair management;
– No frequency or duration documented;
– Restorative sheet dated (MONTH) (YEAR), showed restorative services received seven
times.
During an interview on 12/12/18 at 11:19 A.M., the Administrator said:
– Residents should receive restorative services to improve and/or maintain range of
motion.
– The restorative program should have the frequency and duration of the planned
treatments.
– It should be documented when the residents receive it and if the they refuse it.
– The most common duration is 12 weeks, it depends on the problem and the resident’s
cooperation. – If a resident is discharged from the restorative program there should be a
discharge order written.
During an interview on 12/12/18 at 2:10 P.M., LPN K said they have had some problems with
the restorative program and the staff member doing it just took a leave of absence.
The facility did not provide a policy on restorative services.