Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to ensure each
resident had the opportunity to exercise his/her preference regarding wearing smoking
aprons for three out of fourteen sampled residents (Residents #23, #26, and #29). This had
the potential to affect all smokers in the facility. The census was 53.
1. Review of the facility’s smoking policy, not dated, showed a fire blanket or fire apron
is required for residents that smoke.
2. Observation on 7/17/18 through 7/20/18 at 10:30 A.M., 1:15 P.M., and 3:30 P.M. of
residents in the smoking area showed all residents wore a smoking apron. Additional
observations showed Residents #23, #26, and #29 present and wearing smoking aprons.
3. Review of Resident #23’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/31/18, showed the following:
-admission date of [DATE];
-Understood, understands;
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 15
out of 15, cognitively intact;
-No behaviors;
-Independent with bed mobility;
-Required supervision for eating and locomotion on and off the unit;
-No impairments in ROM in upper or lower extremities;
-Uses a wheelchair for mobility;
-Currently uses tobacco.
Review of the resident’s Smoking Assessment, dated 7/19/18, showed he/she is a safe
smoker.
During an interview on 7/20/18 at 5:00 P.M., the resident said everyone has to wear the
smoking aprons, but not everyone likes it. He/She is okay with wearing it, because the
aprons keep him/her from burning himself/herself or catching on fire. He/She is pretty
sure he/she could smoke without burning himself/herself. The residents who don’t like to
wear the aprons because it is too hot can make do for 15 to 20 minutes.
4. Review of Resident #26’s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Understood, understands;
-Brief Interview for Mental Status (BIMS) of 15 out of 15, cognitively intact;
-No behaviors;
-Independent in all activities of daily living (ADL);
-No impairments in range of motion (ROM) in upper or lower extremities;
-Does not use mobility devices;
-[DIAGNOSES REDACTED].
-Current tobacco use not marked yes or no.
Review of the resident’s Smoking Assessment, dated 7/19/18, showed he/she is a safe
smoker.
During an interview on 7/19/18 at 10:00 A.M. the resident said everyone has to wear the
smoking aprons while they are smoking. Some of the residents will drop their cigarettes or
fall asleep while smoking. The aprons keep them from catching on fire or burning their
clothes. He/She is independent, walks around without assistance, and feeds
himself/herself. He/She can smoke without dropping a cigarette. He/She does not really
care about wearing the aprons, but the apron gets really hot when it is hot outside.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
He/She would rather not wear the aprons, but that is the way it is.
5. Review of Resident #29’s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Understood, understands;
-BIMS of 14 out of 15, cognitively intact;
-No behaviors;
-Independent in all ADLs;
-No impairments in ROM in upper or lower extremities;
-Does not use mobility devices;
-[DIAGNOSES REDACTED].
-Current tobacco use not marked yes or no.
Review of the resident’s Smoking Assessment, dated 7/19/18, showed he/she is a safe
smoker.
During an interview on 7/20/18 at 5:15 P.M., the resident said he/she does not like to
wear the smoking apron, and he/she does not think he/she should have to wear it.
6. During an interview on 7/20/18 at 1:45 P.M. Laundry Aide C said all residents who smoke
must wear an apron and it is not based on any evaluation. He/She said everyone wears one
so no one feels pointed out. The aide said the apron protects the residents in case they
fall asleep or accidentally drop the cigarette. He/She said Residents #26 and #29 are
independent and able to do everything for themselves so it is not really necessary for
them to wear one, but they do.
7. During an interview on 7/20/18, at 7:00 P.M., the administrator said all residents are
required to wear a smoking apron.

F 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to organize and participate in resident/family groups in the
facility.

Based on interviews and record reviews, facility staff failed to provide the resident
council with written responses, actions, and rationale taken regarding their concerns.
This had the potential to affect all residents in the facility. The facility census was
53.
1. During a group interview on 7/18/18 at 9:55 A.M., with 10 residents identified by the
facility as alert and oriented, the residents said the Activity Director (AD) attends each
of the meetings and takes notes for them. The residents said the AD tells them what
department staff had to say about their concerns but they have not received any responses
in writing.
2. Review of the resident council meetings minutes showed the following:
-April (YEAR)-no resident concerns were noted in the resident council minutes;
-May (YEAR)-the residents were concerned about the response time on call lights and the
coffee being too hot;
-June (YEAR)-notes under old business said Call light response depends on shift is
somewhat better. It depends on staffing. There were no new concerns noted in the resident
council minutes.
3. During an interview on 7/20/18 at 12:00 P.M., the AD said he/she has worked as the
director for three months and is the only staff in the activity department. He/She attends
the monthly resident council meetings and takes notes. He/she uses a form the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
administrator gave her and residents’ concerns are written on the second page under the
section titled New Business. The staffs’ responses to the residents’ concerns for the
previous month are recorded on the front page of the form under Old Business. He/She talks
to different departments about the residents’ concerns, but what he/she writes on the form
does not address each of the concerns. He/She said the notes simply restate the residents’
concerns from the previous month. He/she said he/she did not know he/she needed to address
each concern in writing for the residents. The AD said facility staff have not responded
to any of the residents’ concerns in writing, to include actions taken or rationale.
4. During an interview on 7/20/18, at 5:26 P.M., the administrator said resident council
members should receive follow up information from their concerns. He/She said the facility
staff need to make sure they communicate more clearly to the resident council.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed to maintain petty cash at the
facility to ensure residents had access to petty cash on an ongoing basis. This had the
potential to affect all residents for which the facility managed funds. The census was 53.

1. Review of Resident #18’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/27/18, showed the following:
– admission date of [DATE];
– Understood, understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 15
out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s Authorization for Petty Cash on hand form, signed and dated by
the resident on 3/30/18, showed the resident authorized the facility to manage his/her
petty cash on hand.
Review of the resident’s Beauty and Barber Shop Services form, signed and dated by the
resident on 3/16/18, showed the resident wanted his/her haircuts paid for from petty cash.

2. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s Authorization for Petty Cash on hand form, signed and dated by
the resident on 7/23/18, showed the resident authorized the facility to manage his/her
petty cash on hand.
3. Review of the facility’s admission packet on 7/20/18 at 1:00 P.M. showed the packet
contained an Authorization for Resident Fund Petty Cash on Hand form. The form was located
in the Financial Section of the packet. A resident signed the form to authorize the
facility to manage his/her petty cash on hand.
4. Review of resident funds on 7/19/18 at 12:50 P.M. showed the facility did not have a
record of resident petty cash.
5. During an interview on 7/19/18 at 2:45 P.M., the bookkeeper in charge of resident funds

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
said she does not keep petty cash at the facility, because she does not have a safe. She
has a locked closet and does not feel that is secure to hold the resident’s money. When a
resident requests petty cash, she goes to the bank and withdraws it and tries to withdraw
money on the same day the resident requests it. She said she is not able to give residents
their money right on the spot, if a resident needs money immediately, then she cannot do
that. She said she typically goes to the bank around noon and residents who request money
after noon, have to wait until the next day to get their money, even if it is less than
$50. She is the only facility staff person that can withdraw resident money and if she is
not at the facility, the residents do not get money until she returns. The residents
cannot get money while she is on vacation.
6. During an interview on 7/20/18 at 2:30 P.M., the bookkeeper said the corporate office
staff put together the current admission packet. She said she reviews the section labeled
Financial Section with new residents and/or their responsible party. She explains the form
as authorizing deposits into the resident’s account, not as having money on hand at the
facility. The Authorization for Resident Fund Petty Cash on Hand form is part of the
current admission packet, but the form does not apply to everyone. If someone insisted
that they have petty cash, then she would do it, she would just have to go out and get a
lock box. She said it is her personal preference not to have petty cash at the facility.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, and interview, the facility staff failed to repair or paint areas to
maintain a homelike environment in resident rooms 203, 204, 205, 300, 301, 302, 306, 307,
308, 309, 310, 311, 400, 401, and 402. The facility census was 53.
1. Observation on all days of the survey, 7/17/18 through 7/19/18 , showed the following:
– Central bathroom toilet bolts uncut and uncovered; the quarter round at the entrance
wall to the shower chipped and unfinished; the air vent in the shower is visibly dusty,
entrance door is visibly dirty;
– Resident room [ROOM NUMBER] bathroom toilet bolts uncut and uncovered, with brown and
yellow caulk around bottom of toilet;
– Resident room [ROOM NUMBER] bathroom toilet bolts uncut and uncovered, with brown and
yellow caulk around bottom of toilet;
– Resident room [ROOM NUMBER] bathroom toilet bolts uncut and uncovered;
– Resident room [ROOM NUMBER] bathroom toilet bolts uncut and uncovered, with black marks
along bottom of all walls;
– Resident room [ROOM NUMBER] bathroom toilet bolts uncut and uncovered, with the
baseboard loose from the under the sink, and the toilet seat extender rusted on support
braces.
2. Observation on 07/17/18, at 11:06 A.M., showed the bathroom walls, in room [ROOM
NUMBER], with chips in the paint on the door frame, and the wall across from toilet with
long discolored rub marks in the wall with breaks in the paint. Additional observation
showed room [ROOM NUMBER] and 307 with chips in the paint on the door frame, and the wall
across from toilet with long discolored rub marks in the wall with breaks in the paint.
Further observation showed the door going into room [ROOM NUMBER] had a deep gouge on the
door, and missing paint exposing the dry wall around the sink and soap dispenser.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
3. Observation on 7/17/18, at 11:12 A.M., showed the wall behind both resident’s beds in
room [ROOM NUMBER] with missing paint and the outlet by the beds with the dry wall cut,
and the sheet rock exposed. Additional observation showed the paint around the soap
dispenser.
4. Observation on 7/17/18, at 11:14 A.M., showed an unpainted and unfinished piece of ply
wood attached to the wall by the resident’s bed in room [ROOM NUMBER] B.
5. Observation on 7/17/18 at 11:15 A.M., showed gouges and scratches in the bathroom door
of resident room [ROOM NUMBER] and 402, and in the room door of 400, 401, and 402.
6. Observation on 7/17/18, at 11:18 A.M., showed in room [ROOM NUMBER]/310, the bathroom
with chips in the paint on the door frame, exposed brown tape around the soap dispenser,
and the wall across from toilet with long discolored rub marks in the wall with breaks in
the paint.
7. Observation on 7/17/18, at 11:26 A.M., showed in room [ROOM NUMBER]/311, the bathroom
contained deep gouges in the wall next to the sink.
8. Observation on 07/17/18 at 3:48 PM, showed the room door and bathroom door of resident
room [ROOM NUMBER] contained multiple gouges and scratches in the paint and wood, and the
vanity contained a large section of missing trim from the front area near the sink.
9. Observation on 7/19/18, at 11:45 A.M., showed in room [ROOM NUMBER] A, the
nightstand/dresser with chips in the wood exposing the raw ply wood on the top corner and
the front.
10. During an interview on 7/19/18, at 11:45 A.M., certified nurse assistant (CNA) B said
there is a maintenance log where they document the repairs needed like light bulbs, or
something that is broken. He/She said the staff do not usually put painting needs or
furniture damage in the log unless it needs to be fixed right away.
During an interview on 7/27/18, at 2:52 P.M., the maintenance director said staff are
expected to put repairs needed on the maintenance log and let him/her know what repairs
need to be done. He/She said he/she put up the ply wood in 307 a couple of months ago,
until he/she could get a hole in the wall patched and has not gotten back to it. He/She
said he/she does an environmental walk through to look for areas that need to be painted
or repaired every two weeks or so, but he/she does not get to address all the needs right
away because he/she has to prioritize.
During an interview on 7/20/18, at 5:26 P.M., the administrator said that there is a
maintenance repair log at the nurses station for staff to communicate with the maintenance
director what is needed. He/She said the maintenance director is expected to do
environmental rounds to look for painting and minor repairs.

F 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a
condition of admission; and must tell residents what care they do not provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the admission policy
did not require the resident to waive potential facility liability accident or personal
injury during facility outings or for loss or damage to personal belongings for six out of
14 sampled residents (Residents #2, #15, #17, #34, #39, and #51). This had the potential
to affect all facility residents. The census was 53.
1. Review of Resident #2’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/16/18, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 5)
– admission date of [DATE];
– Sometimes understood, usually understands;
– Moderately impaired cognition, decisions are poor, supervision required;
– [DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 4/3/15.
2. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– BIMS score of 12 out of 15, moderate cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s Non-Liability Statement for Personal Property showed the
following:
– The resident waived the facility’s responsibility for personal items brought into the
facility which were lost or damaged while residing at the facility;
– Signed by the responsible party;
– Dated 5/18/15.
3. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Usually understood, sometimes understands;
– Severe cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s Personal Laundry Agreement form, showed the following:
– The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
– Signed by the Power of Attorney;
– Dated 8/4/17.
Review of the resident’s Cable/Satellite Services form, showed the following:
– The resident authorized payment for the facility to provide basic cable television
service, but released the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection;
– Signed by the Power of Attorney;
– Dated 8/4/17.
4. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Usually understood, usually understands;
– BIMS score of 7 out of 15, severe cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s Consents and Authorizations form, showed the following:
-The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 6)
responsibility for damage to personal clothing;
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection;
-Signed by the responsible party;
-Dated 12/6/17.
Review of the resident’s Personal Laundry Agreement form, showed the following:
– The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
– Signed by the responsible party;
– Dated 12/7/17.
Review of the resident’s Cable/Satellite Services form, showed the following:
– The resident authorized payment for the facility to provide basic cable television
service, but released the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection;
– Signed by the responsible party;
– Dated 12/7/17.
5. Review of Resident #39’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– BIMS score of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s Personal Laundry Agreement form, showed the following:
– The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
– Signed by the resident;
– Dated 3/16/18.
Review of the resident’s Cable/Satellite Services form, showed the following:
– The resident authorized payment for the facility to provide basic cable television
service, but released the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection;
– Signed by the resident;
– Dated 3/16/18.
6. Review of Resident #51’s annual MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– BIMS score of 14 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s Cable/Satellite Services form, showed the following:
– The resident authorized payment for the facility to provide basic cable television
service, but released the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection;
– Signed by the resident
– Not dated.
The resident agreed for the facility to maintain his/her personal laundry, understood
commercial grade equipment is used for laundering, and released the facility from any
responsibility for damage to personal clothing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 7)
-The resident agreed for the facility to provide basic cable television service, but
released the facility from any responsibility for damage to the personal television set as
a result of the television cable installation and connection.
7. Review of the facility’s Personal Laundry Agreement form, showed the resident could
agree for the facility to maintain his/her personal laundry, understood commercial grade
equipment is used for laundering, and released the facility from any responsibility for
damage to personal clothing.
8. Review of the facility’s Cable/Satellite Services form, showed the resident authorizes
payment for the facility to provide basic cable television service, but releases the
facility from any responsibility for damage to the personal television set as a result of
the television cable installation and connection.
9. Review of the facility’s Non-Liability Statement for Personal Property showed the
resident waived the facility’s responsibility for personal items brought into the facility
which were lost or damaged while residing at the facility.
10. During an interview on 7/20/18 at 2:15 P.M., the Social Worker said he has worked as
the social worker at the facility for [AGE] years. He is responsible for reviewing the
admission packet with the new residents and/or the responsible party. The current
admission packet was put together by the corporate office staff. He reviews the section
labeled Social Services Section. The Consents and Authorization page is part of the
current admission packet. It is a corporate policy. The third paragraph discusses the
facility doing the resident’s laundry. This paragraph asks the resident to release the
facility from any responsibility for damage to personal clothing. He does not know why it
asks the residents to waive responsibility. He would expect the staff to provide
reasonable care for the resident’s laundry. He is not sure if the items would be replaced
if lost or damaged as this is handled by the business office. The fourth paragraph
discusses the facility providing basic cable television service. This paragraph asks the
resident to release the facility from any responsibility for damage to the personal
television set as a result of the television cable installation and connection. That
section is not relevant to their residents, because the facility provides basic cable to
the resident. The form does ask the resident to waive the facility’s responsibility if
anything would happen to the television due to the basic cable service. He was not aware
the resident’s could not be asked to waive the facility’s responsibility for their
personal belongings. He does not know why this was put into the admission packet.
During an interview on 7/20/18 at 2:30 P.M. the Business Office Manager said the current
admission packet was put together by corporate office staff. She reviews the section
labeled Financial Section with the new residents and/or responsible party. The Consents
and Authorization page is part of the current admission packet, but it is part of the
Social Services section. She does not review it with the residents. Her section does have
some forms which basically say the same thing as the Consents and Authorization form. The
Cable/Satellite Services form asks the resident to waive the facility’s responsibility for
damage to their television as a result of the cable or satellite installation or
connection. The facility will not be responsible for the resident’s television due to
wiring, lightning strikes, or anything of that nature. She was told by management that the
facility does not cover those losses. The Personal Laundry Agreement asks the resident to
waive the facility’s responsibility for loss or damage of the resident’s personal
belongings during the laundering process. She is not sure why the form asks the resident
to waive the responsibility, because the facility usually does replace clothing that is
lost or damaged.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0620

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to complete the baseline care
plan within 48 hours, and review or provide a copy to one resident (Resident #13) or
his/her responsible party, of two sampled new admissions. The facility census is 53.
1. Review of the resident’s face sheet showed the resident admitted to the facility on
[DATE].
Review of Resident #13’s significant change (SCSA) Minimum Data Set (MDS), a federally
mandated assessment, dated 1/31/18, showed staff documented the resident as:
-Severe cognitive impairment;
-Severe depression;
-Limited physical assistance of one staff member for eating;
-Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene
-Dependent on one staff member for bed mobility, and transfers;
-81 lbs.;
-Oxygen use.
Review of the resident’s Baseline Care Plan, dated 1/27/18, showed staff completed the
baseline care plan 10 days after the resident’s admission. Review of the care plan did not
contain a signature or date of when the baseline care plan had been reviewed with the
resident or responsible party.
During an interview on 7/19/18 at 2:12 P.M., licensed practical nurse (LPN) A said the
baseline care plan is in the admission paperwork and should be completed on admission.
He/She said he/she is not sure who gives a copy to the resident/responsible party.
During an interview on 7/20/18 at 5:26 P.M., the director of nursing (DON) said the
baseline care plan should be done on admission. He/She said he/she did not know how long
the facility had to complete it, or that a copy should be given to the resident/family
member, or his/her resident representative.
During an interview on 7/20/18 at 7:36 P.M., the MDS coordinator (MDSC) said the charge
nurses complete the baseline care plan on admission. He/She is not sure who follows up and
checks on them, or who gives a copy to the resident/responsible party.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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, facility staff failed to develop and
implement comprehensive, person centered care plans for three residents (Resident #10,
#34, and #206) of fifteen sampled residents. The facility census was 53.
1. Review of Resident #10’s, quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 4/28/19, showed the staff assessed the resident as:
-Cognitively intact;
-Extensive assistance of one staff member for locomotion, and hygiene;
-Extensive assistance of two or more staff members with bed mobility;
-Dependent with two or more staff members with transfers, dressing, toilet use, and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
bathing;
-Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot).
The MDS did not contain Restorative Nursing minutes or oxygen use.
Review of the Nurse’s notes, dated 5/21/2018, showed staff documented the resident’s
portable oxygen was empty. The resident’s oxygen level is 70% on room air. Administered a
[MEDICATION NAME] (medicated aerosol treatment) breathing treatment as per physician’s
orders [REDACTED]. A concentrator for the resident has been ordered, waiting for delivery.
Review of the resident’s Nurse’s notes, dated 5/31/2018, showed staff documented the
resident’s oxygen saturation was 80% on room air. This nurse administered a scheduled
breathing treatment and resident’s oxygen saturation stabilized at 95% on 2 L/NC.
Review of the resident’s Nurse’s notes, dated 6/07/2018, showed staff documented the
resident had shortness of breath and decreasing oxygen saturation when not on oxygen.
Review of the resident’s Nurse’s notes, dated 6/11/2018, showed staff documented the
resident had oxygen at 2 L, and oxygen saturation at 95%.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Care Plan, last updated 6/26/18, did not contain directions to
staff related to the resident’s limited range of motion or oxygen use.
Staff did not develop a comprehensive person centered care plan, including measurable
objectives and timeframes to address the resident’s limited range of motion or oxygen use.
2. Review of Resident #34’s admission Minimum Data Set (MDS), a federally mandated
resident assessment tool, dated 12/19/17, showed staff assessed the resident as follows:
-Indwelling catheter (tube inserted into the bladder to drain urine);
-Urinary incontinence not rated, resident had a catheter in place during the entire
lookback period;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated 1/25/18, showed staff are directed:
-[DIAGNOSES REDACTED].
-Resident experiences bladder incontinence at times;
-Ask the resident if he/she needs to use the bathroom on a routine basis.
Additional review showed staff did not document any interventions, goals, or objectives
related to the resident’s urinary catheter.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Indwelling catheter;
-Urinary incontinence not rated, resident had a catheter in place during the entire
lookback period;
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s nurse’s notes dated 7/8/18, showed staff documented the
resident’s foley catheter was leaking urine. Staff documented they removed the catheter
and replaced it.
Observation on 7/19/18 at 10:09 A.M. showed the resident in his/her room in a wheelchair
with a cather in place.
Observation on 7/19/18 at 11:47 A.M. showed the resident in his/her room with a catheter
in place.
Staff did not develop a comprehensive person centered care plan, including measurable
objectives and timeframes to address the resident’s urinary catheter.
3. 10. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severely impaired cognition;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
-Did not display behaviors or reject care;
-Dependent on two or more staff for transfers and bathing;
-Required extensive assistance of two or more staff for bed mobility, dressing, toilet
use, and personal hygiene;
-Required extensive assistance of one staff for eating.
Review of the facility’s restorative nursing documentation for (MONTH) and (MONTH) (YEAR),
showed staff did not provide restorative nursing services to the resident.
Review of the resident’s care plan, last updated 7/19/18, showed staff are directed:
-The resident requires assistance with all activities of daily living (ADLs);
-Requires hoyer lift (mechanical lift) for transfers.
Additional review showed the care plan did not provide any direction to staff related to
the resident’s mobility, contractures, or need for restorative nursing services.
Observation on 7/18/18 at 4:22 P.M., showed the resident with contracted hands.
Observation and interview on 7/19/18 at 9:35 A.M., showed CNA F and CNA B transferred the
resident into bed from his/her wheelchair with the hoyer lift. Observation showed the
resident with contracted knees. CNA F said he/she does not think staff provide any
restorative services to the resident.
Staff did not develop a comprehensive person centered care plan, including measurable
objectives and timeframes to address the resident’s contractures.
4. During an interview on 7/20/18 at 7:36 P.M., the MDS Coordinator said staff update the
care plans on Tuesdays with preferences, weight loss, medication changes, behaviors, and
falls. He/She also said if resident information related to care is not in the care plan
he/she must have missed it.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, facility staff failed to revise or
update care plans to ensure interventions were in place to prevent a decline in health for
four residents (Resident #15, #19, #42 and #51). The facility census was 53.
1. Review of the Resident Assessment Instrument (RAI) manual, dated (MONTH) (YEAR),
directs staff with care planning as follows:
-Care Planning-Establishing a course of action with input from the resident (resident’s
family and/or guardian or other legally authorized representative), resident’s physician
and interdisciplinary team that moves a resident toward resident-specific goals utilizing
individual resident strengths and interdisciplinary expertise; crafting the how of
resident care.
-Implementation-Putting that course of action (specific interventions derived through
interdisciplinary individualized care planning) into motion by staff knowledgeable about
the resident’s care goals and approaches; carrying out the how and when of resident care.
-Evaluation-Critically reviewing individualized care plan goals, interventions and
implementation in terms of achieved resident outcomes as identified and assessing the need
to modify the care plan (i.e., change interventions) to adjust to changes in the
resident’s status, goals, or improvement or decline.
-Staff must note transient changes in the resident’s status in the resident’s record and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
implement necessary assessment, care planning, and clinical interventions, even though an
MDS assessment is not required.
-Residents’ preferences and goals may change throughout their stay, so facilities should
have ongoing discussions with the resident and resident representative, if applicable, so
that changes can be reflected in the comprehensive care plan.
The care plan should be revised on an ongoing basis to reflect changes in the resident and
the care that the resident is receiving.
2. The facility did not have a policy to direct staff on revisions and updates of resident
care plans.
3. Review of Resident # 15’s care plan, last reviewed on 9/18/17, showed the following:
– Problem start date: 7/23/17;
– Problem: The resident has a history of falls;
– Goal: The resident will remain free from injury through the next review;
– Approach: Staff to give resident verbal reminders not to ambulate or transfer without
assistance;
– No updates for falls on 3/25/18, 5/25/18, 5/30/18, and 7/2/18.
Review of the resident’s progress notes, dated 3/25/18, showed staff documented at 1:33
A.M., the resident observed on the floor in front of his/her bed.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident
assessment tool, dated 5/14/18, showed the following:
– admission date of [DATE];
– BIMS score of 12 out of 15, moderate cognitive impairment;
– Required limited assistance with bed mobility, locomotion on and off unit;
– Required extensive assistance with transfers, dressing, toilet use, and personal
hygiene;
– [DIAGNOSES REDACTED].
– No falls since admission.
Review of the resident’s progress notes, dated 5/25/18, showed staff documented at 8:15
A.M., the nurse was alerted to resident’s room due to the fact that he/she was on the
floor. The nurse approached the resident, and he/she was sitting on the floor next to
his/her bathroom. The resident stated that he was attempting to transfer himself/herself
from the toilet to the wheelchair. The resident missed the wheelchair and landed on the
floor.
Review of the resident’s progress notes, dated 5/30/18, showed staff documented at 9:33
A.M., the resident in his/her wheelchair in the dining room and slid out of his/her
wheelchair. Unwitnessed fall.
Review of the resident’s progress notes, dated 7//2/18, showed staff documented at 11:59
A.M., the resident had no signs of injury from fall earlier today.
Staff did not update the resident’s care plan with revisions related to the resident’s
repeated falls, or document review of the current interventions.
4. Review of Resident #19’s quarterly MDS, dated ,[DATE] /18, showed the staff assessed
the resident as:
-Severe cognitive impairment;
-Limited physical assistance of one staff member for eating, toilet use, hygiene;
-Dependent with one staff for bathing;
-No falls since last assessment.
Review of the resident’s Care Plan, last updated 2/28/18, directed staff to:
-Resident at risk for falling;
-Staff to Provide toileting assistance;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Staff to keep room free of clutter;
-Staff to keep floors dry;
-Staff to keep frequently used items within reach;
-Staff to monitor resident for fatigue;
-Staff to notify physician and guardian of any falls/injuries.
The care plan did not contain updates or reevaluation of interventions after the resident
fell on [DATE], 4/30/18, and 7/8/18.
Review of the resident’s Nurses Notes, dated 3/29/2018, showed staff documented staff
found the resident on the floor in front of his/her bed.
Review of the resident’s Nurses Notes, dated 4/30/2018, showed staff documented the
resident slid out of his/her shoes falling backward and hit the back of his/her head on
the floor. Resident complained of pain in the back right side of his/her head and right
hip pain. The resident is increasingly lethargic and struggling to keep his eyes open. The
physician sending the resident to the emergency room .
Review of the resident’s quarterly MDS, dated ,[DATE] /18, showed the staff assessed the
resident as:
-Severe cognitive impairment;
-Limited physical assistance of one staff member for eating, toilet use, hygiene;
-Dependent with one staff for bathing;
-No falls since last assessment.
The assessment did not contain the resident’s falls from 3/29/18 and 4/30/18.
Review of the resident’s Nurses Notes, dated 7/9/18, showed the staff documented the
resident fell on [DATE].
Observation on 7/18/18, at 3:44 PM, showed the resident ambulating without devices.
Observation showed the resident’s gait unsteady and the resident stumbled.
The resident’s care plan did not contain documentation to show the interventions were
reviewed or updated after the resident’s falls.
5. Review of Resident #42’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severely impaired cognition;
-Always incontinent of urine;
-Did not have a urinary tract infection in the last 30 days before the assessment;
-Required extensive assistance of two or more staff for toileting and personal hygiene.
Review of the resident’s nurses’ notes, dated 4/2/18, showed staff documented new orders
for [MEDICATION NAME] (antibiotic) 875 mg by mouth twice daily along with acidophilus
([MEDICATION NAME]) tablets daily for UTI, will end 4/12/18.
Review of the resident’s nurses’ notes, dated 6/16/18, showed staff documented resident
currently on Bactrim (antibiotic) for UTI.
Review of the resident’s nurses’ notes, dated 6/24/18, showed staff documented resident
currently on Bactrim for UTI.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Always incontinent of urine;
-Did not have a urinary tract infection in the last 30 days before the assessment;
-Required extensive assistance of two or more staff for toilet use, and personal hygiene.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s nurses’ notes, dated 7/8/18, showed staff documented this nurse
contacted the physician’s office and reported the resident’s labwork, including
urinalysis. New orders to start AZO (supplement to treat urinary tract infection symptoms)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
three times daily for five days if resident is symptomatic.
Review of the resident’s care plan, last updated on 7/16/18, showed staff did not provide
any direction or interventions related to the resident’s frequent urinary tract
infections. Staff did not revise the resident’s care plan to include any goals,
interventions, or direction to staff for monitoring of the resident’s frequent urinary
tract infections.
6. Review of Resident #51’s care plan, last reviewed on 1/28/18, showed the following:
– Problem start date: 1/28/18;
– Problem: Resident is at risk for falling;
– Goal: Resident will remain free from injury;
– Approach: Staff to give resident verbal reminders not to ambulate or transfer without
assistance;
– No update for fall on 3/8/18.
Review of the resident’s progress notes showed staff documented on 3/8/18 at 7:45 P.M.,
the nurse heard a loud noise and found resident lying on the floor of his/her room, near
air conditioning unit, on his/her back with head up, knees toward chest. Wheel chair near
bed and nightstand. Resident said he/she was trying to get into his/her bed when he/she
fell .
Review of the resident’s annual MDS, dated [DATE], showed the following:
-admission date of [DATE];
– BIMS score of 14 out of 15, cognitively intact;
– Required limited assistance with transfers, dressing, toilet use, and personal hygiene;
– [DIAGNOSES REDACTED].
– No falls since admission.
Staff did not update the resident’s care plan to include the resident’s fall on 3/8/18,
any new interventions for falls, or review of current interventions.
7. During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said staff
are expected to update the care plan with any changes to conditions, falls, new wounds, or
any other changes to reflect the resident’s current care needs.
During an interview on 7/20/18, at 7:36 P.M., the MDS coordinator (MDSC) said care plans
are updated on Tuesdays with resident preferences, weight loss, medication changes,
behaviors. He/She said the staff discuss falls in the quality assurance meeting but do not
reevaluate the care plan to see if new interventions need to be added. He/She said he/she
follows the Resident Assessment Instrument (RAI) manual on how to code the MDS and
complete or revise the care plans.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record review, the facility failed to ensure
sufficient staffing to meet residents’ needs for bathing for nine of 14 sampled residents
(Resident’s #2, #5, #10, #15, #17, #18, #19, #42, and #206). This had the potential to
affect all residents in the facility. The census was 53.
1. Review of Resident #2’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/16/18, showed the following:
– admission date of [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
– Sometimes understood, usually understands;
– Moderately impaired cognition, decisions are poor, supervision required;
– Required limited assistance with bed mobility, locomotion on unit, dressing, and eating;
– Required extensive assistance with transfers, walk in room, toileting, and personal
hygiene;
– Required total assistance for bathing;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets, for the month of June, showed staff documented
they provided showers on 6/1/18, 6/12/18, 6/15/18, and 6/19/18. Staff did not provide four
of eight scheduled showers for the resident.
Review of the resident’s shower sheets, for the month of July, showed staff documented
they provided a shower on 7/17/18. Staff did not provide five of six scheduled showers for
the resident.
2. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 10
out of 15, moderate cognitive impairment;
– Required limited assistance for transfers, dressing, toilet use, eating, bathing, and
personal hygiene;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets, for the month of June, showed staff documented the
resident refused a shower on 6/1/18, and they provided a shower on 6/12/18, and 6/26/18.
Staff did not provide five of eight scheduled showers for the resident.
3. Review of Resident #10’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Cognitively intact;
-Extensive assistance of one staff member for locomotion, and hygiene;
-Extensive assistance of two or more staff members with bed mobility;
-Dependent with two or more staff members with transfers, dressing, toilet use, and
bathing.
Review of the resident’s Care Plan, last updated 5/28/18, directed staff to provide a
shower twice a week and prn.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 6/4/18, 6/11/18, 6/14/18, and 6/21/18.
Staff did not provide four of eight scheduled showers for the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 7/9/18, and 7/12/18.
Staff did not provide four of six scheduled showers for the resident.
Observation showed on 7/17/18, at 2:00 P.M., the resident in his/her bed. Observation
showed the resident’s hair greasy and uncombed. The resident has a body odor and long
facial hair.
During an interview on 7/17/18, at 2:00 P.M., the resident said the staff do not have time
to do his/her showers twice a week. He/She said it would be nice to feel cleaner.
4. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– BIMS score of 12 out of 15, moderate cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets, for the month of June, showed staff documented
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, and 6/21/18. Staff did not
provide three of eight scheduled showers for the resident.
Review of the resident’s shower sheets, for the month of July, showed staff documented
they provided showers on 7/2/18, 7/5/18, and 7/12/18. Staff did not provide three of six
scheduled showers for the resident.
5. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Usually understood, sometimes understands;
– Severe cognitive impairment;
– Required limited assistance with bed mobility and eating;
– Required extensive assistance with dressing, toileting, and personal hygiene;
– Required total assistance for transfers and bathing;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets for the month of June, showed staff documented they
provided showers on 6/1/18, 6/15/18, 6/19/18, and 6/26/18. Staff did not provide four of
eight scheduled showers for the resident.
Review of the resident’s shower sheets for the month of July, showed staff documented
they provided showers on 7/10/18, 7/13/18, 7/17/18, and 7/20/18. Staff did not provide two
of six scheduled showers for the resident.
6. Review of Resident #18’s Care Plan, dated 2/18/18, directed staff to provide a shower
twice a week and prn.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively intact;
-[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side);
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
dressing, and hygiene;
-Extensive assistance of one staff member for toilet use, and bathing.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 6/4/18, 6/11/18, 6/14/18, 6/19/18, and 6/21/18.
Staff did not provide three of eight scheduled showers for the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 7/9/18, 7/12/18, and 7/16/18.
Staff did not provide three of six scheduled showers for the resident.
Observation on 7/17/18, at 2:44 P.M.,, showed the resident’s hair greasy, and a brown
substance under his/her fingernails.
During an interview on 7/17/18, 2:44 P.M., the resident said the residents are supposed to
get showers twice a week but the facility will take the bath aide off of his/her
assignment to work on the floor, so we only get a shower one time a week a lot. He/She
said they are always short staffed. He/She said a bath once a week is not enough, it makes
him/her feel itchy because of the dry skin.
7. Review of Resident #19’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Severe cognitive impairment;
-Limited physical assistance with toilet use and hygiene;
-Dependent on one staff member for bathing.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, 6/21/18, and 6/26/18.
Staff did not provide two of eight scheduled showers for the resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 7/9/18, 7/12/18, and 7/16/18.
Staff did not provide three of six scheduled showers for the resident.
Review of the resident’s Care Plan, last updated 7/18/18, directed staff to provide a
shower twice a week and as needed.
Observation on 7/18/18, at 11:00 A.M., showed the resident at the nurses station. The
resident’s hair was unkempt, he/she had a dried brown substance from his/her lips to
his/her chin, he/she had long facial hair, and his/her fingernails showed a brown
substance under them. He/She had discolored, crusty spots on the front of his/her shirt
and on the top thigh area of his/her pants.
8. Review of Resident #42’s care plan, dated 1/1/18, showed staff are directed:
-Provide a shower twice a week and as needed;
-Assist the resident with activities of daily living (ADLs) as needed.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented the
resident refused a shower on 6/13/18, and they provided showers on 6/14/18 and 6/27/18.
Staff did not provide five of eight scheduled showers for the resident.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Did not display behaviors and did not reject care during the look back period;
-Required assistance of one staff for bed mobility;
-Required extensive assistance of two or more staff for transfers, dressing, toilet use,
and personal hygiene;
-Dependent on one staff for bathing.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided a shower for the resident on 7/17/18 and 7/18/18. Staff did not provide four of
six scheduled showers for the resident.
9. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severely impaired cognition;
-Did not display behaviors or reject care;
-Dependent on two or more staff for transfers and bathing;
-Required extensive assistance of two or more staff for bed mobility, dressing, toilet
use, and personal hygiene;
-Required extensive assistance of one staff for eating.
Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they
provided a shower on 6/4/18, 6/11/18, 6/18/18, 6/21/18, and 6/26/18. Staff did not provide
three of eight scheduled showers to the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they
provided a shower on 7/16/18. Staff did not provide five of six scheduled showers for the
resident.
Review of the resident’s care plan, last updated 7/19/18, showed staff are directed:
-The resident requires assistance with all activities of daily living (ADLs);
-Provide a shower twice a week and as needed.
Observation on 7/18/18 at 4:22 P.M., showed the resident with dark brown debris under
his/her fingernails.
Observation on 7/19/18 at 9:20 A.M., showed the resident with dark brown debris under
his/her fingernails.
Observation on 7/19/18 3:42 P.M., showed the dark brown debris remained under his/her
fingernails.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
10. During an interview on 7/20/18, at 10:47 A.M., certified nurse assistant (CNA) H said
they have had holes in the schedule for call ins or people that have quit. He/She said the
shower aide will have to work the floor with a full assignment if the facility does not
have enough staff, and then the showers do not get completed.
During an interview on 7/20/18, at 2:00 P.M., licensed practical nurse (LPN) A said staff
should offer residents a shower at least twice a week and as needed or requested. He/She
said staffing is tight sometimes and showers do not get completed as scheduled.
During an interview on 7/20/18, 5:26 P.M., the director of nursing (DON) said staff are
expected to offer showers at least twice a week and as needed.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, interviews, and record reviews, facility staff failed to provide an
ongoing program of activities designed to meet the resident’s interests for three sampled
residents (Residents #9 #13, and #39), and failed to provide weekend and evening
activities for all resident’s. The facility census was 53.
1. During a group interview, on 7/18/18 at 9:55 A.M., with 10 residents identified by the
facility as alert and oriented, the residents said there are activities on the weekend. On
Saturday morning there is bingo every once in a while. On Sunday there is church, but most
of the time they cancel it. There are no other activities on the weekend. The residents
also said daily activities end around 4:00 P.M. There are no activities after dinner. Once
a month a music group will come to the facility in the evening. That is the only activity
after 4:00 P.M. during the month. Some of the residents are night owls and would enjoy
evening activities.
2. Review of the (MONTH) activity calendar showed the following:
– Two activities occurred after dinner time. The activities occurred at 7:00 P.M. on
4/17/18 and 4/19/18, and both were music related activities;
– There were no other activities were scheduled for weekdays after 3:30 P.M.;
– A movie activity was scheduled on each Saturday at 2:00 P.M.;
– No other activity was scheduled for Saturdays;
– A church activity was scheduled at 2:00 P.M. for Sundays on 4/1/18, 4/8/18, and 4/15/18;
– Visit with friends was scheduled for Sundays on 4/22/18 and 4/29/18. No time was listed
on the activity calendar;
– No other activity was scheduled for Sundays.
3. Review of the (MONTH) activity calendar showed the following:
– Two activities occurred after dinner time. The activities occurred at 7:00 P.M. on
5/15/18 and 5/17/18, and both were music related activities;
– There were no other activities were scheduled for weekdays after 3:30 P.M.;
– Resident’s individual activity of choice was scheduled for Saturdays on 5/5/18 and
5/26/18, and Sundays on 5/6/18 and 5/27/18. No time was listed on the activity calendar;
– Bingo was scheduled at 10:00 A.M. on Saturday, 5/12/18;
-A Spring Fling was scheduled for 10:00 A.M. on Saturday, 5/19/18;
– No other activity was scheduled for Saturdays;
– A church activity was scheduled for 2:00 P.M. for Sundays on 5/13/18 and 5/20/18 and A
Gift for the Ladies was scheduled for 10:00 A.M. on Sunday, 5/13/18.;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
– No other activity was scheduled for Sundays.
4. Review of the (MONTH) calendar showed the following:
– Two activities occurred after dinner time. The activities occurred at 7:00 P.M. on
6/19/18 and 6/21/18, and both were music related activities;
– There were no other activities were scheduled for weekdays after 3:30 P.M.;
– Resident’s individual activity of choice was scheduled for all Saturdays during the
month and on Sunday, 6/24/18. No time was listed on the activity calendar;
– A church activity was scheduled for 2:00 P.M. for Sundays on 6/3/18, 6/10/18, and
6/17/18;
– No other activities were scheduled for Saturdays or Sundays.
5. Review of the (MONTH) activity calendar showed the following:
– Two activities occurred after dinner time. The activities occurred at 7:00 P.M. on
7/17/18 and 7/19/18, and both were music related activities;
– There were no other activities scheduled for weekdays after 3:30 P.M.;
– Resident’s individual activity of choice was scheduled for Saturdays on 7/14/18,
7/21/18, and 7/28/18 and for Sundays on 7/1/18 and 7/22/18. No time was listed on the
activity calendar;
– A church activity was scheduled for 2:00 P.M. for Sundays on 7/8/18, 7/15/18, and
7/29/18;
– No other activities were scheduled for Saturdays or Sundays.
6. Review of Resident #9’s annual MDS, dated [DATE], showed the staff documented the
resident as:
-Moderate cognitive impairment;
-Mild depression;
-Limited physical assistance with bed mobility, ambulation, dressing, and toilet use;
-Extensive physical assistance with transfers, and hygiene;
-Dependent assistance with bathing;
-Somewhat important to have things to read and listen to music.
Review of the resident’s Care Plan, dated 4/28/18, showed it directed staff:
-Resident prefers activities that identify with prior lifestyle;
-Resident will not exhibit boredom/isolation through next review;
-Staff to provide a monthly activities calendar;
-Staff to remind resident of the daily activity;
-Staff to talk with resident about her likes and hobbies;
-Staff to Encourage resident to become involved with others and come out of her room;
-Staff to provide 1:1 sessions when able;
-Staff to encourage residents family/friends to visit often.
Review of the resident’s Activity Record, dated (MONTH) (YEAR), showed the resident
attended exercise on 6/1/18, and bingo on 6/1/18. The documentation did not contain
attendance at any other activities for June.
Review of the resident’s Activity Record, dated (MONTH) (YEAR), showed the resident
attended fourth of (MONTH) celebration on 7/4/18, root bear floats on 7/5/18, and pretty
nails on 7/6/18. The documentation did not contain attendance at any other activities for
July.
Observations on 7/17/18-7/20/18, showed the resident in bed in his/her room. Observation
showed the resident was not engaged in any activities in his/her room, and staff did not
engage the resident in an activity.
During an interview on 7/17/18, at 11:23 A.M., the resident said that he/she gets bored.
He/She said that there is one staff member that will paint his/her nails. He/She said no
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
one ever comes just to visit with him/her, just to do what they have to do.
7. Review of Resident #13’s, admission MDS, dated [DATE], showed the staff documented the
resident as:
-Severe cognitive impairment;
-Severe depression;
-Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene
-Dependent on one staff member for bed mobility, and transfers;
-Somewhat important to listen to music, be around animals, keep up with the news, go
outside when the weather is good, and attend religious services.
Review of the resident’s Care Plan, dated 1/24/18, showed it directed staff:
-Resident prefers activities that identify with prior lifestyle;
-Resident will report participation in a satisfying activity program through next review;
-Staff to provide a monthly activities calendar;
-Staff to remind resident of the daily activity;
-Staff to come take resident to the activities gofer choice;
-Staff to talk with res/family about her likes and hobbies;
-Staff to provide adequate rest periods;
-Staff to encourage family and friends to come in and visit often.
Review of the resident’s Activity Record, dated (MONTH) (YEAR), showed the resident
attended exercise on 6/1/18, and bingo on 6/1/18. The documentation did not contain
attendance at any other activities for June.
Observations on 7/17/18-7/20/18, showed the resident in bed in his/her room. Observations
did not show the resident engaged in any activities in his/her room, and staff did not
engage the resident in an activity.
8. Review of Resident #39’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
-Intact cognition;
-Moderate depression;
-Resident prefers activities that identify with prior lifestyle;
-Music and outdoors activities are somewhat important;
-Dependent on two staff for transfers;
-Required assistance of one staff for locomotion on and off the unit;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/28/18, showed staff are directed:
-Remind the resident of the daily activity;
-Talk with the resident about his/her likes and hobbies;
-Likes to stay in his/her room a lot.
Review of the resident’s (MONTH) activity calendar showed staff documented the resident
did not attend any activities on 22 of the 30 days. Staff did not document any one on one
activities with the resident.
Observation and interview on 7/17/18 at 3:48 P.M., showed Resident #39 in his/her bed with
the privacy curtain drawn completely around his/her bed. The resident said staff never get
him/her out of bed, there is nothing to do and he/she gets bored and frustrated.
Observation on 7/18/18 at 10:06 A.M., showed the resident in his/her bed with the privacy
curtain drawn completely around his/her bed. Staff did not engage the resident in an
activity.
9. During an interview on 7/20/18 at 12:00 P.M., the Activity Director (AD) said he/she
has worked as the Activity Director for three months. He/She is the only staff in the
activity department. His/Her hours are from 8/8:30 A.M. to 4:30/5:00 P.M., Monday through
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
Friday. Activities are recorded in a binder. In the binder, each resident has their own
activity calendar. When the resident attends the activity, he/she highlights it on the
calendar. At the end of the month, the calendar is uploaded into the computer record.
(MONTH) and prior months are located in the resident’s hard chart. He/She does not have a
list of one-to-one residents, and said he/she does not know what one-to-one activities
are. He/She did not know he/she had to do one-to-one activities with some of the
residents. Occasionally, he/she will spend time painting a resident’s nails or talking to
a resident, but he/she does not record it anywhere. He/She does not have a list of
residents, but he/she knows which residents would enjoy one-to-one activities. He/She goes
to care plan meetings but was not aware that one-to-one activities are listed in resident
care plans. Activity calendars are posted in each resident’s room. He/She goes to each
resident’s room to invite them to the daily activities. He/She does not keep record of
resident refusals or responses to the activity. The last activity of the day is at 2:30
P.M. so residents can be finished in time for dinner. Residents begin going to dinner at
3:30 – 4:00 P.M. He/she leaves work at 5:00 P.M. so there are no activities after dinner.
One exception is on the third Tuesday of the month when a music group comes to the
facility at 7:00 P.M. There are no other evening activities. Saturday activities are
resident individual activity of choice. The residents can play games, do puzzles, or
color. He/she will set up bingo on Saturdays too. Bingo is on the calendar one time
between the months of (MONTH) through June. Sometimes the housekeepers or the nurse’s
aides will set up a movie on Saturdays. On Sunday, a church group will come to the
facility at 2:00 P.M. There are no other activities besides church. Residents can visit
with friends or do an individual activity of choice. If a resident does not attend church
then there are no organized activities for them to do on Sundays.
During an interview on 7/20/18, at 5:26 P.M., the administrator (ADM) said the AD has been
doing activities since April. He/She said the AD is not enrolled in a class to be
certified. The ADM said the company that owns the facility does the class and he/she does
not know when the next class will be. He/She said the AD should do 1 on 1’s with the
resident’s and document them. The ADM said church is the only scheduled activity on the
weekend, and music groups are the only scheduled activity in the evening.

F 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure the activities program is directed by a qualified professional.

Based on interviews, the facility failed to ensure the activities program was directed by
a qualified professional. The census was 53.
1. During an interview on 7/20/18 at 12:00 P.M., the Activity Director (AD) said he/she
has worked as the Activity Director for three months. He/she is the only staff in the
activity department. He/she was the van driver before he/she became the Activity Director.
He/she had some training before becoming the Director. The training consisted of the
previous Activity Director showing him/her a few things when he/she took the position.
He/she does not have any certifications. He/she does not have any formal training. He/she
did not go to any classes, including online classes.
2. During an interview on 7/20/18, at 5:26 P.M., the administrator (ADM) said the AD has
been doing activities since April. He/She said the AD is not enrolled in a class to be
certified. He/She said the company that owns the facility does the class and he/she does
not know when the next class is.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0686

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record review, the facility staff failed to prevent
the development of a pressure ulcer for one resident (Resident #5) after a fall that
caused an increase in pain, and decreased mobility. The facility also failed to implement
interventions to decrease continued pressure to prevent worsening of the wound. The
facility census was 53.
1. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated (MONTH)
(YEAR), showed the following definitions:
-Stage 1 pressure injury is intact skin with localized area of non-blanchable (when you
press on the area of redness the redness does not go away) [DIAGNOSES REDACTED] (redness).
Presence of blanchable [DIAGNOSES REDACTED] changes in sensation, temperature, or firmness
may precede visual changes;
-Stage 2 pressure injury is a partial-thickness loss of skin with exposed dermis (the
thick layer of living tissue below the top layer of skin that forms the true skin). The
wound bed is viable, visible and deeper tissue are not visible. Granulation tissue (new
connective tissue), slough (dead tissue in the process of separating from the body which
is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or
falls off from health skin) are not present;
-Stage 3 pressure injury is a full thickness loss of skin, where adipose (fat) is visible
in the ulcer and granulation tissue and rolled wound edges are often present. Slough and
eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue
damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a
thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage or bone are not
exposed;
-Stage 4 pressure injury is a full-thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or
eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges,
undermining and or tunneling often occur. Depth varies by location;
-Unstageable pressure injury is a full thickness skin and tissue loss in which the extent
of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or
eschar;
-Deep Tissue Pressure Injury is an intact or non-intact skin with localized area of
persistent non-intact skin with localized area of persistent non-blanchable deep red,
maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or
blood filled blister. This injury results from intense and/or prolonged pressure and shear
forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual
extent of tissue injury, or may resolve without tissue loss. If necrotic tissue,
subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures
are visible, this indicates a full thickness pressure injury (unstageable, stage 3 or
stage 4 pressure injury).
2. Review of the facility’s Pressure Reducing Overlay Mattresses policy, dated (MONTH)
(YEAR), showed the following:
– Position mattress on bed mattress;
– Cover loosely with single sheet;
– More than one underpad and additional linen will negate the benefit of the overlay

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 22)
mattress;
– Replace top linen;
– Position resident comfortably with call light within reach.
3. Review of the facility’s Care and Prevention of Pressure Ulcer policy, dated (MONTH)
(YEAR), showed the following:
– Observe skin. Any persistent reddened area that remains after pressure is relieved is a
high risk area for a pressure ulcer to begin;
– Use pressure-reducing devices to relieve pressure;
– Turn the resident every two hours and position with pads or pillows to protect bony
prominences;
– Use elbow and heel protectors if needed.
4. Review of the facility’s General Wound and Skin Care Guidelines, dated 2009, showed the
following:
– Evaluate the need for a pressure reduction surface for bed and/or chair, as well as the
need for heel/elbow protectors or specialized protection;
– Select a dressing that keeps the wound bed moist and the periwound skin dry, it should
be at least two inches larger than the affected area;
– Reevaluate dressing and skin integrity every shift. Reevaluate the wounds response to
the prescribed treatment on a regular basis, and when needed make the recommendations for
treatment changes and inform the physician of changes in wound status;
– Date and initial all dressings at the time of application;
– Thoroughly document all wound information such as type, location, stage (if applicable),
length, width, depth, drainage, notation of tunneling or undermining, description of
tissue, state of periwound area, treatment of [REDACTED].
– Educate residents, families, friends, and staff on interventions to prevent skin
breakdown.
5. Review of Resident #5’s Monthly Nurse’s Observation form, dated 5/9/18, showed nursing
staff documented the following:
– Usually understands and is understood;
– Does not express pain;
– Pain management is not necessary;
– Independent for bed mobility, transfers, locomotion, and toilet use;
– Skin appears good;
– No reference to specific skin/wound documentation;
– No comments/narrative note related to skin appearance;
– No other comments or other information.
Review of the resident’s Braden Scale (determines risk for pressure ulcer development)
assessment, dated 5/16/18, showed a score of 22, Not at Risk.
Review of the resident’s medical record showed on 6/6/18 staff documented a weekly skin
observation report, skin intact with no skin issues.
Review of the resident’s shower sheets/skin monitoring forms showed on 6/12/18, staff
documented bruising and swelling present on left wrist area; form signed by Certified
Nursing Aide (CNA) only. Staff did not document any information related to the resident’s
heels.
Review of nurses’ notes, dated 6/13/18, at 1:58 A.M., showed staff documented the resident
returned to the facility from hospital emergency room , with a [DIAGNOSES REDACTED]. Order
for bed rest. Follow up in 1-2 weeks.
Review of the resident’s weekly skin reports showed staff did not document any skin
assessment for the week of 6/13/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 23)
Review of skin assessment/shower sheets showed staff documented on 6/19/18, the resident
went to a doctor appointment and staff did not complete any bath or skin monitoring, form
signed by CNA only.
Review of the resident’s follow-up appointment documentation, dated 6/19/18, showed the
resident’s physician documented the following:
– [DIAGNOSES REDACTED].
– Note that left iliac has fracture that is old;
– Physical and therapy and occupational therapy ordered three times a week for six weeks;
– Comments/Precautions are weight bearing as tolerated (WBAT), no restrictions, activity
as tolerated.
Review of the resident’s weekly skin reports showed:
-Staff did not document any skin assessment for the week of 6/20/18;
– On 6/25/18, staff first documented, open area on right calf. No other wounds noted.
Review of the resident’s skin assessment/shower sheets showed on 6/26/18, staff documented
open blisters present on right shin area, form signed by Certified Medication Technician
(CMT) only.
Review of the skin assessment/shower sheets showed on 7/2/18, staff did not document any
comments regarding skin, form signed and dated by CNA and charge nurse.
Review of the resident’s weekly skin report showed on 7/2/18, staff first documented the
resident with an area on the right heel which measured 1 cm x 1 cm. Wound bed has thick
red adherent slough. Wound edges are rolled and white. Surrounding skin is boggy, pale
pink, and non-blanchable.
Review of the resident’s wound report showed on 7/2/18, staff documented the resident with
a Stage 2 pressure ulcer on his/her right heel which measured 1.0 x 1.0, depth is NA. The
pressure ulcer was acquired in house. Exudate present. Tunneling is not present. Status is
new. Clean wound with normal saline, pat dry, apply xeroform petroleum dressing
(medicating, deodorizing, occlusive and non-adhering wound dressing) to wound bed, cover
with [MEDICATION NAME] (nonadherent dressing), secure with [MEDICATION NAME] daily and as
needed until healed. The wound bed has thick red adherent slough, wound edges are rolled
and white. Surrounding skin is boggy and pale pink, non-blanching. Resident takes vitamins
and supplements. The doctor was notified.
Review of the resident’s physician’s orders [REDACTED].
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– An order dated 7/2/18 through open ended, for right heel: cleanse with wound cleanser,
apply xeroform [MEDICATION NAME] to wound bed, cover with gauze, secure with [MEDICATION
NAME] every three days and as needed until healed, [DIAGNOSES REDACTED].
Review of the resident’s Care Plan, last reviewed on 7/2/18, showed the following:
– Problem start date of 1/23/18;
– Problem: Resident is at risk for pressure ulcers;
– Goal: Resident’s skin will remain intact through next review;
– Approach: Do weekly skin assessments, provide shower twice a week and as needed, staff
to inspect skin on shower days and report any issues to the charge nurse;
– Note on 7/2/18: Area noted to right heel. treatment of [REDACTED]. Float heels.
Review of the resident’s nurses’ notes, dated 7/5/18 at 11:28 A.M., showed staff
documented the resident has a Stage 3 pressure wound to right heel and vascular wound to
right medial ankle receiving treatment. On antibiotic treatment for [REDACTED].
Review of nurse’s notes showed staff did not document further information after 7/5/18
regarding the Stage 3 pressure wound to the right heel to show ongoing monitoring for
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 24)
improvement or decline.
Review of the resident’s skin assessment/shower sheet showed on 7/6/18, staff did not
document any comments regarding skin, form signed and dated by CNA and charge nurse.
Review of the resident’s Monthly Nurse’s Observation form, dated 7/8/18, showed the
following:
– Usually understands and is understood;
– Expresses pain;
– Pain management is effective;
– Requires assistance for bed mobility, transfers, locomotion, and toilet use;
– Skin appears fair, warm, and pale;
– Did not document specific skin/wound documentation;
– No comments/narrative note related to skin appearance;
– No other comments or other information.
Review of weekly skin reports showed on 7/9/18, staff documented the resident had an area
on his/her right heel which measured 1.7 cm x 3.8 cm. Wound bed has thick red adherent
slough, wound edges are rolled and white. Skin appears to be sloughing off around the
wound edge. Surrounding skin is boggy, pale pink, and non-blanchable.
Review of the resident’s wound report showed on 7/9/18, staff documented the resident with
a Stage 2 pressure ulcer on his/her right heel which measured 1.7 x 3.8, depth is NA. The
pressure ulcer was acquired in house. Exudate present. Tunneling is not present. Status is
deteriorating. Clean wound with normal saline, pat dry, apply xeroform petroleum dressing
to wound bed, cover with [MEDICATION NAME], secure with [MEDICATION NAME] daily and as
needed until healed. The wound bed has thick red adherent slough, wound edges are rolled
and white. Surrounding skin is boggy and pale pink, non-blanching. Resident takes vitamins
and supplements. Staff documented the doctor was notified;
– No other wound reports present.
Review of the resident’s skin assessment/shower sheets, showed on 7/10/18, staff did not
document any comments regarding skin, form signed and dated by CNA and charge nurse.
Review of the resident’s skin assessment/shower sheets showed:
– On 7/13/18 staff did not document any comments regarding skin, form signed and dated by
CNA and charge nurse;
– On 7/16/18, the resident refused and no bath or skin monitoring was completed, form
signed and dated by CNA and charge nurse.
Review of the resident’s Braden Scale assessment, dated 7/16/18, showed a score of 16, At
Risk.
Observation on 7/17/18 at 2:13 P.M. showed the resident in his/her room, in his/her
wheelchair. The resident wore a bandage on his/her right foot and ankle. The resident wore
two shoes, with the right shoe folded down under his/her heel. The resident did not wear
heel floats. The foot rests for the wheel chair were present, but the resident propelled
himself/herself in the wheelchair with his/her hands and feet.
Observation 7/18/18 at 12:00 P.M. showed the resident propelled himself/herself down the
hallway toward his/her room in his/her wheelchair with his/her hands and feet. The
resident wore socks, with no shoes or heel floats. Observation also showed a bandage on
his/her right heel.
Observation on 7/19/18 at 9:45 A.M. showed Nurse Assistant (NA) D assisted the resident
from his/her wheelchair into his/her bed. NA D covered the resident with a blanket. NA D
did not place heel floats on the resident. The heel floats were not observed in the
resident’s room. NA D did not float the resident’s feet with a pillow. The resident’s
heels rested directly on the mattress.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 25)
During an interview on 7/19/18 at 10:00 A.M., NA D said he/she has worked at the facility
for three weeks. He/she usually worked the day shift. He/she has worked with the resident
on previous occasions and was familiar with the resident. When he/she laid the resident
down in bed, he/she just did what he/she usually did when he/she gets the resident out of
bed. He/she did not know how to find information on the resident’s orders or care plans.
The NA said he/she would have to ask the head nurse to get more information.
Observation on 7/19/18 at 11:19 A.M. showed the resident present for lunch in the dining
room. The resident had no heel floats and no foot rests on his/her wheelchair.
Observation on 7/19/18, at 2:48 P.M., showed the resident in bed. Observation showed the
resident’s right heel with a large wound. The resident’s wound had three areas within the
wound. The upper area of the wound showed white, macerated tissue (softening and breaking
down of skin due to prolonged exposure to moisture) in a quarter sized area that had
depth. The lower part of the wound had pink shiny tissue that raised to an area with
bright red tissue that had dead translucent skin covering the area. The wound edges were
thick, hard, dead skin that had loosened on the edges separating from the wound, with
eschar on the right outer edge of the wound. Observation showed the resident did not have
a specialty mattress.
During an interview on 7/19/18, at 2:48 P.M., licensed practical nurse (LPN) A said the
wound has slough and eschar and you cannot see the base of the wound. He/She said the
upper deep part of the wound measured 1.3 cm in length, 2.2 cm in width, and at least 0.4
cm in depth. He/She said the whole wound measured 4.6 in length, and 8.5 cm in depth.
He/She said the CNAs are expected to float the resident’s heels when he/she is in bed, and
the resident is not supposed to wear tennis shoes, he/she should only have slippers and
the slipper should have the back under the heel. The LPN said the resident did not have
new interventions started with hip pain and immobility, but staff started the new
interventions when they identified the wound.
During an interview on 7/19/18, at 3:07 P.M., the nurse practitioner said at this point
the wound is at least a Stage 3 pressure ulcer because of the depth and slough in the
upper part of the wound, but it is unstageable at this time because you cannot see the
wound bed, so the wound could be a Stage 4.
Review of skin assessment/shower sheets showed on 7/20/18, staff documented the resident
had a red area under his/her stomach and a sore on the right heel, form signed and dated
by CNA and charge nurse;
– No other shower sheets present.
During an interview on 7/20/18, at 5:36 P.M., the director of nursing (DON) said staff are
expected to reevaluate residents with a decline in functioning. He/She said with any
physical decline a resident’s pressure ulcer risk could increase, the reevaluation helps
staff to assess the resident so that interventions could be put in place to prevent
pressure ulcers from developing. He/She said that interventions for residents at risk for
pressure ulcers would include to float the resident’s heels to keep the pressure off the
heels while in bed, or pressure reducing devices to the resident’s feet/chair. He/She said
staff are expected to follow the pressure reduction intervention in the care plan to
prevent pressure ulcer development or worsening of unhealed pressure ulcers.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to provide
restorative nursing services to maintain or improve the resident’s ability to function for
three residents (Resident #10, #18, and #206) of 15 sampled residents. The facility census
was 53.
1. Review of the facility’s policies showed they did not have a policy for the Restorative
Nursing Program.
2. Review of Resident #10’s, quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 4/28/19, showed the staff assessed the resident as:
-Cognitively intact;
-Extensive assistance of one staff member for locomotion, and hygiene;
-Extensive assistance of two or more staff members with bed mobility;
-Dependent on two or more staff members for transfers, dressing, toilet use, and bathing;
-Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot);
-Staff did not document Restorative Nursing minutes on the MDS.
Review of the resident’s Care Plan, last updated 6/26/18, showed it did not contain
directions to staff related to the resident’s limited range of motion.
Review of the resident’s medical record showed it did not contain a Restorative nursing
plan or restorative nursing documentation.
Observation on 7/18/18, at 4:07 P.M., showed the resident needed physical assistance to
move his/her right leg.
3. Review of Resident #18’s Care Plan, last updated 9/11/17, directed staff:
-Resident has left sided [MEDICAL CONDITION] due to stroke;
-Resident will compensate using her other side
through next review;
-Staff to apply arm rest to residents wheelchair;
-Staff to apply Velcro strap to lower extremity to keep
on his/her petal;
-Staff to set up his/her meal tray as needed;
-Staff to assist resident with all his/her activities of daily living as
needed.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively intact;
-[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side);
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
dressing, and hygiene;
-Extensive assistance of one staff member for toilet use, and bathing;
-Functional limitation in range of motion (ROM) in one lower extremity (hip, knee, ankle,
foot), and one upper extremity (shoulder, elbow, wrist, hand).
-Staff did not document Restorative Nursing minutes on the MDS.
Review of the resident’s Restorative Nursing Treatment Plan, dated 5/24/18, showed it
directed staff:
-[DIAGNOSES REDACTED].
-Goal: pain management and improve/maintain alignment;
-Two times weekly;
-Progressive left upper extremity shoulder and hand ROM for contractor management;
-Neck stretches and ROM, neck rotation, and reminders of proper neck positioning;
-Left ankle brace
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
Review of the resident’s Restorative Nursing Treatment Plan, dated 7/11/18, showed it
directed staff:
-Function maintenance of transfers, sit to stand with limited assistance of one staff
member;
-Maintenance of gait with right hand on wheelchair with limited assistance
Review of the resident’s Restorative Daily Documentation and Program Note, dated
7/1/18-7/19/18, showed staff documented:
-Passive ROM left upper extremity and left lower extremity, staff documented completed on
7/2/18, 7/6/18, 7/10/18, 7/12/18, and 7/13/18 (did not contain documentation for 7/14/18
through 7/20/18);
-Ankle Foot Orthosis (AFO) (a support intended to control the position and motion of the
ankle, compensate for weakness, or correct deformities), did not contain documentation
that staff placed the AFO/splint;
-Neck stretches/rotation, staff documented completed on 7/10/18, 7/12/18, and 7/13/18 (did
not contain documentation for 7/14/18 through 7/20/18);
-Ambulation, did not contain documentation that staff ambulated the resident.
Observation on 7/17/18, at 11:01 A.M., showed the resident propelled himself/herself down
the 300 hall. Observation showed the resident with hand contractures of the left hand, the
resident did not have a hand splint or roll in his/her hand. Further observation showed
the resident could not move his/her left leg, and it rested in a twisted position on
his/her foot rest.
During an interview on 7/17/18, on 3:12 P.M., the resident said he/she does not know what
restorative nursing is. He/She said that no one helps him/her stretch his/her left arm and
leg, or do any exercises. He/She said he/she did not know that he/she should stretch her
left arm/leg to prevent further contractures. He/She said that he/she had a splint for
his/her hand and a splint for his/her ankle but no one puts them on him/her.
During an interview on 7/20/18 at 3:00 P.M., Certified Nursing Aide (CNA) G said he/she
does not document the restorative services provided by CNAs who work on the floor, and if
there are items not marked as provided, those are therapies the CNAs provide. He/She said
the CNAs are expected to document any restorative therapy they provide.
4. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severely impaired cognition;
-Did not display behaviors or reject care;
-Dependent on two or more staff for transfers and bathing;
-Required extensive assistance of two or more staff for bed mobility, dressing, toilet
use, and personal hygiene;
-Required extensive assistance of one staff for eating;
-Did not receive any restorative nursing services during the lookback period;
-Did not have any impairment in upper or lower extremity range of motion.
Review of the facility’s restorative nursing documentation for (MONTH) and (MONTH) (YEAR),
showed staff did not provide restorative nursing services to the resident.
Review of the resident’s care plan, last updated 7/19/18, showed staff are directed:
-The resident requires assistance with all activities of daily living (ADLs);
-Requires hoyer lift (mechanical lift) for transfers.
The care plan did not provide any direction to staff related to the resident’s mobility,
contractures, or need for restorative nursing services.
Observation on 7/18/18 at 4:22 P.M., showed the resident with contracted hands.
Observation and interview on 7/19/18 at 9:35 A.M., showed CNA F and CNA B transferred the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
resident into bed from his/her wheelchair with the hoyer lift. Observation showed the
resident with contracted knees. CNA F said he/she does not think staff provide any
restorative services to the resident.
During an interview on 7/20/18 at 3:00 P.M., CNA G said the resident does have
contractures and staff had provided restorative therapy in the past. The CNA said staff
stopped providing services for a time due to issues with the resident’s hips. CNA G said
he/she did not know why staff did not start the resident on restorative services after the
issue resolved, and said he/she did not receive any orders to restart the resident on
restorative services. The CNA said I guess we dropped the ball on this resident. He/She
said if staff identify a resident with contractures or a decline, they typically recommend
the resident receive restorative therapy. CNA G also said he/she does not document the
restorative services provided by CNAs who work on the floor, and if there are items not
marked as provided, those are therapies the CNAs provide. He/She said the CNAs are
expected to document any restorative therapy they provide.
During an interview on 7/20/18, at 10:23 A.M., the MDS coordinator (MDSC) said Resident
#206 had a decline in 12/17 so the staff focused on his/[MEDICAL CONDITION] and did not do
a restorative program. He/She said when the resident'[MEDICAL CONDITION] resolved the
facility did not start him/her on any therapy or restorative nursing program because of
his/her confusion. He/She said staff did not try passive ROM. He/She said restorative
nursing staff are expected to complete the programs set up for residents and document what
they have done. He/She did not know why restorative nursing programs did not contain
documentation for Resident #18 or why Resident #10 did not have a restorative plan.
During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said that
residents with contractures or who need assistance ambulating should be on a restorative
plan. He/She said the restorative aides are trained by physical therapy staff and CNA
class. He/She is not sure why some residents do not have a plan or why there is not
documentation on residents with a current plan.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record review, the facility failed to take
precautions to prevent potential accidents for five out of 14 sampled residents (#2, #5,
#15, #18, and #23.) The census was 53.
1. During a group interview, on 7/18/18 at 9:55 A.M., with 10 residents identified by the
facility as alert and oriented, the residents said the coffee in the dining room is too
hot. The [MEDICAL CONDITION] mouth when they drink it, and they are afraid they will get
burned. They mentioned their concern at a resident council meeting, and the Activity
Director looked into it for them. The Activity Director said there was no temperature dial
on the coffee pot so they could not turn down the temperature.
Observations on 7/18/18 at 10:55 A.M. showed the coffee temperatures measured 164 degrees
Fahrenheit (F; a scale of temperature on which water freezes at 32° and boils at 212°
under standard conditions). All coffee temperatures were measured using a calibrated
analog, stem-type thermometer.
Observations on 7/19/18 at 3:30 P.M. showed coffee temperatures measured 155 degrees F.
During an interview on 7/20/18 at 3:09 P.M., the dietary manager (DM) said the residents

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
did report the coffee was really hot and he/she told the coffee vendor representative.
He/she said the coffee vendor representative said that’s the temperature, and there isn’t
a way to turn it down. He/She said the coffee is 170 degrees. The DM said he/she does not
know what the hot liquid protocol assessment refers to. The DM said he/she did not report
the coffee temperatures to the administrator.
2. Review of Resident #2’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/16/18, showed the following:
– admission date of [DATE];
– Sometimes understood, usually understands;
– Moderately impaired cognition, decisions are poor, supervision required;
– Required limited assistance with eating;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record showed the following:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– An order dated 2/27/17, regular diet with food cut up for independent feeding;
– Nurse’s note, dated 5/16/18 at 7:59 A.M., staff documented the nurse gave the resident a
cup of coffee, per resident’s request. The resident spilled the entire cup on his/her
right leg. The resident’s right thigh is really red and warm to the touch. Family and
Director of Nursing notified.
Review of the resident’s hot liquid assessment, dated 2/27/17 showed staff assessed the
resident as not at risk when drinking hot liquids. The resident’s record did not contain
an updated form.
Review of the resident’s care plan, last reviewed on 7/18/18, showed the following:
– Problem start date: 7/18/18
– Problem: Resident has a regular diet with food cut up for independent feeding;
– Goal: Resident will eat more independently;
– Approach: Staff to sit resident at the cuing table for assistance as needed;
– Did not address or mention hot liquid spills or precautions.
Observation of the resident on 7/19/18 at 11:20 A.M., showed the resident ate a lunch of
soup, cornbread, okra, water, and red liquid. The resident eats with his/her hands. Staff
encourages the resident to use utensils, but the resident continues to eat with hands. The
staff assist the resident with eating and drinking. The resident did not have coffee.
3. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 12
out of 15, moderate cognitive impairment;
– Required limited assistance with eating;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record showed the following:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– An order dated, 9/15/17, regular diet with food cut up for independent eating, nectar
thick liquids.
Review of the resident’s hot liquid assessment, dated 12/26/17, showed the resident was at
risk while drinking hot liquids and the Protocol for Hot Liquid Safety should be
initiated.
Review of the resident’s care plan, last reviewed on 9/18/17, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
– Problem start date: 7/23/17;
– Problem: Resident has a regular diet with nectar thick liquids;
– Goal: Resident will not have any adverse effects from his diet;
– Approach: Staff to monitor for signs and symptoms of aspiration;
– Did not address or mention hot liquid spills or precautions.
Observation of the resident at meal times on 7/20/18 at 11:45 A.M. showed the resident
drank coffee from a coffee cup unassisted, and without facility staff present at the
resident’s table during meal time.
During an interview on 7/20/18 at 5:26 P.M., the administrator said the facility does not
have a hot liquid protocol.
4. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Usually understood, usually understands;
– BIMS of 10 out of 15, moderate cognitive impairment;
– Requires limited assistance for bed mobility, transfers, toilet use, eating, bathing,
and personal hygiene;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record showed the following:
– [DIAGNOSES REDACTED].
– hosptalized on [DATE] for pain in right due to fall. X-rays showed suspected right
inferior pubic ramus (pelvis) fracture;
– Recommendation from doctor during hospital discharge, dated 6/12/18, included wear shoes
that fit well and have soles that grip;
– Follow-up appointment for fall dated 6/19/18 noted [DIAGNOSES REDACTED].
Review of the resident’s Care Plan, last reviewed on 7/2/18, showed the resident was a
fall risk and needed assistance with activities of daily living (ADL). The care plan did
not provide direction to staff related to the resident’s transfer status.
Review of the resident’s Lift Assessment, dated 1/24/18, showed a score of 3 points,
requires a minimum of two staff to lift/transfer.
Observation and interview on 7/19/18 at 9:45 A.M. showed the resident sat in his/her
wheelchair with slippers on his/her feet, and waited to be transferred into his/her bed.
Nurse’s assistant (NA) D used a gaitbelt to transfer the resident from the wheelchair to
the bed. NA D wrapped the gait belt around the resident and locked the wheelchair. The
resident’s wheelchair faced the bed. NA D stood on the left side of the resident. NA D put
his/her right arm under the resident’s right arm and grabbed the gaitbelt on the
resident’s back with his/her left hand. NA D lifted the resident using the resident’s
right arm and gaitbelt. The resident attempted to stand, but said his/her feet and
slippers were slipping on the floor. NA D sat the resident back into the wheelchair and
left the slippers on the resident. NA D assisted the resident to stand again with his/her
hands in the same position, using the resident’s right arm and gaitbelt. NA D lifted the
resident with the gaitbelt and the resident’s right arm and turned to his/her right with
the resident. The resident shuffled his/her feet in an unsteady gait, turned his/her body
leading with the left side, and put his/her hand on the bed. NA D reached over the
wheelchair to turn the resident 180 degrees from the wheelchair to the bed. The resident
sat on the bed, and NA D stepped in front of the resident. NA D removed the gaitbelt and
said he/she should have made the gaitbelt a little tighter around the resident. The
resident attempted to scoot backward on the bed but said his/her feet were slipping in the
slippers again. NA D put his/her feet in front of the resident and told the resident to
push his/her feet up against his/her feet. The resident rested his/her feet up against NA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
D’s feet and scooted back on the bed. NA D removed the resident’s slippers. The NA did not
transfer the resident in a manner to prevent accidents.
During an interview on 7/19/18 at 10:00 A.M., NA D said he/she has worked at the facility
for three weeks. He/she usually worked the dayshift. He/she has worked with the resident
on previous occasions and was familiar with the resident. He/she was aware of the
resident’s transfer status because he/she asked another certified nurse’s assistant (CNA).
He/she did not know how to find a resident’s transfer status without asking another staff.
He/she would have to ask the head nurse. When he/she laid the resident down in bed, he/she
just did what he/she usually did when he/she gets the resident up out of bed. He/she did
not know how to find information on the resident’s orders or care plans. The NA said
he/she would have to ask the head nurse to get more information.
Review of the facility’s Positioning the Resident policy, dated (MONTH) (YEAR), showed the
following steps to move a resident up in bed when a resident can sit up:
– Assist resident to sitting position;
– Place resident’s hand flat on bed above buttocks;
– Place on arm across lower back and other arm under knee close to thighs;
– Instruct resident to push with feet and, on signal, guide hips toward head of bed.
5. Review of Resident #18’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively intact;
-[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side);
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
dressing, and hygiene;
-Extensive assistance of one staff member for toilet use, and bathing;
-Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot),
and one upper extremity (shoulder, elbow, wrist, hand).
During an interview on 7/17/18, at 2:50 P.M., the resident said his/her transfer aide bed
rail completely turns and is loose. He/She said that he/she depends on it to get out of
bed and he/she is, scared it is going to turn and I am going to fall. He/She said he/she
reported it over a month ago but the maintenance man said it could not be fixed.
Observation on 7/17/18, at 2:50 P.M., showed the resident’s transfer aide bed rail turns
all the way around and moves back and forth when the resident placed his/her hand on the
transfer aide.
During an interview on 7/20/18, at 5:26 P.M., the administrator said he/she did not know
about the transfer rail being loose, and it should be fixed immediately.
During an interview on 7/27/18, at 2:52 P.M., the maintenance director said he/she did not
recall the transfer aide bed rail needing repair. He/She said resident equipment should be
fixed right away.
6. Review of Resident #23’s annual MDS, dated [DATE], showed the following:
– admission date of [DATE];
-Understood, understands;
– BIMS of 15 out of 15, cognitively intact;
– No behaviors;
– [DIAGNOSES REDACTED].>- Currently uses tobacco.
Observation on 7/18/18 at 10:45 A.M., the resident propelled himself/herself outside to
the smoking area outside the facility’s front entrance door. The resident did not remove
his/her oxygen tank before going outside to smoke. The resident propelled out the door and
past the residents who were smoking while his/her oxygen tank and nasal cannula were on.
Observation showed on 7/19/18, at 10:58 A.M., showed the resident outside smoking.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
Observation showed the resident extinguished his/her cigarette and Laundry Aide C pulled
the resident’s oxygen tubing from the back of his/her chair and placed his/her nasal
cannula on. Additional observation showed the resident with a portable oxygen tank
attached to the back of his/her chair while he/she was smoking.
During an interview on 7/19/18, at 11:05 A.M., the administrator (ADM) said staff are
expected to take off the resident’s oxygen prior to him/her going outside and put the tank
in a safe cart inside the door of the facility. He/She said an oxygen tank should not be
in the smoking area.
During an interview on 7/20/18 at 5:00 P.M., the resident said he/she usually does not
smoke while his/her oxygen tank is on his wheelchair. Sometimes he/she gets in a hurry to
get outside on time and forgets to leave it inside. The staff in the smoking area will
remove it and set it away from the group. Yesterday, he/she was in a hurry, because he/she
was running late. He/she only took off his/her nasal cannula and hung it on the back of
his/her wheelchair. He/she left the oxygen tank on his/her wheelchair while he/she was
outside smoking. No one removed the oxygen tank from his/her wheelchair while he/she was
smoking. He/She does not know if the oxygen was turned on or off at the time.
During an interview on 7/20/18 at 1:45 P.M., Laundry Aide C said he/she was outside with
the smokers yesterday. He/she was present when the resident came outside with his/her
oxygen tank on the back of his/her wheelchair. The resident wanted to come outside for a
real quick cigarette. The rest of the residents were already outside when Resident #5 came
outside. The resident’s oxygen tank should have stayed inside by the door. He/she did not
take the oxygen tank off the resident’s wheelchair. He/she did not take the oxygen tank
inside or away from the group. He/she let the resident stay outside with the tank on the
back of his/her wheelchair. All the residents outside were smoking, including Resident #5,
near the oxygen tank. He/she does not remember if the tank was turned on or off. He/she
remembers the nasal cannula was off, because he/she helped the resident put it back on.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to follow
through on dietitian recommendations, physician’s orders, interventions, and reevaluate
interventions for effectiveness for two residents (Resident #9, and #13) with weight loss.
The facility census was 53.
1. Review of the facility’s Weight Monitoring policy, dated (MONTH) (YEAR), directs the
staff to:
-Large weight variances particularly weight loss trends, are significant risk factors for
the ill and debilitated elderly, the facility will monitor weight changes monthly;
-Weekly weights will be obtained on residents who show a significant weight change until
weight is stable;
-Copy of the monthly weights and weight status report will be submitted to the Registered
Dietitian Consultant on or before the next monthly visit and reviewed by the quality
assurance nurse.
2. Review of the Resident #9’s current Face Sheet, undated, showed the resident has the
following Diagnosis: [REDACTED].
-Unspecified [MEDICAL CONDITION];
-Pruritus (Severe itching);

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
-Bacterial pneumonia;
-Acute upper respiratory infection;
-Urinary tract infection;
-Diarrhea;
-Severe protein-calorie malnutrition;
-Vitamin deficiency.
Review of the resident’s Physician’s Orders Sheets (POS), dated 1/1/18-7/18/18, showed the
physician directed staff to serve:
-Regular diet, no meat per resident’s request may supplement protein with other foods;
-Provide snack for the resident at bedtime with small frequent snacks throughout the day;
-6/27/18 to discontinue Protein pudding twice a day.
-6/27/18 start house supplement drink 4 ounces (oz) with meals.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 1/28/18, showed the staff documented the resident as:
-Moderate cognitive impairment;
-Mild depression;
-No behaviors;
-Set up assistance with eating;
-Limited physical assistance with bed mobility, ambulation, dressing, and toilet use;
-Extensive physical assistance with transfers, and hygiene;
-Dependent assistance with bathing;
-101 pounds (lbs);
-No oral problems (edentulous not checked).
Review of the resident’s Progress Notes, dated 3/9/18, showed the dietitian documented:
-Resident’s weight is down 3 lbs. 3.9% over the last 30 days now 94 lbs, body max index
(BMI) is 19.64 underweight;
-Receives Regular diet and is supplemented with Boost Pudding;
-Meal intake varies, usually 25-75%;
-Prefers to eat in his/her room;
-Has previously been on VHC (high calorie nutritional drink), but was discontinued after
some weight gain;
-Recommend: Clarify Boost pudding order to include two times daily with meals, add super
cereal at breakfast, and restart Boost VHC 120 cubic centimeters (cc) three times daily
with medication pass.
Review of the resident’s comprehensive Nutrition Assessment, dated 4/6/18, showed the
dietitian documented:
-[DIAGNOSES REDACTED].
-Regular diet, no meat per resident’s request, likes peanut butter and jelly sandwiches in
place of meat, and boost pudding;
-Likes peanut butter and jelly sandwiches, and cottage cheese;
-Current weight 92.8 lbs,
-No oral problems (edentulous not checked);
-Body Mass Index 92.8 underweight;
-More than 5% weight change in 30 days;
-Recommend Clarify boost pudding orders to twice a day with meals, add cottage cheese to
lunch and dinner meals for additional protein, add super cereal at breakfast, and boost
VHC (a high protein supplement) three times a day with med pass.
Review of the resident’s annual MDS, dated [DATE], showed the staff documented the
resident as:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
-Moderate cognitive impairment;
-Mild depression;
-No behaviors;
-Set up assistance with eating;
-Limited physical assistance with bed mobility, ambulation, dressing, and toilet use;
-Extensive physical assistance with transfers, and hygiene;
-Dependent assistance with bathing;
-93 pounds (lbs) (7.9% weight loss since 1/28/18);
-No oral problems (edentulous not checked).
Review of the resident’s Care Plan, dated 4/28/18, directed staff:
-At risk for weight loss;
-Provide resident with ordered diet;
-Offer double portions of things the resident likes;
-Offer alternative if the resident does not like the main meal;
-Resident does not want meat;
-Resident prefers peanut butter and jelly sandwiches often;
-Provide ordered boost pudding;
-Notify the physician and durable power of attorney with significant weight loss;
-Monitor for need to change diet consistency.
Review of the resident’s weight record showed staff documented:
-1/1/18: 101 pounds (lbs);
-1/19/18: 100.6 lbs;
-2/1/18: 97.8 lbs;
-2/19/18: 94.2 lbs;
-3/1/18: 94.4 lbs;
-3/20/18: 93.8 lbs;
-4/1/18: 92.8 lbs;
-4/11/18: 93.6 lbs;
-4/27/18: 91.4 lbs;
-5/1/18: 92.8 lbs;
-5/19/18: 91.8 lbs;
-6/1/18: 90 lbs, (10.89% wt loss since 1/1/18);
-6/14/18: 92 lbs;
-7/1/18: 91 lbs;
-7/12/18: 90 lbs, (10.89% wt loss since 1/1/18).
Observation on 7/17/18 at 11:23 A.M., showed CNA B offered the resident dressing and
gravy, onion rings and a banana for his/her meal order. The resident asked if there is any
other option, and the CNA repeated dressing and gravy, onion rings and a banana. The
resident said I cannot eat meat, and the staff member repeated dressing and gravy, onion
rings and a banana. Further observation showed the staff did not serve the resident a 4 oz
supplement drink, or boost pudding. The staff did not offer the resident a protein or an
alternate entree that did not contain meat, or a protein supplement.
During an interview on 7/17/18 at 11:25 A.M., the resident said he/she cannot eat meat and
a lot of the food here, because he/she does not have teeth, mainly he/she cannot chew it,
and some of it bothers his/her stomach. He/She said sometimes he/she gets a peanut butter
and jelly sandwich. He/She said they finally had cottage cheese that he/she could eat. The
resident said it would be nice to have a cheese sandwich or something like that, but it is
not an option. The resident said her family used to bring him/her snacks but they do not
anymore, and the facility will bring him/her snacks sometimes but not every day. He/She
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 35)
said he/she is hungry all the time. He/She said, I don’t get enough protein and I only
weigh 91 pounds.
Observation on 7/17/18 at 12:20 P.M., showed staff served the resident in his/her room,
dressing with gravy, onion rings, a banana, and lemonade. Further observation showed the
staff did not serve the resident a 4 oz supplement drink, or boost pudding.
Observation on 7/18/18 at 12:12 P.M., showed staff served the resident in his/her room,
Mexican casserole with meat, onion rings, boost pudding and a banana. Observation showed
the resident’s meal ticket on his/her tray said cottage cheese.
During an interview on 7/18/18 at 12:14 P.M., the resident said he/she requested cottage
cheese and did not receive it. The resident said he/she did not like the casserole, it was
too spicy and had meat in it. He/She said staff did not offer him/her an alternate.
Observation on 7/19/18 at 12:41 P.M., showed the activity director served the resident
chicken and dumplings, two pieces of corn bread, strawberries and lemonade. The resident
said to the staff member, I don’t like cornbread, and the staff member replied you do not
have to eat the cornbread. The staff member did not offer the resident an alternative to
the meat in the chicken and dumplings, or an alternative for the cornbread. Further
observation showed staff did not serve the resident a 4 oz supplement drink, or boost
pudding.
During an interview on 7/19/18 at 12:45 P.M., the resident said he/she would try to eat
the noodles in the chicken and dumplings. He/She said the staff did not offer him/her an
alternate.
Observation on 7/20/18, at 12:21 P.M., showed the resident in his/her bed with his/her
tray. The tray contained french fries, onion rings, boost pudding, and cobbler.
During an interview on 7/20/18 at 12:21 P.M., the resident said staff told him/her the
kitchen did not have cottage cheese. He/She said the staff did not offer him/her an
alternate. He/She said, the staff talk so fast and I don’t have time to think of what I
want to eat, or even ask for anything else before they are gone.
3. Review of the resident’s current Face Sheet, undated, showed the resident has the
following Diagnosis: [REDACTED].
-Adult failure to thrive;
-Unspecified open wound, right lower leg;
-Dry eye syndrome of bilateral lacrimal glands;
-Major [MEDICAL CONDITION], single episode;
-Deficiency of other vitamins;
-Hypertension;
-Constipation;
-Injury of unspecified body region;
-Paresthesia of skin;
-History of falling;
-Abrasion, right lower leg;
-Cachexia;
-Multiple fractures of ribs, right side;
-Cardiomegaly.
Review of Resident #13’s POS, dated 1/19/18-7/19/18, showed staff are directed to
-1/21/18 start house shakes/supplements three times a day with medication pass;
-1/24/18 oxygen at three liters per nasal cannula continuous;
-2/2/18 start Mechanical soft diet;
-5/2/18 discontinue mechanical soft diet;
-5/2/18 start regular diet.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
Review of the resident’s significant change status assessment (SCSA) MDS, dated [DATE],
showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Severe depression;
-Limited physical assistance of one staff member for eating;
-Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene
-Dependent on one staff member for bed mobility, and transfers;
-81 lbs.;
-Oxygen use.
Review of the resident’s Care Plan, dated 1/24/18, shows staff are directed to:
-Provide ordered diet;
-Monitor intake;
-Provide double portions of the things that he/she likes;
-Offer alternate if the resident does not like the main dish;
-Encourage family to bring in favorite foods/snacks;
-Notify physician and durable power of attorney of any significant weight loss.
Review of the Physician’s Certification for Medicare Hospice Benefit, dated 2/5/18, showed
the resident has a terminal [DIAGNOSES REDACTED].
Review of the resident’s weight record showed staff documented:
-1/19/18 81.6 lbs;
-2/1/18 80.6 lbs;
-2/7/18 77 lbs;
-3/1/18 71.6 lbs;
-4/1/18 68.8 lbs (15.68 % weight loss);
-5/1/18 67.2 lbs (17.64 % weight loss);
-6/1/18 70.4 lbs;
-7/1/18 72.4 lbs.
Review of the resident’s Progress Notes, dated 3/09/2018, showed the dietitian documented:
-Resident has lost 10 lbs, 12.9% over the last 30 days, now 70.2 lbs, BMI 13.71 very
underweight;
-Unsure of diet, no order in chart;
-Gets house supplement three times a day for snacks;
-Nursing and dietary report resident has been refusing to come to the dining room or eat
at all;
-Usually likes milk;
-Family here often and sometimes brings in food;
-Takes [MEDICATION NAME] 15 milligrams (antidepressant) which should improve appetite;
-Is on Hospice care;
-Continue encouraging food and fluids;
-Recommend: Add diet orders to chart.
Review of the resident’s Progress Notes, dated 4/06/2018, showed the dietitian documented:
-Resident continues to lose weight, down 12 lbs,15.7% in 90 days, down 2 lbs, 3.9% in 30
days now 68.8#;
-BMI 13.44 underweight;
-Has been evaluated by Speech Therapy- they have recommended Mechanical soft diet;
-Intake poor 1-25% usually;
-Receives house supplement three times a day;
-The resident has been requesting regular consistency meat- especially bacon;
-Family wound like him/her to have bacon, and other regular consistency foods;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
-Family has been educated on choking hazards, but feel Regular consistency better;
-Takes [MEDICATION NAME] 7.5 mg which can improve appetite;
-Liberalize diet to regular per family and resident preference;
-Recommend: Add house supplement three times a day with meals for additional calories.
Review of the physician’s orders and care plan showed staff did not document or obtain
directions for the staff to serve bacon, or other regular foods.
Review of the Nutrition quarterly review, dated 5/1/18, showed staff documented:
-Mechanical soft diet;
-Current weight 69 lbs;
-House shakes/supplements three times a day;
-Resident refuses all shakes sent from dietary department.
Review of the resident’s Progress Notes, dated 5/2/18, showed the dietitian documented:
-Resident has lost 14 lbs, 17.8% over the last 90 days, down 1 lbs in 30 days. Now 67.2#
BMI 13.12;
-Receives mechanical soft diet and house supplement three times a day;
-Has poor appetite (0-25%) and often refuses house supplement – shakes & ice cream
attempted with poor intake;
-Continues requesting bacon, but not allowed on mechanical soft diet;
-Evaluated by speech therapy today;
-Will be trying regular diet over the next several days and bacon will be allowed;
-Takes [MEDICATION NAME] 15 mg which can improve appetite;
-Continues on Hospice care;
-Recommend: Boost Breeze or VHC (depending on resident preference) 90 cc three times a day
with med pass, discontinue house supplement- refuses to drink.
Review of the physician’s orders and care plan showed staff did not obtain or document
direction to the staff to administer Boost Breeze or VHC.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff documented the
resident as:
-Severe cognitive impairment;
-Severe depression;
-Limited physical assistance of one staff member for eating;
-Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene
-Dependent on one staff member for bed mobility, and transfers;
-67 lbs.;
-Oxygen use.
Review of the assessment showed the staff did not code the resident as a weight loss.
Review of the resident’s Progress Notes, dated 6/7/2018, showed the dietitian documented:
-Resident’s weight is down 11 lbs, 14% over the last 6 months, but has been steady over
the last 90 days;
-Diet has been liberalized to Regular,
-BMI 13.71 underweight
-Intake generally poor 1-25%;
-House supplement three times a day;
-Takes [MEDICATION NAME] 15 mg which can improve appetite;
-No new recommendations.
Review of the resident’s Progress Notes, dated 7/5/2018, showed the dietitian documented:
-Wt down 9 lbs, 11.3% over the last 6 months, but has been trending up over the last 90
days.
-Now 72.4 lbs BMI 14.14 underweight;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
-Is on Hospice care;
-Receives Regular diet, fluids are encouraged 120 ml water four times a day with med pass;
-Intake fair 25-75% usually;
-Spoke with dietary, he/she does not like supplement drink/ice milk, prefers milk;
-Takes [MEDICATION NAME] 15 mg which can improve appetite;
-Recommend: Whole milk three times a day with meals.
Observation on 7/17/18 at 12:21 P.M., showed the resident in bed in a fetal position with
his/her eyes closed. Further observation showed his/her lunch tray with his/her plate
covered, his/her dessert covered with a transparent film, his/her silverware still wrapped
in a napkin as it came from dietary, and a glass of koolaide. The resident’s tray did not
contain milk.
Observation on 7/17/18 at 12:52 P.M., showed the resident in bed in a fetal position with
his/her eyes closed. Further observation showed his/her lunch tray with his/her plate
covered, his/her dessert covered with a transparent film, his/her silverware still wrapped
in a napkin as it came from dietary, and a glass of koolaide.
Observation on 7/17/18 at 3:01 P.M., showed staff collected the resident’s lunch tray from
his/her room. Observation showed his/her lunch tray remained with his/her plate covered,
his/her dessert covered with a transparent film, his/her silverware still wrapped in a
napkin as it came from dietary, and a glass of koolaide.
Observation on 7/18/18 at 12:15 P.M., showed the resident in bed in a fetal position with
his/her eyes closed. Observation showed the resident’s lunch on the bedside table and the
resident’s food untouched.
Observation on 7/19/18 at 12:27 P.M., showed the resident sat on the side of his/her bed
with his/her oxygen on. Observation showed CNA B served the resident chicken and
dumplings, cornbread, fried okra, peaches, a banana, and a glass of milk.
Observation on 7/19/18 at 12:44 P.M., showed the resident consumed 25% of his/her chicken,
a few pieces of okra, and drank his/her milk.
During an interview on 7/17/18 at 3:02 P.M., the resident’s family member said the food
choices are terrible, they have one alternate for a week and there is nothing else. If
he/she doesn’t like a riblet, he/she is stuck for the whole week. He/She said, having the
same alternate twice a day for a week is crazy to me, or they have chicken as the
alternate and a different version of chicken as the meal so if you don’t like chicken what
are you supposed to eat?. The family member also said staff took the resident’s tray at
3:00 and the tray looked like they didn’t even set it up for him/her, the silverware was
still wrapped up and his/her lunch remained untouched. He/She said he/she thinks the staff
try not to wake him/her up because the resident is grumpy. The family member said they
have asked the staff to give the resident bacon at least every breakfast, but they don’t
always do that, and sometimes that is all he/she eats. He/She said, I don’t know why they
can’t give him/her bacon every meal, can’t they make extra at breakfast and reheat it?
He/She said they have problems getting him/her to eat anything else. He/She said the
family buys the resident bran flakes because he/she will eat that, but the facility does
not have them, and he/she will drink milk. The family member said the resident receives
hospice services because of his/her weight loss.
During an interview on 7/20/18 at 11:13 A.M., the MDS coordinator (MDSC) said the resident
is on hospice for abnormal weight loss.
During an interview on 7/20/18 at 12:26 P.M., the resident said he/she ate some of his/her
riblet sandwich, and his/her milk.
During an interview on 7/20/18, at 1:44 P.M., the dietary manager (DM) said the dietician
instructed him/her to supplement the protein for Resident #9 with boost pudding. He/She
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
said if he/she has cottage cheese he/she will give it to him/her. He/She said he/she has
to be careful with food substitutions, because he/she can’t do for one what he/she cannot
do for all. He/She said if the resident wants cottage cheese every meal then other
residents will want it and then it gets out of control. The DM said he/she expects staff
to offer the resident items he/she can eat, and said there is not a list of appropriate
protein foods the resident prefers. The DM said the resident consumes the Boost pudding
sometimes. He/She said he/she is not aware the resident requested cottage cheese
yesterday. He/She said he/she is not aware the resident was served casserole with meat in
it or chicken and dumplings. He/She said the kitchen does not have a menu for residents
who do not eat meat. He/She said the resident continues to lose weight, and they have not
tried anything new. He/She said Resident #13 prefers bacon, bran flakes, and coffee every
morning and he/she usually eats breakfast. He/She said that staff have not tried bacon at
other meal times, because they would have to cook it. He/She said staff are expected to
send whole milk with every meal.
During an interview on 7/20/18 at 3:09 P.M., the DM said he/she interviews residents about
their likes and dislikes on admission and it is put into the electronic record. He/She
said the information about likes and dislikes is not available to the kitchen staff or the
CNA’s. He/She said the alternate is the same for a week for lunch and supper, so it may be
pork fritter one week and riblet sandwiches the next. He/She said the staff are not
expected to cook any other foods for residents by request.
During an interview on 7/20/18 at 5:26 P.M., the administrator (ADM) said dietary staff
are expected to interview the residents about their likes/dislikes and document on their
dietary card. He/She said if a resident does not like something, a substitution of equal
nutritional value should be offered. He/She said if Resident #9 does not like meat an
alternate of equal nutritional value should be offered. He/She said Resident #13 likes
bran flakes, and bacon. The administrator said he/she never thought about serving bacon at
meals other than breakfast.
During an interview on 8/1/18 at 8:00 P.M., the registered dietitian (RD) said he/she
expects the staff to interview each resident for his/her likes and dislikes, and honor
those requests. He/She said staff are expected to offer the resident an alternate of equal
nutritional value. He/She said Resident #9 does not like meat, and the staff should offer
the resident the alternate food he/she likes, such as a peanut butter and jelly sandwich,
grilled cheese, or cottage cheese as often as he/she will eat it. The RD said if Resident
#13 only eats bacon, bran flakes, and milk it is reasonable to send him/her those items
every meal to encourage him/her to eat something. He/She said both residents are
malnourished and need whatever calories and protein they can get. The RD also said if
he/she recommends new interventions or supplements, the staff are expected to try those
interventions, and if the resident does not like them, staff are expected to document the
results. The RD said that then he/she can recommend something else for staff to try.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to administer
oxygen as directed by the physician for two resident’s (Resident #9, and #13), and failed
to obtain a physician’s orders [REDACTED].#10). The facility staff failed to change the
oxygen and medication nebulizer tubing according to the facility policy to prevent

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
bacterial contaminates that spread infection for three resident’s (Resident #9, #10, and
#13). The facility census was 53.
1. Review of the facility’s policy Oxygen Administration, dated (MONTH) (YEAR), showed
staff are directed:
-To administer oxygen to the resident when insufficient oxygen is being carried by the
blood to the tissues;
-Check the physician’s orders [REDACTED].
-Set the flow meter to the rate the ordered by the physician;
-Place mask or cannula on resident as indicated above;
-Label humidifier and/or tubing with date and time opened.
The policy did not contain directions to staff on when to change the oxygen and medication
nebulizer tubing.
2. Review of Resident #9’s annual Minimum Data Set (MDS), a federally mandated resident
assessment, dated 4/28/18, showed the staff documented the resident as:
-Moderate cognitive impairment;
-Mild depression;
-No behaviors;
-Set up assistance with eating;
-Limited physical assistance with bed mobility, ambulation, dressing, and toilet use;
-Extensive physical assistance with transfers, and hygiene;
-Dependent assistance with bathing;
-93 pounds (lbs);
-Oxygen therapy.
Review of the resident’s Care Plan, last updated on 5/4/18, showed staff are directed:
-Oxygen use;
-Provide oxygen as ordered;
-Staff to ensure that tubing is clean and change per protocol;
-Staff to monitor oxygen saturation levels;
-Staff to monitor lung sounds/coughing;
-Staff to notify physician and durable power of attorney of any respiratory distress.
Review of the resident’s physician’s orders [REDACTED].
Observation on 7/17/18, at 11:23 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator
set at 1.5 liters (L).
Observation on 7/18/18, at 10:18 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator
set at 2.5 L.
Observation on 7/19/18, at 11:32 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator
set at 2.5 L. The resident told Certified Nurse’s Aide (CNA) B, I cannot breathe.
Observation on 7/20/18, at 12:21 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18, and the oxygen concentrator
set at 3 L.
3. Review of Resident #10’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
-Cognitively intact;
-Extensive assistance of one staff member for locomotion, and hygiene;
-Extensive assistance of two or more staff members with bed mobility;
-Dependent with two or more staff members with transfers, dressing, toilet use, and
bathing;
-Functional limitation in range of motion in one lower extremity (hip, knee, ankle, foot).
The MDS did not contain documentation of oxygen use.
Review of the Nurse’s notes, dated 5/21/2018, showed staff documented the resident’s
portable oxygen was empty. The resident’s oxygen level is 70% on room air. Administered a
[MEDICATION NAME] (medicated aerosol treatment) breathing treatment as per physician’s
orders [REDACTED]. A concentrator for the resident has been ordered, waiting for delivery.
Review of the resident’s Nurse’s notes, dated 5/31/2018, showed staff documented the
resident’s oxygen saturation was 80% on room air. This nurse administered a scheduled
breathing treatment and resident’s oxygen saturation stabilized at 95% on 2 L/NC.
Review of the resident’s Nurse’s notes, dated 6/07/2018, showed staff documented the
resident had shortness of breath and decreasing oxygen saturation when not on oxygen.
Review of the resident’s Nurse’s notes, dated 6/11/2018, showed staff documented the
resident had oxygen at 2 L, and oxygen saturation at 95%.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Care plan, last updated 6/26/18, showed it did not contain
direction to staff about oxygen use.
Observation on 7/17/18, at 11:09 A.M., showed the resident with oxygen on via nasal
cannula with the tubing dated 7/7/18. Observation showed the oxygen concentrator set at
2.5 L.
Observation on 7/18/18, at 10:30 A.M., showed the resident with oxygen on via nasal
cannula dated 7/7/18. Observation showed the oxygen concentrator set at 2.5 L.
4. Review of Resident #13’s Care Plan, dated 1/24/18, showed it directed staff:
-Resident has Oxygen;
-Staff to administer oxygen as ordered;
-Staff to monitor oxygen saturation;
-Staff to monitor for respiratory distress;
-Staff to monitor lung sounds;
-Staff to change oxygen tubing per facility protocol;
-Staff to notify physician and responsible party of any respiratory distress.
Review of the resident’s significant change (SCSA) MDS, dated [DATE], showed the staff
documented the resident as:
-Severe cognitive impairment;
-Severe depression;
-Limited physical assistance of one staff member for eating;
-Extensive assistance of one staff member for dressing, toilet use, bathing, and hygiene
-Dependent on one staff member for bed mobility, and transfers;
-81 lbs.;
-Oxygen therapy.
Review of the resident’s physician’s orders [REDACTED].
-Oxygen 3 Liters per minute per nasal cannula continuous for shortness of breath;
-Change oxygen tubing weekly;
-Change nebulizer tubing weekly.
Observation on 7/17/18, at 11:19 A.M., showed the resident on his/her right side curled
into a ball on his/her bed with his/her eyes closed. Observation showed the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
nasal cannula tubing connected to his/her concentrator on the floor under the end of
his/her bed. Further observation showed the resident’s concentrator set on 1 L the nasal
cannula dated 7/7/18, and the resident’s portable oxygen tank on his/her wheelchair dated
7/7/18.
Observation on 7/18/18, at 12:09 P.M., showed the resident in bed. Observation showed the
resident’s oxygen concentrator off and the nasal cannula tubing in a bag dated 7/7/18.
Observation on 7/19/18, at 11:29 A.M., showed the resident in his/her bed in a fetal
position. Observation showed the resident’s oxygen nasal cannula tubing dated 7/17/18 in a
bag on the floor, and the concentrator turned off.
During an interview on 7/19/18, at 12:53 P.M., the certified nurse assistant (CNA) B said
the resident’s concentrator is set at 1 L/minute. The CNA said the resident only uses it
when he/she is anxious to make him/her feel better.
Observation on 7/20/18, at 12:26 P.M., showed the resident in bed with his/her nasal
cannula on the bed next to him/her. Observation showed his/her oxygen set at 1 L/min per
nasal cannula, with the oxygen tubing undated.
5. During an interview on 7/19/18, licensed practical nurse (LPN)A said staff are expected
to follow physician’s orders [REDACTED]. He/She said if the tubing is on the floor the
staff should replace it for infection control reasons.
During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said oxygen
should be administered according to a physician’s orders [REDACTED].

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough nursing staff every day to meet the needs of every resident; and have a
licensed nurse in charge on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record review, the facility failed to ensure
sufficient staffing to meet residents’ needs for ten of 14 sampled residents (Resident’s
#2, #5, #10, #15, #17, #18, #19, #42, #43, and #206). This had the potential to affect all
residents in the facility. The census was 53.
1. During a group interview, on 7/18/18 at 9:55 A.M., with 10 residents identified by the
facility as alert and oriented, the residents said the staff put in a lot of hours. Most
staff work 12 to 16 hours. It can take a long time to get a call light answered at night.
It can take up to 30 minutes. It is very difficult to get the call light answered during a
meal time, because all the staff are busy taking residents to the dining room or assisting
residents with eating.
2. Review of Resident #2’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/16/18, showed the following:
– admission date of [DATE];
– Sometimes understood, usually understands;
– Moderately impaired cognition, decisions are poor, supervision required;
– Required limited assistance with bed mobility, locomotion on unit, dressing, and eating;
– Required extensive assistance with transfers, walk in room, toileting, and personal
hygiene;
– Required total assistance for bathing;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets, for the month of June, showed staff documented
they provided showers on 6/1/18, 6/12/18, 6/15/18, and 6/19/18. Staff did not provide four

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 43)
of eight scheduled showers for the resident.
Review of the resident’s shower sheets, for the month of July, showed staff documented
they provided a shower on 7/17/18. Staff did not provide five of six scheduled showers for
the resident.
3. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 10
out of 15, moderate cognitive impairment;
– Required limited assistance for transfers, dressing, toilet use, eating, bathing, and
personal hygiene;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets, for the month of June, showed staff documented the
resident refused a shower on 6/1/18, and they provided a shower on 6/12/18, and 6/26/18.
Staff did not provide five of eight scheduled showers for the resident.
4. Review of Resident #10’s, quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively intact;
-Extensive assistance of one staff member for locomotion, and hygiene;
-Extensive assistance of two or more staff members with bed mobility;
-Dependent with two or more staff members with transfers, dressing, toilet use, and
bathing.
Review of the resident’s Care Plan, last updated 5/28/18, directed staff to provide a
shower twice a week and prn.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 6/4/18, 6/11/18, 6/14/18, and 6/21/18.
Staff did not provide four of eight scheduled showers for the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 7/9/18, and 7/12/18.
Staff did not provide four of six scheduled showers for the resident.
Observation showed on 7/17/18, at 2:00 P.M., the resident in his/her bed. Observation
showed the resident’s hair is greasy, and uncombed. The resident has a body odor and long
facial hair.
During an interview on 7/17/18, at 2:00 P.M., the resident said that the staff do not have
time to do his/her showers twice a week. He/She said it would be nice to feel cleaner.
4. Review of Resident # 15’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understood, understands;
– BIMS score of 12 out of 15, moderate cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets, for the month of June, showed staff documented
they provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, and 6/21/18. Staff did not
provide three of eight scheduled showers for the resident.
Review of the resident’s shower sheets, for the month of July, showed staff documented
they provided showers on 7/2/18, 7/5/18, and 7/12/18. Staff did not provide three of six
scheduled showers for the resident.
5. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Usually understood, sometimes understands;
– Severe cognitive impairment;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 44)
– Required limited assistance with bed mobility and eating;
– Required extensive assistance with dressing, toileting, and personal hygiene;
– Required total assistance for transfers and bathing;
– [DIAGNOSES REDACTED].
Review of the resident’s shower sheets for the month of June, showed staff documented they
provided showers on 6/1/18, 6/15/18, 6/19/18, and 6/26/18. Staff did not provide four of
eight scheduled showers for the resident.
Review of the resident’s shower sheets for the month of July, showed staff documented
they provided showers on 7/10/18, 7/13/18, 7/17/18, and 7/20/18. Staff did not provide two
of six scheduled showers for the resident.
6. Review of Resident #18’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Cognitively intact;
-[MEDICAL CONDITION] or [MEDICAL CONDITION] (paralysis on one side);
-Limited physical assistance of one staff member for bed mobility, transfers, locomotion,
dressing, and hygiene;
-Extensive assistance of one staff member for toilet use, and bathing.
Review of the resident’s Care Plan, dated 2/18/18, directed staff to provide a shower
twice a week and prn.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 6/4/18, 6/11/18, 6/14/18, 6/19/18, and 6/21/18.
Staff did not provide three of eight scheduled showers for the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 7/9/18, 7/12/18, and 7/16/18.
Staff did not provide three of six scheduled showers for the resident.
Observation on 7/17/18, at 2:44 P.M.,, showed the resident’s hair greasy, and brown
substance under his/her fingernails.
During an interview on 7/17/18, 2:44 P.M., the resident said the residents are supposed to
get showers twice a week but the facility will take the bath aide off his/her assignment
to work on the floor, so we only get a shower one time a week a lot. He/She said they are
always short staffed. He/She said a bath once a week is not enough, it makes him/her feel
itchy because of the dry skin. He/She said call lights are a problem too. He/She said when
staff is short I have to wait sometimes over 20 minutes and I have to go in (urinate) in
my pants.
7. Review of Resident #19’s quarterly MDS, dated [DATE], showed the staff assessed the
resident as:
-Severe cognitive impairment;
-Limited physical assistance with toilet use and hygiene;
-Dependent on one staff member for bathing.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 6/4/18, 6/11/18, 6/14/18, 6/18/18, 6/21/18, and 6/26/18.
Staff did not provide two of eight scheduled showers for the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided showers on 7/9/18, 7/12/18, and 7/16/18.
Staff did not provide three of six scheduled showers for the resident.
Review of the resident’s Care Plan, last updated 7/18/18, directed staff to provide a
shower twice a week and as needed.
Observation on 7/18/18, at 11:00 A.M., showed the resident sitting at the nurses station.
The resident’s hair was unkempt, he/she had a dried brown substance from his/her lips to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
his/her chin, he/she had long facial hair, and his/her fingernails showed a brown
substance under them. He/She had discolored, crusty spots on the front of his/her shirt
and on the top thigh area of his/her pants.
8. Review of Resident #42’s care plan, dated 1/1/18, showed staff are directed:
-Provide a shower twice a week and as needed;
-Assist the resident with activities of daily living (ADLs) as needed.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented the
resident refused a shower on 6/13/18, and they provided showers on 6/14/18 and 6/27/18.
Staff did not provide five of eight scheduled showers for the resident.
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-Severe cognitive impairment;
-Did not display behaviors and did not reject care during the look back period;
-Required assistance of one staff for bed mobility;
-Required extensive assistance of two or more staff for transfers, dressing, toilet use,
and personal hygiene;
-Dependent on one staff for bathing.
Review of the resident’s shower sheets for (MONTH) (YEAR), showed staff documented they
provided a shower for the resident on 7/17/18 and 7/18/18. Staff did not provide four of
six scheduled showers for the resident.
9. Review of Resident #43 quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Understands, understood;
– BIMS of 15 out of 15, cognitively intact;
– Required limited assistance with transfers, dressing, toileting, personal hygiene, and
bathing;
– [DIAGNOSES REDACTED].
During an interview, Resident #43 said his/her only concern is that there is no one at the
nurse’s station during meals. He/she has pushed his/her call light, and no facility staff
answered until meal time was over. He/She is concerned if someone fell that they would
have to wait a long time for an answer help.
10. Review of Resident #206’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Severely impaired cognition;
-Did not display behaviors or reject care;
-Dependent on two or more staff for transfers and bathing;
-Required extensive assistance of two or more staff for bed mobility, dressing, toilet
use, and personal hygiene;
-Required extensive assistance of one staff for eating.
Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they
provided a shower on 6/4/18, 6/11/18, 6/18/18, 6/21/18, and 6/26/18. Staff did not provide
three of eight scheduled showers to the resident.
Review of the resident’s shower sheets for (MONTH) (YEAR) showed staff documented they
provided a shower on 7/16/18. Staff did not provide five of six scheduled showers for the
resident.
Review of the resident’s care plan, last updated 7/19/18, showed staff are directed:
-The resident requires assistance with all activities of daily living (ADLs);
-Provide a shower twice a week and as needed.
Observation on 7/18/18 at 4:22 P.M., showed the resident with dark brown debris under
his/her fingernails.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 46)
Observation on 7/19/18 at 9:20 A.M., showed the resident with dark brown debris under
his/her fingernails.
Observation on 7/19/18 3:42 P.M., showed the dark brown debris remained under his/her
fingernails.
11. During an interview on 7/17/18, at 3:02 P.M., a family member said sometimes there are
only two aides for 50 plus people here on days and evenings but especially after 6 p.m.
and there is not enough to put them to bed. Our family stays until 9:00 and puts our
family members to bed. He/She said his/her family member wants one shower a week but
he/she has gone two -three weeks without a shower at all. He/She said there was one night
there were only two aides and another family member and myself felt bad for the staff and
the residents so we were helping pass trays and they called the director of nursing (DON).
He/she said the DON didn’t come help or send anyone, staff just said that we could not
help the staff with resident meals.
During an interview on 7/19/18, at 9:19 A.M., the administrator (ADM) said the facility
staffs with minimum CNA staffing of three aides on days, three aides on evenings, and two
on night shift. He/She said that staffing has been a huge issue for the facility.
During an interview on 7/20/18, at 10:47 A.M., certified nurse assistant (CNA) H said they
have had holes in the schedule for call ins or people that have quit. He/She said the
shower aide will have to work the floor with a full assignment if the facility does not
have enough staff and then the showers do not get completed. He/She said there have been
evenings after 6 p.m. that there are only 2 aides and we do what we can, there are
supposed to be at least three aides. He/She said Resident #9 had to wait on me a really
long time to be changed one time and I felt so bad, I just couldn’t get to him/her. He/She
said the call lights are all going off and stay on longer than they should when we are
short staffed.
During an interview on 7/20/18, at 2:00 P.M., license practical nurse (LPN) A said staff
should offer residents a shower at least twice a week and as needed or requested. He/She
said staffing is tight sometimes and showers do not get completed as scheduled.
During an interview on 7/20/18, 5:26 P.M., the director of nursing (DON) said staff are
expected to offer showers at least twice a week and as needed. The DON said staffing is a
challenge.

F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food that accommodates resident
allergies, intolerances, and preferences, as well as appealing options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to provide
and/or honor resident food preferences for two residents (Resident #9, and #13), and
facility staff also failed to serve one diabetic resident (Resident #19) a tray after
he/she had been administered insulin, of 15 sampled residents. Additionally the facility
failed to provide alternates to meet the needs of four residents (Resident #9, #10, #13,
and #19) that had the potential to affect all the residents. The facility census was 53.
1. Review of the facility’s Menus for [DATE]-[DATE], showed they directed the staff to
serve:
-[DATE] Lunch: brown sugar glaze ham, candied sweet potatoes, buttered spinach, dinner
roll, margarine, pumpkin pie, coffee or tea (see substitution request below, staff served
turkey, dressing, green beans, gravy, and strawberry ring cake);

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 47)
-[DATE] Dinner: tomato soup, crackers, grilled cheese sandwich, cucumber onion salad,
mandarin oranges, coffee, milk or tea;
[DATE] Lunch: peppered pork loin, au gratin potatoes, zucchini and tomatoes, dinner roll,
margarine, strawberry ring cake, coffee or tea;
[DATE] Dinner: sloppy joe on bun, chips, baked pork and beans, chilled peaches, coffee or
tea and milk;
[DATE] Lunch: BBQ chicken, red bliss potatoes, cream style corn, bread of choice,
margarine, fresh banana, coffee or tea;
[DATE] Dinner: Salisbury steak, gravy, mashed potatoes, broccoli, bread of choice,
margarine, fruit cup, coffee, tea or milk;
[DATE] Lunch: stuffed pepper casserole, capri blend vegetables, bread, margarine, apricot
halves, coffee or tea;
[DATE] Dinner: egg salad platter crackers, danish or muffin, margarine, baked apples,
coffee or tea, milk.
2. Review of the facility’s documentation from the Registered Dietitian (RD), dated
[DATE], directed staff about changing the lunch menu for [DATE]. The RD recommended to
substitute the turkey, dressing, green beans, gravy, and strawberry ring cake. The RD said
to check the spreadsheet from other meals for portion sizes.
3. Review of Resident #9’s physician’s orders [REDACTED].
-Regular diet, no meat per resident’s request, may supplement protein with other foods;
-Provide snack for the resident at bedtime with small frequent snacks throughout the day;
-[DATE]: discontinue Protein pudding twice a day.
-[DATE]: start house supplement drink 4 ounces (oz) with meals.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated [DATE], showed the staff documented the resident as:
-Moderate cognitive impairment;
-Set up assistance with eating;
-101 pounds (lbs);
-No oral problems (edentulous/did not have teeth not checked).
Review of the resident’s Comprehensive Nutrition Assessment, dated [DATE], showed the
dietitian documented:
-[DIAGNOSES REDACTED].
-Regular diet, no meat per resident’s request, likes peanut butter and jelly sandwiches in
place of meat, and boost pudding;
-Likes peanut butter and jelly sandwiches, and cottage cheese;
-Current weight 92.8 lbs,
-No oral problems (edentulous not checked);
-Body Mass Index 92.8 underweight;
-More that 5% weight change in 30 days;
-Recommend clarify boost pudding orders to twice a day with meals, add cottage cheese to
lunch and dinner meals for additional protein, add super cereal at breakfast, and boost
VHC (a high calorie/protein supplement) three times a day with med pass.
Review of Resident #9’s annual MDS, dated [DATE], showed staff documented the resident as:
-Moderate cognitive impairment;
-Set up assistance with eating;
-93 pounds (lbs) (7.9% weight loss since [DATE]);
-No oral problems (edentulous not checked).
Review of the resident’s Care Plan, dated [DATE], showed it directed staff:
-At risk for weight loss;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 48)
-Provide resident with ordered diet;
-Offer double portions of things that the resident likes;
-Offer alternative if the resident does not like the main meal;
-Resident does not want meat;
-Resident prefers peanut butter and jelly sandwiches often;
-Provide ordered boost pudding;
-Notify the physician and durable power of attorney with significant weight loss;
-Monitor for need to change diet consistency.
Review of the resident’s weight record showed staff documented:
-[DATE] 101 pounds (lbs);
-[DATE] 100.6 lbs;
-[DATE] 97.8 lbs;
-[DATE] 94.2 lbs;
-[DATE] 94.4 lbs;
-[DATE] 93.8 lbs;
-[DATE] 92.8 lbs;
-[DATE] 93.6 lbs;
-[DATE] 91.4 lbs;
-[DATE] 92.8 lbs;
-[DATE] 91.8 lbs;
-[DATE] 90 lbs, (10.89% wt loss since [DATE]);
-[DATE] 92 lbs;
-[DATE] 91 lbs;
-[DATE] 90 lbs, (10.89% wt loss since [DATE]).
Observation on [DATE], at 11:23 A.M., showed CNA B offered the resident dressing and
gravy, onion rings and a banana for his/her meal order. The resident asked if there is any
other option, and the CNA repeated dressing and gravy, onion rings and a banana. The
resident said I cannot eat meat, and the staff member repeated dressing and gravy, onion
rings and a banana. Further observation showed the staff did not serve the resident a 4 oz
supplement drink, or boost pudding. The staff did not offer the resident a protein or an
alternate entree that did not contain meat, or a protein supplement.
During an interview on [DATE], at 11:25 A.M., the resident said he/she cannot eat meat and
a lot of the food provided here, because he/she does not have teeth mainly, so he/she
cannot chew it, and some of it bothers his/her stomach. He/She said sometimes he/she can
get a peanut butter and jelly sandwich. He/She said they finally had cottage cheese that
he/she could eat. The resident said it would be nice to have a cheese sandwich or
something like that but it is not an option. The resident said his/her family used to
bring him/her snacks but they do not anymore, and staff bring him/her snacks sometimes but
not every day. He/She said that he/she is hungry all the time. He/She said, I don’t get
enough protein and I only weigh 91 pounds.
Observation on [DATE], at 12:20 P.M., showed staff served the resident in his/her room,
dressing with gravy, onion rings, a banana, and lemonade. Further observation showed the
staff did not serve the resident a 4 oz supplement drink, or boost pudding.
Observation on [DATE], at 12:12 P.M., showed staff served the resident in his/her room,
Mexican casserole with meat, onion rings, boost pudding and a banana. Observation showed
the resident’s meal ticket on his/her tray said cottage cheese, and the resident did not
receive cottage cheese.
During an interview on [DATE], at 12:12 P.M., the resident said he/she requested cottage
cheese and did not receive it. The resident said he/she did not like the casserole, it was
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 49)
too spicy and had meat in it. He/She said the staff did not offer him/her an alternate.
Observation on [DATE], at 12:41 P.M., showed the Activity director served the resident
chicken and dumplings, two pieces of corn bread, strawberries and lemonade. The resident
said to the staff member, I don’t like cornbread, and the staff member replied you do not
have to eat the cornbread. The staff member did not offer the resident an alternative to
the meat in the chicken and dumplings, or an alternative for the cornbread. Further
observation showed the staff did not serve the resident a 4 oz supplement drink, or boost
pudding.
During an interview on [DATE], at 12:45 P.M., the resident said he/she would try to eat
the noodles in the chicken and dumplings. He/She said the staff did not offer him/her an
alternate.
Observation on [DATE], at 12:21 P.M., showed the resident in his/her bed with his/her
tray. The tray contained french fries, onion rings, boost pudding, and cobbler.
During an interview on [DATE], at 12:21 P.M., the resident said that staff told him/her
the kitchen did not have cottage cheese. He/She said the staff did not offer him/her an
alternate. He/She said, the staff talk so fast and I don’t have time to think of what I
want to eat, or even ask for anything else before they are gone.
4. Review of Resident #13’s significant change (SCSA) MDS, dated [DATE], showed the staff
documented the resident as:
-Severe cognitive impairment;
-Limited physical assistance of one staff member for eating;
-81 lbs.
Review of the resident’s quarterly MDS, dated [DATE], showed the staff documented the
resident as:
-Severe cognitive impairment;
-Limited physical assistance of one staff member for eating;
-67 lbs.
Review of the assessment showed staff did not code the resident as a weight loss.
Review of the resident’s POS, dated [DATE]-[DATE], directed staff to:
-[DATE] start house shakes/supplements three times a day with medication pass;
-[DATE] oxygen at three liters per nasal cannula continuous;
-[DATE] start Mechanical soft diet;
-[DATE] discontinue mechanical soft diet;
-[DATE] start regular diet;
-[DATE] Discontinue House shakes/supplements.
Review of the resident’s Care Plan, dated [DATE], directed staff to:
-Provide ordered diet;
-Monitor intake;
-Provide double portions of the things that he/she likes;
-Offer alternate if the resident does not like the main dish;
-Encourage family to bring in favorite foods/snacks;
-Notify physician and durable power of attorney of any significant weight loss.
Review of the resident’s weight record showed staff documented:
-[DATE] 81.6 lbs;
-[DATE] 80.6 lbs;
-[DATE] 77 lbs;
-[DATE] 71.6 lbs;
-[DATE] 68.8 lbs (15.68 % weight loss);
-[DATE] 67.2 lbs (17.64 % weight loss);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 50)
-[DATE] 70.4 lbs;
-[DATE] 72.4 lbs.
Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented:
-Resident has lost 10 lbs, 12.9% over the last 30 days, now 70.2 lbs,BMI 13.71 very
underweight;
-Unsure of diet, no order in chart;
-Gets house supplement three times a day for snacks;
-Nursing and dietary report resident has been refusing to come to the dining room or eat
at all;
-Usually likes milk;
-Family here often and sometimes brings in food;
-Takes [MEDICATION NAME] 15 milligrams (antidepressant) which should improve appetite;
-Is on Hospice care;
-Continue encouraging food and fluids;
-Recommend: Add diet orders to chart.
Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented:
-Resident continues to lose weight, down 12 lbs,15.7% in 90 days, down 2 lbs, 3.9% in 30
days now 68.8#;
-BMI 13.44 underweight;
-Has been evaluated by Speech Therapy- they have recommended Mechanical soft diet;
-Intake poor ,[DATE]% usually;
-Receives house supplement three times a day;
-The resident has been requesting regular consistency meat- especially bacon;
-Family wound like her to have bacon, and other regular consistency foods;
-Family has been educated on choking hazards, but feel Regular consistency better;
-Takes [MEDICATION NAME] 7.5 mg which can improve appetite;
-Liberalize diet to regular per family and resident preference;
-Recommend: Add house supplement three times a day with meals for additional calories.
Review of the physician’s orders [REDACTED].
Review of the Nutrition quarterly review, dated [DATE], the staff documented:
-Mechanical soft diet;
-Current weight 69 lbs;
-House shakes/supplements three times a day;
-Resident refuses all shakes sent from dietary department.
Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented:
-Resident has lost 14 lbs, 17.8% over the last 90 days, down 1 lbs in 30 days. Now 67.2#
BMI 13.12;
-Receives mechanical soft diet and house supplement three times a day;
-Has poor appetite (,[DATE]%) and often refuses house supplement – shakes & ice cream
attempted with poor intake;
-Continues requesting bacon, but not allowed on mechanical soft diet;
-Evaluated by speech therapy today;
-Will be trialing regular diet over the next several days and bacon will be allowed;
-Takes [MEDICATION NAME] 15 mg which can improve appetite;
-Continues on Hospice care;
-Recommend: Boost Breeze or VHC (depending on resident preference) 90 cc three times a day
with med pass, discontinue house supplement- refuses to drink.
Review of the physician’s orders [REDACTED].
Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 51)
-Resident’s wt is down 11 lbs, 14% over the last 6 months, but has been steady over the
last 90 days;
-Diet has been liberalized to Regular,
-BMI 13.71 underweight
-Intake generally poor ,[DATE]%;
-House supplement three times a day;
-Takes [MEDICATION NAME] 15 mg which can improve appetite;
-No new recommendations.
Review of the resident’s Progress Notes, dated [DATE], showed the dietitian documented:
-Wt down 9 lbs, 11.3% over the last 6 months, but has been trending up over the last 90
days.
-Now 72.4 lbs BMI 14.14 underweight;
-Is on Hospice care;
-Receives Regular diet, fluids are encouraged 120 ml water four times a day with med pass;
-Intake fair ,[DATE]% usually;
-Spoke with dietary, he/she does not like supplement drink/ice milk, prefers milk;
-Takes [MEDICATION NAME] 15 mg which can improve appetite;
-Recommend: Whole milk three times a day with meals.
Observation on [DATE], at 12:21 P.M., showed the resident in bed in a fetal position with
his/her eyes closed. Observation showed his/her lunch tray with his/her plate covered,
his/her dessert covered with a transparent film, his/her silverware still wrapped in a
napkin like it came from dietary, and a glass of koolaide. Further observation showed the
resident’s tray did not contain milk, bacon, bran flakes, or a nutritional supplement.
During an interview on [DATE], at 3:02 P.M., the resident’s family member said the food
choice is terrible, they have one alternate for a week and there is nothing else. If
he/she doesn’t like riblet, he/she is stuck for the whole week. He/She said, having the
same alternate twice a day for a week is crazy to me, or they have chicken as the
alternate and a different version of chicken as the meal so if you don’t like chicken what
are you supposed to eat. He/She said we asked the staff to give him/her bacon at least
every breakfast but they don’t always do that, and sometimes that is all he/she eats.
He/She said I don’t know why they can’t give her bacon every meal, can’t they make extra
at breakfast and reheat it. He/She said we have problems getting him/her to eat anything.
He/She said the family buys him/her bran flakes because he/she will eat that, and drink
milk. He/She said the resident is on hospice because of his/her weight loss.
Observation on [DATE], at 12:15 P.M., showed the resident in bed in a fetal position with
his/her eyes closed. Observation showed the staff served the resident Mexican casserole,
au gratin potatoes, zucchini and tomatoes, a dinner roll, margarine, and strawberry ring
cake. Observation showed the resident’s food is untouched. Further observation showed the
resident’s tray did not contain milk, bacon, bran flakes, or a nutritional supplement.
Observation on [DATE], at 12:27 P.M., showed the resident sitting on the side of his/her
bed. Observation showed CNA B served the resident chicken and dumplings, cornbread, fried
okra, peaches, a banana, and a glass of milk. Further observation showed the resident’s
tray did not contain bacon, bran flakes, or a nutritional supplement.
Observation on [DATE], at 12:44 P.M., showed the resident consumed 25% of his/her chicken
and dumplings, a few pieces of okra, and drank his/her milk.
During an interview on [DATE], at 11:13 A.M., the MDS coordinator (MDSC) said the resident
is on hospice for abnormal weight loss on the hospice admission form.
During an interview on [DATE], at 12:26 P.M., the resident said he/she ate some of his/her
riblet sandwich, and his/her milk.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 52)
5. Review of Resident #19’s quarterly MDS, dated 5/ /18, showed the staff assessed the
resident as:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-Insulin injections seven days a week;
-Limited physical assistance of one staff member for eating.
Review of the resident’s physician’s orders [REDACTED].
-[MEDICATION NAME] (a fast acting insulin) on a sliding scale: If blood sugar is 200 to
249- give 6 units, 250 to 299- give 8 units, 300 to 349- give 12 units, 350 to 399- give
15 units, greater than 400- call the physician. Check blood sugar and administer insulin
at 8:00 A.M., 11:00 A.M., 4:00 P.M., and 8:00 P.M.;
-Levimer (a long acting insulin) administer 14 units at 7:00 A.M., and 8:00 P.M.
Review of the resident’s Care Plan, last updated [DATE], directed staff to:
-Resident is an Insulin dependent Diabetic;
-Goal: Resident will be absence of signs of [DIAGNOSES REDACTED]
or [MEDICAL CONDITION];
-Staff to provide diet as ordered;
-Staff to take all accu checks (check blood sugar) as ordered;
-Staff to provide all ordered medications;
-Staff to administer all insulins as ordered;
-Staff to rotate insulin sites;
-Staff to monitor for signs and symptoms of hypo/hyper glycemia (low or high blood sugar,
symptoms include: fatigue, shakiness, change in mental status, sweating, change in mood or
behavior);
-Staff to provide a bedtime snack;
-Staff to notify physician of any significant changes.
Observation on [DATE], at 12:,[DATE]:55 P.M., showed the staff did not serve the resident
a tray. Observation showed a staff member entered the resident’s room at 12:30 P.M. and
reminded him/her it is time for lunch.
During an interview on [DATE], at 12:55 P.M., certified nurse assistant (CNA) B said the
staff were done serving lunch trays. He/She said he/she did not know that the resident did
not get a tray.
During an interview on [DATE], at 1:05 P.M., licensed practical nurse (LPN) A said that if
the resident does not eat the staff are expected to let the nurse know. He/She said staff
are expected to bring every resident a tray even if they say they do not want one to see
if they change their mind. The LPN said that the resident’s blood sugar was over 200 so
he/she received six units of insulin so it is important that he/she eat. He/She said the
staff did not make him/her aware the resident did not get a tray.
During an interview on [DATE], at 10:23 A.M., the MDS coordinator (MDSC) said that the
resident has hypoglycemic episodes. He/She said if the resident refused the meal staff
should immediately notify the nurse. He/She said the staff are expected to bring a tray to
every resident no matter what. He/She also said if you bring the tray to the resident
he/she usually will go ahead and eat it.
6. During an interview on [DATE], at 12:00 P.M., Resident #10 said the facility only
serves one alternate for the week, or we can have peanut butter and jelly. He/She said if
you like the alternate for the week it is ok, you may get a little tired of it. He/She
said if you don’t like it, it’s the pits.
7. During an interview on [DATE], at 2:58 P.M., Resident #18 said he/she does not always
like the food items the facility serves and the alternate isn’t much better. He/She said
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 53)
the alternate is the same food for lunch and dinner for a week, so if you don’t like it,
tough luck.
8. During an interview on [DATE], at 1:44 P.M., the dietary manager (DM) said he/she was
instructed by the dietitian to supplement the protein for Resident #9 with boost pudding.
He/She said if he/she has cottage cheese he/she will give it to him/her. He/She said
he/she has to be careful with food substitutions because he/she can’t do for one what
he/she cannot do for all. He/She said if the resident wants cottage cheese every meal then
the next resident wants it and then it gets out of control. The DM said that he/she
expects staff to offer the resident items he/she can eat, and said there is not a list of
appropriate protein foods that the resident prefers. The DM said the resident only
consumes the Boost pudding sometimes. He/She said he/she is not aware the resident
requested cottage cheese yesterday. He/She said he/she is not aware the resident was
served casserole with meat in it or chicken and dumplings. He/She said the kitchen does
not have a menu for residents who do not eat meat. He/She said the resident continues to
lose weight, and they have not tried anything new. He/She said Resident #13 prefers bacon,
bran flakes, and coffee every morning and he/she usually eats breakfast. He/She said that
staff have not tried bacon at other meal times, because they would have to cook it. He/She
said staff are expected to send whole milk with every meal. He/She said staff are expected
to bring every resident a tray at meals, and Resident #19 got missed because his meal card
got turned the wrong way.
During an interview on [DATE], at 3:09 P.M., the DM said he/she interviews residents about
their likes and dislikes on admission and enters the information into the electronic
record. He/She said the information about likes and dislikes is not available to the
kitchen staff or the CNA’s. He/She said that the alternate is the same for a week for
lunch and supper, so it may be pork fritter one week and riblet sandwiches the next.
He/She said the staff are not expected to cook any other foods for residents by request.
During an interview on [DATE], at 5:26 P.M., the director of nursing (DON) said that staff
are expected to follow the physician’s orders [REDACTED].
During an interview on [DATE], at 5:26 P.M., the administrator (ADM) said dietary staff
are expected to interview the resident’s about their likes/dislikes and place on their
dietary card. He/She said if a resident does not like something then a substitution of
equal nutritional value should be offered. He/She said if Resident #9 does not like meat
an alternate of equal nutritional value should be offered. He/She said that Resident #13
likes bran flakes, and bacon. He/She never thought about serving bacon more than
breakfast. He/She said the alternate is the same for lunch and dinner for a week, and then
it is changed to another alternate.
During an interview on [DATE], at 8:00 P.M., the registered dietitian (RD) said he/she
expects the staff to interview each resident for his/her likes and dislikes, and honor
those request. He/She said staff are expected to offer the resident an alternate of equal
nutritional value. He/She said Resident #9 does not like meat, and the staff should offer
the resident the alternate food he/she likes like peanut butter and jelly sandwich,
grilled cheese, or cottage cheese as often as he/she will eat it. He/She said if Resident
#13 only eats bacon, bran flakes, and milk it is reasonable to send him/her those items
every meal to encourage him/her to eat something. The RD said both residents are
malnourished and need whatever calories and protein they can get. He/She said that if
he/she recommends new interventions or supplements, the staff are expected to try those
interventions, and if the resident does not like them to document the results. He/She said
that then he/she can recommend something else for staff to try. The RD also said all
residents should receive a tray for each meal. He/She said with Resident #19, he/she may
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 54)
have consumed some of the tray if it were there for him/her to see, and with diabetic
residents it is important to report to the charge nurse if they do not eat a meal. The RD
said the alternate always available menu is new to the facility. He/She said facility
staff were supposed to start with a few options like corn dogs, hamburgers, chicken
strips, french fries, and onion rings and then expand the menu to include more foods each
week until they had a large always available menu. He/She said the facility did not
consult with him/her about offering one alternate for every lunch and dinner for a week.
He/She said having one alternate for lunch and dinner for a week is not an adequate method
to ensure that residents have a variety of food options.

F 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure therapeutic diets are prescribed by the attending physician and may be delegated
to a registered or licensed dietitian, to the extent allowed by State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to ensure
Resident #1 received a gluten free diet due to a gluten allergy, as ordered by his/her
physician. The facility census was 53.
1. Review of Resident #1’s Minimum Data Set (MDS), a federally mandated resident
assessment, dated [DATE], showed staff assessed the resident as follows:
-Moderately impaired cognition;
-Inattention and disorganized thinking occur; fluctuate and vary in severity;
-Moderate depression;
-Did not display behaviors or reject care during the lookback period;
-Received tube feeding (liquid nutrition delivered directly into the stomach through a
tube in the stomach) and mechanically altered diet.
Review of the resident’s physician order [REDACTED]. Additional Review of the POS
[REDACTED].
Review of a care plan meeting note, dated [DATE], showed staff documented the resident
with a [DIAGNOSES REDACTED].
Review of the Dietician’s note, dated [DATE], showed staff documented the resident with
weight loss of five pounds over thirty days due to loose stools due to noncompliance with
the gluten free diet.
Review of the resident’s care plan, last updated [DATE], showed staff are directed:
-[DIAGNOSES REDACTED].
-History of weight loss;
-Provide the resident with ordered diet;
-The resident is rarely capable of making daily decisions without cues due to cognitive
loss and dementia;
-Remind the resident about his/her gluten free diet when he/she orders;
-Document when he/she refuses the gluten free diet;
-Offer an alternate if the resident doesn’t like/want the main dish;
-Staff to explore dietary options with resident;
-Monitor resident’s allergy.
Review of the facility’s Menus for [DATE]-[DATE], directed the staff to serve:
-[DATE] Lunch: brown sugar glaze ham, candied sweet potatoes, buttered spinach, dinner
roll, margarine, pumpkin pie, coffee or tea (see substitution request below, staff served
turkey, dressing, green beans, gravy, and strawberry ring cake);

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 55)
-[DATE] Dinner: tomato soup, crackers, grilled cheese sandwich, cucumber onion salad,
mandarin oranges, coffee, milk or tea;
[DATE] Lunch: peppered pork loin, au gratin potatoes, zucchini and tomatoes, dinner roll,
margarine, strawberry ring cake, coffee or tea;
[DATE] Dinner: sloppy joe on bun, chips, baked pork and beans, chilled peaches, coffee or
tea and milk;
[DATE] Lunch: BBQ chicken, red bliss potatoes, cream style corn, bread of choice,
margarine, fresh banana, coffee or tea;
[DATE] Dinner: Salisbury steak, gravy, mashed potatoes, broccoli, bread of choice,
margarine, fruit cup, coffee, tea or milk;
[DATE] Lunch: stuffed pepper casserole, capri blend vegetables, bread, margarine, apricot
halves, coffee or tea;
[DATE] Dinner: egg salad platter, crackers, danish or muffin, margarine, baked apples,
coffee or tea, milk.
Staff did not provide a gluten free diet menu. Additional review showed staff listed the
meal alternate for lunch and supper for [DATE] through [DATE] as BBQ rib on bun, onion
rings, and apricots.
Observation on [DATE] at 12:08 P.M., showed staff served the resident turkey, and gravy
with dressing. Staff did not provide the resident a gluten free meal, and did not offer
the resident a gluten free alternative.
Observation on [DATE] at 12:00 P.M., showed staff served the resident chicken and
dumplings, peaches and tea. Staff did not provide the resident a gluten free meal, and did
not offer the resident a gluten free alternative.
2. During an interview on [DATE] at 12:15, the Dietary Manager (DM) said staff served the
resident hot tea, broth, and two packages of crackers for lunch. The DM said the crackers
are not gluten free, and the facility does not have gluten free crackers available at this
time.
During an interview on [DATE] at 1:45 P.M., the DM said the only gluten free alternative
currently available to the resident is gluten free cereal. The DM said staff have offered
the resident gluten free bread but the resident didn’t like it. He/She did not know if
staff tried more than one brand of gluten free bread. The DM said staff have never
provided a completely gluten free menu to the resident, because he/she doesn’t stick to
the diet. He/She said staff tell the resident what is on the menu, and if he/she selects
an item with gluten, they tell the resident it contains gluten and ask if he/she still
wants it, but do not offer a gluten free substitute of the same food item such as a
hamburger bun or pasta. The DM said staff offer the gluten free cereal or other things we
have on hand that do not contain gluten as an alternative to the food items with gluten.
Staff do not prepare gluten free menu items for the resident and do not offer to prepare
gluten free versions of the items on the menu. The DM said he/she did not know if staff
have attempted to prepare gluten free versions of the resident’s preferred foods, like
biscuits and gravy.
During an interview on [DATE] at 5:26 P.M., the DON and administrator said staff have not
provided gluten free items to Resident #1, and the facility does not have a menu with
gluten free substitutes of equal nutritional value.
During an interview on [DATE] at 5:30 P.M., Certified Nurse’s Aide (CNA) B said staff do
not offer the resident gluten free alternatives when they ask him/her what he/she wants to
eat at meals. The CNA said if the resident selects an item that is not gluten free staff
will remind him/her it contains gluten, but the resident usually chooses to eat it. The
CNA said staff do not offer a gluten free option, just remind the resident what he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 0808

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 56)
chose contains gluten.
During an interview on [DATE] at 5:38 P.M., Licensed Practical Nurse (LPN) A said the
resident often chooses the main entree offered, even if it contains gluten. He/She said
staff do not offer the resident gluten free options, they just remind the resident that
the items he/she selected contain gluten. The LPN said staff have not contacted the
resident’s physician and asked about changing or modifying the ordered diet. LPN A also
said he/she does not know if staff have tried to prepare various gluten free foods for the
resident to determine if there are gluten free foods he/she would enjoy in place of the
items on the menu with gluten. The LPN said staff can tell when the resident eats gluten,
because he/she will have loose stools, especially after foods like biscuits and gravy. LPN
A said the resident continues to eat the biscuits and gravy because he/she really likes
them. The LPN said he/she thought staff had tried to offer the resident gluten free
biscuits and gravy for breakfast some time ago, but did not remember if staff had
attempted to prepare the resident gluten free biscuits and gravy recently.
During an interview on [DATE], at 8:00 P.M., the registered dietitian (RD) said staff are
expected to offer the resident the gluten free diet. He/She said the staff have a
spreadsheet column with a gluten free diet for every meal. He/She said the staff should
not offer the regular meal but honor requests, if a resident wants something not on
his/her menu. He/She said the resident has very bad side effects from eating gluten, and
it is important to try to offer him/her a variety of gluten free options to choose from
because of the effects it has on him/her. He/She said that there is gluten free bread that
can be stored in the freezer that would make it affordable for one resident. He/She said
some of the menus are a slight variation to the regular menu and some are a whole
different meal. The RD said he/she did not know the staff were not offering the gluten
free menu available to them, and that gluten free cereal did not have enough nutrition to
be an equal substitute for meals.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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, facility staff failed to wash hands
and change gloves during care in a manner to prevent the spread of infection for four
residents (Resident #7, #10, #23, and #206). Staff also failed to sanitize a multiple
resident use glucometer between residents in order to prevent the spread of infection.
Additionally, staff failed to change and store oxygen and medication nebulizer tubing in a
manner to prevent the spread of infection for three residents (Resident #9, #10, and #13)
out of 14 sampled residents. The facility census was 53.
1. Review of the facility’s policy on Handwashing, dated (MONTH) (YEAR). showed staff are
directed to reduce transmission of organisms from resident to resident, nursing staff to
resident, and resident to nursing staff. The policy directed the staff on how to wash
their hands. The policy did not direct the staff when to wash their hands or the use of
hand sanitizer.
2. Observation on 7/18/18, at 10:30 A.M., showed Resident #10 in his/her bed. Certified
nurse assistant (CNA) B provided incontinence care to the resident. Observation showed the
CNA changed his/her gloves three times during incontinence care when he/she went from a
dirty area to a clean area. The CNA did not cleanse or wash his/her hands with any of the
glove changes. The CNA did not provide perineal care in a manner to prevent the spread of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Some

(continued… from page 57)
infection.
Observation on 7/19/18 at 9:23 A.M., showed CNA F and CNA B transferred Resident #206 into
bed from his/her wheelchair with the hoyer lift. CNA F provided incontinence care to the
resident. He/She used the same area of the wipe for multiple wipes of the resident’s
perineal area. The CNA did not provide perineal care in a manner to prevent the spread of
infection.
Observation on 7/19/18 at 2:30 P.M., showed CNA B and CNA F transferred Resident #7 into
bed from his/her gerichair and provided incontinence care. CNA B cleansed the resident’s
bottom, and changed his/her gloves but did not wash his/her hands. The CNA touched the
resident’s clean brief, clean bed linens, and the hoyer lift pad with his/her contaminated
gloves. The CNA did not provide care in a manner to prevent the spread of infection.
Observation on 7/19/18, at 3:24 P.M., showed nurse assistant (NA) H, and NA D assisted
Resident #23 to the bathroom. NA D cleansed the resident’s back folds, soiled with feces.
Observation showed NA D removed his/her gloves, did not cleanse or wash his/her hands, and
touched the residents skin, the mechanical lift, propelled his/her chair out of the
bathroom, and applied his/her nasal cannula oxygen tubing with his/her contaminated hands.
The NA left the room and did not cleanse his/her hands. The CNA did not provide care in a
manner to prevent the spread of infection.
3. During an interview on 7/19/18, at 3:30 P.M., NA H said staff are expected to cleanse
or wash their hands before they provide care to a resident and after care of a resident.
Staff are expected to change their gloves and cleanse their hands between dirty and clean
areas, and when they change their gloves.
During an interview on 7/20/18, at 10:47 A.M., NA D said staff are expected to wash their
hands when they go in a room and when they go out, and between dirty and clean task.
He/She said, I totally forgot to wash my hands.
During an interview on 7/20/18, at 5:23 P.M., certified nurse assistant (CNA) B said staff
are expected to change their gloves and wash their hands before and after care, between
dirty and clean areas, and when they change gloves. He/She said he/she forgot to wash
his/her hands when providing care.
4. Review of the facility’s policy on blood glucose monitoring, dated (MONTH) (YEAR),
showed staff are directed:
-Place equipment on a clean surface;
-Disinfect glucose monitor after use and return to cart.
Review of the facility’s policy on blood glucometer disinfecting, dated (MONTH) (YEAR),
showed staff are directed to clean the blood glucose meter prior to use with approved with
10% bleach or comparable product, place on clean field and let air dry according to
manufacturer’s directions. Do not touch the clean field with gloves including the test
port. Glucometer may be wrapped in another wipe and stored.
5. Review of the manufacturer’s recommendations for the facility’s multiple resident use
glucometer showed staff are directed:
-Use a manufacturer approved product to clean and disinfect the glucometer;
-Allow the surface of the glucometer to remain wet at room temperature for the contact
time listed on the wipe’s directions for use;
-Wipe all external areas of the meter, including both front and back surfaces until
visibly wet;
-Wipe the meter dry, or allow to air dry.
6. Observation on 7/19/18 at 11:15 A.M., showed CMT E at the medication cart. The CMT
placed the multiple resident use glucometer on top of the medication cart and gathered
supplies to check Resident # 10’s blood sugar. CMT E entered the resident’s room, placed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Some

(continued… from page 58)
the glucometer on the resident’s bed, prepared the resident, and checked the resident’s
blood sugar. The CMT returned to the medication cart and placed the glucometer on top of
the cart. He/She did not sanitize the glucometer before or after he/she checked the
resident’s blood sugar.
Observation on 7/19/18 at 11:20 A.M., showed CMT E removed the glucometer from the top of
the medication cart, gathered supplies, and entered Resident #19’s room. The CMT placed
the glucometer on top of the resident’s refrigerator, prepared the resident, and checked
his/her blood sugar. The CMT returned to the medication cart and placed the glucometer on
top of the cart. He/She did not sanitize the glucometer before or after he/she checked the
resident’s blood sugar.
Observation on 7/19/18 at 11:27 A.M., showed CMT E removed the glucometer from the top of
the medication cart, gathered supplies, and entered Resident #16’s room. The CMT placed
the glucometer on the resident’s bed, prepared the resident, and checked the resident’s
blood sugar. The CMT returned to the medication cart and placed the glucometer on top of
the cart. He/She did not sanitize the glucometer before or after he/she checked the
resident’s blood sugar.
During an interview on 7/19/18 at 11:42 A.M., CMT E said he/she did not know staff are
expected to sanitize multiple use resident glucometers between each resident. The CMT said
he/she did not receive instruction to sanitize the glucometer between residents, but it
makes sense.
7. Review of the facility’s policy Oxygen Administration, dated (MONTH) (YEAR), showed
staff are directed:
-To administer oxygen to the resident when insufficient oxygen is being carried by the
blood to the tissues;
-Check the physician’s orders [REDACTED].
-Set the flow meter to the rate the ordered by the physician;
-Place mask or cannula on resident as indicated above;
-Label humidifier and/or tubing with date and time opened.
The policy did not contain directions to staff on when to change the oxygen and medication
nebulizer tubing, or how to store the tubing and equipment when not in use.
8. Observation on 7/17/18, at 11:23 A.M., showed Resident #9’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or
change the resident’s respiratory equipment in a manner to prevent the spread of
infection.
Observation on 7/18/18, at 10:18 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or
change the resident’s respiratory equipment in a manner to prevent the spread of
infection.
Observation on 7/19/18, at 11:32 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or
change the resident’s respiratory equipment in a manner to prevent the spread of
infection.
Observation on 7/20/18, at 12:21 A.M., showed the resident’s nebulizer pump on the floor
and the mouthpiece and tubing undated, uncovered, and resting on the floor under his/her
bed. Observation showed the concentrator tubing dated 7/7/18. The staff did not store or
change the resident’s respiratory equipment in a manner to prevent the spread of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265418

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

07/20/2018

NAME OF PROVIDER OF SUPPLIER

DIXON NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

403 EAST 10TH STREET
DIXON, MO 65459

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 – Some

(continued… from page 59)
infection.
9. Observation on 7/17/18, at 11:09 A.M., showed Resident #10’s oxygen on via nasal
cannula with the tubing dated 7/7/18. The staff did not change the resident’s respiratory
equipment in a manner to prevent the spread of infection.
Observation on 7/18/18, at 10:30 A.M., showed the resident with oxygen on via nasal
cannula dated 7-7-18. The staff did not change the resident’s respiratory equipment in a
manner to prevent the spread of infection.
10. Observation on 7/17/18, at 11:19 A.M., showed Resident #13 on his/her right side
curled into a ball on his/her bed with his/her eyes closed. Observation showed the
resident’s nasal cannula tubing connected to his/her concentrator on the floor under the
end of his/her bed. Further observation showed the nasal cannula dated 7/7/18, and the
resident’s portable oxygen tank on his/her wheelchair dated 7/7/18. The staff did not
store or change the resident’s respiratory equipment in a manner to prevent the spread of
infection.
Observation on 7/18/18, at 12:09 P.M., showed the resident in bed. Observation showed the
nasal cannula tubing in a bag dated 7/7/18. The staff did not change the resident’s
respiratory equipment in a manner to prevent the spread of infection.
Observation on 7/19/18, at 11:29 A.M., showed the resident in his/her bed in a fetal
position. Observation showed the resident’s oxygen nasal cannula tubing dated 7/17/18 in a
bag on the floor. The staff did not store or change the resident’s respiratory equipment
in a manner to prevent the spread of infection.
Observation on 7/20/18, at 12:26 P.M., showed the resident in bed with his/her nasal
cannula on the bed next to him/her. Observation showed the oxygen tubing undated. The
staff did not change the resident’s respiratory equipment in a manner to prevent the
spread of infection.
11. During an interview on 7/19/18, licensed practical nurse (LPN)A said staff are
expected to change oxygen tubing and nebulizer tubing once a week. He/She said if the
tubing is on the floor the staff should replace it for infection control reasons. He/She
said staff are expected to wash their hands before and after care of a resident, between
dirty and clean task while providing care, and with glove changes. He/She said the
glucometer should be cleansed between residents according to manufacturer’s instructions.
During an interview on 7/20/18, at 5:26 P.M., the director of nursing (DON) said staff
should change oxygen tubing and medication nebulizer tubing weekly. He/She said when the
tubing is not in use it should be coiled and in a bag. He/She said staff are expected to
wash their hands before and after care of a resident, between dirty and clean task while
providing care, and with glove changes. He/She said the glucometer should be cleansed
between residents according to manufacturer’s instructions.