Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to notify the resident and the
resident’s representative in writing of a transfer or discharge to a hospital, including
the reasons for the transfer, and failed to provide the Ombudsman (a resident advocate who
provides support and assistance with problems and/or complaints regarding the facility) a
copy of the notification, for three residents (Resident #9, #22, #24) out of 12 sampled
residents. The facility census was 33.
1. Record review of Resident #9’s nurses’ notes showed the following information:
-On 8/14/18, at 4:00 P.M., staff documented the resident yelled for help from bed. He/she
writhed in bed and complained of pain at the upper middle back and underneath the left
shoulder blade. The resident complained of shortness of breath, which was also evident.
Staff noted the left lung was expanded without air movement. Thick, white phlegm in
his/her throat made the resident vomit. Vital signs showed the resident’s oxygen
saturation level was 65% on 2 liters of oxygen per minute (lpm), which increased to 72%
when the rate was increased to 4 lpm. The respiration rate was 24, hear rate 122 beats per
minute (bpm), and blood pressure 182/89. The resident was listless,[MEDICAL CONDITION] (swollen) in all four extremities and stomach, and unable to transfer self to a wheelchair
(required two staff for assist). Staff transferred the resident in the wheelchair to the
hospital next door and gave report to hospital staff. The hospital assessed the resident
and called the facility regarding a transfer to a larger hospital with a [DIAGNOSES
REDACTED]. Staff documented they notified the resident’s family, but did not document they
sent a written notice of the transfer to the resident, resident’s representative or
Ombudsman;
-On 8/16/18, the resident readmitted to the nursing facility.
Record review of the resident’s medical record showed no letter to the responsible party
regarding the transfer on 8/14/18.
2. Record review of Resident #22’s nurses’ notes showed the following information:
-On 7/5/18, at 7:00 P.M., staff transferred the resident to the hospital related to signs
and symptoms of a severe urinary tract infection [MEDICAL CONDITION]. Staff informed the
resident’s family, but did not document they sent a written notice of the transfer to the
resident, the resident’s representative, and the Ombudsman;
-On 7/10/18, at 4:00 P.M., the resident readmitted to the facility.
Record review of the resident’s medical record did not show a copy of a written notice
provided to the resident, resident’s representative, or Ombudsman regarding the transfer
on 7/5/18.
3. Record review of Resident #24’s nurses’ notes showed the following information:
-On 7/27/18, at 5:45 P.M., based on the description of a urinalysis sample and low output,
staff received a physician order [REDACTED]. Staff documented they informed the resident’s
family, but did not document they sent a written notice of the transfer to the resident,
resident’s representative, and the Ombudsman;
-On 7/31/18, at 7:00 P.M., the resident readmitted to the facility.
Record review of the resident’s medical record did not show a copy of a written notice
provided to the resident, resident representative, or Ombudsman regarding the transfer on
7/27/18.
4. During an interview via telephone on 8/30/18, at 10:21 A.M., the Social Service
Director (SSD) said he/she did not do written notifications to residents or their
representatives regarding a transfer to the hospital. Notifications were only sent upon

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
permanent discharges. The nursing staff was responsible for verbally notifying a
resident’s family if a resident was sent out to the hospital. The SSD said the Ombudsman
told him/her that he/she did not want notification unless the transfer was anticipated as
permanent.
5. During an interview on 8/30/18, at 2:15 P.M., the administrator, Director of Nursing
(DON), and Assistant Director of Nursing (ADON) said they did not know that a written
notification to the resident, resident’s representative, and Ombudsman were required for a
transfer to the hospital with anticipated return.
6. Record review of a facility document entitled, Admission, Transfer & Discharge
Rights Policy showed the following information:
-Transfer and discharge includes movement of a resident to a bed outside of the certified
facility whether that bed is in the same physical plant or not;
-The facility will not transfer or discharge the resident unless the transfer or discharge
is necessary for the resident’s welfare and the resident’s needs cannot be met in the
facility;
-Before a resident is transferred, the facility will notify the resident, and if known, a
family member or legal representative of the resident of the transfer or discharge. This
notice shall be in writing and shall include the reason for transfer. The notice will be
made at least 30 days before the resident is transferred or discharged unless an immediate
transfer or discharge is required by the resident’s urgent medical needs. In the above
situation, notice will be made as soon as practical before transfer or discharge;
-Contents of the transfer notice shall include: reason for transfer/discharge, effective
date of transfer/discharge, location to which the resident is transferred/discharged .
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to consistently complete an
accurate skin and wound assessment for one resident (Resident #23) out of a sample of 12
residents. The facility census was 33.
Record review of the facility’s skin care protocol, showed the following information:
-When an alteration in skin integrity is observed, the physician and family/power of
attorney will be notified within 24 hours of any skin condition or open area.
-The nurse will implement measures to assist in healing. These include but are not limited
to pressure relief, turning, repositioning, clean linens, keeping the resident clean and
dry, application of moisture barrier/creams/ointments/treatments, and maintaining adequate
nutrition and hydration. Interventions will be included on the resident’s individual care
plan.
-Any open area or skin condition will be monitored daily and treated per physician’s
orders [REDACTED].
-All wounds/conditions will be documented weekly in the chart. This documentation includes
measurements and a description of the wound.
-The nurse will also document any factors that may delay the healing of the wound, i.e.
poor appetite, weight loss, diagnoses, compliance. These will also be addressed in the
care plan as appropriate.
1. Record review of Resident #23’s face sheet (a document that gives a resident’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
information at a quick glance) showed the following information:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the physician order [REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, completed by facility staff, dated 08/01/18, showed the following
information:
-At risk of developing pressure ulcers;
-Moisture associated skin damage (caused by prolonged exposure to various sources of
moisture, characterized by inflammation of the skin).
Record review of the weekly skin assessment, dated 08/01/18, showed the following
information:
-Skin warm, dry and intact;
-Constant redness on left skin at the ankle;
-The nurse did not document any measurements or further description of the wound.
Record review of the bath/shower sheet, dated 08/01/18, showed no skin issues noted.
Record review of the nurse’s note, dated 08/02/18, showed the following information:
-At 9:20 P.M., found 2.0 (did not clarify type of unit measurement) fluid-filled blister
on the back of the resident’s left leg when cream applied to the resident’s legs;
-Informed resident of findings, put low socks back on resident.
Record review of the bath/shower sheet, dated 08/03/18, showed staff indicated a blister
on the resident’s left lower leg. No description noted.
Record review of the (MONTH) (YEAR) bath/shower sheets, showed staff did not complete
bath/shower sheets between the dates of 08/04/18-08/14/18.
Record review of the weekly skin assessment, dated 08/08/18, showed the resident had a red
intact skin area on the left lower extremity. The nurse did not document any further
description or measurements of the red area.
Record review of the resident’s care plan, dated 08/10/18, showed the following
information:
-Potential for pressure ulcer development due to immobility;
-The resident will have intact skin, free of redness, blisters, or discoloration
by/through review date;
-Follow facility policies/protocols for the prevention/treatment of[REDACTED].>-Monitor/document/report PRN any changes in skin status: appearance, color,
wound healing, signs of infection, wound size, stage;
-Weekly treatment documentation to include measurement of each area of skin breakdown’s
width, length, depth, type of tissue and exudate.
Record review of the nurse’s note, dated 08/12/18, showed the following information:
-At 8:30 A.M., the resident’s family member advised the nurse of a wound on the resident’s
left lower posterior leg;
-Superficial area measuring approximately half dollar in size, circular wound;
-The nurse did not clarify if the area was open;
-Small amount of clear drainage present with no odor;
-Wound circled by red area extending approximately one inch;
-The nurse contacted the physician and received an order to apply [MEDICATION NAME] (topical antibiotic used to treat or prevent infections) twice a day (BID) and dressing;
-Culture the wound.
Record Review of the POS [REDACTED].
Record review of the weekly skin assessment, dated 08/12/18, showed the following
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
information:
-Blister on the back of the resident’s left calf, measuring one centimeter;
-No further description of the wound bed, drainage, pain, or skin surrounding the wound
noted.
Record review of the nurse’s note, dated 08/13/18, showed the following information:
-At 6:30 P.M., the nurse practitioner examined the back of the resident’s left leg;
-He/she drained the blister;
-Discontinued the [MEDICATION NAME] ointment;
-Ordered adaptive dressing with [MEDICATION NAME] (specialized gauze pads) and [MEDICATION
NAME] (elasticated tubular bandage).
Record Review of the POS [REDACTED].
Record review of the bath/shower sheets, dated 08/15/18 and 08/17/18, showed no skin
issues noted.
Record review of the weekly skin assessment, dated 08/22/18, (previous skin assessment
completed on 8/12/18, 10 days earlier), showed the following information:
-Lower left extremity weakened;
-Skin is pink, warm, and dry without any redness or open areas noted.
Record review of the bath/shower sheets, dated 08/27/18 and 08/29/18, showed no skin
issues noted.
Record review of the weekly skin assessment, dated 08/29/18, showed the following
information:
-Area on back of left leg healing;
-Adaptive dressing;
-Continued redness on lower left extremity;
-The nurse did not document any further description, measurements of the wound base, or
the skin surrounding the wound.
During an interview on 08/29/18, at 2:30 P.M., Licensed Practical Nurse (LPN) E said
during a two week period at the beginning of August, staff did not complete bath sheets on
all residents as the facility did not have a bath aide. All staff, including nurses and
other administration staff, aided in giving residents’ showers.
During an interview on 08/30/18, at 9:20 A.M., Certified Nursing Assistant (CNA) B said
he/she will notify the charge nurse and document on the bath sheet any skin conditions
that are observed.
During an interview on 08/30/18, at 9:25 A.M., CNA C said he/she will write on the shower
sheet any skin conditions observed and will notify the nurse.
During an interview on 08/30/18, at 9:45 A.M., LPN D said bath aides notify him/her of
compromised skin and he/she will observe the skin and if necessary will notify the
director of nursing (DON), the physician, and the family. If a new order is received or
discontinued, he/she will write on the POS and then will update the treatment
administration record or the medication administration record. The nurse will also notify
the medication technician.
During an interview on 08/30/18, at 10:45 A.M., LPN E said if a CNA notifies him/her of a
skin condition on a resident, he/she will assess the skin and provide proper treatment.
He/she would notify the physician, DON, and family. He/she has observed Resident #23’s
blister on his/her leg. The blister opened approximately three weeks ago.
During an interview on 08/30/18, at 10:55 A.M., the DON said bath aides will alert the
nurse if there are skin concerns. Nurses do not notify the physician of a water blister
until they open, however the nurse would document in the treatment book to watch daily.
The nurse would initial everyday they observed the area of concern. Nurses are aware of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
who requires treatment/observation as they go through the treatment book page by page
every shift.
F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to promptly stop administration
of an antibiotic medication discontinued by the nurse practitioner for one resident
(Resident #23) out of a sample of 12 residents. The facility census was 33.
1. Record review of Resident #23’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following information:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the nurses’ note, dated 08/12/18, showed the following information:
-At 8:40 P.M., the nurse practitioner called and gave an order for [REDACTED].
Record review of the physician order [REDACTED].
Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] -On 08/12/18, PM;
-On 08/13/18, AM and PM.
Record review of the nurse’s note, dated 08/13/18, showed the following information:
-At 6:30 P.M., the nurse practitioner examined the back of the resident’s left leg;
-He/she drained the blister and discontinued the Bactrim.
Record review of the physician order [REDACTED].
Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] -On 08/14/18, AM and PM;
-On 08/15/18, AM and PM.
During an interview on 08/30/18, at 9:45 A.M., Licensed Practical Nurse (LPN) D said if a
new order is received or discontinued, he/she will write on the POS and then will update
the treatment administration record or the medication administration record. The nurse
will also notify the medication technician.
During an interview on 08/30/18, at 12:10 P.M., Certified Medication Technician (CMT) F
said he/she would stop administering a discontinued medication as soon as the order is
received. The nurse will mark in the Medication Administration Record [REDACTED] During an interview on 08/30/18, at 2:25 P.M., the Director of Nursing (DON) said when a
medication is discontinued, the nurse who receives the order is responsible for updating
the POS and the medication/treatment administration record.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

Based on observation, interview, and record review, the facility failed to keep non-food
contact surfaces in the kitchen clean and sanitary. The facility census was 33.
1. Record review of the 2013 Missouri Food Code showed the following information:
-Physical facilities shall be cleaned as often as necessary to keep them clean;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 5)
-Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust,
dirt, food residue, and other debris.
Record review of the facility’s (MONTH) (YEAR) daily cleaning schedule showed the
following information:
-Staff are to sweep all floors during AM and PM shifts;
-AM staff initialed the floors swept daily from 08/01/18-08/06/18;
-PM staff initialed floors were swept on 08/01/18 and 08/02/18;
-No PM staff initials were present for 08/03/18;
-PM staff initialed floors were swept on 08/04/18 and 08/05/18;
-No PM staff initials were present on 08/06/18;
-No AM staff initials were present from 08/07/18-08/10/18;
-AM staff initialed the floors swept on 08/11/18;
-No AM staff initials were present for 08/12/18;
-AM staff initialed the floors were swept daily from 08/13/18-08/30/18.
-PM staff initialed the floors swept daily from 08/07/18-08/21/18;
-No PM staff initials were present on 08/22/18;
-PM staff initialed the floors swept daily from 08/23/28-08/29/18.
Observation of the kitchen on 08/27/18, at 10:20 A.M., showed the following:
-One dead bug in front of the three door refrigerator;
-One dead bug, of same kind, by the side of the stove;
-One dead bug by dietary manager’s desk;
-One dead bug located outside of the kitchen door leading to the dining room;
-Multiple dead bugs in dry storage area, bug traps present;
-Food particles under the dry storage racks.
Observation of the kitchen on 08/29/18, at 10:28 A.M., showed the following:
-One dead bug by the deep freezer;
-One dead bug by the side of the stove;
-Multiple dead bugs behind the three door refrigerator;
-One dead bug under the three compartment sink;
-One dead bug under the dietary manager’s desk in the kitchen,
-Daylight could be seen under the door in the kitchen from the outside;
-Multiple dead bugs in the dry storage area;
-Food particles under the dry storage racks;
-One dead bug under the industrial mixer.
Observation of the kitchen on 08/30/18, at 10:16 A.M., showed the following:
-Four dead bugs behind the stove;
-One dead bug by the side of the stove;
-Door in kitchen to the outside cracked open;
-Four dead bugs by the side of the freezer;
-Four dead bugs by the three compartment sink;
-One dead bug under the steam table;
-Two dead bugs under the cart by the hand washing station;
-One dead bug under the rack holding bin of plastic wear;
-One dead bug under the industrial mixer;
-One dead bug under the food prep table;
-Two dead bugs behind the three door refrigerator;
-Eight dead bugs located in the dry storage, two bug traps present;
-Food particles under the dry storage racks.
During an interview on 08/30/18, at 10:29 A.M., Dietary Aide (DA) J said there is an AM
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 6)
and PM cleaning check list. The floors are swept daily after every shift, which includes
sweeping all areas including dry storage.
During an interview on 08/30/18, at 10:34 A.M., DA K said he/she tries to verify tasks are
being done, like sweeping, between every shift. When a task is complete, staff initial the
checklist.
During an interview on 08/30/18, at 1:35 P.M., the dietary manager said he/she believes
staff are not truly cleaning the floors and are just sweeping the main areas.
F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Make sure there is a pest control program to prevent/deal with mice, insects, or other
pests.

Based on observation and interview, the facility failed to maintain an effective pest
control system when multiple bugs and flies were noted throughout resident rooms, the
kitchen and dining room, hallways and common areas. The facility census was 33.
1. Observation on 8/27/18, at 9:35 A.M., showed the main entrance vestibule contained
several dead bugs on the floor and multiple dead bugs inside a cardboard Orkin pest trap
on the floor.
2. Observation on 8/27/18, beginning at 10:20 A.M., showed large (thumbnail length) black
oblong-shaped dead bugs in resident rooms 109, 112 and 113 (two bugs), West hallway (three
bugs), and South hallway (two bugs). The vestibule area between the West outside door and
inner exit door contained numerous dead bugs on the floor, in the window sills, and inside
a cardboard Orkin pest trap located on the floor.
3. Observation on 8/27/18, at 12:25 P.M., showed multiple flies in the dining room. Two
residents used their napkins to wave away flies that landed on their plates and glasses.
4. During a resident group interview on 8/28/18, at 10:00 A.M., all five residents in
attendance agreed that the facility had too many bugs and flies, especially in the dining
room.
5. Observation on 8/30/18, at 10:30 A.M., showed a large black bug moving quickly across
the South hallway floor. CNA A, who walked down the hallway, shook his/her head and said,
Oh, those water bugs are everywhere!
6. Observation on 08/27/18, at 10:20 A.M., showed at least four dead bugs in the kitchen
area.
7. Observation on 08/29/18, at 9:10 A.M., showed two bugs in the 200 hallway, one dead on
his/her back, the other in an upright position, no movement observed.
8. Observation on 08/29/18, at 10:48 A.M., showed at least four dead bugs in the kitchen
area.
9. Observation on 08/30/18, at 10:16 A.M., showed at least 23 dead bugs in the kitchen
area.
10. Observation on 08/30/18, at 10:37 A.M., showed a dead bug in the 200 hallway.
11. During an interview on 08/30/18, at 10:29 A.M., Dietary Aide (DA) J said he/she has
noticed water beetles in the facility. He/she said staff are aware of the bugs and they
can be seen crawling around all the time, but mostly this month.
12. During an interview on 08/30/18, at 12:51 P.M., Certified Nursing Assistant (CNA) G
said when he/she sees water bugs, he/she kills the bugs and sweeps them up. He/she has
informed the charge nurse and the administrator about the bugs.
13. During an interview on 08/30/18, at 1:10 P.M., Housekeeping (HK) H said he/she has

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265843

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

08/30/2018

NAME OF PROVIDER OF SUPPLIER

APPLETON CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

600 NORTH OHIO, PO BOX 98
APPLETON CITY, MO 64724

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 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 7)
noticed water bugs. He/she will kill the bugs and notify the administrator.
14. During an interview on 08/30/18, at 1:15 P.M., HK I said they have bugs all over the
facility. He/she will vacuum up the bugs. The administrator will put out bug traps when
Orkin pest control can’t come in to spray. Pest control was at the facility in (MONTH) and
believes they come every three months. He/she has advised the administrator of the bugs.
15. During an interview on 08/30/18, at 1:35 P.M., the dietary manager (DM) said the
facility has water bugs. When staff see the bugs, they alert him/her and the DM notifies
the administrator. Most of the bugs he/she has observed have been dead and staff sweeps
them up. The pest control company needs to come more often and he/she has gone to the
hardware store and has bought additional bug traps.
16. During an interview on 8/30/18, at 11:55 A.M., Maintenance B said he/she had seen a
pest control service man in the building, but did not know when or the name of the
service.
17. During an interview on 8/30/18, at 12:07 P.M., the administrator said the facility
uses pest traps/boxes purchased from Orkin Pest Control. The kitchen is treated by Orkin
and the administrator sprays the building for bugs when necessary. The administrator said
the flies seemed to be worse than usual during the current week.
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