PEMISCOT COUNTY MEMORIAL HOSPITAL
Nursing Home Inspector
PO BOX 489, HIGHWAY 61 AND REED STREET
HAYTI, MO 63851
Pemiscot County
Phone: 573-359-1372
Provider Number: 26A469
Last Inspection: 05/24/2017
About the Nursing Home
Number of Beds: 66
Number of Residents: 28
Beds Available: 38
Percent Occupancy: 42%
Insurance Accepted: Medicaid
Types of Councils: Resident
Ownership: Government - County
Within Hospital?: YES
About State Inspection Deficiencies
Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.
The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.
Please note: Findings in these inspections do not present a complete picture of the quality of care provided.
Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.
Deficiency Ratings
Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:
Severity Rating = Scope + Level of Harm.
Deficiency Rating= Sum of ALL Severity Ratings
| Severity |
Scope |
Level of Harm |
| 2 |
1-Isolated |
1-Potential for minimal harm |
| 3 |
2-Pattern |
1-Potential for minimal harm |
| 3 |
1-Isolated |
2-Minimal harm or potential for actual harm |
| 4 |
3-Widespread |
1-Potential for minimal harm |
| 4 |
2-Pattern |
2-Minimal harm or potential for actual harm |
| 4 |
1-Isolated |
3-Actual harm |
| 5 |
3-Widespread |
2-Minimal harm or potential for actual harm |
| 5 |
2-Pattern |
3-Actual harm |
| 5 |
1-Isolated |
4-Immediate jeopardy to resident health or safety |
| 6 |
3-Widespread |
3-Actual harm |
| 6 |
2-Pattern |
4-Immediate jeopardy to resident health or safety |
| 7 |
3-Widespread |
4-Immediate jeopardy to resident health or safety |
Deficiency Ratings
By Year
Lower Numbers Are Better
|
59
2017 |
50
2016 |
40
2014 |
Medicare Ratings
| Overall Rating: |
 |
| Health Rating: |
 |
| Staff Rating: |
 |
| Quality Rating: |
 |
Details by Inspection Date
| Failed To: Keep residents' personal and medical records private and confidential. |
Isolated :
Minimal
|
  3
|
7/8/2017
|
| |
| Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. |
Pattern :
Minimal
|
4
|
7/8/2017
|
| |
| Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. |
Pattern :
Minimal
|
4
|
7/8/2017
|
| |
| Failed To: Provide activities to meet the interests and needs of each resident. |
Pattern :
Minimal
|
4
|
7/8/2017
|
| |
| Failed To: Ensure the activities program is directed by a qualified professional. |
Pattern :
Minimal
|
4
|
7/8/2017
|
| |
| Failed To: Provide housekeeping and maintenance services. |
Pattern :
Minimal
|
4
|
7/8/2017
|
| |
| Failed To: Conduct initial and periodic assessments of each resident's functional capacity. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Completely assess the resident at least every twelve months. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Assure that each resident’s assessment is updated at least once every 3 months. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Ensure services provided by the nursing facility meet professional standards of quality. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Store, cook, and serve food in a safe and clean way. |
Widespread :
Minimal
|
5
|
7/8/2017
|
| |
| Failed To: Have a program that investigates, controls and keeps infection from spreading. |
Isolated :
Minimal
|
3
|
7/8/2017
|
| |
| Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. |
Pattern :
Minimal
|
4
|
7/8/2017
|
| |
| Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Provide housekeeping and maintenance services. |
Pattern :
Minimal
|
4
|
4/28/2016
|
| |
| Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Ensure services provided by the nursing facility meet professional standards of quality. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. |
Widespread :
Minimal
|
5
|
4/28/2016
|
| |
| Failed To: Post nurse staffing information/data on a daily basis. |
Widespread :
Potential
|
4
|
4/28/2016
|
| |
| Failed To: 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Store, cook, and serve food in a safe and clean way. |
Widespread :
Minimal
|
5
|
4/28/2016
|
| |
| Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. |
Isolated :
Minimal
|
3
|
4/28/2016
|
| |
| Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. |
Pattern :
Minimal
|
4
|
4/28/2016
|
| |
| Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. |
Pattern :
Minimal
|
4
|
4/28/2016
|
| |
| Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated :
Minimal
|
3
|
1/16/2015
|
| |
| Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. |
Pattern :
Minimal
|
4
|
2/1/2015
|
| |
| Failed To: Provide housekeeping and maintenance services. |
Isolated :
Minimal
|
3
|
2/1/2015
|
| |
| Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. |
Isolated :
Minimal
|
3
|
1/16/2015
|
| |
| Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. |
Isolated :
Minimal
|
3
|
1/15/2015
|
| |
| Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated :
Actual
|
4
|
1/16/2015
|
| |
| Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. |
Isolated :
Minimal
|
3
|
1/15/2015
|
| |
| Failed To: Ensure residents maintain acceptable nutritional status. |
Isolated :
Minimal
|
3
|
1/15/2015
|
| |
| Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. |
Isolated :
Minimal
|
3
|
1/16/2015
|
| |
| Failed To: Store, cook, and serve food in a safe and clean way. |
Widespread :
Minimal
|
5
|
1/16/2015
|
| |
| Failed To: Have a program that investigates, controls and keeps infection from spreading. |
Isolated :
Minimal
|
3
|
1/15/2015
|
| |
| Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. |
Isolated :
Minimal
|
3
|
1/15/2015
|
| |
Complaint Investigation Deficiencies
These deficiencies resulted from complaints investigated by the state inspectors and substantiated.
| Failed To: Conduct initial and periodic assessments of each resident's functional capacity. |
Isolated :
Minimal
|
3
|
10/20/2016
|
| |
| Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. |
Isolated :
Minimal
|
3
|
10/20/2016
|
| |
About The Staff
(
Higher Numbers Are Better)
| Staffing Hours Per Day Per Resident... |
This Facility |
County Avg |
MO State Avg |
| Number of Residents |
28 |
38.33 |
74.26 |
| Registered Nurses |
0.39 |
0.38 |
0.60 |
| Licensed Practical / Vocational Nurses |
1.75 |
1.37 |
0.72 |
| Certified Nursing Assistants |
2.08 |
2.38 |
2.43 |
| Total Staff Hours |
4.21
|
4.13 |
3.75 |
About the Residents
(
Lower Numbers Are Better)
| Percent of Residents... |
This Facility | % |
County Avg | % |
MO State Avg | % |
|
of high risk long-stay residents with pressure ulcers
|
|
21
|
|
14
|
|
5
|
|
of long-stay residents assessed and appropriately given the pneumococcal vaccine
|
|
65
|
|
87
|
|
88
|
|
of long-stay residents assessed and appropriately given the seasonal influenza vaccine
|
|
92
|
|
95
|
|
93
|
|
of long-stay residents experiencing one or more falls with major injury
|
|
1
|
|
3
|
|
4
|
|
of long-stay residents who have depressive symptoms
|
|
9
|
|
6
|
|
3
|
|
of long-stay residents who lose too much weight
|
|
3
|
|
4
|
|
7
|
|
of long-stay residents who received an antianxiety or hypnotic medication
|
|
27
|
|
34
|
|
26
|
|
of long-stay residents who received an antipsychotic medication
|
|
24
|
|
13
|
|
18
|
|
of long-stay residents who self-report moderate to severe pain
|
|
4
|
|
11
|
|
7
|
|
of long-stay residents who were physically restrained
|
|
0
|
|
0
|
|
0
|
|
of long-stay residents whose ability to move independently worsened
|
|
9
|
|
9
|
|
15
|
|
of long-stay residents whose need for help with daily activities has increased
|
|
6
|
|
11
|
|
14
|
|
of long-stay residents with a catheter inserted and left in their bladder
|
|
6
|
|
3
|
|
2
|
|
of long-stay residents with a urinary tract infection
|
|
0
|
|
1
|
|
4
|
|
of low risk long-stay residents who lose control of their bowels or bladder
|
|
41
|
|
28
|
|
32
|
|
of short-stay residents assessed and appropriately given the pneumococcal vaccine
|
|
15
|
|
64
|
|
74
|
|
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
|
|
30
|
|
10
|
|
12
|
|
of short-stay residents with pressure ulcers that are new or worsened
|
|
0
|
Not Available
|
|
|
68
|