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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 – Few

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, interview and record review, the facility failed to ensure residents
were cared for in a dignified manner when staff did not ensure residents skin was covered
in public areas for two residents (Residents #8 and #30) out of 12 sampled residents. The
facility census was 35.
1. Review of the facility’s Dignity policy, revised 12/15, showed:
– Appropriate care is taken to ensure the resident’s right to privacy and dignity, as well
as the resident health and safety, are protected during the performance of any clinical
procedure.
2. Review of Resident #8’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/9/18, showed:
– Able to make daily decisions;
– Required supervision of staff for personal hygiene and dressing;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised 5/21/18, showed:
– Assist resident to change clothes when resident cannot or will not complete the task;
– Please remind the resident to change clothes daily and whenever needed.
Observation on 7/11/18 from 11:22 A.M. until 12:00 noon, showed the resident sat at
his/her table with his/her backside to other residents in the dining room. The resident’s
shirt and pants did not meet and at least two inches of his/her buttock crevice was
visible.
Observation and interview on 7/12/18 from 6:55 A.M. to 7:37 A.M., showed the resident sat
at the dining room table with his/her backside visible to other residents seated in the
dining room. At least eight inches of bare skin across the width of the resident’s lower
back and hips were visible where the T-shirt and pants did not reach each other. At least
two inches of the crevice of his/her buttocks was visible. The resident said, he/she was
hungry and had dressed him/herself but did not know any skin was showing. Dietary staff
were in and out of the dining room and passed by the resident’s table. Licensed Practical
Nurses (LPN’s) A and B were in and out of the dining room passing medications to residents
and were by the resident’s table. Staff did not assist the resident to adjust his/her
clothing to cover the bare skin. At 7:37 A.M., the resident finished his/her breakfast and
stood with his/her wheeled walker. The resident’s T-shirt fell down the resident’s back
but still lacked about two inches from reaching the waist band of the resident’s pants in
the back. His/her buttocks crevice remained visible as the resident walked out of the
dining room and down the hallway to his/her room.
3. Review of Resident # 30’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Required extensive assistance of staff with dressing;
– Dependent on staff for transfers;
– Limited range of motion to upper and lower extremities on both sides;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised 6/5/18, showed:
– The resident needed extensive assistance of staff with dressing and transfers.
Observation and interview on 7/12/18 from 6:55 A.M. until the resident left the dining
room at 7:30 A.M., showed an area of skin at least eight inches long and two inches wide
to the resident’s right side and towards his/her abdomen where the shirt and pants did not
meet. The resident said he/she did not want his/her stomach to show. LPN’s A and B were 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 – Few

(continued… from page 1)
the dining room at the resident’s table and did not re-adjust the resident’s clothing to
cover his/her skin.
4. During an interview on 7/13/18 at 8:01 A.M., the Acting Director of Nurses said:
– Staff should eye ball each resident to make sure they are dressed for the day in the
mornings;
– Skin should not be showing in the dining room;
– When passing by residents in the dining room, if the resident allows, staff should
assist the resident out of the dining room to adjust the resident’s clothing, otherwise do
what they can to make the needed adjustments there in the dining room;
– Staff should let social services know if a resident’s clothing is too small and social
services would then notify the family or the guardian to provide larger clothing.

F 0570

Level of harm – Potential for minimal harm

Residents Affected – Some

Assure the security of all personal funds of residents deposited with the facility.

Based on interview and record review, the facility failed to purchase a surety bond in an
amount sufficient to ensure security of all personal funds the facility held for
residents. The facility census was 35.
1. Review of the facility surety bond showed the facility maintained a bond for $10,000.
Review of the facility bond worksheet, dated 7/13/18, showed:
– The facility’s average monthly balance was $8057.14;
– The facility’s required bond should be $12,000.
During an interview on 7/13/18 at 8:56 A.M., the Business Office Manager (BOM) said:
– The facility should have a bond to cover resident funds;
– Resident #1 received a social security surplus of $20,000 in (MONTH) (YEAR) which raised
the average balance for several months;
– He/she contacted the facility’s corporate office in (MONTH) to increase the facility’s
bond, but it had not been done yet.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
This deficiency is uncorrected. For previous examples, refer to the Statement of
Deficiencies dated [DATE].
Based on interview and record review, the facility failed to ensure staff addressed
discrepancies regarding resident code status, such as Do Not Resuscitate (DNR) or
Cardio-Pulmonary Resuscitation (CPR), for one resident (Resident #902). The facility
census was 33.
1. Review of the facility policy on CPR, dated [DATE], showed:
– The resident or his/her surrogate must sign a DNR for the resident;
– The resident’s physician must write a DNR order;
– Staff must document the resident’s wishes in the resident’s medical records.

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
Review of Resident 902’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed:
– Moderate cognitive impairment;
– Required extensive staff assistance for hygiene and toileting;
– Frequently incontinent of bladder;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s out of hospital DNR, dated [DATE], showed:
– The form was signed by the resident’s public administrator (PA);
– The resident’s PA requested DNR status.
Review of the resident’s order sheet (POS), dated (MONTH) (YEAR), showed the resident was
a full code (in case the resident’s heart stopped beating and/or the resident stopped
breathing staff must perform CPR).
During an interview on [DATE] at 1:00 P.M., regarding a resident’s code status, Licensed
Practical Nurse (LPN) A said:
– He/she would look at the chart for the out of hospital DNR;
– He/she would check the resident’s POS;
– If they did not match, he/she would perform CPR.
During an interview on [DATE] at 1:30 P.M., the Director of Nursing (DON) said:
– The resident’s PA signed an out of hospital DNR;
– The resident’s POS stated a full code;
– Staff checked each resident’s POS, but missed the discrepancy.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain a clean, comfortable,
and homelike environment. The facility census was 35.
1. Observation on 7/10/18 at 10:00 A.M., showed the resident in room [ROOM NUMBER]:
– Lay in his/her low air-loss bolstered bed with tears in both bolsters exposing the foam;
– A very strong odor of urine in the room.
Observation on 7/11/18 at 8:32 A.M., showed the resident asleep in his/her room with a
very strong odor of urine in the room.
During an interview on 7/11/18 at 9:03 A.M., the Housekeeping Supervisor (HS) said:
– His/her staff cleaned rooms daily;
– None of the staff reported any odors in resident rooms;
– Housekeeping staff must find the causes of odors and eliminate them.
Observation on 7/11/18 at 10:26 A.M., of the resident showed:
– A very strong odor of urine in the room;
– Certified Nurse Aide (CNA) A and CNA B provided care to the resident;
– Both CNA’s removed and replaced the resident’s wheelchair cushion.
During an interview on 7/11/18 at 10:26 A.M., CNA A and CNA B said:
– The room had a very strong odor of urine;
– They thought the odor was due to the resident’s wheelchair cushion.
Observation on 7/11/18 at 1:44 P.M., showed the resident was not in the room, and the room
had a strong odor of urine.

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Observation on 7/12/18 at 8:37 A.M., showed the resident was not in the room, and the room
had a strong odor of urine.
During an interview on 7/12/18 at 8:37 A.M., the Director of Nursing (DON) said:
– He/she was unaware that the resident’s room had a persistent odor;
– Staff must investigate room odors;
– Staff must ensure resident rooms are odor free.
2. Observation on 7/10/18 at 1:30 P.M., showed the following:
-Cobwebs, and dead bugs by the bookshelf in the family room at the end of the 300 hall;
-room [ROOM NUMBER] wall heating unit was rusted and cracked all along the top;
-room [ROOM NUMBER] wall heating unit was falling off and partially hanging on the floor,
a piece of two by four was underneath it to keep it from completely falling off;
-room [ROOM NUMBER] bottom of door frame scuffed and chipped up;
-Bottoms of door frames on both sides of the double doors leading into the dining room
were scuffed and chipped;
-Rooms 103, 104, 105, 106, 108, 111, and 113 bottom of door frames were scuffed and
chipped;
-Door frame to the shower room on 100 hall was covered with scuff and chipped marks.
During an interview on 7/13/18 at 8:40 A.M., the Maintenance Director said he checks doors
at least once a month and makes weekly rounds of the facility. He said he is aware of the
condition of the wall heating units in rooms [ROOM NUMBERS] and put the two by four piece
of wood there to keep it from falling down completely. He said he fixes things when he
can.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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**
This deficiency is uncorrected. For previous examples, refer to the Statement of
Deficiencies dated 7/13/18.
Based on observation, interview and record review, the facility failed to follow the
comprehensive care plan for one resident and failed to revise the care plan after falls
for the resident (Resident #24). The facility census was 33.
1. Review of the facility’s fall management guidelines, revised 7/14/2017, showed, in
part:
– Each resident is assisted in attaining/maintaining his/her highest practicable level of
function by providing the resident adequate supervision, assistive devices and/or
functional programs as appropriate to minimize the risk for falls;
– The Interdisciplinary Team (IDT) evaluates each resident’s fall risks;
– A plan of care is developed and implemented, based on this evaluation, with ongoing
review;
– If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in
place to minimize the risk of future falls;
– The Director of Nursing (DON)/designee is responsible for coordination of an
interdisciplinary approach to managing the processes for prediction, risk assessment,
treatment, evaluation, monitoring, and calculation of resident falls;
– Falls defined: current CMS guidelines regarding falls state that a fall refers to
unintentionally coming to rest on the ground, floor, or other lower level but not as a

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 – Few

(continued… from page 4)
result of an overwhelming external force (i.e. resident pushes another resident). An
episode where a resident lost his/her balance and would have fallen if not for staff
intervention, is considered a fall. A fall without injury is still a fall.
2. Review of Resident #24’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 8/14/18, showed:
– Severely impaired cognitive skills;
– Required extensive assistance of one staff for bed mobility, transfers and toilet use;
– Frequently incontinent of bowel and bladder;
– Had two falls since admission without injury;
– [DIAGNOSES REDACTED].
Review of the resident’s fall scale, dated 8/15/18, showed:
– A score of 80 (scores of 45 and higher are considered high risk for falls).
Review of the resident’s care plan, revised 9/18/18, showed:
– The resident had a potential to fall;
– Interventions: be sure pathways are kept clear and room is free of clutter; the resident
is receiving [MEDICATION NAME] (medication used to treat depression), and could put
him/her at a higher fall risk; remind resident to walk up into his/her walker, otherwise
he/she becomes very stooped over; keep resident’s walker close to him/her; help resident
wear well-fitting footwear with nonskid soles; the resident is being evaluated and treated
by therapy department; keep call light close to the resident and remind him/her to use it
if he/she needs assistance as he/she may not remember this; the resident has a wheelchair
for optional mobility; foot rests are not to be used with the wheelchair.
Review of the resident’s nurse’s notes showed:
– 10/6/18 at 9:34 P.M.: At 6:30 P.M., the resident’s roommate was in the hallway outside
their door and yelled for help. Resident #24 was on the floor. Resident assessed and
neuros (neurological assessment, an assessment of the motor responses to determine if the
nervous system is impaired) started. Redirected resident to ask for help, but he/she is
forgetful;
– 10/6/18 at 10:27 P.M.: At 10:00 P.M., Certified Nurse Aide (CNA) reported the resident
fell and cut his/her forehead. The resident was on the floor. Resident assessed and neuro
assessment started. Treatment ordered for skin tear;
– 10/7/18 at 2:36 A.M.: At 2:00 A.M., the laceration over the resident’s right eye
continued to bleed. The resident was transferred to the hospital;
– 10/7/18 at 6:06 A.M.: The hospital called with report. Placed three stitches on
laceration over right eye. CAT (CT) scan on head, face, cervical and neck were negative.
Awaiting transportation back to the facility;
– 10/7/18 at 8:45 A.M.: The resident returned to the facility. Neuros started. The
resident educated to ask for assistance when needed;
– 10/7/18 at 9:40 A.M.: The resident found sitting on the floor in the hallway beside
his/her wheelchair. Resident assessed and neuros started;
– 10/8/18 at 9:42 P.M.: Nurse in the hall outside the resident’s room and heard a loud
noise in the resident’s room and saw the resident on the floor in front of his/her TV,
with new skin tears to his/her right inner forearm. Resident redirected to ask for help
when getting up, but he/she is very forgetful and does not ask. Family contacted but were
unable to come and sit with the resident.
Observation and interview on 10/10/18 at 10:50 A.M., showed:
– The resident sat on the side of his/her bed and was wearing hipsters (padded garment
worn to protect the hips);
– CNA E said the resident started wearing them on 10/9/18 after he/she fell ;
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 – Few

(continued… from page 5)
– The resident’s bed was raised and the brakes were not locked;
– After CNA E provided incontinent care, CNA E transferred the resident into his/her
wheelchair;
– CNA E placed the foot rests on the wheelchair and took the resident to the dining room.
Review of the resident’s care plan, revised 9/18/18, showed:
– The care plan was not updated with current falls and did not include any new
interventions.
During an interview on 10/11/18 at 2:25 P.M., the DON said:
– The care plans are updated by the social worker and the MDS Coordinator, but the MDS
coordinator left last week;
– The care plans should be updated with a change in condition;
– There should be new interventions on the care plan related to each fall;
– The resident’s bed should be in a low position and locked;
– The resident should not have the foot rests on his/her wheelchair;
– The hipsters should have been care planned.

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, interview, and record review, the facility failed to ensure staff
followed professional standards of practice, when staff failed to follow physicians’
orders for two residents (Residents #13 and #9) of 12 sampled residents. Additionally,
staff did not change oxygen tubing and humidifiers for two residents (Residents #15 and
#21) and did follow manufacturers’ instructions for two residents’ medications (Residents
#22 and #13). The facility census was 35.
1. Review of the package insert, dated (MONTH) 2012, for Neupro patch showed:
– The medication was used to treat [MEDICAL CONDITION] (a disease of the nerves) disease;
– Staff should apply the patch daily;
– Staff should not apply to the same area of the skin more than one time every 14 days.
Review of Resident # 22’s care plan, dated 5/21/18, showed:
– [DIAGNOSES REDACTED].
– Did not address staff applying the resident’s Neupro patch.
Review of the resident’s Medication Administration Record [REDACTED]
– an order for [REDACTED].>- Did not show staff charted site placement.
Observation on 7/12/18 at 7:20 A.M., showed:
– Licensed Practical Nurse (LPN) A removed the resident’s Neupro patch from his/her left
arm and discarded the patch;
– LPN A applied the patch to the resident’s right arm;
– LPN A did not chart the site of application.
During an interview on 7/12/18 at 7:20 A.M., LPN A said:
– He/she did not chart the site of application, because he/she applied the patch to
opposite arms daily;
– The resident did not want the patch any where but on the arms;
– He/she should educate the resident about the benefits of alternating site application.
During an interview on 7/12/18 at 8:15 A.M., the Director of Nursing (DON) said:
– Staff should always alternate sites for the Neupro patch according to manufacturer’s

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 6)
instructions;
– If a resident refused to allow staff to alter sites, staff should educate the resident;
– If the resident still refused to allow staff to alternate patch sites, staff should care
plan the resident’s refusal to alternate sites.
2. Review of the insert for [MEDICATION NAME] Ophthalmic solution, 0.3%, showed, in part:
– Do not touch the dropper tip to the surface of the eye.
Review of Resident #13’s physician order sheet (POS), dated (MONTH) (YEAR), showed:
– an order for [REDACTED].
Observation on 7/11/18 at 9:28 A.M., showed:
– LPN B placed tissues, eye drop bottle and gloves on a paper towel and washed his/her
hands and applied gloves;
– LPN B touched the tip of the eye dropper to the resident’s upper eyelid and instilled
one drop in the resident’s right eye.
During an interview on 7/12/18 at 9:15 A.M., LPN B said:
– The eye dropper should not touch the resident’s eyelid.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– Staff should not touch the eye dropper to the eyelid.
3. Review of the facility policy, dated 1/1/2014, on oxygen concentrators showed the
policy did not address changing tubing and humidifiers.
Review of Resident #15’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 4/22/18, showed staff assessed the resident as:
– Cognitively impaired;
– Dependent upon staff for transfers, dressing, toileting, and hygiene;
– Shortness of breath when lying down and upon exertion;
– Received oxygen therapy.
Review of the resident’s care plan, dated 5/17/18, showed staff:
– Did not document the resident received oxygen therapy;
– Did not address changing the resident’s oxygen tubing and oxygen humidifier.
Observations on 7/10/18 at 9:06 A.M. and 7/11/18 at 8:36 A.M., showed:
– The resident received oxygen through a humidifier;
– Staff did not label the resident’s oxygen tubing with the date it was last changed.
4. Review of Resident #21’s care plan, dated 7/10/18, showed:
– The resident received oxygen therapy as needed;
– Did not address changing the resident’s oxygen tubing and humidifier.
Review of the resident’s admission MDS, dated [DATE], showed staff assessed the resident
as:
– Cognitively impaired;
– Totally dependent on staff for transfers, hygiene, and toileting;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 7/2/18, showed an order for
[REDACTED].>Observations on 7/10/18 at 10:24 A.M. and 7/11/18 at 1:44 P.M., showed
staff did not label the resident’s oxygen tubing and humidifier with the date it was last
changed.
During an interview on 7/11/18 at 3:10 P.M., the DON said:
– Oxygen tubing and humidifiers should be changed and dated by the evening staff every
Sunday;
– He/she worked the evening shift last Sunday and did not change the oxygen tubing and
humidifiers.
5. Review of Resident #9’s MAR, dated (MONTH) (YEAR), showed:
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 7)
– an order for [REDACTED].>- Staff to ensure medication is given 12 hours apart.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed staff administered the
medication as follows:
– 7/1/18, no time for the morning dose and the evening dose at 8:00 P.M.;
– 7/3/18, morning dose 8:00 A.M. and no time for the evening dose;
– 7/4/18, morning dose 7:00 A.M. and no time for the evening dose;
– 7/5/18, morning dose no time and evening dose 8:00 P.M.;
– 7/6/18, morning dose at 7:00 A.M. and evening dose 8:00 P.M.;
– 7/7/18, morning dose 7:00 A.M. and evening dose 8:00 P.M.;
– 7/9/18, morning dose no given and evening dose 8:00 P.M.;
– 7/10/18, morning dose 7:00 A.M. and evening dose 8:00 P.M.;
– 7/11/18, morning dose 7:00 A.M. and evening dose no time given;
– 7/12/18, morning dose 9:00 A.M.
Observation on 7/12/18 at 9:10 A.M., showed LPN A administered the resident’s [MEDICATION
NAME] 46 units subcutaneously (under the skin).
During an interview on 7/12/18 at 9:10 A.M., LPN A said that he/she did not realize the
medication should be administered 12 hours apart.
During an interview on 7/12/18 at 10:00 A.M., the DON said staff should administer insulin
as ordered.

6. Review of Resident #13’s face sheet, showed an admission date of [DATE].
Review of the resident’s POS, dated (MONTH) (YEAR), showed:
– an order for [REDACTED].
Review of the resident’s E-chart, on 7/11/18 at 1:00 P.M., showed:
– The resident did not have a [MEDICAL CONDITION] panel drawn since admission.
Review of the Journal of Family Practice website showed the TSH level should be evaluated
no earlier than 6 weeks after initiating therapy or adjusting [MEDICATION NAME] dosage.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– The resident had not had any TSH or Free T4 (tests used to determine [MEDICAL CONDITION]
function) drawn since the resident was admitted ;
– The pharmacy consultant reviews the charts and makes recommendations for labs to be
completed;
– The DON reviews the pharmacy recommendations to make sure the labs have been drawn.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided proper perineal and/or grooming care for three dependent residents (Residents
#10, #21, and #236) out of 12 sampled residents. The facility census was 35.
1. Review of the facility policy, dated 1/1/2014, on perineal care showed:
– Staff should separate the perineal folds and clean between;
– Staff must clean all areas affected by incontinence.
2. Review of Resident #21’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument, dated 5/8/18, showed staff assessed the resident as:
– Cognitively impaired;

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 – Few

(continued… from page 8)
– Totally dependent on staff for transfers, personal hygiene, and toileting;
– [DIAGNOSES REDACTED].
– Received hospice care.
Review of the resident’s care plan, dated 7/10/18, showed:
– The resident required extensive staff assistance for care;
– Did not address perineal care.
Observation on 7/11/18 at 10:26 A.M., showed Certified Nurse Assistant (CNA) A and CNA B:
– Removed the resident’s brief, which was soaked with urine from front and back;
– CNA A cleaned the front perineal area of the resident;
– Without cleaning the back of the resident, CNA A placed a clean brief on the resident.
During an interview on 7/11/18 at 10:30 A.M., CNA A said he/she should have cleaned the
back of the resident.
3. Review of Resident #10’s urinalysis report, dated 3/15/18, showed:
– The presence of a UTI;
– The resident’s physician started the resident on an antibiotic.
Review of the resident’s care plan, dated 2/28/18, showed staff should assist the resident
with perineal care as needed.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 4/19/18, showed staff assessed the resident as:
– Cognitively impaired;
– Required extensive staff assistance for toileting and hygiene;
– Frequently incontinent of bladder;
– Occasionally incontinent of bowel.
Observation on 7/11/18 at 9:34 A.M., showed:
– CNA A provided perineal care and cleaned both groins;
– He/she did not spread the resident’s perineal folds and clean in between the folds.
During an interview on 7/11/18 at 9:40 A.M., CNA A said he/she should have spread the
resident’s perineal folds and cleaned between them.
During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff must
always spread the perineal folds and clean between them. Staff should always clean the
front and the back of the resident.
4. Review of Resident #236’s admission MDS, dated [DATE], showed staff assessed the
resident as:
– Moderately impaired cognitive skills;
– Dependent on two staff for bed mobility and toilet use;
– Required extensive assistance of two staff for transfers;
– Required extensive assistance of one staff for dressing and personal hygiene;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, initiated on 5/21/18, showed:
– The resident is a two person assist with the Hoyer (mechanical lift) at all times for
nursing staff;
– The care plan did not address personal hygiene.
Observation on 7/11/18 at 8:35 A.M., showed:
– CNA D assisted the resident from bed into his/her wheelchair and the resident propelled
him/herself down the hall and was weighed;
– The resident’s hair was matted;
– Staff did not comb the resident’s hair, provide or offer oral care or wash his/her face
before leaving his/her 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 – Few

(continued… from page 9)
– The resident passed several staff and other residents in the hall.
Observation on 7/12/18 at 9:43 A.M., showed:
– CNA D used the gait belt and assisted the resident with the use of his/her walker and
ambulated to the bedside commode;
– The resident’s pants were wet;
– CNA D assisted the resident onto the bedside commode, removed the resident’s incontinent
brief, which was saturated with urine and removed the resident’s wet pants;
– The resident urinated on his/her hand and the floor;
– CNA D did not clean the resident’s hand or clean the resident’s feet before he/she
applied clean non-skid socks;
– CNA D and Licensed Practical Nurse (LPN) B used the gait belt and assisted the resident
to stand;
– CNA D did not clean the entire buttocks that had been in contact with urine;
– CNA D applied skin barrier cream to the resident’s buttocks;
– LPN B pulled the resident’s incontinent brief up;
– CNA D reminded LPN B he/she still needed to clean the front;
– LPN B pulled the incontinent brief down and cleaned the front perineal folds;
– LPN B used a new wipe and used the same area to clean the front perineal folds and did
not manipulate and thoroughly cleanse all the perineal folds;
– CNA D and LPN B pulled the resident’s incontinent brief and pants up and assisted
him/her into the wheelchair.
During an interview on 7/12/18 at 12:02 P.M., LPN B said he/she:
– Should not use the same area of the wipe to clean different areas of the skin;
– Should clean all areas of the of the skin in contact with urine or feces.
During an interview on 7/12/18 at 1:03 P.M., CNA D said he/she:
– Should clean all areas of the skin where urine or feces has touched the skin;
– Should not use the same area of the wipe to clean different areas of the skin;
– Should have made sure the resident had his/her hair combed before he/she left the room
and offered to brush the resident’s teeth or swab their mouth.
5. During an interview on 7/13/18 at 8:01 A.M., the DON said:
– She expected staff to wash the resident’s face, hands, use deodorant, good oral care and
comb hair when staff assisted the resident to get up in the morning;
– If the resident was incontinent of urine, staff should clean all areas of the skin where
urine has touched;
– Staff should not use the same area of the wipe to clean different areas of the skin.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
safely transferred residents using gait belts and mechanical lifts for seven residents
(Residents #10, #236, #15, #18, #21, #34, and #30) out of 12 sampled residents.
Additionally, staff failed to ensure a resident wore his/her smoking apron while smoking
unsupervised for one resident (Resident #14). The facility census was 35.
1. Review of the facility policy, dated 1/1/2014, on the use of gait belts showed the
policy did not address locking the resident’s wheelchair during transfers. Review of 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 10)
policy showed staff were instructed to place the gait belt around the resident’s waist,
snug but not tight, avoiding ribs, hipbone or breast. The policy did not indicate where
the staff should place their hands on the gait belt.
2. Review of Resident #10’s care plan, dated 4/13/18, showed:
– [DIAGNOSES REDACTED].
– Staff should use a gait belt for transfers.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/19/18, showed:
– Cognitively impaired;
– Required staff assistance for transfers;
– Not steady with transfers;
– Used a wheelchair.
Observation on 7/11/18 at 9:34 A.M., showed:
– Without locking the wheelchair, Certified Nurse Assistant (CNA) A transferred the
resident using a gait belt from the wheelchair to the toilet;
– Without locking the wheelchair, CNA A transferred the resident from the toilet to
his/her wheelchair.
During an interview on 7/11/18 at 9:40 A.M., CNA A said he/she should have locked the
wheelchair before transferring the resident.
During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff
should always lock wheelchairs when transferring a resident.
3. Review of Resident #236’s admission MDS, dated [DATE], showed:
– Cognitive skills moderately impaired;
– Dependent on two staff for bed mobility;
– Required extensive assistance of two staff for transfers;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, initiated on 5/21/18, showed;
– The resident is a two person assist for transfers.
Observation on 7/12/18 at 9:43 A.M., showed:
– CNA D placed the gait belt around the resident’s waist and placed the walker in front of
him/her;
– CNA D grabbed the back of the gait belt and the front of the gait belt because the
resident had difficulty standing;
– The gait belt was loose and slid up under the resident’s arm pits;
– The resident ambulated to the bedside commode;
– After CNA D and LPN B provided incontinent care, LPN B grabbed the side of the gait belt
with one hand and placed his/her hand under the resident’s arm and CNA D grabbed the other
side of the gait belt;
– The gait belt was loose and slid up under the resident’s arm pits;
– CNA D and LPN B grabbed the back of the resident’s pants and assisted the resident to
transfer into his/her wheelchair.
During an interview on 7/12/18 at 12:02 P.M., LPN B said:
– He/she tried not to grab the resident’s pants or arm during transfers but sometimes they
do so the resident’s pants do not fall down, but we should try to use the gait belt.
During an interview on 7/12/18 at 1:03 P.M., CNA D said:
– The gait belt should not slide up, if it does, it should be tightened up;
– He/she should not grab a hold of the resident’s arm or the resident’s pants during
transfers.
During an interview on 7/13/18 at 8:01 A.M., the DON 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 11)
– The gait belt should not slide up under the resident’s arm pits, if it slides up, staff
should stop the transfer and readjust it;
– Staff should not grab the back of the resident’s pants or the resident’s arm during
transfers.
4. Review of the policy, dated 1/1/2014, on mechanical lift transfers showed:
– Did not address leaving the casters on the lift unlocked;
– Did not address keeping the lift legs spread;
– Did not address adhering to manufacturer’s instructions.
Review of the undated user manual for the Invacare lift, the facility’s mechanical lift,
showed:
– When lifting a resident, staff should never lock the casters;
– When lifting and transferring a resident, staff should always keep the legs spread.
5. Review of Resident #18’s quarterly MDS, dated [DATE], showed:
– Severe cognitive impairment;
– Total dependence upon staff for transfers;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 5/3/18, showed staff should use a mechanical
lift to transfer the resident.
Observation on 7/10/18 at 8:43 A.M., showed:
– CNA D locked the casters on the mechanical lift and lifted the resident from his/her
wheelchair;
– CNA D unlocked the casters;
– Both CNAs moved the resident over his/her bed;
– CNA D locked the mechanical lift casters and lowered the resident.
During an interview at the time of the observation, both CNA’s said they thought they were
supposed to lock the mechanical lift casters when lifting or lowering a resident.
6. Review of Resident #21’s admission MDS, dated [DATE], showed:
– Cognitively impaired;
– Total dependence upon staff for transfers, hygiene, and toileting;
– [DIAGNOSES REDACTED].
– Received hospice care.
Review of the resident’s care plan, dated 6/12/18, showed staff should transfer the
resident using a mechanical lift.
Observation on 7/11/18 at 10:26 A.M., showed:
– Without spreading the mechanical lift legs, CNA A raised the resident from his/her bed;
– Without spreading the mechanical lift legs, CNA A and CNA B moved the resident over the
wheelchair;
– Without locking the wheelchair, CNA B lowered the resident into the wheelchair.
During an interview on 7/11/18 at 10:30 A.M., both CNAs said:
– They thought they should not spread the lift legs when lifting, lowering, and
transferring a resident;
– They should have locked the resident’s wheelchair before lowering the resident.
7. Review of Resident #34’s quarterly MDS, dated [DATE], showed:
– Cognitive skills intact;
– Required extensive assistance of one staff for bed mobility;
– Dependent on the assistance of two staff for transfers;
– No impairment to upper or lower extremities;
– [DIAGNOSES REDACTED].
The resident’s care plan, dated 6/12/18, did not address how the resident was to be
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 12)
transferred.
Observation on 7/12/18 at 9:15 A.M., showed:
– LPN A and CNA B placed the lift pad under the resident;
– LPN A moved the mechanical lift under the bed with the legs of the lift closed;
– CNA B and LPN A hooked the lift sling up to the lift;
– LPN A opened the legs of the mechanical lift, locked the the rear casters, and raised
the resident up from the bed;
– LPN A unlocked the rear casters and backed the lift away from the bed;
– CNA B placed the resident’s wheelchair between the legs of the lift;
– LPN A locked the rear casters on the mechanical lift and CNA B locked the brakes on the
resident’s wheelchair;
– LPN A lowered the resident into his/her wheelchair and CNA B and LPN A unhooked the lift
sling from the lift.
During an interview on 7/12/18 at 12:19 P.M., CNA B said:
– The brakes should be locked on the mechanical lift.
During an interview on 7/12/18 at 12:25 P.M., LPN B said:
– The casters or brakes should be locked when raising or lowering the resident.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– Per the manufacturer’s guidelines, the brakes should not be locked on the mechanical
lift;
– He/she thought staff should not spread the mechanical lift legs when transferring a
resident;
– Staff should always lock a resident’s wheelchair when transferring a resident.
8. Review of the manufacturer’s guideline for the Invacare Stand Up Lift showed:
– Invacare does NOT recommend locking the rear swivel casters of the Stand Up Lift when
lifting and lowering an individual. Doing so could cause the lift to tip and endanger the
resident and the assistants.
– Invacare DOES recommend that the rear swivel casters be left unlocked during lifting and
transferring procedures to allow the Stand Up Lift to stabilize itself when the patient is
initially lifted from and transferred to a stationary object (bed or chair).
9. Review of Resident #30’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Dependent on staff for transfers;
– Limited range of motion to both sides upper and lower extremities;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 6/5/18, showed:
– Transfer the resident to the toilet and shower chair with the Stand Up Lift and two
staff assist at all times.
Observation on 7/11/18 at 1:46 P.M., showed CNA B and CNA D transferred the resident from
his/her wheelchair to the shower chair with the Stand Up Lift. CNA B locked the rear
casters of the lift as he/she lifted the resident from the wheelchair and lowered the
resident on to the shower chair.
During an interview on 7/11/18 at 2:37 P.M., CNA B said:
– He/she received CNA training at the facility. He/she was trained to lock the back
casters on the Stand Up Lift while lifting and lowering the resident.
During an interview on 7/13/18 at 8:01 A.M., the acting DON said she did not know what the
manufacturer’s guideline for the Stand Up Lift directed regarding the rear casters being
locked or unlocked during lifting and lowering the resident.
10. Review of Resident #14’s Smoking Safety Screen, effective date 3/25/18, showed 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 13)
facility team determined the resident was safe to smoke with supervision.
Review of the resident’s MDS, dated [DATE], showed:
– Moderately impaired decision making skills;
– Required extensive assistance for activities of daily living;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 5/16/18, showed
– The resident is a smoker and can smoke unassisted. The resident should always wear a
smoking apron.
Review of the resident’s smoking care plan, initiated on 7/11/18, showed the resident is
able to smoke unsupervised with his/her smoking apron on.
Observation on 7/11/18 at 10:24 A.M., the resident sat on the front porch unattended,
smoking a cigarette without wearing a smoking apron. At 10:30 A.M., the resident lit a
second cigarette without wearing a smoking apron. As he/she lit the second cigarette, the
resident’s forearm jerked up and down. LPN B came out to the front porch and held the
resident’s hand for a minute, then returned inside the facility. LPN B did not take a
smoking apron out to the resident.
During an interview on 7/11/18 at 11:42 A.M., the acting Director of Nurses said:
– The resident was supposed to wear a smoking apron when he/she smoked;
– The Smoking Assessment directed staff to ensure the resident was supervised;
– She interpreted supervision as the staff knowing the resident needed an apron on when
he/she went out to smoke.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide care
and services in a manner to prevent urinary tract infections [MEDICAL CONDITION] for
residents with catheters. Staff failed to keep catheter tubing and urinary drainage bags
off the floor and below the bladder, failed to appropriately clean catheter tubing and
drainage spouts, and failed to change a catheter as directed by the physician for two
sampled residents (Residents #30 and #34) out of 12 sampled residents. The facility census
was 35.
1. Review of Resident #30’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/31/18, showed staff assessed the resident
as:
– Able to make daily decisions;
– Indwelling catheter.
Review of the resident’s care plans, one revised on 6/5/18 and one initiated on 7/11/18,
directed staff to:
– Provide proper catheter care every shift;
– Keep the drainage bag below the level of the bladder, make sure there are no kinks or
loops in the tubing;
– Watch for and report to the charge nurse symptoms of a UTI.
Observation on the following dates and times showed:
– 7/10/18 at 1:38 P.M., the resident sat in his/her wheelchair in his/her room, 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
catheter tubing rested on the floor (about 10 inches), the dignity bag that held the
urinary drainage bag also rested on the floor;
– 7/11/18 at 08:49 A.M., the resident sat in his/her wheelchair with the catheter tubing
under the resident’s foot on the foot pedal, and the dignity bag touched the floor;
– 7/11/18 at 11:59 A.M., the resident sat in the dining room, his/her dignity bag and
tubing dragged the floor;
– 7/11/18 at 1:46 P.M., CNA B and CNA D transferred the resident from the wheelchair to
the shower chair with the sit-to-stand lift. CNA D placed the dignity bag on the floor of
the lift. The floor of the lift had dirt and debris on it. After staff transferred the
resident to the shower chair, two to three inches of the dignity bag lay on the floor. CNA
B took the urinary drainage bag out of the dignity bag and hung the drainage bag back on
the lower bar of the shower chair. Two to three inches of the drainage bag rested on the
shower room floor. The urine in the drainage bag was reddish amber in color. The drainage
bag rested on the the shower stall floor during the resident’s shower. CNA B attempted to
get urine in the tubing to drain into drainage bag. He/she held the tubing high above the
resident’s bladder, the urine ran backwards up tubing. CNA B emptied 300 cc of amber
urine, he/she did not clean the drainage spout before he/she placed the spout back inside
the holder on the drainage bag. The resident expressed the desire to use the toilet. CNA B
moved the shower chair, the drainage bag fell to the floor, and the wheel of the shower
chair rolled across the drainage bag. The resident had a bowel movement, CNA B provided
perineal care. CNA B changed gloves, did not wash hands, and used a new wipe to clean down
the catheter tubing.
During an interview on 7/11/18 at 2:37 P.M., CNA B said:
– The catheter tubing, drainage bag and dignity bag could not touch the floor;
– He/she was not taught to clean the drainage spout with alcohol pads.
During an interview on 7/13/18 at 8:01 A.M., the acting Director of Nurses said:
– Staff should not allow the catheter tubing, drainage bag or dignity bag to ever touch
the floor;
– Staff should clean the drainage spout with alcohol pads when they remove it from the
holder on the catheter drainage bag and before they replace it in the holder.
2. Review of Resident #30’s POS, dated 7/2018, showed the physician ordered a 20 french
Foley catheter, change every month on the 13th (original order on 3/22/18).
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as:
– Able to make daily decisions;
– Had an indwelling catheter;
– [DIAGNOSES REDACTED].
Record review of the resident’s May, (MONTH) and (MONTH) (YEAR) treatment administration
records (TAR’s), showed:
– Month of (MONTH) – staff did not initial they changed the resident’s catheter;
– Month of (MONTH) – staff initialed on 6/24 they changed the resident’s catheter, but
drew a line through the initial to indicate they documented in error;
– Month of (MONTH) – staff did not initial they changed the resident’s catheter.
Observation and interview on 7/10/18 at 1:38 P.M., showed the resident sat in his/her room
in his/her wheelchair. The catheter tubing lay on the floor under the wheelchair and the
urinary drainage bag was in the dignity bag that rested on the floor. The resident said
he/she did not remember the last time staff changed his/her catheter.
Review of the resident’s care plan, initiated 7/11/18, directed staff to change catheter
as ordered.
During an interview on 7/13/18 at 8:01 A.M., the acting Director of Nursing said staff
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
should follow the physician’s orders [REDACTED].
3. Review of Resident #34’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
– Cognitive skills intact;
– No impairment to upper or lower extremities;
– Frequently incontinent of bladder;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 7/10/18 at 9:24 A.M., showed:
– The resident sat in his/her wheelchair on the front porch and the dignity bag rested on
the ground.
Observation on 7/11/18 at 1:20 P.M., showed:
– The resident’s dignity bag rested on the floor;
– CNA A placed a trash bag on the floor and sat the graduate on it;
– CNA A unclamped the drainage spout, did not clean it and emptied the urine into the
graduate, dumped the graduate in the toilet then emptied more urine from the drainage bag;
– CNA A did not clean the drainage spout after he/she emptied the urine and replaced it in
the sleeve.
During an interview on 7/11/18 at 1:40 P.M., CNA A said:
– He/she was not taught to clean the port when emptying the drainage bag;
– The drainage bag should not rest or drag on the floor.
Observation on 7/11/18 at various times showed:
– The resident’s dignity bag rested or dragged on the floor as the resident propelled
him/herself in his/her wheelchair.
Review of the resident’s care plan, initiated on 7/11/18, showed:
– The resident had a Foley catheter related to urinary obstruction;
– Catheter care as ordered.
Observation on 7/12/18 at 6:43 A.M., showed:
– The resident’s dignity bag rested on the floor;
– CNA E placed the graduate directly on the floor;
– CNA E opened the clamp on the drainage spout and emptied the urine then placed the
drainage bag back in the dignity bag and hung it on the side of the bed;
– CNA E did not clean the drainage spout.
During an interview on 7/12/18 at 6:49 A.M., CNA E said:
– He/she was not trained to clean the drainage spout;
– He/she should have placed the graduate in a trash bag and not on the floor.
– The drainage bag or the dignity bag should not be on the floor.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– The drainage bag nor the catheter bag should rest on the floor or drag on the floor;
– The drainage spout should be cleaned before and after emptying it.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to communicate the consultant

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
pharmacist’s (PharmD) recommendations to residents’ physicians for three residents
(Residents #5, #21 and #25) out of 12 sampled residents. The facility census was 35.
1. Review of Resident #21’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/8/18 showed:
– Cognitively impaired;
– Total dependence upon staff for transfers, hygiene, and toileting;
– [DIAGNOSES REDACTED].
– Received hospice care.
Review of the resident’s Drug Regimen Review (DRR), dated 5/24/18, showed PharmD
documented:
– A recommendation to add blood pressure parameters to the resident’s [MEDICATION NAME]
(used to treat high blood pressure (BP), [MEDICATION NAME] (used to treat high BP),
[MEDICATION NAME] (used to treat high BP), [MEDICATION NAME] (used to treat high BP), and
[MEDICATION NAME] (used to treat high BP);
– A recommendation for pulse parameters for [MEDICATION NAME] (may cause a slow heart
rate);
– There was no documentation indicating the recommendations were relayed to the resident’s
physician.
Review of the resident’s physician’s orders [REDACTED].
– No BP parameters for [MEDICATION NAME], or [MEDICATION NAME];
– No pulse parameters for [MEDICATION NAME].
2. Review of Resident #25’s care plan, revised on 2/20/18, showed:
– The resident received [MEDICATION NAME] (antidepressant) and [MEDICATION NAME]
(antidepressant) routinely.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s DRR, dated 6/29/18, showed PharmD documented:
– The resident has been on [MEDICATION NAME] 10 mg. daily and [MEDICATION NAME] 10 mg.
(note; error by PharmD, should be 150mg) daily for some time;
– Quarterly dose reduction trials must be attempted to minimize or discontinue medications
that are unnecessary;
– Did not show any documentation the information was sent to the physician or if the
physician responded.
Review of the resident’s POS, dated (MONTH) (YEAR), showed:
– an order for [REDACTED].>- an order for [REDACTED].>3. Review of Resident #5’s
DRR, dated 3/27/18, showed PharmD documented:
-A recommendation for Gradual Does Reduction (GDR) [MEDICATION NAME] (antipsychotic) and
[MEDICATION NAME] (antidepressant);
-No documentation to show this was communicated with the physician or his/her response.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Cognitively impaired;
– Antipsychotic medication received on a routine basis;
– A GDR has not been attempted.
Review of residents POS, dated (MONTH) (YEAR), showed:
-[MEDICATION NAME] 25 mg tab, one tab at bedtime, started 8/26/16;
-[MEDICATION NAME] 25 mg tab, .5 tab in the morning, started 8/26/16;
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-[MEDICATION NAME] HCL 25 mg tab, (generic for [MEDICATION NAME]), one daily, started
1/29/17.
4. During an interview on 7/11/18 at 11:00 A.M., the Director of Nursing (DON) said:
– He/she recently assumed the position of DON;
– He/she had never seen a DRR sheet;
– He/she did not know what to do with the DRRs.
During an interview on 7/11/18 at 11:10 A.M., the Regional Nurse Consultant (RNC) said
staff must communicate the DRR with the residents’ physicians. The RNC did not know who is
responsible for this.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
administered medications with a medication error rate less than 5%. Staff made three
errors out of 27 opportunities for error, resulting in an error rate of 11%. This affected
three of 12 sampled residents (Residents #28, #236, #13). The facility census was 35.
1. Review of the facility policy on medication administration, dated 1/1/2014, showed
staff should administer medications in accordance with physicians’ orders.
2. Review of the package insert for K-Dur, dated (MONTH) 2004, showed:
– The medication was a potassium replacement;
– The medication must be administered with meals and a full glass of water.
Review of Resident #28’s Medication Administration Record [REDACTED].
Observation on 7/11/18 at 4:15 P.M., showed:
– The resident in bed without any snacks or food;
– Registered Nurse (RN) A gave the resident K-Dur 20 meq without food.
During an interview on 7/11/18 at 4:15 P.M., RN A said:
– The resident would not get a meal until at least 5:30 P.M.;
– He/she did not give K-Dur with a meal.
During an interview on 7/12/18 at 8:15 A.M., the Director of Nursing (DON) said staff
should always administer K-Dur with meals.
3. Review of Resident #236’s physician order sheet (POS), dated (MONTH) (YEAR), showed:
– an order for [REDACTED].
Observation and interview on 7/11/18 at 9:10 A.M., showed:
– LPN B removed 800 microgram (mcg.) of folic acid and said they use the folic acid 800
mcg. for the one mg., and administered it to the resident.
During an interview on 7/12/18 at 7:55 A.M., LPN B said:
– He/she thought 800 mcg was equal to 1 mg.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– If the micrograms are not equivalent to 1 mg., then the physician should be notified for
a new order or clarification.
4. Review of the insert for [MEDICATION NAME] Opthalmic solution, showed, in part:
– Do not touch the dropper tip to the surface of the eye.
Review of the website, www.webmd.com., for [MEDICATION NAME] ([MEDICATION NAME])
Ophthalmic solution, 0.3%, showed:
– Do not touch the dropper tip or let it touch the eye or any other surface;
-Tilt head back, look upward and pull down the lower eyelid to make a pouch;

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
– Hold the dropper directly over the eye and place one drop into the eye;
– Look downward and gently close eyes for one to two minutes;
– Place one finger at the corner of the eye (near the nose) and apply gentle pressure for
one to two minutes. This will prevent the medication from draining out;
– Try not to blink and do not rub the eye.
Review of Resident #13’s POS, dated (MONTH) (YEAR), showed:
– an order for [REDACTED].
Observation on 7/11/18 at 9:28 A.M., showed:
– LPN B placed tissues, eye drop bottle and gloves on a paper towel and washed his/her
hands and applied gloves;
– LPN B touched the tip of the eye dropper to the resident’s upper eyelid and instilled
one drop in the resident’s right eye;
– LPN B placed his/her finger in the middle of the resident’s closed upper eye for 30
seconds, removed gloves and washed his/her hands.
During an interview on 7/12/18 at 9:15 A.M., LPN B said:
– The eye dropper should not touch the resident’s eyelid;
– He/she should have applied lacrimal pressure to the inner eye by the resident’s nose for
one minute.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– Staff should not touch the the eye drop to the eyelid and should apply lacrimal pressure
to the corner of the eye for one minute.

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 failed to ensure staff
properly stored and discarded resident medications and stock medications. Staff failed to
date medications when opened and failed to discard expired medications. This affected
three of 12 sampled residents (Resident #15, #21, and #38). The facility census was 35.
1. Observation on 7/10/18 at 10:07 A.M., of the storage room showed:
– Nine, 13 ounce containers of petroleum jelly, expired 5/18;
– One, four ounce container of [MEDICATION NAME] solution skin cleanser, expired 2/2012;
– Two, 16 ounce packages of epsom salt, expired 5/2018;
– The 200 hall medication cart contained: one opened bottle of Vitamin C, expired 1/18;
one opened bottle of Aspirin, 325 mg., expired 1/18; one bottle of senior tabs, expired
6/18; Resident #15 had a bottle of deep sea nasal spray, expired 5/18; [MEDICATION NAME]
80 mg., expired 2/18; [MEDICATION NAME] 0.5 mg. and [MEDICATION NAME] sulfate 3 mg., 89
vials did not have a pharmacy label.;
– Resident #15 had [MEDICATION NAME] sulfate, 100 mg. per 5 ml., filled on 2/22/18 and did
not have a date when staff opened it and had less than 12 ml. left in the bottle;
– The medication room: two unopened Tresiba insulin pens did not have a pharmacy label;
Resident #38 was deceased and had an unopened vial of [MEDICATION NAME] and two bottles of
[MEDICATION NAME] insulin.
During an interview on 7/10/18 at 10:07 A.M., Licensed Practical Nurse (LPN) A said he/she
did not know who the 89 vials of [MEDICATION NAME] and [MEDICATION NAME] sulfate, and 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 19)
Tresiba insulin pens belonged to. LPN A said all nurses and CMT’s should check for
outdated medications, staff should not use outdated medications, and medications should be
labeled with the date they are opened.
During an interview on 7/13/18 at 8:01 A.M., the Director of Nursing (DON) said:
– She thought a nurse had been assigned to check for expired medications but did not know
who it was;
– Staff should not administer medications that are expired or use treatment medications
that are expired;
– Medications and insulin pens should be dated when opened.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure meals and snacks are served at times in accordance with resident’s needs,
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

Based on observation and interview, the facility failed to ensure staff offered HS
(bedtime) snacks to each resident, which affected seven (Resident #2, #3, #6, #12, #22,
#26 and #30) of seven residents who attended the group meeting. The facility census was
35.
1. During the resident group meeting, on 7/11/18 at 3:07 P.M., the following residents
said:
– Resident #22 said he/she did not get any snacks at bedtime;
– Resident #2 said if you ask for a snack you can have one;
– All seven residents said the staff do not offer a snack at bedtime;
– All seven residents said they would take a snack at bedtime if it was offered to them.
During an interview on 7/12/18 at 1:03 P.M., Certified Nurse Aide (CNA) D said:
– There was a snack cart in the medication room and snacks were supposed to be offered,
especially to those with diabetes, but he/she did not think it was done.
During an interview on 7/13/18 at 8:01 A.M., the Director of Nursing (DON) said:
– There was a snack cart in the medication room, and after supper she would ask each
resident if they wanted a snack, especially those with diabetes;
– Staff should document if a resident accepts or refuses the HS snack.
During an interview on 7/13/18 at 10:30 A.M., the dietary supervisor said:
– The dietary staff prepare HS snacks and keep them in the medication room;
– Peanut butter and jelly sandwiches are kept in the medication room;
– They keep a metal cart with drawers with different types of individual snacks, such as
oatmeal cream pies, fudge rounds, applesauce, and peanut butter and cheese crackers;
– The facility does not have a form or documentation to show if the resident received or
was offered an HS snack.

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, the facility failed to ensure staff

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 20)
used proper infection control when staff failed to wear gloves when administering insulin
and failed to clean the glucometer after use for one of 12 sampled residents (Resident
#25). Additionally, the facility did not ensure staff who provided care for two residents
(Residents #29 and #236) in isolation washed their hands between dirty and clean tasks and
before they left the residents’ rooms. The facility census was 35.
1. Review of the undated manufacturer’s instructions for the facility’s Assure Platinum
glucometer showed:
– Contact with blood represented a potential infection risk;
– Staff should clean and disinfect the meter after use.
Review of the facility policy, dated 1/1/2014, on cleaning glucometers showed staff should
clean and disinfect all glucometers after each use.
Review of Resident #25’s physician order sheet (POS), dated (MONTH) (YEAR), showed an
order for [REDACTED].
Observation on 7/11/18 at 10:55 A.M., showed:
– Licensed Practical Nurse (LPN) B performed a blood glucose for Resident #25;
– After performing the blood glucose, he/she put the used glucometer in a bag labeled with
the resident’s name.
During an interview on 7/11/18 at 10:55 A.M., LPN B said:
– Each resident had his/her own bag containing his/her glucometer machine and glucometer
supplies;
– According to facility policy, the night shift cleaned each resident’s glucometer machine
every night.
During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff
should always disinfect every glucometer after use.
2. Observation on 7/11/18 at 9:51 A.M., showed Licensed Practical Nurse (LPN) B
administered an insulin injection to Resident #25 without wearing gloves.
During an interview on 7/11/18 at 9:51 A.M., LPN B said he/she always gave injections
without wearing gloves.
During an interview on 7/11/18 at 3:10 P.M., the Director of Nursing (DON) said staff
should always wear gloves when administering injections.
3. Review of the facility’s Handwashing policy, issued 2/16, showed:
– To provide guidelines to staff for proper and appropriate hand washing and hygiene
techniques that will aid in the prevention of the transmission of infections;
– Staff will perform hand hygiene by washing hands for at least 15 seconds with anti- or
non-antimicrobial soap and water should be performed under the following conditions:
– When hands are visibly dirty or soiled with blood or other body substances;
– Before entering and leaving an isolation room;
– Before applying gloves and after removing gloves or other personal protective equipment;
– After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin;
– After handling items potentially contaminated with blood, body fluids, or secretions;
– Before moving from a contaminated body site to a clean body site during resident care;
example: after providing perineal care, before applying moisture barrier cream or other
treatments;
– After providing direct resident care;
– If exposure to an infectious disease is suspected or proven.
Review of the facility’s Isolation Precautions policy, dated 1/1/14, showed:
– To establish transmission based precautions for residents who are suspected or confirmed
to have communicable diseases/infections that could be transmitted to others;
– Appropriate communication/notices will identify the resident/room with isolation
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 21)
precautions implemented;
– Contact Precautions – Prior to entering the isolation room, the following steps are
required, perform hand hygiene and apply gloves and gown prior to entering the room;
– While providing direct resident care, remove gloves and wash hands after coming in
contact with infectious material;
– Remove gloves and perform hand-hygiene before leaving the room (do not use alcohol-based
hand gels for isolation due to suspected or confirmed [MEDICAL CONDITION] ([MEDICAL
CONDITION], a bacterium that can cause symptoms ranging from diarrhea to a life
threatening inflammation of the colon).
4. Review of Resident #30’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Required extensive assistance of staff with toilet use, personal hygiene and bathing;
– Indwelling catheter and occasionally incontinent of bowel.
Review of the resident’s care plan, revised 6/5/18, showed:
– Please offer the toilet before and after meals, activities, and before going to bed;
– Required extensive assist with bathing as scheduled;
– Please be sure to provide proper catheter care every shift.
Observation on 07/11/18 01:46 P.M., showed CNA B assisted the resident with his/her shower
as needed. The resident expressed he/she needed to use the toilet. CNA B moved the shower
chair over to the toilet. CNA B wiped fecal matter from the rectal area with four wipes,
changed gloves but did not wash his/her hands, used a wipe and cleaned the tip of the
perineal fold which had bright red blood. CNA B changed his/her gloves, did not wash hands
and cleaned down the resident’s catheter tubing. CNA B changed his/her gloves, did not
wash hands and proceeded to dress the resident.
During an interview on 7/11/18 at 2:37 P.M., CNA B said he/she should wash hands:
– When entering the resident’s room;
– Before and after he/she provided care and in between glove changes;
– During a shower, he/she should wash his/her hands every time he/she changed his/her
gloves to clean another area of the resident’s body.
5. Review of Resident #29’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Required assistance of staff with toilet use, personal hygiene and dressing;
– Indwelling catheter;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s current care plan showed no care plan for [MEDICAL CONDITION] or
[MEDICAL CONDITION].
Review of the resident’s current POS, dated (MONTH) (YEAR), showed the physician ordered
[MEDICATION NAME] 125 mg./ per 5 ml, suspension , give 5 ml every 6 hrs for[DIAGNOSES
REDACTED].
Observation on 7/10/18 at 1:07 P.M., showed a plastic three-drawer container outside the
resident’s door that held personal protective equipment (PPE) used for residents on
isolation precautions. There was no notification posted to direct visitors to see the
nurse to see if it was alright to enter the resident’s room. The resident lay in his/her
low bed with a catheter drainage bag inside a dignity bag, the bottom of which rested on
the floor. CNA A and CNA C did not wash their hands. CNA A provided perineal care and
catheter care, assisted CNA C to roll the resident to his/her side and cleaned fecal
material from the resident’s rectum. Without changing his/her gloves or washing his/her
hands, CNA A wiped moisture barrier cream on the resident’s buttocks and genitalia.
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 22)
Without changing his/her gloves or washing his/her hands, CNA A proceeded to place a clean
brief on the resident, pulled the resident’s gown down, positioned a pillow behind the
resident’s back and underneath the resident’s head. CNA A retrieved a graduate from the
bathroom, drained the urinary drainage bag of 300 cc of amber colored urine. CNA A placed
the used graduate in a plastic bag and told CNA C he/she would hand the bag to CNA C at
the resident’s doorway. CNA C bagged up soiled linens and trash and placed them in the
biohazard receptacles, removed his/her PPE, retrieved a clean plastic bag and without
washing his/her hands opened the resident’s door, held the plastic bag open for CNA A to
place the bagged graduate into. CNA C carried the plastic bag down the hallway. CNA A
removed his/her PPE, did not wash his/her hands and reopened the resident’s door, grabbed
a clean pair of gloves, picked up the remote to lower the resident’s bed and touched
buttons on the resident’s television before he/she removed his/her gloves and washed
his/her hands.
During an interview on 7/11/18 at 9:18 A.M., CNA A said the resident was on isolation
because he/she had [MEDICAL CONDITION].
During an interview on 7/11/18 at 11:10 A.M., LPN A said staff should have placed a sign
on the door for visitors to see the nurse before entering the resident’s room.
During an interview on 7/11/18 at 2:25 P.M., CNA A said he/she should wash his/her hands:
– Before gloving and when changing gloves;
– Before and after resident care;
– Anytime he/she touches a resident or touches anything soiled;
– After cleaning fecal matter, before applying cream to the resident’s bottom or before
repositioning a resident in his/her bed.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– Staff should wash their hands when they enter the resident’s room;
– Staff should wash their hands if they get their gloves soiled while giving care, they
should change gloves and wash their hands and put on new gloves;
– Staff should wash hands between dirty and clean tasks;
– Before they leave a resident’s room and when they reenter a resident’s room;
– If staff provided care for a resident on isolation, they should remove their gown and
gloves, then their mask and wash their hands before they leave the room;
– Resident #29 had a [DIAGNOSES REDACTED].
6. Review of Resident #236’s admission MDS, dated , 4/16/18, showed:
– Cognitive skills moderately impaired;
– Dependent on two staff for bed mobility, transfers and toilet use;
– Occasionally incontinent of bowel and bladder.
Review of the resident’s care plan, revised on 7/10/18, showed:
– The resident had [MEDICAL CONDITION] infection, (MRSA, a type of staph bacteria
resistant to the antibiotic [MEDICAL CONDITION]);
– Administer antibiotics per physician’s orders;
– The resident was on contact precautions [MEDICAL CONDITION];
– Contact isolation precautions [MEDICAL CONDITION] in nares (nose).
Review of the physician’s order sheet (POS), dated (MONTH) (YEAR), showed:
– 7/3/18: an order for [REDACTED].>- 7/10/18: an order for [REDACTED].>Observation
on 7/10/18 at 8:38 A.M., showed:
– The resident was in a low bed;
– The door was half way open;
– A plastic three drawer cart on wheels was placed outside the resident’s room which
contained PPE to be used prior to entering 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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 23)
– The facility did not have a sign posted on the outside of the resident’s door informing
visitors about the isolation precautions.
Observation on 7/11/18 at 8:19 A.M., showed:
– The resident’s door was open;
– CNA D applied gloves, gown and mask then entered the resident’s room. He/she did not
wash his/her hands;
– CNA D transferred the resident from his/her bed to his/her wheelchair;
– CNA D removed the gloves, gown and mask and left the room to get a portable oxygen
canister;
– CNA D did not wash his/her hands before leaving the resident’s room;
– CNA D did not wash his/her hands, applied gloves, gown and mask and brought a portable
oxygen canister in the resident’s room;
– CNA D gave the resident a mask to wear in the hallway and instructed him/her to go down
the hall and get weighed;
– CNA D removed his/her gloves, gown and mask, did not wash his/her hands and left the
room.
Observation on 7/12/18 at 9:43 A.M., showed:
– The resident’s door was open;
– CNA D applied gloves, gown and mask and entered the resident’s room;
– CNA D transferred the resident from his/her chair to the bedside commode;
– The resident was incontinent of urine and his/her pants were wet;
– CNA D removed the resident’s wet incontinent brief and wet pants;
– CNA D removed gloves, did not wash his/her hands and applied gloves;
– The resident urinated on the floor;
– CNA D cleaned the urine with a towel;
– CNA D removed his/her gloves, did not wash his/her hands and applied new gloves;
– CNA D put a clean incontinent brief on the resident and clean pants;
– CNA D provided incontinent care and applied skin barrier cream to the resident’s
buttocks;
– CNA D removed gloves, did not wash his/her hands and applied new gloves;
– CNA D assisted the resident with dressing and the resident put a mask on and left the
room;
– CNA D removed his/her gloves, gown and mask and did not wash his/her hands before
leaving the room.
Observation at different times throughout the survey from 7/10/18 – 7/13/18, showed:
– The resident’s door was left open and did not have a sign instructing visitors to see
the nurse before entering the resident’s room.
During an interview on 7/12/18 at 1:03 P.M., CNA D said:
– He/she should wash hands before care, between clean and dirty tasks, between glove
changes, when entering and leaving residents’ rooms;
– He/she should have washed his/her hands before entering the isolation room;
– He/she thought there should have been a sign on the resident’s door about him/her being
in isolation;
– The resident’s door should have been closed.
During an interview on 7/13/18 at 8:01 A.M., the DON said:
– Staff should wash their hands when they enter the resident’s room, if the gloves get
soiled, between clean and dirty tasks, between glove changes and if they leave the room
and reenter;
– Staff should wash their hands when removing PPE;
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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 24)
– When a resident was in isolation, staff should post a sign on the resident’s door.

F 0881

Level of harm – Potential for minimal harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program that includes antibiotic use protocols and a system to monitor
antibiotic use. This deficient practice had the potential to affect all residents in the
facility. The facility census was 35.
1. Record review of the facility’s blank, undated and unsigned Antibiotic Stewardship
form, showed the facility had not developed or implemented an Antibiotic Stewardship
Program that should include:
– Protocols to optimize the treatment of [REDACTED].
– Procedure to reduce the risk of adverse events, including the development of
antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use;
– Procedure to promote and implement a facility-wide system to monitor the use of
antibiotics including a system of reports related to monitoring antibiotic usage and
resistance data;
– Designated appropriate facility staff accountable for promoting and overseeing
antibiotic stewardship;
– Accessing pharmacists and others with experience or training in antibiotic stewardship;
– Implementation of a policy or practice to improve antibiotic use;
– Regular reporting on antibiotic use and resistance to relevant staff such as prescribing
clinicians and nursing staff;
– Educate staff and residents about antibiotic stewardship.
During an interview on 7/13/18 at 11:08 A M., the Regional Nurse Consultant said corporate
staff were writing the policy and procedures for the Antibiotic Stewardship Program, but
as of today’s date it had not been rolled out or implemented at this facility.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Based on interview and record review, the facility failed to ensure all residents were
offered the influenza (flu) and pneumonia vaccines in a timely manner. This affected two
of 12 sampled residents (Residents #10 and #21). The facility census was 35.
1. Review of the facility policy, dated 1/1/2014, on flu vaccine showed:
– Staff must screen all residents for flu vaccine history;
– Staff must offer flu vaccine to all residents during flu season (typically (MONTH)
through May).
Review of the facility policy, dated 1/1/2014, on pneumonia vaccine showed:
– Staff must assess all residents for pneumonia vaccine history;
– Staff must offer pneumonia vaccine to all unvaccinated residents.
2. Review of Resident #10’s medical records showed:
– Date of admission was 11/29/13;
– Staff last administered flu vaccine to the resident on 10/2016;

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:

265728

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

NAME OF PROVIDER OF SUPPLIER

KING CITY MANOR

STREET ADDRESS, CITY, STATE, ZIP

300 WEST FAIRVIEW
KING CITY, MO 64463

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
– No record that staff offered the flu vaccine in (YEAR).
3. Review of Resident #21’s medical records showed:
– Date of admission was 4/26/18;
– Staff did not assess the resident’s immunization status on admission;
– Staff did not offer the resident any immunizations.
During an interview on 7/12/18 at 10:00 A.M., the Director of Nursing said:
– Staff should offer residents immunizations according to the Center for Disease Control
Guidelines;
– The facility does not have a mechanism to monitor offering residents immunizations.

F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure they maintained an
effective pest control program. The facility census was 35.
1. Observation throughout the survey on 7/10/18 to 7/13/18, showed:
– Flies in the bathroom between room [ROOM NUMBER] and room [ROOM NUMBER];
– Flies landing on various residents;
– Flies in the shower room on the 200 hall;
– A resident with a fly swatter in his/her motorized wheelchair;
– Director of Nursing (DON) with a fly swatter in her office;
– Flies in the kitchen during meal prep;
– Flies in the family room at the end of the 300 hall.
Observation throughout the survey on 7/10/18 to 7/13/18, showed staff, residents and
visitors entering and exiting through the front door, which opened directly into the main
dining room. The front porch was the resident smoking area.
During a resident council interview on 7/11/18 at 3:05 P.M., six out of seven residents
said the flies are terrible. Flies are always by the trash can in the dining room, get in
their milk and cereal, and bother them when they try to sleep.
During an interview on 7/11/18 at 1:35 P.M., DON said the flies in the facility are
terrible.
During an interview on 7/12/18 at 7:40 A.M., Maintenance Director said he has not noticed
a lot of flies, just a few. They have not done anything to address the files in the
facility. He believes the flies are there because of how frequently the front door opens.