SHADY LAWN LIVING CENTER

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0582 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on record review and interview, the facility failed to issue SNF (skilled nursing facilities) ABN (Advanced Beneficiary Notice) Form CMS (Centers for Medicare and Medicaid) – to each resident within the appropriate time frames once it was determined the residents were no longer eligible for skilled nursing services as provided in Medicare Part A. This affected three of three sampled residents (Residents #16, #19, and #241). The facility had a census of 39 at the time of the survey. 1. The facility did not have a policy directing staff on when to provide the SNF-ABN Form to residents. Record review of Resident #19’s medical records showed the following: – Resident #19 went on Medicare Part A skilled services on 12/4/18, with the last covered day of Part A services on 12/17/18. – The Part A Services were terminated by the provider when benefit days were not exhausted. No reason was given for the termination of services. – No signed SNF ABN Form CMS- form was found in the resident’s file. Record review of Resident #241’s medical records showed the following: – Resident #241 went on Medicare Pat A skilled services on 8/6/18, with last day of Part A skilled covered services on 8/6/18, when the resident was discharging to home. – No signed SNF, ABN, Form CMS- form was found in the resident’s file. Record review of Resident #16’s medical records showed the following: – Resident #16 went on Medicare Part A skilled services on 12/26/18, with last day of Part A services on 12/24/18. – The Part A Services were terminated by the provider when benefit days were not exhausted because the resident was not participating in therapy. – No signed SNF, ABN, Form CMS- form was found in the resident’s file. During an interview on 3/6/19, at 11:51 A.M., the Social Service Designee said: – She had placed the form SNF- ABN Form CMS- in the resident’s admission packet for Resident #91 but the form was never signed and returned. – She placed the form SNF- ABN Form CMS- in a separate folder and had forgotten to given them out on admission to Residents #16 and #241. – He/she was unaware of any other time he/she was to provided form SNF-ABN Form CMS- to the residents.
	F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	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 observation, interview, and record review, the facility failed to inform the resident and family/legal representative of their bed hold policy at the time of transfer/discharge to the hospital for one of 12 sampled residents (Resident #4). The facility census was 39. 1. Review of the facility’s undated Bed Hold Guidelines policy showed: – The facility will notify all residents and/or their representative of the bed hold

(X4) ID PREFIX TAG

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

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on record review and interview, the facility failed to issue SNF (skilled nursing
facilities) ABN (Advanced Beneficiary Notice) Form CMS (Centers for Medicare and Medicaid)
– to each resident within the appropriate time frames once it was determined the residents
were no longer eligible for skilled nursing services as provided in Medicare Part A. This
affected three of three sampled residents (Residents #16, #19, and #241). The facility had
a census of 39 at the time of the survey.
1. The facility did not have a policy directing staff on when to provide the SNF-ABN Form
to residents.
Record review of Resident #19’s medical records showed the following:
– Resident #19 went on Medicare Part A skilled services on 12/4/18, with the last covered
day of Part A services on 12/17/18.
– The Part A Services were terminated by the provider when benefit days were not
exhausted. No reason was given for the termination of services.
– No signed SNF ABN Form CMS- form was found in the resident’s file.
Record review of Resident #241’s medical records showed the following:
– Resident #241 went on Medicare Pat A skilled services on 8/6/18, with last day of Part A
skilled covered services on 8/6/18, when the resident was discharging to home.
– No signed SNF, ABN, Form CMS- form was found in the resident’s file.
Record review of Resident #16’s medical records showed the following:
– Resident #16 went on Medicare Part A skilled services on 12/26/18, with last day of Part
A services on 12/24/18.
– The Part A Services were terminated by the provider when benefit days were not exhausted
because the resident was not participating in therapy.
– No signed SNF, ABN, Form CMS- form was found in the resident’s file.
During an interview on 3/6/19, at 11:51 A.M., the Social Service Designee said:
– She had placed the form SNF- ABN Form CMS- in the resident’s admission packet for
Resident #91 but the form was never signed and returned.
– She placed the form SNF- ABN Form CMS- in a separate folder and had forgotten to given
them out on admission to Residents #16 and #241.
– He/she was unaware of any other time he/she was to provided form SNF-ABN Form CMS- to
the residents.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 observation, interview, and record review, the facility failed to inform the
resident and family/legal representative of their bed hold policy at the time of
transfer/discharge to the hospital for one of 12 sampled residents (Resident #4). The
facility census was 39.
1. Review of the facility’s undated Bed Hold Guidelines policy showed:
– The facility will notify all residents and/or their representative of the bed hold

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265846

If continuation sheet
Page 1 of 14

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 1) guidelines. – This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave. – If the resident or representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs during the week. Signed authorization must be received by the first business day following discharge if it occurs on week-end or holiday. – Bed holds are strictly voluntary. If the bed is not held and is not available when the resident wants to be readmitted , the resident’s name will be placed on a waiting list for the next available bed. Review of the facility’s undated Notice of Payment policy showed: – Room reserves will be charged to Semi-Private Pay and Private Pay residents who leave the facility for any reason and will continue until we are notified by the resident or responsible party that the resident will not be returning. Review of the hospital demographic sheet for Resident #4 showed: – admitted : 12/2/18 at 12:27 P.M.; – Medicare/Medicaid payment source. Review of the hospital’s History and Physical, dated 12/2/18, at 4:02 P.M., showed: – Assessment: Systemic [MEDICAL CONDITION] response syndrome ([MEDICAL CONDITION], [DIAGNOSES REDACTED] (a rare, [DIAGNOSES REDACTED], chronic skin disorder characterized by blistering, urticarial [MEDICAL CONDITION] or hives and itching); – Left lower extremity [MEDICAL CONDITION]; – Fluid overload with possible acute [MEDICAL CONDITION] exacerbation; – [DIAGNOSES REDACTED]; – Blisters to bilateral feet. Review of the nurses’ progress note (NPN), dated 12/6/18, at 1:15 P.M., showed: – Returned from hospital, no complaints of shortness of breath or pain and vital signs stable. Review of the social service progress note (SSPN), dated 12/6/18, at 2:47 P.M., showed: – Resident had outbreak of [DIAGNOSES REDACTED]; – Resident started on steroid medication by injection and by mouth. Review of the Entry Tracking Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/18, showed: – No reassessment required. During an interview on 3/5/19, at 3:52 P.M., the Administrator said: – The facility did not send letters to the residents or legal representatives for discharge/transfer to the hospital or for bed holds if the resident returned to the facility. – She did not know a letter had to be sent with each transfer or discharge to the hospital if they were planning to return During an interview on 3/5/19, at 3:52 P.M., the Director of Nursing (DON) said: – Staff did not document they notified the legal representative of the transfer/discharge of the resident to the hospital on [DATE]. During an interview on 3/5/19, at 3:52 P.M., the Social Service Designee (SSD) said: – She did not sent a letter to the resident or the legal representative for bed hold when the resident transferred/discharged to the hospital on [DATE]. – The resident planned to return to the facility.

(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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
guidelines.
– This notification shall be given on admission to the facility, at the time of transfer
to the hospital and at the time of non-covered therapeutic leave.
– If the resident or representative wants to hold the bed, a signed authorization must be
obtained with each discharge. Signed authorization must be received within 24 hours of the
discharge if it occurs during the week. Signed authorization must be received by the first
business day following the discharge if it occurs during the week. Signed authorization
must be received by the first business day following discharge if it occurs on week-end or
holiday.
– Bed holds are strictly voluntary. If the bed is not held and is not available when the
resident wants to be readmitted , the resident’s name will be placed on a waiting list for
the next available bed.
Review of the facility’s undated Notice of Payment policy showed:
– Room reserves will be charged to Semi-Private Pay and Private Pay residents who leave
the facility for any reason and will continue until we are notified by the resident or
responsible party that the resident will not be returning.
Review of the hospital demographic sheet for Resident #4 showed:
– admitted : 12/2/18 at 12:27 P.M.;
– Medicare/Medicaid payment source.
Review of the hospital’s History and Physical, dated 12/2/18, at 4:02 P.M., showed:
– Assessment: Systemic [MEDICAL CONDITION] response syndrome ([MEDICAL CONDITION],
[DIAGNOSES REDACTED] (a rare, [DIAGNOSES REDACTED], chronic skin disorder characterized by
blistering, urticarial [MEDICAL CONDITION] or hives and itching);
– Left lower extremity [MEDICAL CONDITION];
– Fluid overload with possible acute [MEDICAL CONDITION] exacerbation;
– [DIAGNOSES REDACTED];
– Blisters to bilateral feet.
Review of the nurses’ progress note (NPN), dated 12/6/18, at 1:15 P.M., showed:
– Returned from hospital, no complaints of shortness of breath or pain and vital signs
stable.
Review of the social service progress note (SSPN), dated 12/6/18, at 2:47 P.M., showed:
– Resident had outbreak of [DIAGNOSES REDACTED];
– Resident started on steroid medication by injection and by mouth.
Review of the Entry Tracking Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/6/18, showed:
– No reassessment required.
During an interview on 3/5/19, at 3:52 P.M., the Administrator said:
– The facility did not send letters to the residents or legal representatives for
discharge/transfer to the hospital or for bed holds if the resident returned to the
facility.
– She did not know a letter had to be sent with each transfer or discharge to the hospital
if they were planning to return
During an interview on 3/5/19, at 3:52 P.M., the Director of Nursing (DON) said:
– Staff did not document they notified the legal representative of the transfer/discharge
of the resident to the hospital on [DATE].
During an interview on 3/5/19, at 3:52 P.M., the Social Service Designee (SSD) said:
– She did not sent a letter to the resident or the legal representative for bed hold when
the resident transferred/discharged to the hospital on [DATE].
– The resident planned to return to the facility.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few
	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 observation, interview, and record review, the facility failed to ensure staff used the comprehensive assessment to develop, implement, and review a comprehensive person centered plan of care consistent with the resident rights that includes measurable objectives and time frames to include the resident’s medical, nursing, mental and psychological needs and to ensure the care plan was accurate for the care being provided to the resident for various medical and psychological issues which affected two of 12 sampled residents (Residents #4 and #9). The facility census was 39. 1. The facility did not have a policy for the development of comprehensive person-centered care plans. 2. Review of Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff), dated 11/30/18, showed: – Original admitted : 1/23/15; – Readmitted : 5/16/18; – A Brief Interview for Mental Status (BIMS) score of 12 which indicated needed supervision for decision making; – Mood severity score of three which indicated symptoms of feeling depressed, feeling tired, and felt badly about self, happened nearly every day; – Stroke and [MEDICAL CONDITIONS] not marked; – [DIAGNOSES REDACTED]. Review of the nursing progress note (NPN), dated 12/2/18, showed: – Resident in bed with labored breathing; – Respirations 30 per minute (normal 18 per minute); – Temperature 100.6 (normal 98.6); – Complained of shortness of breath; – Left leg swollen, 3+ [MEDICAL CONDITION] and warm to touch, indicative of [MEDICAL CONDITION] (a common bacterial skin infection; may first appear as a red, swollen area that feels hot and tender to the touch; the redness and swelling often spread rapidly; and usually painful) and possible [MEDICAL CONDITION] ([MEDICAL CONDITION], excessive fluid in and around the heart and lungs); – Nurse practitioner notified; – Order received to transfer resident to hospital for evaluation and treatment; – Transferred to hospital via ambulance; – Resident admitted to the hospital for [MEDICAL CONDITION] and [MEDICAL CONDITION] of the left lower leg. Review of the hospital’s History and Physical, dated 12/2/18, at 4:02 P.M., showed: – Assessment: Systemic [MEDICAL CONDITION] response syndrome ([MEDICAL CONDITION], [DIAGNOSES REDACTED]); – Left lower extremity [MEDICAL CONDITION]; – Fluid overload with possible acute [MEDICAL CONDITION] exacerbation; – [DIAGNOSES REDACTED]; – Blisters to bilateral feet. Review of the care plan last updated on 2/19/19, showed:

(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 – Minimal harm or potential for actual harm

Residents Affected – Few

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 observation, interview, and record review, the facility failed to ensure staff
used the comprehensive assessment to develop, implement, and review a comprehensive person
centered plan of care consistent with the resident rights that includes measurable
objectives and time frames to include the resident’s medical, nursing, mental and
psychological needs and to ensure the care plan was accurate for the care being provided
to the resident for various medical and psychological issues which affected two of 12
sampled residents (Residents #4 and #9). The facility census was 39.
1. The facility did not have a policy for the development of comprehensive person-centered
care plans.
2. Review of Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff), dated 11/30/18, showed:
– Original admitted : 1/23/15;
– Readmitted : 5/16/18;
– A Brief Interview for Mental Status (BIMS) score of 12 which indicated needed
supervision for decision making;
– Mood severity score of three which indicated symptoms of feeling depressed, feeling
tired, and felt badly about self, happened nearly every day;
– Stroke and [MEDICAL CONDITIONS] not marked;
– [DIAGNOSES REDACTED].
Review of the nursing progress note (NPN), dated 12/2/18, showed:
– Resident in bed with labored breathing;
– Respirations 30 per minute (normal 18 per minute);
– Temperature 100.6 (normal 98.6);
– Complained of shortness of breath;
– Left leg swollen, 3+ [MEDICAL CONDITION] and warm to touch, indicative of [MEDICAL
CONDITION] (a common bacterial skin infection; may first appear as a red, swollen area
that feels hot and tender to the touch; the redness and swelling often spread rapidly; and
usually painful) and possible [MEDICAL CONDITION] ([MEDICAL CONDITION], excessive fluid in
and around the heart and lungs);
– Nurse practitioner notified;
– Order received to transfer resident to hospital for evaluation and treatment;
– Transferred to hospital via ambulance;
– Resident admitted to the hospital for [MEDICAL CONDITION] and [MEDICAL CONDITION] of the
left lower leg.
Review of the hospital’s History and Physical, dated 12/2/18, at 4:02 P.M., showed:
– Assessment: Systemic [MEDICAL CONDITION] response syndrome ([MEDICAL CONDITION],
[DIAGNOSES REDACTED]);
– Left lower extremity [MEDICAL CONDITION];
– Fluid overload with possible acute [MEDICAL CONDITION] exacerbation;
– [DIAGNOSES REDACTED];
– Blisters to bilateral feet.
Review of the care plan last updated on 2/19/19, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 3) – Updated after the resident’s last hospitalization on [DATE]; – Care plan did not include problems related to [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], [MEDICAL CONDITION], and fluid restriction due to [MEDICAL CONDITION] diagnosed during the last hospitalization on [DATE]. During an interview on 3/7/19, at 10:33 A.M., the Director of Nursing (DON) said: – All [DIAGNOSES REDACTED]. – Care plans should be updated with any change in condition or hospitalization . – Complete assessments should be completed and placed in the nurse’s notes when return from the hospital. 2. Review of Resident # 9’s admission assessment MDS, dated [DATE], showed: – BIMS score of 5 indicating moderately impaired for decision making; – Weight 181; – No behaviors; – [DIAGNOSES REDACTED]. Review of the resident’s nutritional status care plan, dated 9/27/18, showed staff wanted the resident’s weight to remain stable. Staff to monitor weights monthly and record dietary intake. Review of the resident’s weights showed: – (MONTH) (YEAR) – 181 pounds; – (MONTH) (YEAR) – 173 pounds (down 8 pounds in one month or 4.42%); – (MONTH) (YEAR) – 167 pounds (down 14 pounds in two months or 7.7% or a significant weight loss); – (MONTH) (YEAR) – 165 pounds (down 16 pounds in three months or 8.84%, also a significant weight loss). Review of the resident’s quarterly MDS assessment, dated 12/14/18, showed: – BIMS score of 9 indicating modernly impaired for decision making; – Weight 165 pounds (marked no significant weight gain or loss); – No behaviors. Review of the resident’s nutritional status care plan showed staff did not update or revise the plan after they completed the quarterly MDS on 12/14/18. The plan did not mention the resident’s actual weight loss or significant weight loss. Review of the resident’s diet changes recommended by Registered Dietitian (RD) B, dated 12/27/18, showed he/she recommended checking the resident’s [MEDICATION NAME]; adding a multiple vitamin with minerals due to weight loss and wound healing for a diabetic ulcer. Review of the kitchen’s diet changes recommended by RD B, dated 1/3/19, showed he/she recommended increasing the resident’s medication pass supplement to 60 ml (milliliters) three times daily; adding double eggs with breakfast. Review of RD B’s nutritional progress note, dated 1/31/19, at 1:21 P.M., showed: – Diet: Regular; – Supplement: med pass supplement 60 ml twice daily; – Rx: senna (multi-vitamin); – Labs: no new labs; – Weight: 150 pounds – Weight change: 15 pound loss/1 month, 23 pounds loss/3 month; – Increase supplement 90 ml TID (three times daily) and add multivitamin with minerals; – Continue to monitor. Review of the resident’s progress note, dated 2/3/19, showed staff documented the resident’s weight as 145 pounds (a 25 pound weight loss in 6 months or 14.45%). Review of the kitchen’s diet changes recommended by RD B, dated 2/25/19, showed to

(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 3)
– Updated after the resident’s last hospitalization on [DATE];
– Care plan did not include problems related to [MEDICAL CONDITIONS], [DIAGNOSES
REDACTED], [MEDICAL CONDITION], and fluid restriction due to [MEDICAL CONDITION] diagnosed
during the last hospitalization on [DATE].
During an interview on 3/7/19, at 10:33 A.M., the Director of Nursing (DON) said:
– All [DIAGNOSES REDACTED].
– Care plans should be updated with any change in condition or hospitalization .
– Complete assessments should be completed and placed in the nurse’s notes when return
from the hospital.
2. Review of Resident # 9’s admission assessment MDS, dated [DATE], showed:
– BIMS score of 5 indicating moderately impaired for decision making;
– Weight 181;
– No behaviors;
– [DIAGNOSES REDACTED].
Review of the resident’s nutritional status care plan, dated 9/27/18, showed staff wanted
the resident’s weight to remain stable. Staff to monitor weights monthly and record
dietary intake.
Review of the resident’s weights showed:
– (MONTH) (YEAR) – 181 pounds;
– (MONTH) (YEAR) – 173 pounds (down 8 pounds in one month or 4.42%);
– (MONTH) (YEAR) – 167 pounds (down 14 pounds in two months or 7.7% or a significant
weight loss);
– (MONTH) (YEAR) – 165 pounds (down 16 pounds in three months or 8.84%, also a significant
weight loss).
Review of the resident’s quarterly MDS assessment, dated 12/14/18, showed:
– BIMS score of 9 indicating modernly impaired for decision making;
– Weight 165 pounds (marked no significant weight gain or loss);
– No behaviors.
Review of the resident’s nutritional status care plan showed staff did not update or
revise the plan after they completed the quarterly MDS on 12/14/18. The plan did not
mention the resident’s actual weight loss or significant weight loss.
Review of the resident’s diet changes recommended by Registered Dietitian (RD) B, dated
12/27/18, showed he/she recommended checking the resident’s [MEDICATION NAME]; adding a
multiple vitamin with minerals due to weight loss and wound healing for a diabetic ulcer.
Review of the kitchen’s diet changes recommended by RD B, dated 1/3/19, showed he/she
recommended increasing the resident’s medication pass supplement to 60 ml (milliliters)
three times daily; adding double eggs with breakfast.
Review of RD B’s nutritional progress note, dated 1/31/19, at 1:21 P.M., showed:
– Diet: Regular;
– Supplement: med pass supplement 60 ml twice daily;
– Rx: senna (multi-vitamin);
– Labs: no new labs;
– Weight: 150 pounds
– Weight change: 15 pound loss/1 month, 23 pounds loss/3 month;
– Increase supplement 90 ml TID (three times daily) and add multivitamin with minerals;
– Continue to monitor.
Review of the resident’s progress note, dated 2/3/19, showed staff documented the
resident’s weight as 145 pounds (a 25 pound weight loss in 6 months or 14.45%).
Review of the kitchen’s diet changes recommended by RD B, dated 2/25/19, showed to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 4) increase medication pass supplement to 120 ml, TID and to recheck the resident’s potassium levels. During an interview on 3/6/19,at 9:03 A , the Dietary Manager said she provided the weights and significant information like hospitalization s, falls, wounds and not eating to RD B who gives written recommendations to her, the Director or Nursing (DON) and the MDS/Care Plan coordinator monthly. It has been a while since the facility has conducted at risk meeting to discuss the information but she followed up on the recommendations that were in her department such as the supplements. Observation and interview on 3/4/19, at 12:04 P.M., showed Resident #9 who only ate a couple of bites of his/her chicken. The resident moved away from the dining table to a recliner in front of the TV. The resident started making a low wimpy sound then just started crying with tear drops and nose running. Certified Nurse Aide (CNA) A said the resident does not eat well. The resident cries a lot and has lost a lot of weight. Staff try to give him/her Mighty Shakes and protein shakes but can only get him/her to take a few sips. CNA A said the resident cries often. During an interview on 3/5/19, at 10:08 A.M., Physical Therapy Staff A said staff crush the resident’s medications because he/she has trouble swallowing when upset, which is often. Therapy staff watched the resident eat this morning and he/she actually ate 50% of his/her pancakes and eggs which is really good intake for him/her. The resident did not have any problems swallowing this morning. During an interview of 3/5/19, at 10:48 AM., the Dietary Manager said the resident used to be out front. He/she was placed on the special care unit because of wandering. He/she did not eat well so they hoped being of the special care unit with fewer residents and more assistance would be helpful. He/she is just not eating well but he/she likes orange juice so they purchased supplemented orange juice which has helped a little. The physician also increased the resident’s antidepressant which hopefully will help. The resident usually comes out of his/her room to meals and has a weight gain of 3 pounds this month. During an interview on 3/5/19, at 4:26 P.M., the MDS/Care plan coordinator said the resident’s weight loss would not trigger until staff did the resident’s quarterly MDS and care plan review at the end of March. The Dietary Manager had not informed him/her of any significant weight loss. They had not been able to do at risk meeting, so he could have missed knowing about the weight loss since they did not do a (MONTH) at risk meeting. He/she updated care plans after quarterly assessments if there were changes. The resident’s (MONTH) quarterly MDS did not trigger for weight loss, therefore there was no need to update the care plan. He was unaware the resident had a actual significant weight loss that should have been noted on the December’s MDS and therefore care planned. During an interview on 3/6/19, at 1:12 P.M., the Administrator said there is limited information and no follow up on risk meetings. She had to ask the former DON to step down because things were just not getting done. The former DON was not doing risk assessment meetings or doing follow-up on things that should have been done such as the resident’s weight loss. The former DON stepped down in (MONTH) and we just found and hired a new DON a few weeks ago.
	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.

(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)
increase medication pass supplement to 120 ml, TID and to recheck the resident’s potassium
levels.
During an interview on 3/6/19,at 9:03 A , the Dietary Manager said she provided the
weights and significant information like hospitalization s, falls, wounds and not eating
to RD B who gives written recommendations to her, the Director or Nursing (DON) and the
MDS/Care Plan coordinator monthly. It has been a while since the facility has conducted at
risk meeting to discuss the information but she followed up on the recommendations that
were in her department such as the supplements.
Observation and interview on 3/4/19, at 12:04 P.M., showed Resident #9 who only ate a
couple of bites of his/her chicken. The resident moved away from the dining table to a
recliner in front of the TV. The resident started making a low wimpy sound then just
started crying with tear drops and nose running. Certified Nurse Aide (CNA) A said the
resident does not eat well. The resident cries a lot and has lost a lot of weight. Staff
try to give him/her Mighty Shakes and protein shakes but can only get him/her to take a
few sips. CNA A said the resident cries often.
During an interview on 3/5/19, at 10:08 A.M., Physical Therapy Staff A said staff crush
the resident’s medications because he/she has trouble swallowing when upset, which is
often. Therapy staff watched the resident eat this morning and he/she actually ate 50% of
his/her pancakes and eggs which is really good intake for him/her. The resident did not
have any problems swallowing this morning.
During an interview of 3/5/19, at 10:48 AM., the Dietary Manager said the resident used to
be out front. He/she was placed on the special care unit because of wandering. He/she did
not eat well so they hoped being of the special care unit with fewer residents and more
assistance would be helpful. He/she is just not eating well but he/she likes orange juice
so they purchased supplemented orange juice which has helped a little. The physician also
increased the resident’s antidepressant which hopefully will help. The resident usually
comes out of his/her room to meals and has a weight gain of 3 pounds this month.
During an interview on 3/5/19, at 4:26 P.M., the MDS/Care plan coordinator said the
resident’s weight loss would not trigger until staff did the resident’s quarterly MDS and
care plan review at the end of March. The Dietary Manager had not informed him/her of any
significant weight loss. They had not been able to do at risk meeting, so he could have
missed knowing about the weight loss since they did not do a (MONTH) at risk meeting.
He/she updated care plans after quarterly assessments if there were changes. The
resident’s (MONTH) quarterly MDS did not trigger for weight loss, therefore there was no
need to update the care plan. He was unaware the resident had a actual significant weight
loss that should have been noted on the December’s MDS and therefore care planned.
During an interview on 3/6/19, at 1:12 P.M., the Administrator said there is limited
information and no follow up on risk meetings. She had to ask the former DON to step down
because things were just not getting done. The former DON was not doing risk assessment
meetings or doing follow-up on things that should have been done such as the resident’s
weight loss. The former DON stepped down in (MONTH) and we just found and hired a new DON
a few weeks ago.

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.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 5) NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident’s specific conditions and needs which affected three of 12 sampled residents (Resident #23, #29, and #39). The facility census was 39. 1. The facility did not have a policy related to updating a care plan consistent with a resident’s specific conditions and needs. 2. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/9/19, showed: – A Brief Interview for Mental Status (BIMS) score of 14 which indicated he/she made his/her own decisions; – Mood score of 8 which indicated symptoms of having little interest in things, sleeplessness, and feeling tired happen almost daily during last 12 to 14 days; – Independent in all areas; – [DIAGNOSES REDACTED]. Review of the care plan last updated on 11/5/18, showed: – No care plan for [MEDICAL CONDITION]; – No care plan for high blood pressure; – No care plan for [MEDICAL CONDITION]; – No care plan for [MEDICAL CONDITION]; – No care plan for GERD; – No care plan for cardiac arrhythmias; – No care plan for vitamin deficiency; – All currently care planned problem areas not updated since 11/5/18. 3. Review of Resident #39’s nurses notes, dated 2/8/19, showed: – Resident returned from same day surgery from and incision and drain (I & D, a minor surgical procedure to release pus or pressure built up under the skin) to left foot abscess; – Dressing on ankle should remain intact until physician’s appointment and to wear post-op shoe and full weight bearing on left leg; – Bactrim (an antibiotic) started. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/19, showed: – Moderately cognitive impaired; – [DIAGNOSES REDACTED]. – Surgical wound. Review of the resident’s physician order [REDACTED]. – Apply A&D ointment to area on left foot and cover with dressing. Review of the resident’s care plan, updated 2/19/19, showed staff did not update or develop a plan of care for the I&D and surgical wound care to the left ankle/foot. 4. Review of Resident #29’s care plan, updated 10/28/19, showed: – Problem: urinary incontinence; incontinent of bowel and bladder; – Goal: skin will remain intact; – Approach: apply moisture barrier to skin; eliminate dehydrating drinks; encourage fluids; ensure adequate bowel elimination; obtain lab orders; provide assistance for toileting; provide incontinence care after each incontinent episodes; report any signs of skin breakdown. Review of the resident’s quarterly MDS, dated [DATE], showed: – Severely cognitive impaired;

(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)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
developed and updated a care plan consistent with resident’s specific conditions and needs
which affected three of 12 sampled residents (Resident #23, #29, and #39). The facility
census was 39.
1. The facility did not have a policy related to updating a care plan consistent with a
resident’s specific conditions and needs.
2. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/9/19, showed:
– A Brief Interview for Mental Status (BIMS) score of 14 which indicated he/she made
his/her own decisions;
– Mood score of 8 which indicated symptoms of having little interest in things,
sleeplessness, and feeling tired happen almost daily during last 12 to 14 days;
– Independent in all areas;
– [DIAGNOSES REDACTED].
Review of the care plan last updated on 11/5/18, showed:
– No care plan for [MEDICAL CONDITION];
– No care plan for high blood pressure;
– No care plan for [MEDICAL CONDITION];
– No care plan for [MEDICAL CONDITION];
– No care plan for GERD;
– No care plan for cardiac arrhythmias;
– No care plan for vitamin deficiency;
– All currently care planned problem areas not updated since 11/5/18.
3. Review of Resident #39’s nurses notes, dated 2/8/19, showed:
– Resident returned from same day surgery from and incision and drain (I & D, a minor
surgical procedure to release pus or pressure built up under the skin) to left foot
abscess;
– Dressing on ankle should remain intact until physician’s appointment and to wear post-op
shoe and full weight bearing on left leg;
– Bactrim (an antibiotic) started.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/12/19, showed:
– Moderately cognitive impaired;
– [DIAGNOSES REDACTED].
– Surgical wound.
Review of the resident’s physician order [REDACTED].
– Apply A&D ointment to area on left foot and cover with dressing.
Review of the resident’s care plan, updated 2/19/19, showed staff did not update or
develop a plan of care for the I&D and surgical wound care to the left ankle/foot.
4. Review of Resident #29’s care plan, updated 10/28/19, showed:
– Problem: urinary incontinence; incontinent of bowel and bladder;
– Goal: skin will remain intact;
– Approach: apply moisture barrier to skin; eliminate dehydrating drinks; encourage
fluids; ensure adequate bowel elimination; obtain lab orders; provide assistance for
toileting; provide incontinence care after each incontinent episodes; report any signs of
skin breakdown.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Severely cognitive impaired;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 6) – Extensive assist of two staff for all activities of daily living (ADLs); – [DIAGNOSES REDACTED]. Review of telephone orders showed: – 2/4/19: Urinalysis (UA) with culture and sensitivity (C&S); – 2/26/19: [MEDICATION NAME] (an antibiotic used to treat UTIs) 100 milligrams (mg) twice a day (BID) for 7 days. Review of the resident’s care plan showed staff did not update or develop a plan of care for the UTI. During an interview on 3/7/19, at 10:33 A.M. and 1:30 P.M., the Director of Nursing (DON) said: – Care plans should include any and all [DIAGNOSES REDACTED]. – Care plans should be updated at least quarterly and with any change of condition or diagnose. – UTI’s and surgical wounds should be included in the care plan.
	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Ensure services provided by the nursing facility meet professional standards of quality. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff obtained physician orders [REDACTED].#5 and #29) when staff failed to start antibiotics timely for Resident #29 and failed to receive orders for a diet recommendation for Resident #5 and failed to ensure staff reordered medications in a timely manner to make sure one sampled resident (Resident #30) did not run out of his/her breathing treatment solution. The facility census was 39. The facility did not have a policy regarding following physician orders. 1. Review of Resident #5’s care plan, updated 9/21/18, showed: – Problem: Nutritional status; has a body mass index (BMI) of 34.4 and is on a regular diet; – Goals: weight will remain stable; – Approach: regular diet and weigh monthly. Review of the Registered Dietician’s (RD) note, dated 11/28/18, showed: – On regular diet; – Weight 206 pounds (lb); – Weight change: 10 lb weight gain in one month; – Further gain undesirable; continue to monitor and evaluate to decrease calories if indicated. Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff on 12/6/18, showed: – Cognitively intact; – Diagnoses: [REDACTED]. – Weight 209 lb; – No weight gain. Review of the RD note, dated 12/27/18, showed: – Regular diet; – Weight 209 lb;

(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 6)
– Extensive assist of two staff for all activities of daily living (ADLs);
– [DIAGNOSES REDACTED].
Review of telephone orders showed:
– 2/4/19: Urinalysis (UA) with culture and sensitivity (C&S);
– 2/26/19: [MEDICATION NAME] (an antibiotic used to treat UTIs) 100 milligrams (mg) twice
a day (BID) for 7 days.
Review of the resident’s care plan showed staff did not update or develop a plan of care
for the UTI.
During an interview on 3/7/19, at 10:33 A.M. and 1:30 P.M., the Director of Nursing (DON)
said:
– Care plans should include any and all [DIAGNOSES REDACTED].
– Care plans should be updated at least quarterly and with any change of condition or
diagnose.
– UTI’s and surgical wounds should be included in the care plan.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
obtained physician orders [REDACTED].#5 and #29) when staff failed to start antibiotics
timely for Resident #29 and failed to receive orders for a diet recommendation for
Resident #5 and failed to ensure staff reordered medications in a timely manner to make
sure one sampled resident (Resident #30) did not run out of his/her breathing treatment
solution. The facility census was 39.
The facility did not have a policy regarding following physician orders.
1. Review of Resident #5’s care plan, updated 9/21/18, showed:
– Problem: Nutritional status; has a body mass index (BMI) of 34.4 and is on a regular
diet;
– Goals: weight will remain stable;
– Approach: regular diet and weigh monthly.
Review of the Registered Dietician’s (RD) note, dated 11/28/18, showed:
– On regular diet;
– Weight 206 pounds (lb);
– Weight change: 10 lb weight gain in one month;
– Further gain undesirable; continue to monitor and evaluate to decrease calories if
indicated.
Review of the quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument, completed by staff on 12/6/18, showed:
– Cognitively intact;
– Diagnoses: [REDACTED].
– Weight 209 lb;
– No weight gain.
Review of the RD note, dated 12/27/18, showed:
– Regular diet;
– Weight 209 lb;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 7) – Weight change: 3 lb in one month; – Continue to monitor. Review of the RD note, dated 1/31/19, showed: – Regular diet; – Weight 215 lb; – Weight change: 6 lb in one month for a 19 lb gain in 3 months; – Further weight gain undesired; – Recommend a controlled carbohydrate diet (CCHO) and monitor. Review of the resident’s weights in the electronic record showed: – (MONTH) (YEAR): 209 lb; – (MONTH) 2019: 214.8 lb; – (MONTH) 2019: no weight recorded; – (MONTH) 2019: 226.2. Review of the resident’s record showed no weights for (MONTH) 2019, no RD note for February, and the physician did not address the diet recommendation. Review of the (MONTH) 2019 dietary recommendations from the RD showed the resident’s diet had not been addressed by the physician. Review of the physician order [REDACTED]. During an interview on 3/6/19, at 9:40 A.M., the Dietary Manger said: – She receives the request for diet changes as well as the Director of Nursing (DON). The DON addresses the recommendations with the physician. – The (MONTH) 2019 dietary recommendations from the RD showed the resident had a 19 lb weight gain in three months and a CCHO diet was recommended. – Staff should have the physician address the weight gain and diet recommendation by the RD within the month. During an interview on 3/6/19, at 1:40 P.M., the DON said: – There is no documentation that the resident’s diet recommendation from the RD on 1/31/19, was addressed with the physician. – The DON should communicate and receive orders from the physician regarding RD recommendations and weight gain within the week of receiving the recommendation. – Staff should notify the physician of weight changes. 2. Review of Resident #29’s care plan, updated 10/28/1, showed: – Problem: urinary incontinence; incontinent of bowel and bladder; – Goal: skin will remain intact; – Approach: apply moisture barrier to skin; eliminate dehydrating drinks; encourage fluids; ensure adequate bowel elimination; obtain lab orders; provide assistance for toileting; provide incontinence care after each incontinent episodes; report any signs of skin breakdown. Review of the resident’s quarterly MDS, dated [DATE], showed: – Severely cognitive impaired; – Extensive assist of two staff for all activities of daily living (ADLs); – Diagnoses included: [MEDICAL CONDITION] bladder (dysfunction of the bladder due to neurological damage), urinary tract infection [MEDICAL CONDITION], dementia, and anxiety. Review of the telephone order, dated 2/4/19, showed: – Urinalysis (UA) with culture and sensitivity (C&S) if indicated. Review of the UA, dated 2/6/19, showed a C&S was indicated. Review of the C&S, dated 2/8/19, showed a UTI which required antibiotics. Review of the telephone order, dated 2/26/19, showed: – [MEDICATION NAME] (an antibiotic) 100 milligrams (mg) twice a day (BID) for seven days

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– Weight change: 3 lb in one month;
– Continue to monitor.
Review of the RD note, dated 1/31/19, showed:
– Regular diet;
– Weight 215 lb;
– Weight change: 6 lb in one month for a 19 lb gain in 3 months;
– Further weight gain undesired;
– Recommend a controlled carbohydrate diet (CCHO) and monitor.
Review of the resident’s weights in the electronic record showed:
– (MONTH) (YEAR): 209 lb;
– (MONTH) 2019: 214.8 lb;
– (MONTH) 2019: no weight recorded;
– (MONTH) 2019: 226.2.
Review of the resident’s record showed no weights for (MONTH) 2019, no RD note for
February, and the physician did not address the diet recommendation.
Review of the (MONTH) 2019 dietary recommendations from the RD showed the resident’s diet
had not been addressed by the physician.
Review of the physician order [REDACTED].
During an interview on 3/6/19, at 9:40 A.M., the Dietary Manger said:
– She receives the request for diet changes as well as the Director of Nursing (DON). The
DON addresses the recommendations with the physician.
– The (MONTH) 2019 dietary recommendations from the RD showed the resident had a 19 lb
weight gain in three months and a CCHO diet was recommended.
– Staff should have the physician address the weight gain and diet recommendation by the
RD within the month.
During an interview on 3/6/19, at 1:40 P.M., the DON said:
– There is no documentation that the resident’s diet recommendation from the RD on
1/31/19, was addressed with the physician.
– The DON should communicate and receive orders from the physician regarding RD
recommendations and weight gain within the week of receiving the recommendation.
– Staff should notify the physician of weight changes.
2. Review of Resident #29’s care plan, updated 10/28/1, showed:
– Problem: urinary incontinence; incontinent of bowel and bladder;
– Goal: skin will remain intact;
– Approach: apply moisture barrier to skin; eliminate dehydrating drinks; encourage
fluids; ensure adequate bowel elimination; obtain lab orders; provide assistance for
toileting; provide incontinence care after each incontinent episodes; report any signs of
skin breakdown.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Severely cognitive impaired;
– Extensive assist of two staff for all activities of daily living (ADLs);
– Diagnoses included: [MEDICAL CONDITION] bladder (dysfunction of the bladder due to
neurological damage), urinary tract infection [MEDICAL CONDITION], dementia, and anxiety.
Review of the telephone order, dated 2/4/19, showed:
– Urinalysis (UA) with culture and sensitivity (C&S) if indicated.
Review of the UA, dated 2/6/19, showed a C&S was indicated.
Review of the C&S, dated 2/8/19, showed a UTI which required antibiotics.
Review of the telephone order, dated 2/26/19, showed:
– [MEDICATION NAME] (an antibiotic) 100 milligrams (mg) twice a day (BID) for seven days

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 8) for UTI. Review of the Medication Administration Record [REDACTED]. During an interview on 3/7/19, at 9:30 A.M., Registered Nurse (RN) A said: – Staff should put UA and C&S orders in the infection notebook and report during shift change for nurses to look for the results and to receive orders from the physician. – Staff should place lab results in the physicians’ notebook for them to address when they come to the facility or fax to the physician. – Staff should receive orders from the physician within 24-48 hours after receiving the lab results. During an interview on 3/7/19, 1:30 P.M., the DON said: – Staff should place lab orders in the infection notebook and report during shift change for the nurses to look for the results and to receive orders from the physician. – Staff should notify the physician the same day lab results are received. – Staff should start antibiotics the same day the order is received and within 24-48 hours. 3. The facility did not have a policy for medication administration. Review of Resident #30’s annual MDS, dated [DATE], showed: – A Brief Interview for Mental Status (BIMS) score of 11 which indicated supervision needed in making decisions; – No diagnoses for wheezing, asthma, or [MEDICAL CONDITION]. Review of the physician’s orders [REDACTED]. – [MEDICATION NAME]/[MEDICATION NAME] (breathing medication for asthma, [MEDICAL CONDITION], and associated wheezing) per nebulizer (a machine that administers liquid medication in mist form to breathe into the lungs) 3 milliliter vial (ml), one vial QID (four times per day) for wheezing. Review of the 14-Day Administration History, dated 2/22/19 through 3/7/19, showed: – [MEDICATION NAME]/[MEDICATION NAME] 3 ml vial per nebulizer QID for wheezing; – The 3/5/19 P.M. dose, at 5:07 P.M.: Certified Medication Technician (CMT) B initials in parentheses; not administered, drug not available; – The 3/5/19 HS (bedtime) dose, at 9:47 P.M.: Licensed Practical Nurse (LPN) A initials in parentheses; not administered, drug not available; – The 3/6/18 A.M. dose, at 6:49 A.M.: CMT A initials in parentheses; not administered, drug not available; – The 3/6/18 mid-day (MD) dose, at 11:53 A.M.: CMT A initials in parentheses; not administered, drug not available, called pharmacy; to be sent to the facility today (3/6/19); – Information Key: Initials parenthesized = not administered or not charted, see reasons/comments. During an observation and interview on 3/6/19 at 11:35 A.M., CMT A did and said: – He/she did not administer [MEDICATION NAME]/[MEDICATION NAME] 3 ml vial at 11:35 A.M. via the nebulizer because the medication was not in the facility; – He/she did not administer the [MEDICATION NAME] 3 ml vial at 6:49 A.M. because the medication was not in the facility; – Two doses on the evening shift on 3/5/19, at 5:07 P.M. and 9:47 P.M. were not administered because the medication was not in the facility; – He/she did not know why staff did not order the medication on 3/5/19 after the first two doses were missed; – He/she forgot to order the medication this A.M. after the missed dose at 6:49 A.M. but he/she would order the medication now;

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
for UTI.
Review of the Medication Administration Record [REDACTED].
During an interview on 3/7/19, at 9:30 A.M., Registered Nurse (RN) A said:
– Staff should put UA and C&S orders in the infection notebook and report during shift
change for nurses to look for the results and to receive orders from the physician.
– Staff should place lab results in the physicians’ notebook for them to address when they
come to the facility or fax to the physician.
– Staff should receive orders from the physician within 24-48 hours after receiving the
lab results.
During an interview on 3/7/19, 1:30 P.M., the DON said:
– Staff should place lab orders in the infection notebook and report during shift change
for the nurses to look for the results and to receive orders from the physician.
– Staff should notify the physician the same day lab results are received.
– Staff should start antibiotics the same day the order is received and within 24-48
hours.
3. The facility did not have a policy for medication administration.
Review of Resident #30’s annual MDS, dated [DATE], showed:
– A Brief Interview for Mental Status (BIMS) score of 11 which indicated supervision
needed in making decisions;
– No diagnoses for wheezing, asthma, or [MEDICAL CONDITION].
Review of the physician’s orders [REDACTED].
– [MEDICATION NAME]/[MEDICATION NAME] (breathing medication for asthma, [MEDICAL
CONDITION], and associated wheezing) per nebulizer (a machine that administers liquid
medication in mist form to breathe into the lungs) 3 milliliter vial (ml), one vial QID
(four times per day) for wheezing.
Review of the 14-Day Administration History, dated 2/22/19 through 3/7/19, showed:
– [MEDICATION NAME]/[MEDICATION NAME] 3 ml vial per nebulizer QID for wheezing;
– The 3/5/19 P.M. dose, at 5:07 P.M.: Certified Medication Technician (CMT) B initials in
parentheses; not administered, drug not available;
– The 3/5/19 HS (bedtime) dose, at 9:47 P.M.: Licensed Practical Nurse (LPN) A initials in
parentheses; not administered, drug not available;
– The 3/6/18 A.M. dose, at 6:49 A.M.: CMT A initials in parentheses; not administered,
drug not available;
– The 3/6/18 mid-day (MD) dose, at 11:53 A.M.: CMT A initials in parentheses; not
administered, drug not available, called pharmacy; to be sent to the facility today
(3/6/19);
– Information Key: Initials parenthesized = not administered or not charted, see
reasons/comments.
During an observation and interview on 3/6/19 at 11:35 A.M., CMT A did and said:
– He/she did not administer [MEDICATION NAME]/[MEDICATION NAME] 3 ml vial at 11:35 A.M.
via the nebulizer because the medication was not in the facility;
– He/she did not administer the [MEDICATION NAME] 3 ml vial at 6:49 A.M. because the
medication was not in the facility;
– Two doses on the evening shift on 3/5/19, at 5:07 P.M. and 9:47 P.M. were not
administered because the medication was not in the facility;
– He/she did not know why staff did not order the medication on 3/5/19 after the first two
doses were missed;
– He/she forgot to order the medication this A.M. after the missed dose at 6:49 A.M. but
he/she would order the medication now;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 9) – The resident missed a total of four doses of the medication. During an interview on 3/7/19, at 1:30 P.M., the Director of Nursing (DON) said: – If a medication was not in the building, staff should tell the on-coming staff that the medication was not available. – The staff that missed administering the first dose should be the one to call and order the medication from the pharmacy. – If the first staff did not order, then the staff that found the medication missing should call the pharmacy and order the medication. – The physician should be notified of missed doses of any medication.
	F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow-up on the pharmacist’s recommendations for gradual dose reductions (GDRs, a tapering of medication dose in an effort to discontinue or determine the lowest, most effective dose) for one of 12 sampled residents (Resident # 5). The facility census was 39. The facility did not have a policy on GDRs. 1. Review of Resident #5’s care plan, updated 9/21/18, showed: – Problem: [MEDICAL CONDITION] drug use; receives antidepressant medications related to depression; – Goal: will be prescribed the lowest effective dose of medication; – Approach: monitor resident’s mood and response to medication; monitor for effectiveness of medication; pharmacy consultant review; – Problem: [MEDICAL CONDITION] drug use; related to [MEDICAL CONDITION] (disorder that affects a person’s ability to think, feel, and behave clearly); – Goal: will be prescribed the lowest effective dose of medication; – Approach: attempt a GDR in two separate quarters the first year and yearly thereafter; monitor resident’s behavior; pharmacy consultant review. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/6/18, showed: – Cognitively intact; – [DIAGNOSES REDACTED]. – GDR has not been attempted; – GDR has not been documented by a physician as clinically contraindicated; – Received antipsychotic and antidepressant medications seven out of the past seven days. Review of the resident’s monthly drug regimen reviews (MDRR) showed: – 12/27/18: resident on [MEDICATION NAME] (antipsychotic medication) 80 milligrams (mg) twice a day (BID); sertaline (an anti-depressant) 100 mg daily in the morning; – 12/27/18: pharmacist recommends a GDR for sertaline to 50 mg daily in the morning. Review of the resident’s medical record showed the GDR had not been addressed by the physician. Review of the resident’s physician order [REDACTED]. – Order date 7/23/18: Sertaline 100 mg daily in the morning for depressive episodes.

(X4) ID PREFIX TAG

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

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
– The resident missed a total of four doses of the medication.
During an interview on 3/7/19, at 1:30 P.M., the Director of Nursing (DON) said:
– If a medication was not in the building, staff should tell the on-coming staff that the
medication was not available.
– The staff that missed administering the first dose should be the one to call and order
the medication from the pharmacy.
– If the first staff did not order, then the staff that found the medication missing
should call the pharmacy and order the medication.
– The physician should be notified of missed doses of any medication.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to follow-up on
the pharmacist’s recommendations for gradual dose reductions (GDRs, a tapering of
medication dose in an effort to discontinue or determine the lowest, most effective dose)
for one of 12 sampled residents (Resident # 5). The facility census was 39.
The facility did not have a policy on GDRs.
1. Review of Resident #5’s care plan, updated 9/21/18, showed:
– Problem: [MEDICAL CONDITION] drug use; receives antidepressant medications related to
depression;
– Goal: will be prescribed the lowest effective dose of medication;
– Approach: monitor resident’s mood and response to medication; monitor for effectiveness
of medication; pharmacy consultant review;
– Problem: [MEDICAL CONDITION] drug use; related to [MEDICAL CONDITION] (disorder that
affects a person’s ability to think, feel, and behave clearly);
– Goal: will be prescribed the lowest effective dose of medication;
– Approach: attempt a GDR in two separate quarters the first year and yearly thereafter;
monitor resident’s behavior; pharmacy consultant review.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/6/18, showed:
– Cognitively intact;
– [DIAGNOSES REDACTED].
– GDR has not been attempted;
– GDR has not been documented by a physician as clinically contraindicated;
– Received antipsychotic and antidepressant medications seven out of the past seven days.
Review of the resident’s monthly drug regimen reviews (MDRR) showed:
– 12/27/18: resident on [MEDICATION NAME] (antipsychotic medication) 80 milligrams (mg)
twice a day (BID); sertaline (an anti-depressant) 100 mg daily in the morning;
– 12/27/18: pharmacist recommends a GDR for sertaline to 50 mg daily in the morning.
Review of the resident’s medical record showed the GDR had not been addressed by the
physician.
Review of the resident’s physician order [REDACTED].
– Order date 7/23/18: Sertaline 100 mg daily in the morning for depressive episodes.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 10) – Order date 8/27/18: [MEDICATION NAME] 80 mg BID with food for [MEDICAL CONDITION]. During an interview on 3/7/19, at 8:30 A.M., the administrator said: – The facility switched pharmacies in (MONTH) (YEAR). – She did not know GDRs were not completed until surveyors requested the information. – The GDR sheets were delivered in the evening when the pharmacy delivered medications and nursing staff did not know what to do with them. – GDRs have not been routinely done since (MONTH) (YEAR) when the pharmacy changed. – GDRs should be addressed by the physician upon receiving them from the pharmacist.
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Provide and implement an infection prevention and control program. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when they did not wash their hands and change their gloves appropriately during a wound dressing change which affected one of 12 sampled residents (Resident #39); and failed to provide a clean field between residents during accuchecks (blood glucose test) and failed to clean glucometers for two residents (Resident #23 and #31). The facility census was 39. 1. The facility used the Center for Disease Control and Prevention (CDC) Standard Precautions for All Patient Care, dated 7/17/17, showed: – Standard precautions are used for all patient care; – Perform hand hygiene; – Use personal protective equipment (PPE) whenever there is an expectation of possible exposure to infectious material; – Follow respiratory hygiene/cough etiquette principles; – Properly handle and properly clean and disinfect patient care equipment and instruments/devices; clean and disinfect the environment appropriately. 2. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/12/19, showed: – A Brief Interview for Mental Status (BIMS) score of eight, which indicated supervision needed in decision making; – Independent in activities of daily living; – Surgical wound; – Surgical wound care; – Application of non-surgical dressing other than to feet; – Application of ointments other than to feet; – Diagnoses included: Dementia, anxiety, depression, no [DIAGNOSES REDACTED]. Review of the resident’s care plan showed staff did not implement a plan related to the ankle surgical wound or care of the surgical wound. Review of the physician’s orders [REDACTED]. – 2/28/19: Apply A&D (vitamins) ointment to area on foot, cover with ABD pad (dressing pad), secure with netting or [MEDICATION NAME] (a cloth sleeve) to hold in place every shift. During an observation and interview on 3/6/19, at 3:31 P.M., Registered Nurse (RN) A did and said: – Did not wash his/her hands, put on gloves and removed the old dressing from the

(X4) ID PREFIX TAG

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

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
– Order date 8/27/18: [MEDICATION NAME] 80 mg BID with food for [MEDICAL CONDITION].
During an interview on 3/7/19, at 8:30 A.M., the administrator said:
– The facility switched pharmacies in (MONTH) (YEAR).
– She did not know GDRs were not completed until surveyors requested the information.
– The GDR sheets were delivered in the evening when the pharmacy delivered medications and
nursing staff did not know what to do with them.
– GDRs have not been routinely done since (MONTH) (YEAR) when the pharmacy changed.
– GDRs should be addressed by the physician upon receiving them from the pharmacist.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided care in a manner to prevent infection or the possibility of infection when they
did not wash their hands and change their gloves appropriately during a wound dressing
change which affected one of 12 sampled residents (Resident #39); and failed to provide a
clean field between residents during accuchecks (blood glucose test) and failed to clean
glucometers for two residents (Resident #23 and #31). The facility census was 39.
1. The facility used the Center for Disease Control and Prevention (CDC) Standard
Precautions for All Patient Care, dated 7/17/17, showed:
– Standard precautions are used for all patient care;
– Perform hand hygiene;
– Use personal protective equipment (PPE) whenever there is an expectation of possible
exposure to infectious material;
– Follow respiratory hygiene/cough etiquette principles;
– Properly handle and properly clean and disinfect patient care equipment and
instruments/devices; clean and disinfect the environment appropriately.
2. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/12/19, showed:
– A Brief Interview for Mental Status (BIMS) score of eight, which indicated supervision
needed in decision making;
– Independent in activities of daily living;
– Surgical wound;
– Surgical wound care;
– Application of non-surgical dressing other than to feet;
– Application of ointments other than to feet;
– Diagnoses included: Dementia, anxiety, depression, no [DIAGNOSES REDACTED].
Review of the resident’s care plan showed staff did not implement a plan related to the
ankle surgical wound or care of the surgical wound.
Review of the physician’s orders [REDACTED].
– 2/28/19: Apply A&D (vitamins) ointment to area on foot, cover with ABD pad (dressing
pad), secure with netting or [MEDICATION NAME] (a cloth sleeve) to hold in place every
shift.
During an observation and interview on 3/6/19, at 3:31 P.M., Registered Nurse (RN) A did
and said:
– Did not wash his/her hands, put on gloves and removed the old dressing from the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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


	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 11) resident’s ankle; – Removed soiled gloves, did not wash his/her hands and applied clean gloves; – Used gloved finger to remove A&D ointment from medication cup and applied the A&D ointment to the surgical wound with his/her gloved finger; – Did not change his/her gloves, applied a clean dressing and wrapped the wound with an ace wrap; – RN A said the resident sprained his/her ankle and developed an abscess at the site that was incised and drained of infection; – RN A said he/she should wash his/her hands before starting the dressing change; he/she should wash his/her hands and change gloves after removing the old dressing; he/she should use a cotton tipped applicator to apply the A&D ointment and not a gloved finger; and should change gloves and wash his/her hands between any dirty and clean task. 3. Review of Resident #31’s quarterly MDS, dated [DATE], showed: – Cognitively intact; – Diagnoses included: diabetes, lung disease, and depression; – Insulin injections. Review of the POS [REDACTED] – [MEDICATION NAME]at bedtime; – [MEDICATION NAME]three times a day before meals. Observation on 3/6/19, at 11:40 A.M., showed RN A perform accucheck and insulin administration in the following manner: – He/she hand sanitized and applied gloves; – He/she placed the resident’s glucometer on the top of the medication cart with all the accucheck supplies without a clean field; – Performed the accucheck and placed the cotton ball with blood on top of the medication cart; – Placed the glucometer on top of the medication cart. – Retrieved the insulin and needle from the medication cart without removing gloves and washing hands. – Did not clean the top of the insulin bottle with alcohol prior to drawing the medication; – Moved the resident’s glucometer from the top of the medication cart on to the top of the computer; – Administered the insulin and discarded the sharps; – Placed the resident’s glucometer back in the medication cart without disinfecting; – Removed his/her gloves and hand sanitized. 4. Review of Resident #23’s quarterly MDS, dated [DATE], showed: – Cognitively intact; – Diagnoses included: diabetes, lung disease, and high blood pressure; – Insulin injections. Review of the POS [REDACTED] – [MEDICATION NAME]three times a day; – [MEDICATION NAME]at bedtime. Observation on 3/6/19, at 11:50 A.M., showed RN A perform accucheck and insulin administration in the following manner: – He/she hand sanitized and applied gloves; – He/she placed the resident’s glucometer on the top of the medication cart with all the accucheck supplies without a clean field; – Performed the accucheck and placed the cotton ball with blood on top of the medication

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
resident’s ankle;
– Removed soiled gloves, did not wash his/her hands and applied clean gloves;
– Used gloved finger to remove A&D ointment from medication cup and applied the
A&D ointment to the surgical wound with his/her gloved finger;
– Did not change his/her gloves, applied a clean dressing and wrapped the wound with an
ace wrap;
– RN A said the resident sprained his/her ankle and developed an abscess at the site that
was incised and drained of infection;
– RN A said he/she should wash his/her hands before starting the dressing change; he/she
should wash his/her hands and change gloves after removing the old dressing; he/she should
use a cotton tipped applicator to apply the A&D ointment and not a gloved finger; and
should change gloves and wash his/her hands between any dirty and clean task.
3. Review of Resident #31’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Diagnoses included: diabetes, lung disease, and depression;
– Insulin injections.
Review of the POS [REDACTED]
– [MEDICATION NAME]at bedtime;
– [MEDICATION NAME]three times a day before meals.
Observation on 3/6/19, at 11:40 A.M., showed RN A perform accucheck and insulin
administration in the following manner:
– He/she hand sanitized and applied gloves;
– He/she placed the resident’s glucometer on the top of the medication cart with all the
accucheck supplies without a clean field;
– Performed the accucheck and placed the cotton ball with blood on top of the medication
cart;
– Placed the glucometer on top of the medication cart.
– Retrieved the insulin and needle from the medication cart without removing gloves and
washing hands.
– Did not clean the top of the insulin bottle with alcohol prior to drawing the
medication;
– Moved the resident’s glucometer from the top of the medication cart on to the top of the
computer;
– Administered the insulin and discarded the sharps;
– Placed the resident’s glucometer back in the medication cart without disinfecting;
– Removed his/her gloves and hand sanitized.
4. Review of Resident #23’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Diagnoses included: diabetes, lung disease, and high blood pressure;
– Insulin injections.
Review of the POS [REDACTED]
– [MEDICATION NAME]three times a day;
– [MEDICATION NAME]at bedtime.
Observation on 3/6/19, at 11:50 A.M., showed RN A perform accucheck and insulin
administration in the following manner:
– He/she hand sanitized and applied gloves;
– He/she placed the resident’s glucometer on the top of the medication cart with all the
accucheck supplies without a clean field;
– Performed the accucheck and placed the cotton ball with blood on top of the medication

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
cart;
– Placed the glucometer on top of the medication cart.
– Retrieved the insulin and needle from the medication cart without removing gloves and
washing hands;
– Administered the insulin and discarded the sharps;
– Placed the resident’s glucometer back in the medication cart without disinfecting;
– Removed his/her gloves and hand sanitized.
During an interview on 3/7/19, at 9:30 A.M., RN A said:
– The residents each have their own glucometers.
– Staff run test controls on each glucometer and evening staff clean them on Sundays.
– Staff should clean the top of a insulin bottle with alcohol prior to drawing up the
medication.
– Staff should provide a clean field to place glucometers and supplies.
– Staff should remove gloves and hand sanitize after the accucheck and prior to preparing
and administering the insulin.
– Soiled cotton balls with blood should not be placed on top of the medication cart but
disposed of properly.
5. During an interview on 3/7/19, at 1:30 P.M., the Director of Nursing (DON) said:
– Staff should use a clean field when performing accucheck’s and administering insulin.
– Staff should not place blood soiled cotton balls on top of the medication cart but
dispose properly.
– Staff should cleanse the top of insulin bottles with alcohol prior to drawing up the
medication.
– Staff should clean glucometers after each use.
– Hands should be washed before a dressing change, gloves should be changed and hands
washed when soiled;
– Ointments should be applied with a cotton tipped applicator and not a gloved finger.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement a program that monitors antibiotic use.

Based on observation, interview, and record review, the facility failed to implement,
follow, and monitor a facility-wide antibiotic stewardship program. The facility had three
residents on antibiotics in (MONTH) 2019. This deficient practice had the potential to
affect all residents in the facility. The facility census was 39.
Review of the facility’s undated Antibiotic Stewardship policy showed:
– Purpose: devoted to using antibiotics appropriately and prudently to ensure residents do
not have unnecessary adverse reactions or development of antibiotic resistant bacteria
infections while entrusting the facility to their care.
– Roles: nursing administration will monitor use of antibiotics to ensure they are
prescribed prudently. They will educate charge nurses on proper requisition of
antibiotics, and not to automatically jump to antibiotic use. Physicians will adhere to
the facility policy and accept education of policy by facility administration.
– Procedures: antibiotics should be started only if there is clear, clinical indication
that an antibiotic is required to reduce the risk of inappropriate antibiotic use; every
effort should be made to collect culture specimens to determine resistance and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265846

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

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SHADY LAWN LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

13277 STATE ROUTE D
SAVANNAH, MO 64485

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 0881 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 13) susceptibility prior to initiating an antibiotic; prescription of an antibiotic should be clearly documented within the nurses’ notes to include the name of the antibiotic, dosage, length of time prescribed, route and a clear description of why it’s being prescribed.; the least aggressive antibiotic will be used; antibiotic usage will be reviewed at least monthly at quality assurance (QA) meetings and daily QA meetings; antibiotic stewardship policy will be reviewed at least quarterly with the facility’s medical director. During an antibiotic stewardship record review and interview with the Director of Nursing (DON) on 3/7/19, at 1:30 P.M., the DON said: – The facility had an antibiotic stewardship policy and program, but they did not have a monitoring system in place. – The sheet for (MONTH) and (MONTH) 2019 showed residents who have infections and their treatments. – She provided a risk meeting sheet for 2/28/19, that showed three residents on antibiotics, diagnoses, medication, labs, and where acquired; residents with infections in the past 30 days were blank on the form; residents with infections in the past quarter were blank on the form. – No monitoring tool or sheet completed for (MONTH) to show antibiotic usage or monitoring. – No documentation on follow-up, monitoring, or recording any information to the infections, progression, or outcome after treatment and resolving of the infection. – The facility should have a monitoring tool that includes detailed information.

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