Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interviews, facility failed to insure staff treated residents in
a manner that maintained their dignity when staff failed to knock before entering
resident’s room, failed to label residents’ belongings out of sight, and hung signs
instructing staff how to care for residents for eight (#22, #30, #31, #33, #44, #162, #164
and #165) of 16 sampled residents. The census was 79.
1. Review of the facility’s Resident Rights Dignity Issues policy, undated, showed the
following:
-All staff members shall knock on the resident’s room door prior to entering, announce
their intention, and whenever possible obtain permission prior to entering the room;
-Cubicle curtains, window coverings, room and bathroom doors shall be pulled during
resident care and treatment to provide privacy to the resident.
2. Observation on 3/3/19 at 5:30 P.M., showed Resident #22 in the dining room with his/her
name written on his/her socks. The resident’s name could be seen by other residents, staff
and visitors.
Observation on 3/4/19 at 11:05 A.M., showed Resident #22 in the dining room with liquid
dripping out of his/her nose onto his/her arm. Further observation showed staff did not
assist the resident.
Observation on 3/5/19 at 10:04 A.M., showed Resident #22 and Resident #164 in the dining
room with their name written on their socks. The residents’ name could be seen by other
residents, staff and visitors.
3. Review of of Resident #30’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/23/18, showed the following:
– Required total physical assistance of two persons for transfers and bathing;
– Required total physical assistance of one person for bed mobility, locomotion,
toileting, and personal hygiene;
– Required extensive assistance of one person for dressing and eating;
– Has limited range of motion of bilateral upper and lower extremities;
– Received pain medication as needed for occasional pain rated at a four on a scale of
0-10;
– At increased risk for pressure ulcers with one unstageable pressure ulcer;
– Received antipsychotic medication, anxiolytic medication, and antidepressant medication
on seven out of the last seven days.
Review of the resident’s care plan, dated 7/23/19, showed it did not provide direction for
staff regarding application of the splints the resident wears bilaterally on his/her upper
and lower extremities.
Observation on 3/3/19 at ****, showed the resident in his/her room with a splint on
his/her right arm and both legs. Additional observation showed an arm splint on the
resident’s lap. The resident said the splint is for his/her right arm and he/she takes it
off sometimes. The resident said the Certified Nursing Assistants (CNAs) apply the splints
and remove them as directed by the hand written signs taped to the bottom of the
resident’s television shelf. Further observation showed the care signs could be observed
by anyone entering the resident’s room.
Observation on 3/7/19 at 10:38 AM, showed the resident in his/her wheelchair watching
television. Additional observation showed the handwritten signs taped below the television
shelf, visible to any visitor to the resident’s room.
During an interview on 3/6/19 at 12:00 P.M., the facility’s physical therapy director said

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
he/she wrote directions for the application and removal of the resident’s splints and
posted them in the resident’s room.
4. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Severely impaired cognition;
– [DIAGNOSES REDACTED].
– On oxygen therapy.
Observation on 3/5/19 at 3:20 P.M. and 3/6/19 at 8:50 A.M. and 1:00 P.M., showed a care
sign posted in the resident’s room and visible from the open door. The sign read, Leave O2
on 2 liters (L) per minute. Only charge nurses are to change this. Additional review
showed the director of nurses (DON) signed the care sign.
5. Review of Resident #33’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Severely impaired cognition;
– Required extensive assistance for transfers and dressing;
– Total dependence for locomotion on and off the unit;
– [DIAGNOSES REDACTED].
Observation on 3/4/17 at 11:30 A.M., showed the resident in his/her room with an oblong
shaped wet spot of a yellow substance on his/her right shirt sleeve. A CNA entered the
resident’s room and knelt down in front of the resident to speak to him/her. The
resident’s sleeve with the spot was visible. The CNA did not change the resident’s shirt
before he/she propelled the resident to the main dining room for lunch. The resident sat
at a dining room table with other residents. The oblong wet spot with specks of a yellow
substance was visible to other residents and staff in the dining room.
Observations on 3/4/17 at 1:05 P.M., showed the resident at the lunch table in the dining
room with other residents. The oblong wet spot with specks of a yellow substance was
visible to other residents and staff in the dining room. The resident ate his/her lunch
with the soiled shirt on him/her.
6. Review of Resident #44’s admission MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– [DIAGNOSES REDACTED].
– At risk for pressure ulcers.
Observation on 3/4/19 at 11:30 A.M., 3/5/19 at 3:20 P.M., 3/6/19 at 8:50 A.M., showed the
resident in his/her bed. A care sign hung over the resident’s bed and was visible from the
open door. The sign read please make sure that I have my boots on both feet, at all times,
except to shower.
7. Observation on 3/5/19 at 10:47 A.M., showed a care sign above Resident #162’s bed with
instructions on how to care for the resident.
Observation on 3/5/19 at 10:53 A.M., showed Registered Nurse (RN) did not knock on
Resident #165’s door before he/she entered to provide care.
8. During an interview on 3/7/19 at 9:34 A.M., CNA N said facility staff should clean a
resident’s face if it is dirty or change a resident’s clothes if they are dirty. Facility
staff should not take residents to activities or meals with dirty clothes. It is a dignity
issue for the resident. Both facility staff and resident family members hang care signs in
the resident’s room. The signs are to remind the staff of care issues.
9. During an interview 3/7/19 at 9:55 A.M., showed Certified Nurse Assistant (CNA) said
staff should knock on resident’s door before entering a resident’s room. Care signs are
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
hung by the nurses, they put them up there. A resident’s things are labeled by the CNAs or
laundry staff. Facility staff use permanent marker to write it where it is easy to seen,
like the top of shoes. He/she has not had any instruction on labeling the resident’s
belongings.
10. During an interview on 3/7/19 at 10:08 A.M., Registered Nurse (RN) A said he/she puts
the care signs up for everyone to know. He/she always puts a sign over the bed, and the
information is also in the chart and on the MAR. He/She said staff should knock on the
door before entering a room and announce themselves. Additionally, facility staff label
the residents’ clothing and shoes when they come into the facility. Facility staff try to
label them where it is easy to see for laundry. The RN said staff are not instructed on
how to label belongings.
11. During an interview on 3/7/19 at 10:15 A.M., LPN J said care signs are hung in the
resident rooms by therapy staff and nurses. He/She said the facility does not have a
policy about hanging care signs in resident rooms. The LPN said if facility staff see a
resident with dirty clothes, it is expected the staff will change the resident’s clothes.
He/She said staff should not take the resident to meals with dirty clothes, this is a
dignity issue.
12. During an interview on 3/7/19 at 10:40 A.M., CNA O said facility staff should change a
resident’s clothes when they are dirty. He/She said staff should not take residents to
activities or meals with dirty clothes. Additionally, resident clothes are to be labeled
with their names on the inside where it is not visible to others. These are dignity issues
for the resident.
13. During an interview on 3/7/19 at 12:44 P.M., showed the administrator and the DON said
the Social Service staff label residents’ belongings upon admission, and the clothing is
put on the inventory slip. They said shirts are usually labeled on the inside, out of eye
site. They said they do not have a policy or training labeling residents’ clothes, staff
are expected to label the belongings out of eye sight if possible. Additionally, care
signs should not be above the beds, they should be on the care cards inside the resident
closets, and this is covered during staff in-services. The DON said he/she expects care
signs to be posted where visitors could not read them.

F 0553

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Allow resident to participate in the development and implementation of his or her
person-centered plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to notify and conduct
residents and/or family/representative of care plan meetings for 12 out of 18 sampled
resident (Resident #7, #10, #22, #23, #31, #33, #36, #44, #51, #58, #162, #214). This had
the potential to affect all residents in the facility. The census was 79.
1. Review of the facility’s Resident Assessment Instrument (RAI) Guidelines, not dated,
showed the following:
– The care plan is to be completed no later than the 21st day of the resident’s stay;
– The Minimum Data Set (MDS) Coordinator and/or Social Services Director will coordinate
planning and invitations to care plan meetings with residents and families/legal
guardians;
– The resident and his/her family are an integral part of the care plan process;
– Significant effort to include the resident in the process will occur;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0553

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 3)
– Documentation and recommendations from any care plan meeting will be maintained in the
resident’s clinical record.
2. Review of the facility’s care plan policy, dated (MONTH) (YEAR), showed the following:
– The interdisciplinary care plan team is responsible for the periodic review and updating
of care plans at least quarterly;
– The resident, the resident’s family and/or legal representative/guardian or surrogate
are encouraged to participate in the development of and revisions to the resident’s care
plan;
– Every effort will be made to schedule care plan meetings at the best time of the day for
the resident and the family.
3. Review of Resident # 7’s medical record, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheet dated after 12/27/17.
4. Review of Resident #10’s care plan, last reviewed on 7/9/18, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheets dated after 4/18/18.
5. Review of Resident # 22’s medical record, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheet dated after 12/13/17.
6. Review of Resident # 23’s medical record, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheet dated after 12/13/17.
7. Review of Resident #31’s care plan, last reviewed on 10/17/17, showed the following:
– admitted 10//6/17;
– No Care Plan Conference Summary sheets dated after 4/25/18.
During an interview on 3/6/19 at 1:00 P.M., a family member said the facility had not had
a care plan conference for the resident in over six months. They had not received an
invitation to a care plan meeting, and they should be held quarterly.
8. Review of Resident #33’s care plan, last reviewed on 8/31/18, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheets.
9. Review of Resident # 36’s medical record, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheet dated after 2/21/18.
10. Review of Resident #44’s care plan, last reviewd on 12/8/18, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheets.
11. Review of Resident #51’s care plan, last reviewed on 2/11/19, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheet dated after 2/2/18.
12. Review of Resident # 58’s medical record, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheets.
13. Review of Resident # 162’s medical record, showed the following:
– admission date of [DATE];
– No Care Plan Conference Summary sheet dated after 1/17/18.
14. Review of Resident #214’s medical record, showed the following:
– admission date of [DATE];
– No comprehensive care plan;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0553

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 4)
– No Care Plan Conference Summary sheets.
15. During an interview on 3/7/19 at 8:55 A.M., the Social Services Designee said the
current admission packet includes a form about care plan meetings. She said she explains
to the resident and family/responsible party the care plan meetings occur every three
months, and the resident and family/responsible party is invited to the meetings.
16. During an interview on 3/7/19 at 11:40 A.M., the MDS Coordinator said care plan
meetings should be held quarterly. She said she became the MDS Coordinator three years
ago, and she was pretty good about holding care plan meetings in the beginning. She said
she does not send out care plan conference letters and does not want to send them to the
family if they are not showing up for the meetings. The MDS said she does not have care
plan meetings if the family is not going to attend the meeting and she cannot recall when
her last care plan meeting was held. She said a Care Plan Conference Summary sheet is
completed with each care plan conference and she completes the sheet even if the family
does not attend the care plan meeting. The Care Plan Conference Summary sheets are with
each resident’s care plan.
17. During an interview on 3/7/19 at 12:45 P.M., the administrator and the Director of
Nursing (DON) said care plan meetings should occur at admission and quarterly thereafter.
They said care plan meetings are attended by the MDS coordinator, the department heads,
the resident and their family. The resident’s family/responsible party is sent a letter
with the date and time of the care plan meetings. The MDS Coordinator is in charge of
sending out the letters to the families. The administrator and the DON said they could not
verify if the letters go out to the family. They said they believe the last care plan
meeting was in December, (YEAR), there is a schedule of the care plan meetings, but the
administrator and the DON have not reviewed it.

F 0571

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Limit the charges against residents’ personal funds for items or services for which
payment is made under Medicare or Medicaid.

Based on interviews and record reviews, the facility failed to provide a free basic
haircut for Medicaid residents. This had the potential to affect all Medicaid residents.
The census was 79.
Review of the Resident Council Minutes, dated 2/28/19 at 2:35 P.M., showed six residents
and one staff member in attendance. Residents asked when a new hairdresser would be hired
because they were in need of the services of a hairdresser, such as haircuts.
Review of the facility’s admission packet, not dated, showed a Permission for Staff to
Perform Simple Haircuts form. The form said the facility prefers that a licensed
beautician perform beauty/barber services. However, Medicare and Medicaid reimbursement
does include simple haircuts. This will be performed free of charge by a non-licensed
staff member
During a group interview on 3/4/19 at 1:10 P.M., with eleven residents identified by the
facility as alert and oriented, the residents said the facility does not currently have a
hairdresser and does not offer free haircuts. The residents said they did not know exactly
how long the facility has been without a hairdresser but many people need the services,
especially haircuts.
During an interview on 3/7/19 at 4:15 P.M., the administrator and the Director of Nursing
(DON) said the facility has not had a hairdresser since (MONTH) 31, 2019. The facility

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0571

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 5)
takes the residents out of the facility to get their hair cut for which the residents pay,
the facility does not pay for them. The administrator and the DON said they are not aware
the facility should offer Medicaid residents a free, basic haircut as part of the grooming
process. They said they did not know any staff could cut the residents’ hair and do not
offer that to the residents.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Keep residents’ personal and medical records private and confidential.

Based on observation and interview, facility staff failed to ensure the residents’ right
to personal privacy was protected when they left the Medication Administration Record
[REDACTED]. The facility was 79.
1. Observation on 3/3/19 at 4:16 P.M., showed the MAR indicated [REDACTED]. Further
observation showed staff and residents walked by the cart.
Observation on 3/4/19 at 10:10 A.M. showed staff left the computer open and unattended in
the hallway. Further observation showed staff and residents walked past the computer.
Observation on 3/5/19 at 10:04 A.M., showed the staff left the computer open and
unattended in the hallway. Further observation showed staff and residents walked past the
computer.
2. Observation on 3/5/19 at 10:53 A.M., showed Registered Nurse (RN) A did not close the
door or pull the curtain when he/she changed Resident #165’s wound dressing.
3. During an interview on 3/7/19 at 9:55 A.M., Certified Nurse Assistant (CNA) said the
staff computers should not be open unless facility staff is working on them. When facility
staff are finished, the staff should log out and turn it off. Staff should pull the
curtain or shut the door when they provide care.
4. During an interview on 3/7/19 at 10:08 A.M., Registered Nurse (RN) said the MAR
indicated [REDACTED]. Staff should sign out of the computers when they walk away. The RN
said staff should close the door and pull the curtain when providing care to the
residents.
5. During an interview on 3/7/19 at 12:44 A.M., the administrator and Director of Nursing
(DON) said facility staff should close the door and pull the curtain during resident care.
Additionally, staff should make sure the MAR book is closed or covered when they are away
from the medication cart and the computers should be closed before leaving them.

F 0620

Level of harm – Potential for minimal 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, facility staff failed to ensure the admission policy
did not require the resident and/or responsible party to waive potential facility
liability for loss or damage to personal belongings for 18 out of 18 sampled residents
(Residents #3, #7, #10, #13, #22, #23, #24, #30, #31, #33, #34, #36, #44, #51, #57, #58,
#162, #214). This had the potential to affect all residents admitted to the facility. The
census was 79.
1. Review of the facility’s Consent and Authorization forms, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Potential for minimal harm

Residents Affected – Many

(continued… from page 6)
-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.
2. 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.
3. Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/15/18, showed an admission date
of [DATE].
Review of the resident’s medical record showed the resident/responsible party signed the
form in the admission packet on 12/5/16.
4. Review of Resident #7’s annual MDS, dated [DATE], showed an admission date of [DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 9/19/17.
5. Review of Resident #10’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 1/27/03.
6. Review of Resident #13’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 10/20/11.
7. Review of Resident #22’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 11/30/15.
8. Review of Resident #23’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 3/2/16.
9. Review of Resident #24’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 6/18/12.
10. Review of Resident #30’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 7/16/18.
11. Review of Resident #31’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 10/6/17.
12. Review of Resident #33’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Potential for minimal harm

Residents Affected – Many

(continued… from page 7)
signed the form in the admission packet on 4/19/17.
13. Review of Resident #34’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 4/23/18.
14. Review of Resident #36’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 4/30/15.
15. Review of Resident #44’s admission MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 9/5/18.
16. Review of Resident #51’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 11/7/02.
17. Review of Resident #57’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 3/16/17.
18. Review of Resident #58’s admission MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 10/27/18.
19. Review of Resident #162’s quarterly MDS, dated [DATE], showed an admission date of
[DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on 10/18/17.
20. Review of Resident #214’s entry tracking MDS, dated [DATE], showed an admission date
of [DATE].
Additional review of the resident’s medical record showed the resident/responsible party
signed the form in the admission packet on dated 2/1/19.
21. During an interview on 3/7/19 at 8:55 A.M., the Social Service Designee said she is
responsible to review the admission packet with the new residents and/or the responsible
party. She said she did not know the residents could not be asked to waive the facility’s
responsibility for their personal belongings.
22. During an interview on 3/7/19 at 12:45 P.M., the administrator and the Director of
Nursing (DON) said they were not aware they residents could not be asked to waive the
facility’s responsibility for personal belonging brought to the facility.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete initial and periodic
comprehensive assessments of each resident’s functional capacity using the resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
assessment instrument (RAI) for four out of 18 sampled residents (Resident #22, #31, #162,
#214). The census was 79.
1. Review of the facility’s Resident Assessment Instrument (RAI) guidelines, not dated,
showed the RAI process includes:
– Accurate and timely completion of initial assessment within 14 days of admission;
– Annual assessments with care area assessments (CAA) within 366 days of the previous
comprehensive assessment;
– Death in Facility tracking within seven days of expiration;
– Discharge assessment within seven days of discharge.
2. Review of Resident # 22’s medical record, showed an admission date of [DATE].
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment tool,
showed the following:
– An annual MDS, dated [DATE];
– Staff did not complete an annual MDS 12/18 as directed.
3. Review of Resident #31’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– A significant change MDS, dated [DATE];
– Staff did not complete an annual MDS 01/19 as directed.
4. Review of Resident #162’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An admission MDS, dated [DATE];
– Staff did not complete an annual MDS 11/18 as directed.
5. Review of Resident #214’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed staff did not complete MDSs for this resident
as directed.
6. During an interview on 3/7/19 at 11:40 A.M., the MDS Coordinator said she has been the
facility’s MDS coordinator for three years. She also works as a charge nurse on the
evenings and weekends. The MDS Coordinator said she has been too tired to stay and
complete MDS work. She said she has not been in the MDS office in several months; but over
the last three weeks, she has been able to go in once a week. She said comprehensive
assessments should be completed at admission and annually after that. The MDS Coordinator
said she is not aware of a facility policy regarding assessment submission timelines and
she has not seen the RAI manual.
7. During an interview on 3/7/19 at 12:45 P.M., the administrator and the Director of
Nursing (DON) said comprehensive assessments should be completed within 14 days of
admission and yearly after that and comprehensive assessments are also completed for
significant change in the resident’s condition. They said the facility has a policy with
guidelines for completing resident comprehensive assessments. Additionally, the RAI manual
has guidelines and is kept in the DON’s office.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assure that each resident’s assessment is updated at least once every 3 months.

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

Based on interview and record review, facility staff failed to assess residents using the
quarterly review instrument not less frequently than once every three months, for 15 of 18
sampled residents (Resident #3, #7, #10, #13, #23, #24, #30, #33, #34, #36, #44, #51, #57,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
#58, #162). The census was 79.
1. Review of the facility’s Resident Assessment Instrument (RAI) guidelines, not dated,
showed the RAI process includes quarterly assessments within 92 days of the previous
assessment.
2. Review of Resident #3’s medical record, showed an admission date of [DATE].
Review of the resident’s Minimum Data Set (MDS) record, a federally mandated assessment
instrument completed by facility staff, showed the following:
– An annual assessment completed 12/13/17;
– Quarterly assessments completed 6/15/18 and 9/15/18;
– Staff did not complete quarterly assessments after 9/15/18.
3. Review of Resident #7’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An annual assessment completed 10/1/18;
– Staff did not complete quarterly assessments after 10/1/18.
4. Review of Resident #10’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An annual assessment completed 4/8/18;
– Quarterly assessments completed 7/9/18 and 10/9/19;
– Staff did not complete quarterly assessments after 10/9/19.
5. Review of Resident #13’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An annual assessment completed 9/7/18;
– Quarterly assessment completed 11/7/18;
– Staff did not complete quarterly assessments after 11/7/18.
6. Review of Resident #23’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS, showed the following:
– Quarterly assessment completed 9/12/18;
– Staff did not complete quarterly assessments after 9/12/18.
7. Review of Resident #24’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An annual assessment completed 3/23/18;
– Quarterly assessments completed 6/23/18 and 9/23/18;
– Staff did not complete quarterly assessments after 9/23/18.
8. Review of Resident #30’s MDS record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An admission assessment completed on 7/23/18;
– Quarterly assessment completed on 10/23/18;
– Staff did not complete quarterly assessments after 10/23/18.
9. Review of Resident #33’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An annual assessment completed on 5/3/18;
– Quarterly assessments completed on 8/3/18 and 11/3/18;
– Staff did not complete quarterly assessments after 11/3/18.
10. Review of Resident #34’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– An annual assessment completed 5/5/18;
– Quarterly MDS assessments completed 8/3/18 and 11/5/18;
– Staff did not complete quarterly assessments after 11/5/18.
11. Review of Resident #36’s medical record, showed an admission date of [DATE].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
Review of the resident’s MDS, showed the following:
– An annual assessment completed 5/12/18;
– Quarterly assessments completed 8/19/18 and 11/12/18;
– Staff did not complete quarterly assessments after 11/12/18.
12. Review of Resident #44’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– Annual assessment completed 9/12/18;
– Staff did not complete quarterly assessments after 9/12/18.
13. Review of Resident #51’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– Annual assessment completed on 8/11/18;
– Quarterly assessment completed on 11/11/18;
– Staff did not complete quarterly assessments after 11/11/18.
14. Review of Resident #57’s medical record showed an admission date of [DATE].
Review of the resident’s MDS record, showed the following:
– Annual assessment completed on 3/30/18;
– Quarterly assessments completed on 6/30/18 and 10/15/18;
– Staff did not complete quarterly assessments after 10/15/18.
15. Review of Resident #58’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS, showed the following:
– An admission assessment completed 11/09/18;
– Staff did not complete quarterly assessments after 11/09/18.
16. Review of Resident #162’s medical record, showed an admission date of [DATE].
Review of the resident’s MDS, showed the following:
– A quarterly assessment completed 8/1/18;
– Staff did not complete quarterly assessments after 8/1/18.
17. During an interview on 3/7/19 at 11:40 A.M., the MDS Coordinator said she has been the
facility’s MDS coordinator for three years. She also works as a charge nurse on the
evenings and weekends. The MDS Coordinator said she has been too tired to stay and
complete MDS work. She said she has not been in the MDS office in several months; but over
the last three weeks, she has been able to go in once a week. She said comprehensive
assessments should be completed at admission and annually after that. The MDS Coordinator
said she is not aware of a facility policy regarding assessment submission timelines and
she has not seen the RAI manual.
During an interview on 3/7/19 at 12:45 P.M., the administrator and the Director of Nursing
(DON) said a MDS assessments should be completed within 14 days of admission and quarterly
after that. They said the facility has a policy with guidelines for completing resident
assessments. Additionally, the RAI manual has guidelines and is kept in the DON’s office.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to electronically transmit
encoded, accurate, and complete Minimum Data Set (MDS), a federally required resident
assessment completed by facility staff, data to the Centers for Medicare and Medicaid
(CMS) System within 14 days after staff complete a resident’s assessment. This had the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 11)
potential to affect all residents in the facility. The census was 79.
1. Review of the Resident Assessment Instrument (RAI) Manual, dated [DATE], showed
facility staff is directed to submit assessments as follows:
– Within 14 days after a facility completes a resident’s assessment, a facility must
electronically transmit encoded, accurate, and complete MDS data to the CMS System
– Final Validation Report (FVR): A report generated after the successful submission of MDS
3.0 assessment data. This report lists all of the residents for whom assessments have been
submitted in a particular submission batch, and displays all errors and/or warnings that
occurred during the validation process. An FVR with a submission type of production is a
facility’s documentation for successful file submission.
2. Review of the facility’s Resident Assessment Instrument (RAI) guidelines, not dated,
showed the following:
– The facility guideline will routinely establish the admission assessment reference date
(ARD) as the seventh day after admission;
– The ARD of subsequent quarterly assessments will be set monthly by the MDS Coordinator
with input from the interdisciplinary team;
– The MDS Coordinator will prepare a MDS due calendar or list of assessments with ARD
dates for other team members to help facility timely gathering of the necessary
information;
– Current guidelines require and MDS (other than the admission assessment) to be completed
within 14 days of the ARD, electronically encoded into the software system within seven
days of completion, and submitted to the National Repository within 14 days of completion;
– The MDS Coordinator may assign tasks or sections to specific interdisciplinary team
members;
– It is the responsibility of the interdisciplinary team members to complete the RAI
process on time and to provide timely signatures;
– All records are to be electronically submitted to the state weekly;
– Federal guidelines require that specific timelines be consistently followed in regard to
completion and electronic submission.
3. Review of the facility’s MDS FVRs for the prior six months, showed:
– CMS Submission Report, dated [DATE], showed 18 records submitted. Of those 18 records,
warning displayed that 15 records submitted late;
– CMS Submission Report, dated [DATE], showed 12 records submitted. Of those 12 records,
warning displayed that 11 records submitted late;
– CMS Submission Report, dated [DATE], showed 17 records submitted. Of those 17 records,
warning displayed that 12 records submitted late;
– CMS Submission Report, dated [DATE], showed 30 records submitted. Of those 30 records,
warning displayed that 22 records submitted late;
– CMS Submission Report, dated [DATE], showed 15 records submitted. Of the 15 records,
warning displayed that 10 records submitted late;
– CMS Submission Report, dated [DATE], showed 10 records submitted. Of the 10 records,
warning displayed that four records submitted late;
– CMS Submission Report, dated [DATE], showed eight records submitted. Of those eight
records, warning displayed that six records submitted late;
– CMS Submission Report, dated [DATE], showed 26 records submitted. Of those 26 records,
warning displayed that 24 records submitted late.
4. During an interview on [DATE] at 11:40 A.M., the MDS coordinator said she has been in
her position for approximately two years. She she has not been to the state MDS training
and received training from the facility’s corporate nurse. The MDS Coordinator said she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 12)
has not seen the RAI manual and she is not aware of a facility policy regarding the
submission of MDS assessments. She said the Corporate nurse instructed her to submit MDS
assessments to CMS weekly. The MDS Coordinator said the assessments are not submitted
weekly, because she is too busy. She said she often works as the charge nurse on evening
and weekend shifts. The MDS coordinator said she is too tired to stay for the MDS work. In
addition, her password for submitting MDS assessments to CMS expired over two years ago
and she has not reset her password, because she has not been in the MDS office for months.
The MDS Coordinator said in the last three weeks, she has been working on MDS information
once a week. The Director of Nursing (DON) has been submitting the MDS assessments to CMS
for her. She said the DON signs off on them and submits them.
5. During an interview on [DATE] at 3:15 P.M., the administrator and the DON said MDS
assessments should be completed every three months and completed MDS assessments should be
submitted weekly. They said the MDS Coordinator is responsible for submitting the MDS
assessments. They said they thought the MDS Coordinator received training from the
corporate nurse, but she has not taken the state MDS training. The DON said she has been
submitting the MDS assessments for the last four months, because she is the RN who signs
off on the assessments. They said they are aware there is a facility policy for completing
the MDS, and it includes submission guidelines. There is also a RAI manual is in the DON’s
office. They thought the MDS Coordinator was trained on the manual by the corporate nurse.
They were not aware the MDS Coordinator’s password has expired and it is her
responsibility to reset her password.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

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

Based on observation, interview, and record review the facility staff failed to develop
comprehensive care plans to direct the staff in the care of 13 out of 18 sampled residents
(Resident #3, #7, #13, #22, #23, #30, #31, #34, #36, #57, #58, #162, #214). The census was
79.
1. Review of the facility’s care plan policy, dated (MONTH) (YEAR), showed the following:
– The comprehensive care plan will be based on a thorough assessment that includes, but is
not limited to, the Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff;
– Assessment of each resident is an ongoing process and the care plan will be revised as
changes occur in the resident’s condition;
– A well developed care plan will be oriented to:
– Preventing avoidable declines in functioning or functional levels or otherwise
clarifying why another goal takes precedence;
– Managing risk factors to the extent possible or indicating the limits of such
interventions;
– Addressing ways to try to preserve and build upon resident strengths;
– Applying current standards of practice in the care planning process;
– Evaluating treatment of [REDACTED].
– Using an appropriate interdisciplinary approach to care plan development to improve the
resident’s functional abilities;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 13)
– Assessing and planning for care to meet the resident’s medical, nursing, mental, and
psychosocial needs;
– Addressing additional care planning areas that are relevant to meeting the resident’s
needs in the long term care setting.
2. Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 09/15/18, showed the following:
– Cognitively intact with no behaviors;
– Required total physical assistance of one person for bathing;
– Required extensive physical assistance of two persons for bed mobility and transfers;
– Required extensive physical assistance of one person for dressing, toileting, and
personal hygiene;
– Independent with set up help for eating;
– Impaired range of motion (ROM) for one upper and one lower extremity;
– Used a wheelchair for mobility;
– Has a suprapubic catheter and is always incontinent of bowel;
– [DIAGNOSES REDACTED].
– Received pain medication on a schedule and as needed (prn) for complaint of frequent
pain rated at an eight on a 0-10 pain scale;
– At increased risk for pressure ulcers with no wounds at this time;
– Received antidepressant medication and an Opioid medication for seven out of the last
seven days;
– Used oxygen therapy;
– No restraints.
Review of the resident’s care plan, last assessed 09/15/18, showed the care plan did not
provide direction for the resident’s splint.
3. Review of Resident #7’s annual MDS, dated [DATE], showed the following care area
assessment (CAA) triggered and addressed in the care plan:
– Cognitive loss/dementia;
– Communication;
– Urinary Incontinence;
– Activities;
– Nutritional Status;
– Pressure Ulcer.
Review of the resident’s care plan, last reviewed on 10/01/18, showed the following CAAs
were not addressed, did not have measurable goals, and/or timeline for meeting the
resident’s needs identified: cognitive loss/dementia, activities of daily living
(ADL)/rehabilitation, falls, nutrition, activities, urinary incontinence, communication
and [MEDICAL CONDITION] medications.
4. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact with no behaviors;
– Total physical dependence on one to two persons for all ADLs;
– Always incontinent of bowel and bladder;
– Assessed to have no pain;
– Gastrostomy tube and mechanical soft diet;
– Increased risk for pressure ulcers with two unstageable wounds;
– Received antidepressant medications and an antibiotic seven out of the last seven days;
– No restraints.
Review of the resident’s care plan, last assessed on 02/07/19, showed the care plan did
not provide direction for resident transfers or care of the gastrostomy tube.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 14)
5. Review of Resident #22’s annual MDS, dated [DATE], showed the following CAAs triggered
and addressed in the care plan:
– Cognitive loss/dementia;
– Communication;
– Urinary Incontinence;
– Behavioral Symptoms;
– Falls;
– Nutritional Status;
– Pressure Ulcer;
– [MEDICAL CONDITION] Drug Use.
Review of the resident’s care plan, last reviewed on 03/20/18, showed the following CAAs
were not addressed, did not have measurable goals, and/or timeline for meeting the
resident’s needs identified: cognitive loss/dementia, falls, nutrition, activities,
urinary incontinence, communication, pain and [MEDICAL CONDITION] medications.
6. Review of Resident #23’s annual MDS, dated [DATE], showed the following CAAs triggered
and addressed in the care plan:
– Cognitive loss/dementia;
– Communication;
– ADL Functional/Rehabilitation Potential;
– Urinary Incontinence;
– Behavioral Symptoms;
– Falls;
– Nutritional Status;
– Pressure Ulcer;
– [MEDICAL CONDITION] Drug Use.
Review of the resident’s care plan, last reviewed on 03/20/18, showed the following CAAs
were not addressed, did not have measurable goals, and/or timeline for meeting the
resident’s needs identified: cognitive loss/dementia, ADL/rehabilitation, behaviors,
falls, nutrition, activities, urinary incontinence, communication and [MEDICAL CONDITION]
medications.
7. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact with no behaviors;
– Required total physical assistance of two persons for transfers and bathing;
– Required total physical assistance of one person for bed mobility, locomotion,
toileting, and personal hygiene;
– Extensive physical assistance of one person for dressing and eating;
– Impaired ROM of bilateral upper and lower extremities;
– Used a wheelchair for mobility;
– Royston and an [MEDICAL CONDITION];
– Received pain medication as needed for occasional pain rated at a four on a scale of
1-10;
– At increased risk for pressure ulcers with one unstageable ulcer;
– Received antipsychotic, antianxiety, and antidepressant medications for seven out of the
last seven days;
– No restraints.
Review of the resident’s care plan, last assessed on 03/23/18, showed the care plan did
not provide direction for transfers.
8. Review of Resident #31’s quarterly MDS, date 10/31/18, showed the following:
– admission date of [DATE];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 15)
– [DIAGNOSES REDACTED].
– On oxygen therapy;
– On hospice.
Review of the resident’s care plan, last reviewed on 2/6/18, the care plan did not address
the resident on oxygen therapy or on hospice.
9. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact with no behaviors;
– Requires minimal physical assistance of one person for all ADLs;
– Ostomy;
– Occasional mild pain;
– At increased risk for pressure ulcers with no current wounds;
– During the seven day look back, took seven days of insulin, antidepressant, and diuretic
medication.
Review of the resident’s care plan, dated 04/23/18, showed the care plan did not address
the resident’s diabetes and provide guidance for staff regarding diabetic care.
10. Review of Resident # 36’s annual MDS, dated [DATE], showed the following CAAs
triggered and addressed in the care plan:
– Cognitive loss/dementia;
– Communication;
– ADL Functional/Rehabilitation Potential;
– Urinary Incontinence;
– Behavioral Symptoms;
– Falls;
– Nutritional Status;
– Pressure Ulcer;
– [MEDICAL CONDITION] Drug Use.
Review of the resident’s care plan, last reviewed on 08/29/18, showed the following CAAs
were not addressed, did not have measurable goals, and/or timeline for meeting the
resident’s needs identified: behaviors, activities, [MEDICAL CONDITION] medications,
nutrition, [MEDICAL CONDITION], pain, ADLs, falls, pressure ulcer and communication.
11. Review of Resident #57’s five day MDS, dated [DATE], showed the following:
– Mild cognitive impairment with no behaviors;
– Requires extensive to total physical assistance of one to two persons for all ADLs;’
– Has a catheter and is always incontinent of bowel;
– Occasional moderate pain;
– Mechanical soft diet;
– At increased risk of pressure ulcers with one Stage I ulcer and two unstageable ulcers;
– During the seven day look back period, took seven days of an antidepressant,
anticoagulant, antibiotic, diuretic, and four days of an Opioid;
– Intravenous medication (IV).
Review of the resident’s care plan, last assessed on 03/16/18, showed the care plan did
not provide direction for application and removal of the splints for the upper and lower
extremities
12. Review of Resident #58’s annual MDS, dated [DATE], showed the facility did not
addressed following CAAs triggered:
– Cognitive loss/dementia;
– Communication;
– ADL Functional/Rehabilitation Potential;
– Urinary Incontinence;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 16)
– Falls;
– Pressure Ulcer;
– [MEDICAL CONDITION] Drug Use.
Additional review of the resident’s medical record, showed the record did not contain a
care plan.
13. Review of Resident #162’s annual MDS, dated [DATE], showed the following CAAs
triggered and addressed in the care plan:
– Cognitive loss/dementia;
– Communication;
– ADL Functional/Rehabilitation Potential;
– Urinary Incontinence;
– Behavioral Symptoms;
– Falls;
– Nutritional Status;
– Pressure Ulcer;
– [MEDICAL CONDITION] Drug Use.
Review of the resident’s care plan, last reviewed on 01/04/18, showed the following CAAs
were not addressed, did not have measurable goals, and/or timeline for meeting the
resident’s needs identified: nutrition, pressure ulcer, falls, behaviors, urinary, ADLs,
communication, cognitive loss/dementia and [MEDICAL CONDITION] medications.
.14. Review of Resident #214’s medical record, showed the following:
– An admission date of [DATE];
– A baseline care plan, dated 2/1/19;
– Additional review showed the record did not contain a comprehensive care plan.
15. During an interview on 3/7/19 at 11:40 A.M., the MDS Coordinator said a comprehensive
care plan should be completed within seven days of admission.
16. During an interview on 3/7/19 at 12:45 P.M., the administrator and the Director of
Nursing (DON) said a comprehensive care plan should be completed within 14 days of
admission. The care area assessments (CAA) should be addressed in the care plan. If the
CAAs are not addressed in the care plan then an explanation should be provided on the MDS.
The MDS should include the CAAs, goals, and timeframes.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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 update the
plan of care with changes in the resident’s needs for 12 out of 18 sampled residents
(Resident #3, #7, #10, #13, #22, #23, #30, #31, #34, #36, #57, #162). The facility census
was 79.
1. Review of the facility’s Care Plan Comprehensive Policy, dated (MONTH) (YEAR), showed
staff are directed to provide each resident with:
-An individualized comprehensive care plan that includes measurable goals and time frames
will be developed to meet the resident’s highest practicable physical, mental, and
psychosocial well-being;
-The interdisciplinary care plan team, with input from the resident, family, and/or legal
representative will develop and maintain a comprehensive care plan for each resident that

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 17)
identifies the highest level of functioning the resident may be expected to attain;
-Assessment of each resident is an ongoing process and the care plan will be revised as
changes occur in the resident’s condition;
-The Interdisciplinary Care Team is responsible for the periodic review and updating of
care plans:
a. When a significant change in the resident’s condition has occurred;
b. At least quarterly;
c. When changes occur that impact the resident’s care (i.e. change in diet,
discontinuation of therapy,
changes in care areas that do not require a significant change assessment.
2 Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 09/15/18, showed the following:
– Cognitively intact with no behaviors;
– Required total physical assistance of one person for bathing;
– Required extensive physical assistance of two persons for bed mobility and transfers;
– Required extensive physical assistance of one person for dressing, toileting, and
personal hygiene;
– Independent with set up help for eating;
– Impaired range of motion (ROM) for one upper and one lower extremity;
– Used a wheelchair for mobility;
– Had a suprapubic catheter and is always incontinent of bowel;
– [DIAGNOSES REDACTED].
– Received pain medication on a schedule and as needed (prn) for complaint of frequent
pain rated at an eight on a 0-10 pain scale;
– At increased risk for pressure ulcers with no wounds at this time;
– Received antidepressant medication and an Opioid medication for seven out of the last
seven days;
– Used oxygen therapy;
– No restraints.
Review of the resident’s care plan, dated 6/13/17 and last assessed on 09/15/18, showed
the following:
– The resident had a wound documented on 4/27/18. The wound was documented as unstageable
on 05/18/18. No further wound documentation or direction for staff regarding care of the
wound.
– Review of the MDS assessment showed the resident to have frequent pain with a level of
eight on a 0-10 pain scale. Additional review showed pain is not addressed on the care
plan. The care plan does not provide direction to staff for monitoring the level of pain
and when to report the pain, monitoring the [MEDICATION NAME] and what to do if the patch
is missing, and alternative interventions for pain. Review of the pain level assessments
for the last three months show the highest level of pain the resident reported was four on
a 0-10 pain scale. The care plan does not address the change in pain intensity;
-Review of the MDS assessment shows the resident has impaired ROM of an upper and lower
extremity and an increased risk for pressure ulcers, however, the care plan does not
provide direction for positioning the resident for comfort and to reduce pressure. The
care plan does not provide direction for care of the air mattress and the appropriate
settings. The care plan does not address the resident’s use of grab bars bilaterally for
repositioning;
-Review of the restorative therapy notes shows the resident wears a splint on his/her left
leg. The care plan does not provide direction for use of the splint. The care plan does
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 18)
not provide direction for restorative therapy exercises for the left knee contracture.
3. Review of Resident #7’s annual MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Unclear speech;
-Severe cognitive impairment;
-Limited, with one person assist with mobility, dressing, eating, and toileting;
-Extensive, with one person assist with hygiene;
-Frequently incontinent of urine;
-Always incontinent of stool;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 10/28/18, showed it was last reviewed on
10/28/18.
The facility staff did not update the resident’s careplan annually and quarterly as
directed by the facility policy.
4. Review of Resident #10’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– No speech;
– Severe cognitive impairment;
– Total dependence for all activities of daily living (ADLs);
– Impairment of ROM on both sides of upper and lower extremities;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Feeding tube;
– At risk for pressure ulcers;
– Received diuretic and Opioid medications seven out of the last seven days.
Review of the resident’s care plan, dated 4/8/18, showed it was last reviewed on 7/9/18.
The facility staff did not update the resident’s careplan annually and quarterly as
directed by the facility policy.
5. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact with no behaviors;
– Total physical dependence on one to two persons for all ADLs;
– Always incontinent of bowel and bladder;
– Assessed to have no pain;
– Gastrostomy tube and mechanical soft diet;
– Increased risk for pressure ulcers with two unstageable wounds;
– Received antidepressant medications and an antibiotic seven out of the last seven days;
– No restraints.
Review of the resident’s care plan, dated 5/9/18 and last assessed 2/7/19, showed the
following:
– The resident used a seat belt across his/her upper chest when sitting up in a high back
wheelchair. The care plan does not provide direction to staff on the rationale for use,
how to use the seat belt correctly, when to release it, risk factors, any attempted
alternatives and outcomes, how often the resident should be reassessed for use of the
device and continued need;
– The care plan directs staff to transfer the resident using a hoyer lift. The care plan
does not provide guidance for the number of staff required during a transfer. Staff said
the resident no longer requires a hoyer lift and can be transferred with two persons but
the care plan has not been updated to show this change in care needs;
-Review of the restorative physical therapy record shows the resident receives restorative
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 19)
nursing care. The care plan does not provide direction for the restorative exercises. The
physical therapy record shows the resident has contractures of his/her knees, elbows, and
hands.
– The resident has a gastrostomy tube and currently only receives water flushes through
the tube. The care plan has not been revised to show the tube feedings have been
discontinued and when this order was given.
The facility staff did not update the resident’s careplan annually and quarterly as
directed by the facility policy.
6. Review of Resident #22 ‘ s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Rarely makes self-understood;
-Severe cognitive impairment;
-Extensive, 2 person assist with mobility, transfers;
-Extensive, 1 person assist with toileting, hygiene and bathing;
-Occasionally incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Received antianxiety, antidepressant, hypnotic and Opioid medications seven out of the
last seven days.
Review of the resident ‘ s care plan, dated 01/16/18, showed it was last reviewed on
03/20/18.
The facility staff did not update the resident’s careplan annually and quarterly as
directed by the facility policy.
7. Review of Resident #23 ‘ s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Usually makes self-understood;
-Verbal behaviors;
-Limited, one person assist with mobility and transfers;
-Extensive, one person assist with dressing, toileting, hygiene and bathing;
-Frequently incontinent of urine;
-Occasionally incontinent of bowel;
-Received antipsychotic, antianxiety, antidepressant, hypnotic and diuretic for seven out
of the last seven days;
-[DIAGNOSES REDACTED].
Review of the resident ‘ s care plan, dated 05/08/17, showed it was last reviewed on
03/20/18.
The facility staff did not update the resident’s careplan annually and quarterly as
directed by the facility policy.
8. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact with no behaviors;
– Required total physical assistance of two persons for transfers and bathing;
– Required total physical assistance of one person for bed mobility, locomotion,
toileting, and personal hygiene;
– Extensive physical assistance of one person for dressing and eating;
– Impaired ROM of bilateral upper and lower extremities;
– Used a wheelchair for mobility;
– [MEDICATION NAME] and an [MEDICAL CONDITION];
– Received pain medication as needed for occasional pain rated at a four on a scale of
1-10;
– At increased risk for pressure ulcers with one unstageable ulcer;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 20)
– Received antipsychotic, antianxiety, and antidepressant medications for seven out of the
last seven days;
– No restraints.
Review of the resident’s care plan, last updated 07/23/18, showed the care plan did not
address the application and direction for using splints on upper and lower extremities, a
plan for care of the [MEDICAL CONDITION] an updated plan for wound care. The facility
staff did not update the resident’s careplan annually and quarterly as directed by the
facility policy.
9. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Unclear speech;
– Severe cognitive impairment;
– Total dependence with all ADLs;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
– Mechanical altered diet;
– One unstageable pressure ulcer;
– Received antipsychotic and antidepressant medications seven out of the last seven days;
– Oxygen therapy;
– Hospice.
Review of the resident’s care plan, dated 10/17/17, showed it was last reviewed on
10/17/17.
The facility staff did not update the resident’s careplan annually and quarterly as
directed by the facility policy.
10. Review of Resident #34’s quarterly MDS, dated [DATE], showed the the resident had a
gastrostomy tube.
Review of the POS [REDACTED].
Review of the resident’s care plan, dated 06/24/18, showed staff did not update the care
plan with the discontinuation of the flushes on 12/13/18.
11. Review of Resident # 36 ‘ s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Unclear speech;
-Rarely/never makes self -understood;
-Severe cognitive impairment;
-Extensive, one person assist with mobility, ambulation and toileting;
-Total, one person assist with hygiene;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident ‘ s care plan, dated 05/12/18, showed it was last reviewed on
08/29/18. The facility staff did not update the resident’s careplan annually and quarterly
as directed by the facility policy.
12. Review of Resident #57’s five day MDS, dated [DATE], showed the following:
– Mild cognitive impairment with no behaviors;
– Requires extensive to total physical assistance of one to two persons for all ADLs;’
– Has a catheter and is always incontinent of bowel;
– Occasional moderate pain;
– Mechanical soft diet;
– At increased risk of pressure ulcers with one Stage I ulcer and two unstageable ulcers;
– During the seven day look back period, took seven days of an antidepressant,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 – Many

(continued… from page 21)
anticoagulant, antibiotic, diuretic, and four days of an Opioid;
– Intravenous medication (IV).
Review of the resident’s care plan, last assessed on 08/16/18, showed the care plan did
not address the following:
– The wound care has not been updated on the care plan to reflect current treatments;
– The care plan directed staff to stand the resident slowly and failed to show the
resident had a right above the knee amputation and cannot stand;
– The care plan was not updated to show the urinary catheter had been discontinued;
– The care plan failed to provide direction for care of the Midline Intravenous line in
the right upper arm;
– The care plan was not updated to show the changes for the weight loss plan of care;
– Last updates on the care plan were made in (MONTH) (YEAR).
13. Review of Resident # 162 ‘ s quarterly MDS, dated [DATE], showed it following:
-admission date of [DATE];
-Sometimes makes self -understood;
-Severe cognitive impairment;
-Physical, verbal and other behaviors;
-Limited, one person assist with toileting and hygiene;
-Occasionally incontinent of urine;
-Received scheduled and as needed pain medication.
Review of the resident ‘ s care plan, dated 11/18/17, showed it was last reviewed on
01/04/18. The facility staff did not update the resident’s careplan annually and quarterly
as directed by the facility policy.
During an interview on 03/07/19 at 11:43 AM, the Minimum Data Set Coordinator (MDSC) said
he/she completes the care plans. The MDSC said the care plans are to be reviewed quarterly
and the MDSC signs the bottom of the first page of the care plan with the date of the
review. The MDSC said new interventions and changes in care should be written on the care
plan and any nurse can do this. The MDSC said he/she prints out a new care plan yearly,
when the annual care plan is completed. The MDSC said the dates on the care plan should be
updated to show it is a new care plan. The MDSC said he/she is aware care plans and MDS’s
are behind because he/she has been pulled to work the floor.
During an interview on 03/07/19 at 2:31 P.M., the DON said the care plan should be
reviewed quarterly. The care plans are to be updated, as needed, and any nurse can write
on the care plan for any new interventions. The care plan should provide interventions for
falls and weight loss and should be updated as the interventions change. The staff are to
have care plan meetings quarterly with the resident/family.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview, facility staff failed to maintain
professional standards when they failed to secure a physician’s order for splint
application for two residents (Resident #3 and #30), failed to secure a physician’s order
for two residents (Resident #24 and Resident #30) [MEDICAL CONDITION] (a surgical opening
in the abdominal wall to drain feces) and [MEDICATION NAME] (a surgical opening in the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
abdominal wall to drain urine) and did not care plan for the care of the [MEDICAL
CONDITION] and [MEDICATION NAME] for these two residents, failed to follow physician’s
orders for oxygen (Resident #31), failed to ensure a resident’s code status was updated
(Resident #44), failed to secure a physician’s order for care and monitoring of a Midline
Catheter (MC) (a peripheral intravenous catheter (8 centimeters (cm) to 10 cm in length)
that can remain in place for up to 29 days) and did not care plan for the care of the MC
for one resident (Resident #57). Additionally, staff prepared medications in advance for
medication passes scheduled for later in the day. The facility census was 79.
1. During an interview on 3/15/19 at 10:33 A.M., the Director of Nursing (DON) said the
facility does not have a policy for the restorative nursing program or for the use of
splints.
Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 9/15/18, showed the following:
– Impaired range of motion (ROM) of the upper and lower extremity on one side of the body;
– Required extensive physical assistance of one to two persons for activities of daily
living (ADLs);
– At risk for pressure ulcers.
Review of the resident’s physician order sheet (POS), dated 3/1/19 – 3/31/19, showed it
did not contain an order for [REDACTED].>Review of the resident’s treatment
administration record (TAR), dated 3/1/19 – 3/31/19, showed no direction or documentation
for application of the splint.
Review of the restorative therapy record, dated (MONTH) (YEAR) – (MONTH) 2019, showed
certified nursing assistant/restorative aide (CNA/RA), documented on 12/4/18, 12/13/18,
12/17/18, 12/26/18, 01/02/19, 1/30/19, and 2/8/19, the left leg was contracted at the
knee, and, after gentle stretches, the splint is applied.
Review of the resident’s care plan, dated 1/16/18 and updated 9/15/18, showed no direction
for application of the splint to the left leg.
During an interview on 3/7/19 at 10:56 P.M., the resident said he/she wears a splint on
the left leg and the staff apply the splint.
Review of Resident #30’s MDS, dated [DATE], showed the following:
– Impaired ROM of the upper and lower extremities, bilaterally;
– Required total physical assistance of one to two staff for all ADLs;
– At risk for pressure ulcers.
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed no order for splints.
Review of the resident’s TAR, dated 3/1/19 – 3/31/19, showed no direction or documentation
for application of the splints.
Review of the resident’s Care Plan, dated 7/23/18, showed no direction for application of
the splints for his/her legs and arms.
Observation on 3/30/19 at 6:45 P.M., showed the resident sitting in a tilt and space
wheelchair with splints on bilateral lower legs, an air boot on the right foot, a brace on
the left arm, and the brace for the right arm lying in the resident’s lap. Directions for
the application of the splints/braces were observed on handwritten notes taped to the
television shelf, in view of anyone entering the room.
During an interview on 3/6/19 at 11:41 P.M., the physical therapy coordinator said he/she
provided training for staff on applying the splints. The therapist does not know if
direction is in the care plan, but he/she said directions for the splints are hanging in
the resident’s room.
During an interview on 3/6/19 at 12:14 P.M., CNA/RA L said the aides put the splints on
the residents when it’s time. The CNA/RA said this is not documented anywhere. He/She said
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
the directions are hanging in Resident #30’s room. The CNA/RA does not know if direction
is in the care plan.
During an interview on 3/7/19 at 1:52 P.M., the administrator and the DON said all the
CNAs have been trained to do ROM and apply the splints. The DON said the aides put the
splints on and the resident’s keep track of them. The DON said application and removal of
the splints should be in the restorative nursing book and direction for application should
be in the care plan. The DON would expect an order for [REDACTED].
2. Review of the facility’s policy titled [MEDICAL CONDITION] and [MEDICAL CONDITION]
Care, dated (MONTH) (YEAR), showed the purpose is to prevent infection, skin irritation,
alleviate unpleasant odors, and to obtain accurate bowel measurement output.
Review of Resident #24’s quarterly MDS, dated [DATE], showed the resident had an [MEDICAL
CONDITION] and a [MEDICATION NAME].
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed it did not contain an order
for [REDACTED].
Review of the resident’s TAR, dated 3/1/19 – 3/31/19, showed it did not contain direction
for treatment for [REDACTED].
Review of the resident’s nurse’s notes for the last three months, showed they did not
contain documentation of when the [MEDICAL CONDITION] or [MEDICATION NAME] bag was
changed, including condition of the stoma and surrounding skin.
3. Review of Resident’ #30’s quarterly MDS, dated [DATE], showed the resident had a
[MEDICAL CONDITION].
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed no order for the treatment of
[REDACTED].
Review of the resident’s TAR, dated 3/1/19 – 3/31/19, showed no treatment for [REDACTED].
Review of the resident’s nurse’s notes for the last three months, showed they did not
contain documentation of when the [MEDICAL CONDITION] or [MEDICATION NAME] bag was
changed, including condition of the stoma and surrounding skin.
During an interview on 3/6/19 at 12:20 P.M., LPN J said the nurses change the [MEDICAL
CONDITION]/[MEDICAL CONDITION]/[MEDICATION NAME] bags when needed; however, they do not
document this on the TAR or in the nurse’s notes. The LPN said an order should probably be
on the POS, TAR, care plan.
During an interview on 3/7/19 at 1:37 P.M., the administrator and the DON said they expect
a midline catheter, an [MEDICAL CONDITION]/[MEDICAL CONDITION], [MEDICATION NAME], and
splints to have a physician’s order, be on the TAR, and have a care plan providing
direction to staff for care.
4. Review of Resident #31’s quarterly MDS, date 10/31/18, showed the following:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– On oxygen therapy.
Review of the resident’s care plan, last reviewed on 2/6/18, showed the care plan did not
address the resident’s oxygen therapy.
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed an order, dated 1/27/18, for
oxygen at 2 liters (L) per minute per nasal cannula at bedtime.
Observation on 3/4/19 at 11:30 A.M., showed the resident in bed, with a nasal cannula with
oxygen at 2L/minute.
During an interview on 3/4/19 at 11:30 A.M., a family member said the resident is not
supposed to use his/her oxygen during the day. The family member said the POS says the
resident is only supposed to use the oxygen at night.
Observations on 3/5/19 at 3:20 P.M. and 3/6/19 at 8:50 A.M., showed the resident in bed,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
with a nasal cannula with oxygen at 2L/minute.
During an interview on 3/7/19 at 9:34 A.M., CNA N said the CNAs put the nasal cannula on
the residents and the nurses set the oxygen at the correct setting. The CNA said some
resident’s receive oxygen all the time and some receive it only when they are in bed.
He/She said when the physician’s orders say oxygen at bedtime, it means the resident
should receive oxygen anytime they are in bed, not only at nighttime when they are in bed.

During an interview on 3/7/19 at 10:15 A.M., LPN J said physician orders for oxygen at
bedtime means the resident should receive oxygen when they go to bed at night, it does not
mean anytime the resident is in bed. He/She said the CNAs put the nasal cannula on the
residents when they are in bed and the nurses set the oxygen at the correct setting and
let the CNAs know when to put it on the residents.
During an interview on 3/7/19 at 10:40 A.M., CNA O said he/she is responsible for putting
the nasal cannula on the resident when they lay down in bed. Hr/She said the CNAs get the
instructions from the charge nurse. The CNA said when the physician’s orders say the
residents oxygen at bedtime, that means when the resident goes to bed at night, not every
time they lay down in bed.
During an interview on 3/7/19 at 12:45 P.M., the administrator and the DON said physician
orders which read oxygen at bedtime means at night time. They said the orders should
actually read at bedtime and as needed (PRN); however, if the order just says bedtime then
that means at night. A resident with those orders should not be given oxygen every time
they are in bed. They said the CNAs are the ones who put the nasal cannula on the resident
and the CNAs know when to put the oxygen on the resident because the charge nurse will
instruct them.
4. Review of Resident #44’s admission MDS, dated [DATE], showed the following:
– admission date of [DATE];
– Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 2
out of 15, severe cognitive impairment;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
– The hard chart had a red sticker on the binding;
– Red do not resuscitate (DNR) sheet;
– A DNR form, dated 9/5/18, and signed by the resident and the physician;
– POS, dated 3/1/19 – 3/31/19, showed an order, dated 9/5/18, for full code;
– The order, dated 9/5/18, for full code was on all POSs since admission.
During an interview on 3/7/19 at 9:34 A.M., CNA N said a resident’s code status is marked
on the hard chart. He/She said a red sticker on the binding means DNR and a green sticker
on the binding means full code.
During an interview on 3/7/19 at 10:15 A.M., LPN J said facility staff can find a
resident’s code status in several ways. There is a color coded sticker on the binding of
the hard chart at the nurse’s station. A red sticker means the resident is DNR and a green
sticker means full code and there is also a red or green sheet inside the chart which
shows the same information. The LPN said the code status should match across all resident
documents and if the codes do not match then the DON should be notified so she can verify
it with the physician.
During an interview on 3/7/19 at 12:45 P.M., the administrator and the DON said the
residents’ hard chart is color coded. They said red means a DNR code and green means a
full code and the code status is also found on the POS. The administrator and the DON said
the code status should be congruent across all resident documents. If staff observe the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
code status conflict they are expected to have it clarified by the doctor.
Observation on 03/04/18 at 10:37 A.M., showed eight medication cups contained crushed
medication, four medication cups contained whole pills and one cup with liquid on top of
the medication cart in the medication room on the 500 hall.
Observation on 03/04/19 at 10:40 A.M., showed the 500 hall medication cart contained two
open vials of [MEDICATION NAME] (to treat diabetes) with no open date.
Observation on 03/04/19 at 01:00 P.M., showed five medication cups contained medication on
top of the medication cart in the medication room on the 500 hall.
Observation on 03/05/19 at 10:52 A.M., showed ten medication cups that contained crushed
medications and three cups that contained whole pills on top of the medication cart in the
medication room on the 500 hall.
During an interview on 03/05/19 at 11:00 A.M., showed Registered Nurse (RN) A said his/her
medication pass would be at 4:00 P.M. because he/she already pulled the 2:00 P.M.
medications.
During an interview on 03/07/19 at 10:08 A.M., RN A said medications should be prepared in
the medication room one at a time. Staff should only prepare medications for the current
medication pass time. When staff opens a vial of insulin, they should write the open date
on the vial and the medication is good for 30 days. The two undated vials should not be
used. Staff should get a new vial if found without an open date. If staff uses an undated
vial it would be a medication error.
During an interview on 03/07/19 at 12:44 P.M., showed the administrator and Director of
Nursing (DON) said medications should be prepared for one person at a time. Staff should
not pre pop medications and should not have multiple cups of medications on top of the
cart for multiple medication times. Insulin vials should have the date it was opened and
the medication is good for 28 days, if they are found in the cart without an open date,
staff should replace them. Staff are expected to check the date with each use.

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.

Based on observation and interview the facility failed to provide necessary services to
maintain good oral hygiene and grooming for 14 residents (Resident #21, #22, #23, #25,
#36, #58, #162, #163, #164, #166, #170, #172, #173 and #174) who were unable to carry out
their own Activities of Daily Living (ADLs). The facility census was 47.
1. Review of the facility’s Activities of Daily Living (ADL), dated (MONTH) (YEAR), showed
it did not address oral hygiene and grooming.
2. Review of Resident #21’s care plan, dated 12/07/17, showed staff are directed to
provide a comb/brush and cues for grooming hair daily and as needed (PRN).
Observation at 03/05/19 at 10:04 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/06/19 at 08:57 A.M., showed the resident sat in the dining room with
uncombed hair.
3. Review of Resident #22’s Monthly Summary, dated 02/09/19, showed the resident is
totally dependent upon staff for grooming and personal hygiene.
Observation on 03/03/19 at 05:30 P.M., showed the resident sat in the dining room with

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 26)
uncombed hair.
Observation at 03/04/19 at 11:05 A.M., showed the resident sat in the dining room in
his/her wheelchair with liquid dripping out of his/her nose and uncombed hair.
4. Review of Resident # 23’s monthly summary, dated 02/07/19, showed the resident is
totally dependent upon staff for grooming and hygiene.
Observation on 03/05/19 at 10:15 A.M., showed the resident sat in the dining room with a
thick film on his/her dentures, uncombed hair and dried skin flakes in his/her ears.
Observation 03/05/19 at 03:35 P.M., showed the resident sat in the dining room with
uncombed hair.
5. Review of Resident #25’s care plan, dated 12/28/17, showed staff are directed to
provide assistance for grooming hair on a daily basis and PRN.
Observation on 03/03/19 at 05:39 P.M., showed the resident sat in a chair by the nurse’s
station with uncombed hair.
6. Review of Resident #36’s care plan, dated 05/12/18, showed staff are directed to
provide assistance for grooming hair daily and PRN.
Observation on 03/04/19 at 10:08 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation at 03/05/19 at 10:04 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/05/19 at 05:42 P.M., showed the resident sat in the dining with uncombed
hair.
7. Review of Resident # 58’s Admission Clinical Assessment, dated 10/30/18, showed the
resident requires one person assist with personal hygiene.
Observation on 03/05/19 at 05:42 P.M., showed the resident sat in the dining with uncombed
hair.
8. Review of Resident #162’s monthly summary, dated 02/06/19, showed the resident is
totally dependent on staff for grooming.
Observation at 03/05/19 at 10:04 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation 03/05/19 at 03:35 P.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/06/19 at 08:57 A.M., showed the resident sat in the dining room with
uncombed hair.
9. Review of Resident # 163’s monthly summary, dated 02/06/19, showed the resident is
totally dependent on staff for grooming.
Observation at 03/05/19 at 10:04 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/05/19 at 05:42 P.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/06/19 at 08:57 A.M., showed the resident sat in the dining room with
uncombed hair.
10. Review of Resident #164’s care plan, dated 08/27/18, showed staff are directed to
provide assistance for grooming hair daily and PRN.
Observation at 03/05/19 at 10:04 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/05/19 at 05:42 P.M., showed the resident sat in the dining room with
uncombed hair.
11. Review of Resident # 167’s care plan, dated 12/12/17, showed staff are directed to
provide a comb and cues for grooming hair daily and PRN.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 27)
Observation on 03/04/19 at 10:08 A.M., showed the resident sat in the dining room with
uncombed hair.
Observation on 03/05/19 at 05:42 P.M., showed the resident sat in the dining room with
uncombed hair.
12. Review of Resident #170’s care plan, dated 12/17/18, showed the resident depends on
staff assistance for grooming hair daily and PRN.
Observation on 03/05/19 at 05:42 P.M., showed the resident sat in the dining room with
uncombed hair.
13. Review of Resident #172’s care plan, dated 03/28/18, showed staff are directed to
provide necessary supplies for grooming hair and staff are to assist PRN.
Observation on 03/04/19 at 10:08 A.M., showed the resident sat in the dining room with
uncombed hair.
14. Review of Resident #173’s care plan, dated 10/18/18, showed the resident depends on
staff assistance for grooming hair daily and PRN.
Observation on 03/04/19 at 10:08 A.M., showed the resident sat in the dining room with
uncombed hair.
15. Review of the Resident # 174’s care plan, dated 10/28/18, showed staff are directed to
make sure the resident has supplies to comb his/her hair daily and PRN. Additionally,
staff are directed to assist the resident with shaving facial hair.
Observation on 03/04/19 at 10:08 A.M., showed the resident sat in the dining room with
uncombed hair and his/her face unshaven.
Observation on 03/06/19 at 09:29 A.M., showed the resident walked down the hall with
family with uncombed hair and unshaven.
During an interview on 03/07/19 at 09:55 A.M., Certified Nurse Assistant (CNA) A said the
CNA’s assist the resident with dressing, brushing their hair and teeth, and perineal care
in the morning. He/She said staff usually brush the residents’ teeth after breakfast and
these should be done every day when staff get the resident. The CNA said residents are
shaved every day before ten in the morning. The CNA said if he/she notices a resident who
needs any assistance, he/she takes them back to their room and assist them.
During an interview on 03/07/19 at 10:08 A.M., Registered Nurse (RN) A said everyone is
responsible for grooming the residents every morning, staff are expected to wash their
face, comb their hair and brush their teeth. The RN said if a resident needs grooming,
staff should take the resident to their room and men get shaved with their showers twice a
week.
During an interview on 03/07/19 at 12:44 P.M., the administrator and Director of Nursing
(DON) said staff should comb residents’ hair, perform perineal care and brush the
residents’ teeth in the morning. They said staff are expected to take residents to their
room if needed and residents who need shaved, should be shaved daily. The administrator
and the DON said all of this is covered in their CNA training.

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide
services to prevent a decline of activities of daily living (ADL), improve ADLs, decrease
existing limited range of motion (ROM) or contractures (tightening of muscles that

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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)
prevents movement,, holding a limb in a fixed position), or preventing further
contractures for six out of 18 sampled residents (Resident #3, #10, #30, #33, #34, and
#44). The facility census is 79.
1. Review of the facility’s Range of Motion: Active, Active Assistance, and Passive
policy, dated (MONTH) (YEAR), shows the purpose is to move the resident’s joints through
as full a range of motion as possible, to improve or maintain joint mobility and muscle
strength.
During an interview on 3/15/19 at 10:33 A.M., the Director of Nursing (DON) said the
facility does not have a policy for the restorative nursing program or for the use of
splints.
2. Review of Resident #3’s quarterly Minimum Data Set, (MDS) a federally mandated
assessment completed by facility staff, dated 9/15/18, showed the resident to have
impaired range of motion (ROM) of the upper and lower extremity on one side of the body,
required extensive physical assistance of one to two persons for activities of daily
living (ADLs), and at increased risk for pressure ulcers.
Review of the resident’s physician order [REDACTED].>Review of the resident’s treatment
administration record (TAR), dated 3/1/19 – 3/31/19, shows it did not contain direction or
documentation for application of the splint.
Review of the restorative therapy record, dated (MONTH) (YEAR) – (MONTH) 2019, showed the
certified nursing assistant/restorative aide (CNA/RA), documented on 12/4/18, 12/13/18,
12/17/18, 12/26/18, 01/02/19, 1/30/19, and 2/8/19, the left leg was contracted at the
knee, and, after gentle stretches, he/she applied the splint. Additional review, showed
staff did not document the application and removal of the splints on a daily basis.
Review of the resident’s care plan, dated 1/16/18 and updated 9/15/18, showed it did not
contain direction for application of the splint to the left leg.
During an interview on 3/7/19 at 10:56 P.M., the resident said he/she wears a splint on
the left leg and the staff apply the splint. Observation at this time showed the splint in
place on the resident’s left leg.
3. Review of Resident #10’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Impairment of range of motion on both sides of upper and lower extremities;
– Received passive range of motion, restorative programs for three out of the last seven
days;
– Received splint/brace assistance for three out of the last seven days.
Review of the resident’s occupational therapy discharge, dated 5/3/18, showed the resident
demonstrated tolerance of a splint wearing schedule. Additional review showed staff have
been educated and a splint schedule has been established for restorative therapy services
to sustain compliance.
Review of the resident’s restorative care program overview, dated 5/3/18, showed the
following:
– Goals: to sustain joint mobility and to prevent further contractures.
– Approach/recommendations: splint schedule and passive range of motion to bilateral upper
extremities;
– Precautions/comments: splints should be worn five to seven times weekly all day (8 hours
at least).
Review of the resident’s physical therapy discharge, dated 6/7/18, showed recommendations
discussed with resident and/or caregivers include use of orthotics, alternating between a
hip abduction splint and knee extension splint.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 29)
Review of the resident’s care plan, last reviewed on 7/9/18, showed restorative therapy
staff are to work with the resident three to five times weekly for ROM and splints.
Additionally, it directs staff to apply/remove splints on both upper extremities and leg
braces with RA, inspect arms and legs for red marks to ensure pressure is not a problem
with splints/braces.
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed an order dated 7/27/11 for
restorative therapy three times week for range of motion and splinting of all extremities
Review of the resident’s restorative therapy record, showed the following:
– During the month of (MONTH) 2019, the resident did not receive restorative therapy
1/18/19 – 1/31/19;
– During the month of (MONTH) 2019, the resident did not received restorative therapy
2/1/19 – 2/12/19, 2/14/19 – 2/21/19, 2/23/19 – 2/26/19, and 2/28/19;
– During the month of (MONTH) 2019, the resident did not receive restorative therapy
3/1/19 to 3/3/19;
– During the months of (MONTH) to (MONTH) 2019, the facility staff documented the resident
wore splints on 1/4/19 and 2/8/19.
4. Review of Resident #30’s quarterly MDS, dated [DATE], showed staff assessed the
resident to have impaired ROM of the upper and lower extremities, required total physical
assistance of one to two staff for all ADLs, and at increased risk for pressure ulcers.
Review of the resident’s care plan, dated 7/23/18, showed it did not contain direction for
application of the splints for his/her legs and arms.
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed it did not contain an order
for [REDACTED].>Review of the resident’s TAR, dated 3/1/19 – 3/31/19, showed it did not
contain direction or documentation for the application of the splints.
Observation on 3/30/19 at 6:45 P.M., showed the resident sitting in a tilt and space
wheelchair with splints on both lower legs, an air boot on the right foot, a brace on the
left arm. Additional observation showed the brace for the right arm in the resident’s lap.
Further observations show handwritten directions for the application of the splints/braces
taped to the television shelf, in view of anyone entering the room.
5. Review of Resident #33’s quarterly MDS, dated [DATE], showed the following:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Did not receive range of motion, restorative programs, active or passive, in the last
seven days;
– Did not receive splint/brace assistance for three out of the last seven days.
Review of the resident’s physical therapy discharge, dated 11/17/17, showed a functional
maintenance program for restorative nursing was developed. Goals are to maintain lower
extremity strength and range of motion, and to maintain transfers and standing ability.
Instructions for implementation included lower active assisted range of motion and pull to
stand at horizontal bar with minimal assist.
Review of the resident’s care plan, last reviewed on 2/3/19, showed the care plan did not
address restorative therapy or the use of splints/braces.
Review of the resident’s POS, date 3/1/19-3/31/19, showed it did not contain an order for
[REDACTED].>Review of the resident’s restorative therapy record, showed the following:
– During the month of (MONTH) 2019, the resident did not receive restorative therapy
1/18/19 – 1/31/19;
– During the month of (MONTH) 2019, the resident did not received restorative therapy
2/1/19 – 2/12/19, 2/14/19 – 2/21/19, 2/23/19 – 2/26/19, and 2/28/19;
– During the month of (MONTH) 2019, the resident did not receive restorative therapy
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 30)
3/1/19 to 3/3/19.
6. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact;
– No impaired ROM;
– Required minimal assistance of one staff to complete ADLs.
Review of the resident’s care plan, last reviewed 11/25/18, showed it did not contain
direction for restorative care or range of motion.
Review of the resident’s restorative therapy record, completed by the CNA/RA, showed the
resident received restorative nursing care for maintaining balance skills, three times a
week until 1/17/19. Additional review showed care was documented four days from 1/17/19 to
3/7/19.
Review of the medical record showed it did not contain documentation for why the number of
days the resident received restorative care decreased.
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed it did not contain an order
for [REDACTED].>7. Review of Resident #44’s 60 day scheduled assessment, dated 11/2/18,
showed the following:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Impairment in range of motion on one side of lower extremity;
– Did not receive range of motion, restorative programs, active or passive, in the last
seven days;
– Did not receive splint/brace assistance for three out of the last seven days.
Review of the resident’s physical therapy discharge, dated 9/13/18, showed a functional
maintenance program was developed for the resident to be carried out by the restorative
nursing program. Goals for restorative program is to maintain lower extremity ROM.
Approach/recommendations for implementation of goals include ROM/stretches to hips, knees,
ankles all planes.
Review of the resident’s restorative care program overview, dated 9/13/18, showed the
following:
– Goals: Maintain lower extremity range of motion;
– Approach/recommendations: ROM/stretches to hips, knees, ankles all planes;
– Precautions/comments: Resident may attempt to hit, bite, scratch, or spit.
Review of the resident’s care plan, last reviewed on 12/8/18, showed the care plan did not
address restorative therapy or the use of splints/braces.
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed an order dated 9/3/18 for
restorative therapy three to five times weekly for lower extremity range of motion.
Review of the resident’s restorative therapy record, showed the following:
– During the month of (MONTH) 2019, the resident did not receive restorative therapy
1/18/19 – 1/31/19;
– During the month of (MONTH) 2019, the resident did not received restorative therapy
2/1/19 – 2/12/19, 2/14/19 – 2/21/19, 2/23/19 – 2/26/19, and 2/28/19;
– During the month of (MONTH) 2019, the resident did not receive restorative therapy
3/1/19 to 3/3/19;
– During the months of (MONTH) to (MONTH) 2019, the facility staff documented the resident
wore splints on 1/2/19, 1/16/19, and 2/8/19.
8. During an interview on 3/6/19 at 11:41 P.M., the physical therapy coordinator said
he/she provides training for staff on applying the splints. The therapist said he/she does
not know if direction is in the care plan, but he/she said directions for the splints are
hanging in the resident’s room.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 31)
9. During an interview on 3/6/19 at 12:14 P.M., CNA/RA L said the aides put the splints on
the residents when it’s time. The CNA/RA said this is not documented anywhere. He/She said
the directions are hanging in Resident #30’s room. The CNA/RA does not know if direction
is in the care plan. The CNA/RA also said CNA/RA K, the full time RA left temporarily and
the CNAs are supposed to do the restorative care but they don’t always have time.
10. During an interview on 3/7/19 at 9:34 A.M., CNA N said the restorative aide is
responsible for applying and removing the residents’ splints. He/She said the CNAs do not
do it. He/she is not aware of any documentation of when splints are applied or removed.
11. During an interview on 3/7/19 a t 10:15 A.M., LPN J said the CNAs or the restorative
aide are responsible for applying and removing resident’s splints. He/she is not aware if
it is documented.
12. During an interview on 3/7/19 at 10:40 A.M., CNA O said applying and removing splints
are the responsibility of the restorative aide. The CNAs are not supposed to do it, but
sometimes they will if there is no restorative aide working on that day. The restorative
aide is also responsible for the range of motion. He/she thinks the documentation for
splints and ROM is in the restorative notebook.
13. During an interview on 3/7/19 at 1:52 P.M., the administrator and the DON said CNA/RA
K left a couple of months ago temporarily, but all the CNAs are trained to do ROM and
apply the splints. The DON said there are two CNA/RAs trained to be the RA and are
supposed to provide the restorative care when they have time. The DON said the aides put
the splints on and the residents keep track of them. The DON said application and removal
of the splints should be in the restorative nursing book and direction for application
should be in the care plan. The DON said she expects an order for [REDACTED].

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.

Based on observation and interview, facility staff failed to ensure residents’ environment
remained free of accidents or hazards when staff propelled four residents of 16 sampled
residents (#16, #22, #59 and #163) in wheelchairs without footrests. The facility census
was 79.
1. The facility did not have a policy to instruct staff on the proper use of footrests on
wheelchairs.
2. Observation on 3/4/19 at 4:03 P.M., showed Registered Nurse (RN) A propelled Resident
#163 in his/her wheelchair down the hall without footrests. Further observation showed the
resident’s feet slid on the floor.
Observation on 3/4/19 at 4:14 P.M., showed certified nurse assistant (CNA) D propelled
Resident #22 in his/her wheelchair down the hall without footrests. Further observation
showed the resident’s feet slid on the floor.
Observation on 3/5/19 at 5:00 P.M., showed Licensed Practical Nurse (LPN) H propelled
Resident #16 in his/her wheelchair down the hall without footrests. Further observation
showed the resident’s feet slid on the floor.
Observation on 3/6/19 at 12:45 P.M., showed CNA I propelled Resident #59 in his/her
wheelchair without footrests. Further observation showed the resident’s feet slid on the
floor.
3. During an interview on 3/7/19 at 9:55 A.M., CNA B said when staff propel a resident in

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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)
a wheelchair, the wheelchair should have the footrest on. He/She said if a resident’s feet
slide on the floor, staff should stop and put the resident’s feet on the footrest.
4. During an interview on 3/7/19 at 10:08 A.M., RN A said footrest should be on the
wheelchairs when propelling residents. He/She said staff should not push the resident if
the resident’s feet slide on the floor. Staff should put the resident’s feet on the
footrest and make sure they have the bag to hold the footrests.
5. During an interview on 3/7/19 at 12:44 P.M., the administrator and Director of Nursing
(DON) said footrests should be on wheelchairs if staff propel residents. Staff should make
sure the resident’s hands are not hanging down and their feet are on the footrests. Staff
should stop and put their feet on the footrest if they slide on the floor. They said staff
has had extensive training on this.

F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the
director of nurses on a full time basis.

Based on interview and record review, facility staff failed to provide the services of a
Registered Nurse (RN), for at least eight (8) consecutive hours per day, seven days a
week. The facility failed to follow the Facility Assessment Staffing Plan which says the
Director of Nursing (DON) may be a charge nurse if the census is below 60. The facility
census was 79.
Review of the Facility Assessment, dated 11/13/18, showed the DON may be a charge nurse if
the census is below 60.
Review of the facility’s Daily Assignments schedule, dated 12/2/18 – 3/3/19, showed the
facility did not have an RN for eight (8) consecutive hours on the following days:
– 12/1/18 RN A: 5 hours;
– 12/2/18 RN A: 5 hours;
– 12/8/18 DON (census 78);
– 12/9/18 DON (census 77);
– 12/28/18 DON (census 77);
– 1/1/19 DON: 6 hours (census 79);
– 1/14/19 No RN on the Daily Assignment Sheet (census 76);
– 1/15/19 No RN on the Daily Assignment Sheet (census 76);
– 1/19/19 DON (census 76);
– 1/30/19 No RN on the Daily Assignment Sheet (census 75);
– 2/4/19 RN called in. DON (census 76);
– 2/16/19 DON (census 80);
– 2/17/19 DON (census 80);
– 2/22/19 No RN on the Daily Assignment Sheet (census 80);
– 2/25/19 No RN on the Daily Assignment Sheet (census 79);
– 2/27/19 RN A went home sick at 8:00 A.M. (census 79);
– 3/2/19 RN A: 6 hours;
– 3/3/19 RN A: 6 hours.
Review of the facility’s Daily Assignments schedule, dated 12/2/18 – 3/3/19, showed the
facility allowed the Director of Nursing (DON) to work as a charge nurse when the census
was above 59.
– 12/4/18 Evening shift (census 78);

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
– 12/7/18 Night shift (census 78);
– 12/8/18 Night shift (census 78);
– 12/10/18 Day/Evening shift (census 77);
– 12/11/18 Day/Evening shift (census 77);
– 12/14/18 Evening shift (census 77);
– 12/17/18 Evening shift (census 77);
– 12/18/18 Evening shift (census 77);
– 12/25/18 Day/Evening shift (census 78);
– 12/28/18 Day/Evening shift (census 77);
– 12/31/18 Evening shift (census not recorded on the Daily Census Recap);
– 1/1/19 Evening shift (census 77);
– 1/7/19 Evening shift (census 77;
– 1/11/19 Evening shift (census 76);
– 1/16/19 Evening shift (census 76);
– 1/18/19 Evening shift (census 76);
– 1/21/19 Day/Evening shift (census 76);
– 1/23/19 Evening shift (census 76);
– 1/24/19 Evening shift (census 75);
– 1/31/19 Evening shift (census 75);
– 2/1/19 Evening shift (census 76);
– 2/4/19 Day/Evening shift (census 75);
– 2/5/19 Evening shift (census 75);
– 2/7/19 Evening shift (census 76);
– 2/11/19 Evening shift (census 77);
– 2/12/19 Evening shift (census 78);
– 2/18/19 Evening shift (census 79);
– 2/22/19 Evening shift (census 80);
– 2/26/19 Evening shift (census 79).
During an interview on 3/7/19 at 1:58 P.M., the DON said he/she was not aware the DON
could not cover as the RN or work as a charge nurse if the census was above 59. The DON
did not realize the facility assessment said the DON could only work as a charge nurse if
the census is below 60. The DON said he/she knows an RN must be in the building eight
consecutive hours seven days a week but did not realize he/she could not count his/her
time.
During an interview on 3/7/19 at 2:10 P.M., the administrator said he/she was not aware
the DON could not count as the RN in the building, and didn’t realize the DON could not
cover as a charge nurse. The administrator thought if there were additional charge nurses
working, the DON could also work. The DON is listed as a charge nurse on the staffing
sheets.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

Based on observation, interview, and record review, licensed staff failed to ensure the
Controlled Substance Shift Change Count – Check Sheet for the North 7-3 medication cart
was signed by both the on-coming and off-going staff and did not record the number of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
narcotic medication cards to verify the narcotic count was correct each shift. The
facility census was 79.
1. Review of the facility policy titled Narcotic Count Policy, dated (MONTH) (YEAR),
showed the the purpose is to complete a physical inventory of narcotics at each shift
change to identify discrepancies as follows:
– The narcotics supply is to be kept under two locks at all times. The lock on the
medication cart and the lock on the narcotics. These two locks and the medication room are
to be locked at all times;
– One Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Medication
Technician (CMT) going off duty AND one RN, LPN, or CMT coming on duty must counted
justify accuracy of narcotics supply for each individual resident at the change of each
shift;
– Narcotic records are reconciled by a physical count of the remaining narcotic supply at
each shift change by the incoming and outgoing licensed nurse. Records are to be retained
for at least one year.
– After the supply is counted and justified, the nurse/CMT records the date and his/her
signature, verifying that the count is correct.
2. Review of the Controlled Substance Shift Change Count – Check Sheet for the North 7-3
Medication Cart from 2/1/19 to 3/3/19, showed staff did not sign the count and did not
record the number of narcotic medication cards each shift:
– 2/1/19 On-coming Nurse 7 A.M.;
– 2/1/19 Off-going Nurse 3 P.M.;
– 2/1/19 On-coming and Off-going Nurse 11 P.M.;
– 2/2/19 Off-going Nurse 7 A.M.;
– 2/2/19 Off-going Nurse 3 P.M.;
– 2/2/19 On-coming Nurse 11 P.M.;
– 2/3/19 On-coming and Off-going Nurse 7 A.M.;
– 2/3/19 Off-going Nurse 3 P.M.;
– 2/4/19 On-coming Nurse 3 P.M.;
– 2/4/19 Off-going Nurse 11 P.M.;
– 2/5/19 On-coming Nurse 3 P.M.;
– 2/5/19 Off-going Nurse 11 P.M.;
– 2/6/19 On-coming Nurse 11 P.M.;
– 2/7/19 Off-going Nurse 7 A.M.;
– 2/7/19 Off-going Nurse 3 P.M.;
– 2/7/19 On-coming Nurse 11 P.M. and no card count;
– 2/8/19 Off-going Nurse 7 A.M. and no card count;
– 2/8/19 On-coming Nurse 11 P.M. and no card count;
– 2/9/19 Off-going Nurse 7 A.M.;
– 2/9/19 Off-going Nurse 3 P.M.;
– 2/10/19 No card count 7 A.M.;
– 2/10/19 On-coming Nurse 3 P.M. and no card count;
– 2/10/19 On-coming Nurse and Off-going Nurse 11 P.M. and no card count;
– 2/11/19 Off-going Nurse 7 A.M. and no card count;
– 2/11/19 On-coming Nurse 11 P.M.;
– 2/12/19 On-coming Nurse and Off-going Nurse 7 A.M. and no card count;
– 2/12/19 On-coming Nurse and Off-going Nurse 3 P.M. and no card count;
– 2/12/19 Off-going Nurse 11 P.M.;
– 2/13/19 On-coming Nurse 7 A.M.;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
– 2/13/19 On-coming Nurse 11 P.M. and no card count;
– 2/14/19 Off-going Nurse 7 A.M.;
– 2/14/19 Off-going Nurse 3 P.M.;
– 2/14/19 On-coming Nurse 11 P.M. and no card count;
– 2/15/19 Off-going Nurse 7 A.M. and no card count;
– 2/15/19 No card count 3 P.M.;
– 2/15/19 On-coming Nurse 11 P.M. and no card count;
– 2/16/19 On-coming and Off-going Nurse 7 A.M. and no card count;
– 2/16/19 On-coming and Off-going Nurse 3 P.M. and no card count;
– 2/16/19 On-coming and Off-going Nurse 11 P.M. and no card count;
– 2/17/19 On-coming and Off-going Nurse 7 A.M. and no card count;
– 2/17/19 Off going Nurse;
– 2/17/19 On-coming Nurse;
– 2/18/19 On-coming and Off-going Nurse 7 A.M. with no card count;
– 2/18/19 On-coming and Off-going Nurse 3 P.M. with no card count;
– 2/18/19 Off-going Nurse 11 P.M.;
– 2/19/19 No card count 7 A.M.;
– 2/19/19 On-coming Nurse 3 P.M. and no card count;
– 2/19/19 Off-going Nurse 11 P.M.
– 2/20/19 On-coming Nurse 3 P.M.;
– 2/20/19 On-coming and Off-going Nurse 11 P.M. and no card count;
– 2/21/19 Off-going Nurse 7 A.M.;
– 2/21/19 Off-going Nurse 3 P.M.;
– 2/21/19 On-coming Nurse 11 P.M. and no card count;
– 2/22/19 On-coming and Off-going Nurse 7 A.M. and no card count;
– 2/22/19 Off-going Nurse 3 P.M.;
– 2/22/19 On-coming Nurse 11 P.M. and no card count;
– 2/23/19 Off-going Nurse 7 A.M.;
– 2/23/19 Off-going Nurse 3 P.M.;
– 2/23/19 On-coming Nurse 11 P.M. and no card count;
– 2/24/19 On-coming and Off-going Nurse 7 A.M. and no card count;
– 2/24/19 On-coming and Off-going Nurse 3 P.M. and no card count;
– 2/24/19 On-coming and Off-going Nurse 11 P.M. and no card count;
– 2/25/19 Off-going Nurse 7 A.M. and no card count;
– 2/25/19 On-coming Nurse 3 P.M. and no card count;
– 2/25/19 On-coming and Off-going Nurse 11 P.M. and no card count;
– 2/26/19 Off-going Nurse 7 A.M. and no card count;
– 2/26/19 On-coming Nurse 3 P.M. and no card count;;
– 2/26/19 Off-going Nurse 11 P.M.;
– 2/27/19 On-coming Nurse 7 A.M. and no card count;
– 2/27/19 Off-going Nurse 3 P.M. and no card count;
– 2/27/19 On-coming Nurse 11 P.M. and no card count;
– 2/28/19 Off-going Nurse 7 A.M.;
– 2/28/19 Off-going Nurse 3 P.M.;
– 3/1/19 Off-going Nurse 7 A.M. and no card count;
– 3/1/19 On-coming Nurse 3 P.M. and no card count;
– 3/1/19 On-coming and Off-going Nurse 11 P.M. and no card count;
– 3/2/19 Oncoming and Off-going Nurse 7 A.M. and no card count;
– 3/2/19 Oncoming and Off-going Nurse 3 P.M. and no card count;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
– 3/2/19 Oncoming and Off-going Nurse 11 P.M. and no card count;
– 3/3/19 Off-going Nurse 7 A.M. and no card count;
– 3/3/19 On-coming Nurse 3 P.M. and no card count.
3. During an interview on 3/3/19 at 6:08 P.M., Licensed Practical Nurse (LPN) J said the
count is to be done between every shift between the off-going and on-coming staff. The
narcotic count sheet should be signed by the nurses from each shift and the number of
narcotic cards documented. The LPN said she does not know why staff did not complete the
Narcotic Count Sheet for the North 7-3 Medication Cart each shift. The LPN said sometimes
nurses work a double shift and may not sign.
During an interview on 3/3/19 at 6:30 P.M., the administrator said he/she expects the
on-coming and off-going licensed staff to count the narcotics between each shift and
complete the Narcotic Count Sheet. The administrator said nurses/CMTs often work a double
shift and forget to document this on the Narcotic Count Sheet.
During an interview on 3/7/19 at 1:25 P.M., the Director of Nursing (DON) said he/she
expects the on-coming and off-going nurse/CMT to count the narcotics and complete the
narcotic count sheet. The DON was not aware the Narcotic Count Sheet for the North
Medication 7-3 Cart was not completed by staff. He/She said staff may work double shifts
but it should be documented.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to ensure the medication
regimen was free from unnecessary medications when the facility failed to provide a proper
[DIAGNOSES REDACTED].#4, #7, #13, #58) sampled residents. The facility census was 79.
1. Review of the facility’s Antipsychotic Medication Use policy, dated (MONTH) (YEAR),
showed antipsychotic medications therapy shall be used only when it is necessary to treat
a specific condition. Antipsychotic medications shall only be used for the following
conditions/[DIAGNOSES REDACTED].
2. Review of Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/25/18, showed the following:
– Cognitively impaired;
– [DIAGNOSES REDACTED].
– Received antipsychotic medication and antidepressant medications in seven out of the
last seven days.
Review of the physician order [REDACTED]. Additional review showed the order did not
contain a 14 day stop date. Additionally the POS did not contain an appropriate [DIAGNOSES
REDACTED].
3. Review of Resident # 7’s annual MDS, dated [DATE], showed [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed an order for [REDACTED].
4. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:
– Cognitively intact;
– [DIAGNOSES REDACTED].
– Received antidepressant medication seven out of the last seven days.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
Review of the POS [REDACTED]. Dissolve 0.25 ml (0.5 mg) under the tongue every two hours
PRN. Additional review showed the order did not contain a 14 day stop date.
5. Review of Resident #58’s admission MDS, dated [DATE], showed [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 3/1/19 – 3/31/19, showed the following:
– an order for [REDACTED].
– An order, dated 11/1/18, for [MEDICATION NAME] (antianxiety medication) 0.5 mg, half a
tablet twice a day PRN. Further review, showed the record did not contain a 14 day stop
date.
6. During an interview on 3/7/18 at 10:08 A.M., Registered Nurse (RN) A said they do not
have any residents on [MEDICAL CONDITION] medications. He/She said staff should document
why they are giving them and the benefits and notify the family with any medication
change. The RN said residents can only have them for 2 weeks or it needs to be scheduled.
He/She said staff should call the doctor to change. The RN said the resident has to have a
proper [DIAGNOSES REDACTED].
7. During an interview on 3/7/19 at 10:44 A.M., Licensed Practical Nurse (LPN) P said
he/she did not know psychoactive medications required a two week stop date, followed by a
physician review to continue the medication. The LPN said he/she did not have training
about this information.
8. During an interview on 3/7/18 at 12:44 P.M., the administrator and the Director of
Nursing (DON) said [MEDICAL CONDITION] PRN medication orders are for 14 days, then a
physician has to see the resident to reorder, there should be a stop date on the order.
They said the stop date should be on the Medication Administration Record [REDACTED]

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility’s licensed staff failed
to ensure medications were monitored and stored in a safe and effective manner. Licensed
staff failed to remove and discard discontinued medication and improperly labeled
medication from the medication room refrigerator and two medication carts. The facility
census was 79.
1. Review of the facility’s Labeling Drugs and Medications policy, dated (MONTH) (YEAR),
showed all drugs and biologicals must be properly labeled and legible at all times. The
policy does not show direction for staff to date vials of medication when opened, such as
insulin.
2. Review of the manufacturer’s recommendations for [MEDICATION NAME] Insulin (a
rapid-acting human insulin analog used to lower blood glucose), showed the medication must
be discarded 28 days after staff open the vial.
Review of the manufacturer’s recommendations for [MEDICATION NAME] (a long-acting insulin
used for the control of high blood sugar), showed the medication must be discarded 28 days
after the vial is opened.
Review of the manufacturer’s recommendations for Basaglar (a long-acting basal insulin
used to control high blood sugar), showed the medication is not to be used for more than
28 days after opening.
Review of the guidelines provided by the Food and Drug Administration (FDA) for the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
[MEDICATION NAME] Purified Protein Derivative (Mantoux or [MEDICATION NAME]), shows a vial
of [MEDICATION NAME] (Mantoux), which has been entered and in use for 30 days,should be
discarded.
3. Observation [DATE] at 10:37 A.M., showed two bottles of [MEDICATION NAME] opened and
undated in the unit medication cart.
Observation on [DATE] at 11:50 A.M., showed the following in the Nurses’ Medication Cart
on the main hall:
– An opened vial of [MEDICATION NAME] with the open date of [DATE];
– An opened vial of [MEDICATION NAME]without an opened date;
– An opened vial of [MEDICATION NAME] with without an opened date;
– An opened pen of Basaglar with without an opened date.
Observation on [DATE] at 12:00 P.M., showed an opened vial of [MEDICATION NAME] in the
refrigerator of the main medication room without an opened date.
4. During an interview on [DATE] at 12:15 P.M., LPN J said all vials should be dated when
opened. The LPN said the insulin should be discarded after 28 days and the TB ([MEDICATION
NAME]/Mantoux) should be discarded after 30 days. All the vials should have been dated and
the [MEDICATION NAME], dated [DATE], should have been discarded on [DATE]. The LPN said
all staff giving medications are responsible for ensuring medications are labeled
correctly and the vials are dated when opened. The LPN doesn’t know how these vials were
missed. The LPN said the pharmacist comes monthly and checks the carts and the medication
rooms.
5. During an interview on [DATE] at 1: 25 P.M., the administrator and the Director of
Nursing (DON) said when a new vial of medication is opened, it is to be dated with the
open date. The DON said the insulin is to be discarded after 28 days and staff should
check the medication cart for expired medication each time it is used. The DON said she
expects the charge nurses to check the medication carts weekly and the pharmacist comes to
the facility monthly and checks the medication carts and the medication rooms. The DON
expects the [MEDICAL CONDITION] Test Serum ([MEDICATION NAME]/Mantoux) to be dated when
opened and discarded in 30 days.

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 remove soiled
gloves and/or properly wash hands to prevent the spread of bacteria and other infection
causing contaminants during the provision of care and medication administration for six
out of 16 sampled residents (#7, #22, #23, #36, #162 and #165). In addition, the facility
failed to administer the Two-step [MEDICATION NAME] (TB) testing appropriately for five
out of 16 sampled residents (#7, #22, #23, #36 and #162). The facility also failed to
follow infection control protocols for cleaning/disinfecting the glucometer (device to
measure blood sugar levels) during Accu-checks (testing of blood sugar). The census was
79.
1. Review of the facility’s Blood Glucometer Disinfecting Policy, dated (MONTH) (YEAR),
showed staff is directed to clean the blood glucose meter prior to using with approved
wipes with 10% bleach or comparable product, placed on clean field and let air dry
according to manufacturer’s directions.
Observation on 3/4/19 at 10:57 A.M., showed Registered Nurse (RN) A did not clean the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 39)
glucometer before or after he/she obtained Resident #45’s blood sugar.
Observation on 3/5/19 at 10:49 A.M., showed RN A did not clean the glucometer before or
after he/she obtained Resident #162’s blood sugar.
Observation on 3/5/19 at 04:11 P.M., showed RN G did not clean the glucometer before or
after he/she obtained Resident #45’s blood sugar.
During an interview on 3/7/19 at 10:08 A.M., RN A said every night staff do the control
test on the glucometer. Staff should clean the glucometer before and after use with a soft
cloth with water and if visibly soiled they should use the disinfectant wipes.
During an interview on 3/7/19 at 12:44 P.M., showed the administrator and Director of
Nursing (DON) said the glucometer should be cleaned with antimicrobial wipes, the red top
wipes, after each resident. They said the glucometer should be wrapped with a wipe for 2-3
minutes.
2. Review of the facility’s Medication Administration policy, dated (MONTH) (YEAR), showed
staff are directed to wash their hands prior to administering medications.
Observation on 3/4/19 at 1:00 P.M., showed RN A dropped a pill on top of the medication
cart, picked it up with his/her bare hands and put it back in the medication cup. Further
observation showed he/she did not wash her his/her hands in between residents during the
medication pass.
Observation on 3/5/19 at 3:58 P.M., showed RN G touched a pill with his/her bare hands
when he/she administered medications to Resident #163.
During an interview on 3/7/19 at 10:08 A.M., RN A said staff should wash their hands
before and after passing each medication or hand sanitize. He/She said staff should pop
the medication into the medication cup, less touching the better. RN A said he/she touched
them all the time. He/She only uses gloves when touching certain drugs like neoplastic or
certain ones that pregnant women should not touch or liquids. He/She said if facility
staff drop a pill, then the staff should throw it away.
During an interview on 3/7/19 at 12:44 A.M., showed the administrator and DON said staff
should not touch pills with their bare hands. They said staff should wear gloves if they
are touching pills and if a pill is dropped it should be replaced. They said staff should
wash their hands after each resident during medication administration.
3. Review of the facility’s Gloves policy, dated (MONTH) (YEAR), showed staff is directed
to the following:
-Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound
drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these
substances) and/or persons with a rash.
-Gloves must be changed between residents and between contacts with different body sites
of the same resident.
-Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a
glove easier than to the skin on your hands.
Observation on 3/3/19 at 5:34 P.M., showed Certified Nurse Assistant (CNA) C did not wash
his/her hands after he/she scratched his/her head and looked at his/her fingers or before
he/she removed a dinner tray and began cutting up a resident’s food.
Observation on 3/3/19 at 5:35 P.M., CNA C did not wash his/her hands after he/she coughed
into his/her hands or before he/she served the residents’ food trays.
Observation on 3/3/19 at 5:52 P.M., CNA C did not wash his/her hands after he/she touched
his/her mouth or before he/she assisted a resident with eating.
Observation on 3/5/19 at 10:23 A.M., CNA F did not change his/her gloves after he/she
provided perineal care or before he/she assisted Resident #22 to dress. Further
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 40)
observation showed CNA F did not wash his/her hands after he/she removed his/her gloves.
Observation on 3/5/19 at 10:53 A.M., RN A placed Resident #165’s open wound on the
resident’s blanket when he/she provided wound care. Further observation showed the RN did
not wash his/her hands before leaving the resident’s room.
During an interview on 3/7/19 at 9:55 A.M., CNA B said staff should knock on the door,
wash their hands, apply gloves, provide care, and if the gloves get contaminated they
should change their gloves, wash their hands and get new gloves then finish with the care.
He/She said staff should not touch anything clean with dirty gloves. The CNA said when
serving residents, if facility staff touch their face, mouth, hair or cough in their hand,
the staff member should wash their hands before touching the resident’s tray.
During an interview on 3/7/19 at 10:08 A.M., RN A said staff should wash their hands
before and after direct resident care, during perineal care, staff should put on gloves
then wash their hands when they are done. Staff should change their gloves when they are
soiled and wash their hands. Staff that touch their face, hair or cough, should was their
hands before serving food.
During an interview on 3/7/19 at 12:44 P.M., the administrator and the DON said staff
should change their gloves when going from dirty to clean. They should remove their gloves
and wash their hands. If staff touch their face, hair or cough, they should go wash their
hands before serving the residents.
4. Review of the facility’s Surveillance, Infection Control Policy, dated (MONTH) 2006,
showed the following:
-Assessment of the resident at the time of admission to the facility for communicable
diseases and a history of immunization. This will assure recognition of communicable
diseases that will require special precautions and assure recognition of communicable
diseases that will require special precautions and assure the resident is up-to-date on
recommended adult immunizations.
-In accordance with Department of Health rule 19 CSR 20-20.100, all residents new to long
term care who do not have documentation of a previous skin test reaction less than 10 mm
or a history of adequate treatment of [REDACTED].
Review of Resident #7’s medical record, showed the following:
– Physician order [REDACTED].>- Immunization record showed the resident received the
second step on 09/27/17;
– The record did not contain a yearly assessment for 09/2018.
Review of Resident #22’s medical record, showed the following:
– POS, dated 3/1/19, showed an order on 11/30/15 for an annual TB assessment;
– Immunization record showed the resident received the second step on 12/9/15;
– The record did not contain an annual TB assessment for 11/2016, 11/2017, or 11/2018.
Review of Resident #23’s medical record, showed the following:
– Immunization record showed the resident received the second step on 3/14/16;
– The record did not contain an annual TB assessment for 3/2017 or 3/2018.
Review of Resident #36’s medical record, showed the following:
– Immunization record showed the resident received the first step on 5/1/15;
– The record did not contain a second step or an annual TB assessment for 5/2016, 5/2017,
or 5/2018.
Review of the Resident #162’s medical record, showed the following:
– POS, dated 10/18/17, showed an order for [REDACTED].>- The record did not contain an
annual TB assessment for 11/2018.
During an interview on 3/7/19 at 10:08 A.M., RN A said he/she administers the first step
of the TB to the resident upon admission and the results are read 48-72 hours later. If
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265333

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

NAME OF PROVIDER OF SUPPLIER

JONESBURG NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

308 CEDAR AVENUE, PO BOX 218
JONESBURG, MO 63351

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 41)
the results are negative, he/she administers the second step TB in 14 days. The RN said
the POS shows facility staff if an assessment should be done yearly. RN A said he/she
thought another staff member does those and the immunizations will be on the form in the
chart or in the computer.
During an interview on 3/7/19 at 12:44 P.M., showed the administrator and the DON said
TB’s are done upon admission for the first step, and the second step are administered 14
days later. Additionally, they said an assessment should be done annually and they have a
tracking system by admitted .