Putnam County Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

condition, removal of the catheter and staff should call the physician and explain the situation and receive orders for treatment. Staff should notify the physician of the resident's condition when straight catheterization was required. During an interview on 8/13/25 at 2:10 P.M., RN A said on 7/1/25 the resident returned from the hospital with a urinary catheter. RN A removed the catheter with no issues. RN A did not call the discharging hospital or physician to verify the need for the urinary catheter. He/She removed the resident's urinary catheter because the resident was pulling on the catheter and causing pain and there was no diagnosis on the resident's record that required a urinary catheter. RN A notified the physician by secure text app after he/she removed the urinary catheter. The resident had no urine output for two days.

Another RN straight catheterized the resident for residual urine. Staff should have notified the physician of

the resident's change in condition and need for straight catheterization. Staff should follow the facility policy.

During an interview on 8/13/25 at 1:40 P.M. the Director of Nursing said on 7/1/25 the resident returned to

the facility with a urinary catheter, she was not sure why the resident had the catheter. The resident tried to pull the catheter out on the day he/she readmitted to the facility. Staff should notify the physician of the urinary catheter and prior to removing the urinary catheter. Staff should notify the physician of the resident's condition prior to straight catheterization. Staff should notify the resident's family of any change in condition or change in orders. During an interview on 8/13/25 at 2:40 P.M. the resident's physician said the facility communicated with him through a secure text app, fax and phone calls. Staff did not notify him the resident had a catheter until after the catheter was removed and did not notify him the resident was unable to void

before inserting the straight catheter. During an interview on 8/13/25 at 3:20 P.M. the Administrator said staff should notify the physician and family of changes in condition and treatment. Staff should have determined why the resident had the catheter when he/she returned from the hospital and notified the physician before discontinuing the urinary catheter. Intake 2565096

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Putnam County Care Center

1814 Oak Street Unionville, MO 63565

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 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

[DATE REDACTED] at 2:00 P.M. the Administrator said the resident's code status changed from full code to DNR on [DATE REDACTED]. Staff called and notified the administrator while she was playing golf at the golf course. The resident's family member was at the golf course and heard the conversation. The administrator told the resident's family member yes if you want to see the resident you should go. The administrator told the family member, who was not the resident's power of attorney, the resident's code status changed to DNR. The family member misinterpreted the information and thought the resident had coded. She should not disclose any resident's personal medical information to anyone other than the resident's power of attorney. She violated the resident's privacy and the facility privacy policy. Intake 2594218

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Putnam County Care Center

1814 Oak Street Unionville, MO 63565

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

touch;-At 5:38 A.M. the resident was very tender to the perineal skin and meatus and became very anxious and upset, almost violent when touched in any manner. Review of the resident's medical record showed no documentation staff notified the physician or the resident's family the resident was unable to urinate and had pain with touching of the perineal skin and meatus.During an interview on 8/13/25 at 12:40 PM Licensed Practical Nurse (LPN) B said the resident had a catheter when he/she returned from the hospital.

The nurse removed the catheter after the resident returned to the facility, the resident was restless and pulled on the catheter tubing, causing trauma to the perineal skin and insertion site. The nurses decided the catheter did more harm than good. Staff should have an order for a catheter and an order to remove the catheter. When a resident was admitted with a catheter, staff should notify the physician, receive orders for

the urinary catheter and orders for caring and flushing of the urinary catheter. The physician and family should be notified of the change in condition, removal of the catheter and staff should call the physician and explain the situation and receive orders for treatment. Following removal staff should check for urine output and monitor for distension, pain or difficulty urinating. Staff should obtain a physician's order to straight catheterize and notify the physician of the resident's condition when straight catheterization was required.

The resident's perineal skin and meatus peeled and was irritated, red and swollen with purulent drainage

after the catheter was removed. During an interview on 8/13/25 at 2:10 P.M., RN A said on 7/1/25 the resident returned from the hospital with a urinary catheter. RN A removed the catheter with no issues. RN A did not call the discharging hospital or physician to verify the need for the urinary catheter. He/She removed

the resident's urinary catheter because the resident was pulling on the catheter and causing pain and there was no diagnosis on the resident's record that required a urinary catheter. RN A notified the physician by secure text app after he/she removed the urinary catheter. The resident had no urine output for two days.

Another RN straight catheterized the resident for residual urine. Staff should have notified the physician of

the resident's change in condition and need for straight catheterization. Staff should follow the facility policy.

During an interview on 8/13/25 at 1:40 P.M. the Director of Nursing said on 7/1/25 the resident returned to

the facility with a urinary catheter, she was not sure why the resident had the catheter. The resident tried to pull the catheter out on the day he/she readmitted to the facility. No staff called to clarify the reason for the urinary catheter with the discharging hospital or notified the resident's physician of the urinary catheter.

There was no physician's order for a urinary catheter on the resident's medical record. Staff should obtain

an order for the urinary catheter and obtain a physician's order prior to removing the urinary catheter. Staff should notify the physician of the resident's condition prior to straight catheterization. During an interview

on 8/13/25 at 2:40 P.M. the resident's physician said the facility communicated with him through a secure text app, fax and phone calls. Staff should have physician orders for catheter placement, removal and straight catheterization. Staff should monitor and assess a resident if unable to void and required a straight catheterization. Staff should notify the physician for changes in treatment and orders if the resident was unable to void and if the resident had pain. During an interview on 8/13/25 at 3:20 P.M. the Administrator said staff should have determined why the resident had the catheter when he/she returned from the hospital and notified the physician before discontinuing the urinary catheter. Intake 2565096

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Putnam County Care Center

1814 Oak Street Unionville, MO 63565

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 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

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

the resident's left arm, wrap the wheelchair arm rest and not let the resident's left arm dangle. During an

interview on 9/10/25 at 2:00 P.M. Physical Therapy Assistant F said no physical or occupational therapy evaluation or recommendations were provided regarding the resident's left arm injuries during transfers.

Staff did not contact therapy regarding the resident's left arm injuries that occurred during transfers and the resident did not have a sling for use during transfers prior to 8/17/25. During an interview on 8/13/25 at 1:40 P.M. the Director of Nursing said the resident's left arm was flaccid and staff should support the resident's left arm during transfers and prevent injuries. The resident did not have a sling. Staff were educated about protecting the resident's left arm and provide support, so the left arm did not dangle during transfers and avoiding injury to the left arm. The resident's family ordered an immobilizer device to secure the resident's left arm during transfers to prevent further injuries. Resident care plans should be updated and reflect the resident's current care needs and changes in care needs. During an interview on 8/13/25 at 2:40 P.M. the resident's physician said staff should protect the resident's affected arm from injury during transfers and avoid injuries. During an interview on 8/13/25 at 3:20 P.M. the Administrator said staff should prevent injuries during transfers and protect the resident's affected arm. All residents should have safe transfers without injury. Intake 2587150

Event ID:

Facility ID:

If continuation sheet