Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Potential for minimal harm

Residents Affected – Many

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on staff interview and record review, facility staff failed to check the Certified
Nurses’ Assistant (CNA) Registry before hire for all staff to ensure they did not have a
Federal Indicator (a marker given by the federal government to individuals who have
committed abuse/neglect) for three out of eight sampled employees hired since the last
survey. The facility hired 59 new employees since the last survey. The census was 49.
Review of the facility’s Abuse and Neglect policy, dated 11/18, showed staff are directed
the facility will not knowingly employ individuals who have been found guilty of abusing,
neglecting, or mistreating residents or misappropriating their properties. All employees
will have criminal background checks, state and federal required checks, employment
reference checks, and license/certification confirmation. The facility will report any
knowledge it has of actions by a court of law against an employee, which would indicate
that they are unfit for service as a nurse aid or other facility staff, to the nurse aide
registry, licensing authorities or other mandated state agencies.
1. Review of the Activity Director’s employee file, showed the following:
-Hire date of 6/27/18;
– The staff did not complete a CNA registry check until 7/12/18.
2. Review of CMT D’s employee file, showed the following:
-Hire date of 5/1/19;
-Staff did not document a CNA registry check.
3. Review of Cook E’s employee file, showed the following:
-Hire date of 5/3/19;
-Staff did not document a CNA registry check.
4. During an interview on 6/27/19 at 6:20 P.M., the administrator and the Director of
Nursing (DON) said staff are expected to complete and file a CNA registry check for all
staff. The CNA registry checks should be completed before an individual is hired. The
administrative staff have been working together to get the checks completed, but they may
have missed some.

F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff provided notice
of discharge/transfer to the resident or his/her representative for 12 out of 12 sampled
residents with a facility initiated discharge or transfer (Residents #7, #10, #18, #24,
#49, #51, #100, #300, #301, #302, #303, #304). This had the potential to affect all
residents with a facility initiated discharge or transfer. The census was 43.
1. Review of the facility’s policy for resident discharge/transfer to the hospital, dated
11/14/18, showed the following:
-When a resident requires a discharge to the hospital, a letter stating the reason for
transfer will be given to the resident;
-If the resident does not comprehend or understand the reason for discharge to the
hospital, or there is any question, the responsible party will be notified and an
explanation of the bed reservation, as well as, the explanation for the reason for

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 1 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 1)
discharge to the hospital will be given to the resident representative;
-A copy of the receipt of the letter will be maintained in the medical record;
-If a discharge is deemed necessary for non-payment of bill or the facility can no longer
meet the needs of the resident, a separate discharge will be issued.
2. Review of Resident #7’s medical record, showed the following:
-The resident transferred to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
3. Review of Resident #10’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
4. Review of Resident #18’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
5. Review of Resident #24’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
6. Review of Resident #49’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
7. Review of Resident #51’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE] and again on 4/18/19;
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
8. Review of Resident #100’s medical record, showed the following:
-Staff transferred the resident to the hospital 6/23/19;
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
9. Review of Resident #300’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE] and again on 4/22/19;
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative on either date.
10. Review of Resident #301’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
11. Review of Resident #302’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
12. Review of Resident #303’s medical record, showed the following:
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
13. Review of Resident #304’s medical record, showed the following:
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 2 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 2)
-Staff transferred the resident to the hospital on [DATE];
-Additional review showed staff did not document they issued a transfer/discharge letter
to the resident or resident’s representative.
14. During an interview on 6/27/19 at 6:20 P.M., the Administrator and the Director of
Nursing (DON) said the discharge/transferred letters are supposed to be given to the
resident/responsible party. The facility has a three page letter that is supposed to be
given out. The staff have not been completing the letters. There is no reason why the
staff is not getting the letters completed and given to the resident.

F 0680

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure the activities program is directed by a qualified professional.

Based on interviews and record review, the facility failed to ensure the activities
program was directed by a qualified professional. The census was 49.
1. During an interview on 6/26/19 at 11:45 A.M., the Activity Director (AD) said he/she
has worked as the AD for one year. Prior to taking the position, the AD was a social
worker in the facility. He/she had some training from the former AD but has had no other
training. He/she is not currently certified and is not enrolled in a course to become
certified. He/she is the only AD for the facility, and he/she is not assisted or
supervised by any other staff who is certified.
2. Record review of the AD’s employee file on 6/27/19 at 10:00 A.M., showed the file did
not contain an Activity Director certification nor an enrollment in training to become
certified as a Activity Director.
3. During an interview on 6/27/19 at 6:20 P.M., the Administrator (ADM) and the Director
of Nursing (DON) said the AD has been doing activities for approximately a year. The AD is
not enrolled in a class to become certified. The Administrator did not know the AD had to
be certified.

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, facility staff failed to ensure the
residents’ environment remained free of accident hazards when they failed to remove
portable oxygen tanks from the residents’ wheelchairs before smoking for four out of ten
residents who smoked (Resident #9, #22, #24, and #26). In addition, the facility failed to
ensure one resident’s side rails were secured in a manner that prevented the rails from
moving when leaned on by the resident for one resident (Resident #24). The facility census
was 49.
1. Review of the facility’s Oxygen Therapy Policy, undated, showed safety measures: oxygen
speeds up combustion but does not cause a fire. The resident should not be near any open
flames (e.g. a candle, barbeque pit, gas stove, etc.) while the oxygen is in use.
2. Review of Resident #9’s quarterly Minimum Data Set (MDS), a federally mandated

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 3 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 3)
assessment instrument completed by facility staff, dated 6/19/19, showed the following:
– Brief Interview for Mental Status (BIMS) of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s Treatment Administration Record (TAR) dated 6/10/19-7/09/19,
showed an order for [REDACTED].
Observation on 6/25/19 at 10:31 A.M. and at 1:26 P.M., showed the resident sat in his/her
wheelchair and smoked a cigarette in front of the facility. Further observation showed a
portable oxygen tank on the back of his/her wheelchair.
3. Review of Resident #22’s admission MDS, dated [DATE], showed the following:
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy.
Review of the resident’s POS, dated 6/10/19-7/09/19, showed an order for [REDACTED].
Review of the resident’s treatment administration record (TAR) dated 6/10/19-7/09/19,
showed an order for [REDACTED].
Observation on 6/25/19 at 10:31 A.M., showed the resident sat in his/her wheelchair and
smoked a cigarette in front of the facility. Further observation showed a portable oxygen
tank on the back of his/her wheelchair.
Observation on 6/25/19 at 1:26 P.M., showed the resident sat in his/her wheelchair with a
portable oxygen tank on the back of his/her wheelchair and smoked a cigarette in front of
the facility. Further observation showed his/her nasal cannula draped across his/her lap.
4. Review of Resident #26’s admission MDS, dated [DATE], showed the following:
– admission date of [DATE];
– BIMS of 9 out of 15, moderate cognitively impaired;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility.
Review of the resident’s POS, dated 6/14/19 through 7/9/19, showed an order for
[REDACTED].
Observation on 6/25/19 at 10:31 A.M., showed the resident sat in his/her wheelchair and
smoked a cigarette in front of the facility. Further observation showed a portable oxygen
tank on the back of his/her wheelchair.
Observation on 6/25/19 at 1:26 P.M., showed the resident sat in his/her wheelchair in
front of the facility and smoked a cigarette with a portable oxygen tank on the back of
his/her wheelchair.
5. During an interview on 6/25/19 at 2:30 P.M., certified medication technician (CMT) C
said the staff have asked a supervisor before about the residents smoking with the oxygen,
because oxygen is flammable. He/She said staff are directed to shut the oxygen off and
remove the nasal cannula from the residents’ nose.
During an interview on 6/25/19 at 2:30 P.M., licensed practical nurse (LPN) B said if
staff have residents outside for a smoke break, and the residents have an oxygen tank,
staff are expected to turn the oxygen off and remove the nasal cannula from the resident’s
face.
During an interview on 6/25/19 at 2:47 P.M., The Director of Nursing (DON) said staff are
expected to remove any oxygen from a resident before taking them out to smoke. Oxygen
should either be left in the residents’ room, in one of the oxygen compartment storage
areas outside, or in a tank holder inside the exit doors. Staff orientation training
includes instructions to remove the oxygen tanks before smoking. If staff find a resident
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 4 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 4)
outside smoking with oxygen in use, he/she expects staff to report it to supervisor
immediately so it can be corrected. Oxygen should not be in a smoking area.
6. Review of the facility’s Side Rail Policy, dated 1/24/18, showed the following
direction to staff:
– Quarterly inspection of side rails per maintenance and/or designee, for safety and
proper working conditions;
– Monitoring and supervision of railing use.
Review of Resident #24’s quarterly MDS, a federally mandated resident assessment, dated
5/1/19, showed staff assessed the resident as follows:
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Required extensive assistance for bed mobility.
Review of the resident’s POS dated, 6/10/19-7/9/19, showed an order for [REDACTED].
Observation on 6/24/19 at 11:00 A.M. of the resident’s bed, showed the right siderail to
be extremely loose. The resident used the side rail to position his/herself in the bed and
the rail moved back and forth approximately 6 inches.
During an interview on 6/24/19 at 11:00 A.M., Resident #24 said he/she used the bed rail
to turn over or to position himself/herself in bed. He/She said the siderails are very
loose and move when he/she uses them.
During an interview on 6/26/19 at 4:11 P.M., nurse aid (NA) I said he/she was not aware of
any problems with the resident’s bed, but siderails should be firmly attached to the
resident’s bed.
During an interview on 6/26/19 at 4:04 P.M., licensed practical nurse (LPN) A said
siderails should be solid and not move around when the residents use them. He/She has not
been informed of any problems.
During an interview on 6/27/19 at 8:40 A.M., the Maintenance Director said repair/damage
request sheets are available to staff and should be completed if they notice any equipment
in need of repair. He/She follows up on those requests. The Housekeeping Supervisor is
responsible for the installation and maintenance of bed rails.
During an interview on 6/27/19 at 9:10 A.M., the Housekeeping Supervisor said he/she was
not aware the resident’s side rail was loose. Staff do not complete repair/damage requests
for siderails, they give him a verbal report of problems with siderails. The Housekeeping
Supervisor said he/she did not have a regular schedule for inspection and maintenance of
siderails.
During an interview on 6/27/19 at 6:40 P.M., the Administrator and the Director of Nursing
(DON), said residents’ siderails should not be loose or move when residents use them. They
expect the CNAs or nurses to report any issues with siderails to the Maintenance Director.
They did not know Resident #24’s siderails were loose.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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, facility staff failed to obtain a
physician’s order with valid medical justification for use of a urinary catheter (tube

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 5 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 – Some

(continued… from page 5)
inserted into the bladder to drain urine). In addition, the facility staff failed to
ensure the residents’ catheter tubing was not kinked or twisted, failed to place the
drainage bag in a privacy bag, and failed to address the use of catheter in the resident
care plan. This affected six residents out of eight residents with a catheter (Resident
#1, #12, #14, #18, #24, and #36). The census was 49.
1. Review of the facility’s Urinary Catheter Insertion, Care, and Monitoring Policy, dated
(MONTH) 2019, showed the following:
-A resident who enters the facility without an indwelling catheter should not be
catheterized unless clinically necessary. Clinically necessary reasons for urinary
catheterization include: [MEDICAL CONDITION], contamination to a stage III or IV pressure
wound, or a terminal illness or severe impairment that makes positioning or clothing
changes uncomfortable;
-A resident who enters the facility with an indwelling catheter should be reported to the
Director of Nursing (DON). The Quality Assurance Department will examine the charts of
these residents to make sure it is well documented that the catheter is clinically
necessary;
-There must be a physician’s order for catheter insertion, specifying the size and type of
catheter and why the catheter is clinically necessary.
2. Review of Resident #1’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/14/19, showed the following:
– admission date of [DATE];
– BIMS (Brief Interview for Mental Status) of 15 out of 15, cognitively intact;
– Required total dependence for bed mobility;
– Transfers did not occur in seven out of the last seven days;
– No impairments in range of motion for upper or lower extremities;
– Indwelling catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s hospital discharge documentation, dated 6/7/19, showed the
following:
– [DIAGNOSES REDACTED].
– No orders or instructions regarding the use of a catheter.
Review of the resident’s physician’s order sheet (POS), dated 6/7/19, showed the
following:
– [DIAGNOSES REDACTED].
– Order, dated 6/7/19, to change Foley every month on the 10th;
– Order, dated 6/7/19, Foley catheter care daily;
– The POS did not contain orders for catheter tubing or bulb size.
Review of the resident’s current treatment administration record (TAR), showed the
following:
– Treatment, no date, Foley catheter care daily;
– Treatment, dated 6/11/19, change Foley bag monthly and as needed (PRN);
– Treatment, no date, change Foley every month on the 19th, 16 French;
– The TAR did not contain orders for bulb size.
Review of the resident’s medical record showed the resident did not have a baseline care
plan.
Review of the resident’s comprehensive care plan, last reviewed on 6/10/19, showed it did
not contain information regarding the use of a catheter.
Observation on 6/25/19 at 8:30 A.M. and on 6/27/19 at 9:35 A.M., showed the resident in
bed with a catheter in place.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 6 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 – Some

(continued… from page 6)
3. Review of Resident 12’s significant change MDS, dated [DATE], showed the following:
– admission date of [DATE];
– BIMS of 15 out of 15, cognitively intact;
– Limited assistance for bed mobility;
– Total dependence for transfers;
– No impairments in range of motion for upper or lower extremities;
– Does not have an indwelling catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 6/10/19 through 7/9/18, showed the following:
– [DIAGNOSES REDACTED].
– An order, dated 4/9/19, change Foley monthly on the 22nd, 16 French;
– An order, dated 4/9/19, Foley catheter care every shift;
– The POS did not contain a valid medical justification for the use of an indwelling
catheter.
Review of the resident’s Re-Admission Bladder Evaluation, dated 3/26/19, showed the
following:
– Alert and oriented;
– No recent surgery;
– No catheter;
– Has perception of the need to void;
– Bladder not distended;
– Distance to the toilet/commode restricts or facilitates the resident’s toileting
ability;
– No bladder program information.
Review of the resident’s Re-Admission Clinical Health Status form, dated 3/26/19, showed
the following under Section F, Urinary Incontinence:
– Continent of bladder;
– In scheduled toileting plan, history of catheter use in last 48 hours;
– Liners/briefs used;
– No indwelling catheter;
– Summary of Indwelling Catheter Evaluation: All questions are checked NO and there is no
appropriate [DIAGNOSES REDACTED]. Resident is a potential candidate for nursing,
restorative/rehabilitation, or bladder training program.
Review of the resident’s nurses notes, showed the following:
– On 3/26/19 at 2:00 P.M., resident returned to the facility with [DIAGNOSES REDACTED].
Foley catheter removed before discharge;
– On 4/21/19 at 10:50 A.M., doctor conducted rounds. New order for Foley, insert 16
French, 20 cc;
– On 4/21/19 at 3:30 P.M., nurse attempted to insert resident’s Foley with no urine
return. Nurses pushed 10cc fluid, and the resident voiced he/she felt strong
pressure/discomfort. Withdrew the 10cc of fluid and removed Foley. Will attempt next
shift;
– On 4/22/19 at 9:00 P.M., 16 French Foley catheter inserted. Returned 2500 cc of dark
yellow urine, no sediment noted;
– On 5/28/19 at 10:30 P.M., Foley removed. 18 French Foley inserted;
– The nurses notes did not contain information regarding a medical justification for the
use of an indwelling catheter or for the change from a 16 French to an 18 French tubing.
Review of the resident’s care plan, last reviewed on 5/1/19, showed the following:
– [DIAGNOSES REDACTED].
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 7 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 – Some

(continued… from page 7)
– Problem: the resident has an indwelling catheter, atonal bladder;
– Problem start date: 5/1/19;
– Goal: The resident will remain free from catheter-related trauma through review date;
– Interventions: Check tubing for kinks each shift, position bag and tubing below bladder.
Observation on 6/26/19 at 5:07 P.M., showed the resident in his/her wheelchair in his/her
room. The resident’s catheter tubing hung between his/her legs, over an elevated right
foot pedal, and into a privacy bag. The tubing was twisted into several circles inside the
privacy bag.
Observation on 6/27/19 at 9:38 A.M. showed the resident in bed with his/her eyes closed.
The resident’s catheter bag hung in a privacy bag on the resident’s wheelchair, at his/her
bedside. The catheter tubing stretched from the resident on the bed, to the wheelchair,
and into the drainage bag. The tubing was twisted into several circles inside the privacy
bag.
4. Review of Resident # 14’s quarterly MDS, dated [DATE], showed the following:
– BIMS of 15 out of 15,cognitively intact;
– Indwelling catheter;
– Required extensive assistance for bed mobility;
– Dependent on assistance for transfers;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 6/10/19 through 7/9/19, showed staff did not document
an order with medical justification for use of the urinary catheter.
Review of the resident’s care plan, showed the following:
– Problem: the resident has an indwelling catheter;
– Problem start date: 4/22/19;
– Interventions: use an 18 French Units, 30 cubic centimeter (cc) bulb, and change per
physician’s order; check tubing for kinks each shift; position bag below the level of
bladder and away from the entrance door.
Observation on 6/24/19 at 12:45 P.M., showed the resident in his/her bed. His/her catheter
bag contained urine and hung from the bed, in a clear plastic bag, visible from the
hallway. Staff did not place the catheter bag in a privacy bag.
5. Review of Resident #18’s MDS, dated [DATE], showed staff assessed the resident as
follows:
– BIMS of 15 out of 15, cognitively intact;
– Total dependence for transfers and toilet assistance;
– Indwelling catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 6/10/19 through 7/9/19, showed staff did not document
an order for [REDACTED].
Review of the resident’s care plan, showed the following:
– Problem: the resident has an indwelling catheter;
– Problem start date: 12/6/18;
– Interventions: position catheter bag and tubing below the level of the bladder and away
from the entrance room door; check tubing for kinks each shift.
Observation on 6/25/19 at 2:00 P.M., showed the resident in a wheelchair with a catheter
in place.
During an interview on 6/25/19 at 2:20 P.M., the resident said he/she does not want to
have to stay in bed all day and it is just easier to use the catheter.
6. Review of Resident #24’s MDS, dated [DATE], showed the following:
– BIMS of 15 out of 15, cognitively intact;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 8 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 – Some

(continued… from page 8)
– Total dependence for transfers;
– Required extensive assistance for toilet use;
– Indwelling catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 6/10/19 through 7/9/19, showed staff did not document
an order for [REDACTED].>Review of the resident’s care plan, 6/28/19, showed staff
documented the resident with an indwelling urinary catheter and directed staff:
– Problem: the resident has an indwelling catheter;
– Problem start date: 6/28/19;
– Interventions: monitor/record/report to doctor any signs/symptoms of urinary tract
infection; staff will assist me to keep my catheter free from kinks.
Additional review of the resident’s care plan showed staff did not document any
information to show the resident needed a catheter to promote wound healing.
Observation on 6/24/19 at 2:20 P.M., showed the resident in bed with a catheter in place.
During an interview on 6/24/19 at 2:30 P.M., the resident said he/she is able to urinate
normally with a urinal, but he/she drips some. He/She believes the facility is using the
catheter because of his/her pressure sores.
7. Review of Resident #36’s annual MDS, dated [DATE], showed the following:
– BIMS of 15 out of 15, cognitively intact;
– Indwelling catheter;
– Required extensive assistance for bed mobility, toileting, and transfers.
Review of the resident’s POS, dated 6/10/19 through 7/9/19, showed staff did not document
an order with medical justification for use of the urinary catheter.
Review of the resident’s care plan, dated 4/22/19, showed staff documented the resident
with an indwelling urinary catheter and directed staff:
– Problem: the resident has an indwelling catheter;
– Problem start date: 4/22/19;
– Interventions: use an 18 French, 30 cc bulb, and change per physician’s order; check
tubing for kinks each shift; position bag below the level of bladder and away from the
entrance door.
Observation on 6/24/19 at 11:17 A.M. and on 6/25/19 at 9:00 A.M., showed the resident in
his/her bed. Further observation showed the resident with a catheter in place.
8. During an interview on 6/27/19 at 5:16 P.M., licensed practical nurse (LPN) A said
he/she expects to see a [DIAGNOSES REDACTED]. He/She said any resident with a catheter
should have a [DIAGNOSES REDACTED].
9. During an interview on 6/27/19 at 5:41 P.M., LPN B said a resident should have a
[DIAGNOSES REDACTED]. He/She said there should be a [DIAGNOSES REDACTED]. Information
regarding the use of catheter should also be documented in the nurses notes. Staff should
address catheter use in the resident’s care plan.
10. During an interview on 6/27/19 at 6:20 P.M., the administrator and the Director of
Nursing (DON) said staff should document a valid medical [DIAGNOSES REDACTED]. Appropriate
[DIAGNOSES REDACTED]. The resident’s medical record should contain clinical indication and
orders for size of catheter tubing and bulb. If the record does not contain a valid
clinical indications then the catheter should be removed. Staff are expected to place
catheter drainage bags in a privacy bag to protect the resident’s privacy. Staff should
ensure there are no kinks in the tubing, and the tubing should not be in wrapped in
circles.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 9 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 – Some

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, and record reviews, facility staff failed to ensure
oxygen tubing and humidifying bottles were changed and dated per facility policy and to
ensure physician orders [REDACTED].#1, #9, #12, #22, #26). The facility also failed to
ensure bi-level positive airway pressure/continuous positive airway pressure ([MEDICAL
CONDITION]/[MEDICAL CONDITION], machines that help with breathing) were cleaned and
disinfected according to physician orders [REDACTED].#1, #18, #19). The census was 49.
1. Review of the facility’s Oxygen policy, not dated, showed the following:
– There must be a physician’s orders [REDACTED].
– When the Unit Nurse initiates oxygen therapy for a resident, he/she must transcribe the
physician’s orders [REDACTED].
– Oxygen concentrators are to be wiped off with bleach wipes once per week. Filters to be
rinsed out and replaced every week. Oxygen tubing is to be changed at the same time;
– Oxygen tubing should be stored in a zip lock bag marked with date and room number.
2. Review of Resident #1’s physician order [REDACTED].
Review of the resident’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/14/19, showed the following:
– admission date of [DATE];
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility;
Review of the resident’s current treatment administration record (TAR), dated 6/10/19
through 7/9/19, showed the record did not contain any information regarding the use of a
[MEDICAL CONDITION] machine or the care of the machine.
Review of the resident’s medical record showed the resident did not have a baseline care
plan.
Review of the resident’s comprehensive care plan, last reviewed on 6/10/19, showed the
care plan did not contain any information regarding the use of a [MEDICAL CONDITION]
machine or the care of the machine.
Observation and interview on 6/25/19 at 8:30 A.M., showed the resident in bed with a
[MEDICAL CONDITION] mask pushed up on the top of his/her head. The mask and tubing
contained no date. The resident said he/she does not clean his/her mask or tubing. The
resident does not know if the mask or tubing are cleaned by the staff. He/she has not seen
the staff clean the mask or tubing. He/she was not aware if the mask or the tubing had
been changed by the staff since he/she was admitted to the facility.
Observation on 6/27/19 at 9:35 A.M., showed the resident lay in bed and wore his/her
[MEDICAL CONDITION] mask. The mask and tubing did not contain a date.
3. Review of Resident #9’s POS, dated 6/10/19 through 7/9/19, showed an order for
[REDACTED].
Review of the resident’s TAR, dated 6/10/19 through 7/9/19, showed an order for
[REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility.
Observation on 6/24/19 at 11:00 A.M., showed the resident in his/her room with oxygen in

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 10 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
use. Further observation showed the oxygen tubing not dated.
Observation on 6/27/19 at 12:21 P.M., showed the resident in his/her room with oxygen in
use. Further observation showed the oxygen tubing not dated. Observation also showed a
portable tank on the back of the wheelchair with the oxygen tubing uncovered and undated.
4. Review of Resident 12’s POS, dated 3/19/19 through 4/9/19, showed the following:
– An order, dated 3/20/19, change oxygen tubing weekly on Wednesday;
– An order, dated 3/20/19, cleanse concentrator filters and concentrator with bleach wipes
every Wednesday;
– An order, dated 3/26/19, oxygen and 2 liters (L) per nasal cannula, as needed to
maintain oxygen saturation above 90%.
Review of the resident’s POS, dated 3/26/19 through 4/9/19, April, May, and (MONTH) of
2019, showed an order, dated 3/26/19, oxygen and 2 L per nasal cannula as needed to
maintain oxygen saturation above 90%. The POS did not contain orders for cleaning the
concentrator or changing the tubing.
Review of the resident’s TAR, for 4/1/19 April, May, and (MONTH) of 2019, showed an order,
dated 3/26/19, oxygen and 2 L per nasal cannula as needed to maintain oxygen saturation
above 90%. The TAR did not contain orders for cleaning the concentrator or changing the
tubing.
Review of the resident’s significant change MDS, dated [DATE], showed the following:
– admission date of [DATE];
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility.
Observation of the resident on 6/25/19 at 8:40 A.M. and 6/26/19 at 5:07 P.M., showed the
resident in bed with his/her nasal cannula in place, and the oxygen tubing not dated.
5. Review of Resident #18’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility;
– Used [MEDICAL CONDITION]/[MEDICAL CONDITION].
Review of the resident’s POS, dated 6/10/19 through 7/9/19, showed the following:
– an order for [REDACTED].>- Cleanse [MEDICAL CONDITION]/[MEDICAL CONDITION] once
weekly on Wednesday with bleach wipes.
Review of the resident’s TAR, dated 6/10/19 through 7/9/19, showed the TAR did not contain
any orders for oxygen use or cleaning of the resident’s [MEDICAL CONDITION]/[MEDICAL
CONDITION].
Observation on 6/24/19 at 11:00 A.M., showed the resident in a wheelchair and used his/her
[MEDICAL CONDITION]/[MEDICAL CONDITION].
Observation on 6/24/19 at 1:00 P.M., showed the resident’s [MEDICAL CONDITION]/[MEDICAL
CONDITION] mask lay uncovered on a bedside table.
Observation on 6/26/19 at 10:00 A.M., showed the resident in his/her room in a wheelchair,
and used his/her [MEDICAL CONDITION]/[MEDICAL CONDITION].
6. Review of Resident #19’s quarterly MDS, dated [DATE], showed the following:
– BIMS of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility.
Review of the resident’s POS, dated 6/10/19 through 7/9/19, showed an order for
[REDACTED].
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 11 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
Review of the resident’s TAR, dated 6/10/19 through 7/9/19, showed the TAR did not contain
any orders for oxygen use or cleaning of the resident’s [MEDICAL CONDITION]/[MEDICAL
CONDITION].
Observation on 6/24/19 at 11:30 A.M., showed the resident’s nasal cannula lay on the bed,
uncovered and undated. The resident’s [MEDICAL CONDITION]/[MEDICAL CONDITION] mask lay on
a bedside table uncovered.
Observation on 6/25/19 at 1:00 P.M., showed the resident’s nasal cannula wrapped around
the oxygen concentrator uncovered and undated. The resident’s [MEDICAL CONDITION]/[MEDICAL
CONDITION] mask lay on the bedside table uncovered.
Observation on 6/26/19 at 4:00 P.M., showed the resident’s nasal cannula on the bed
uncovered and undated. The resident’s [MEDICAL CONDITION]/[MEDICAL CONDITION] mask lay on
a bedside table uncovered.
7. Review of Resident #22’s POS, dated 6/10/19 through 7/9/19, showed an order for
[REDACTED].
Review of the resident’s TAR, dated 6/10/19 through 7/9/19, showed the following an order
for [REDACTED].
Review of the resident’s admission MDS, dated [DATE], showed the following:
– BIMS score of 15 out of 15, cognitively intact;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility.
Observation on 6/24/19 at 11:54 A.M., showed the resident in his/her bed with portable
oxygen in use with undated tubing. Additional observation showed an oxygen concentrator in
his/her room , and the oxygen tubing uncovered and undated.
Observation on 6/25/19 at 10:31 A.M., showed the resident the resident in his/her
wheelchair with portable oxygen in use as he/she sat outside the facility. Further
observation showed the oxygen tubing undated.
8. Review of Resident #26’s TARs, dated 5/1/19 through 6/30/19, showed staff did not
document oxygen maintenance.
Review of the resident’s POS, dated 6/14/19 through 7/9/19, showed the following:
– An order, dated 6/14/19, for oxygen maintenance, cleanse oxygen concentrator every week
on Wednesday with bleach wipes, cleanse water filter, and replace oxygen tubing every week
on Wednesday;
– An order, dated 6/14/19, for oxygen at 3 L per nasal cannula at all times.
Review of the resident’s admission MDS, dated [DATE], showed the following:
– admission date of [DATE];
– BIMS of 9 out of 15, moderate cognitively impaired;
– [DIAGNOSES REDACTED].
– Received oxygen therapy while a resident at the facility.
Observation on 6/25/19 at 8:35 A.M., showed the resident received oxygen by nasal cannula
with undated oxygen tubing.
Observation on 6/26/19 at 4:55 P.M., showed the resident received oxygen by nasal cannula
with undated oxygen tubing.
Observation on 6/27/19 at 9:38 A.M., showed the resident received oxygen by nasal cannula
with undated oxygen tubing.
9. During an interview on 6/27/19 at 5:16 P.M., licensed practical nurse (LPN) A said
oxygen tubing is changed by the certified medication technicians (CMTs) once a week, on
Wednesdays. The CMTs put a piece of tape on the tubing with the date so staff know it has
been changed. C-Pap machines have weekly cleaning orders and are signed out on the TAR by
the person responsible for cleaning it.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 12 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
During an interview on 6/27/19 at 5:41 P.M., LPN B said CMTs are expected to change oxygen
tubing monthly. The tubing is marked with tape containing the date when it was changed.
C-Pap machines are cleaned weekly and are signed out by staff in the TAR.
During an interview on 6/27/19 at 5:52 P.M., CMT C said staff change and date oxygen
tubing every Wednesday.
During an interview on 6/27/19 at 6:20 P.M., the administrator and the Director of Nursing
(DON) said staff are expected to change and date oxygen tubing, with either a piece of
tape or a label, once a week on Wednesdays. C-Pap machines should have physician’s orders
[REDACTED]. It is expected that staff store oxygen tubing in a bag when it is not in use
by the resident. CMTs are in charge of changing the oxygen tubing. All orders for care and
use of C-Pap/[MEDICAL CONDITION] and oxygen should be noted in the POS and the TAR. It is
expected that orders for cleaning the machines and the tubing are carried forward or
discontinued. The nurses and the DON review the residents’ POS to ensure orders are
carried forward or discontinued.

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation, interview, and record review, facility staffed failed to post
required nurse staffing information, which included the total number of staff and the
actual hours worked by both licensed and unlicensed nursing staff directly responsible for
resident care, per shift, on a daily basis. The facility census was 49.
1. Observation on 6/24/19 at 1:15 P.M., showed staff did not post required nurse staff
information, to include the total number of staff and the actual hours worked by both
licensed and unlicensed nursing staff directly responsible for resident care, per shift.
2. Observation on 6/25/19 at 10:00 A.M., showed staff did not post required nurse staffing
information, to include the total number of staff and the actual hours worked by both
licensed and unlicensed nursing staff directly responsible for resident care, per shift.
3. Observation on 6/26/19 at 3:30 P.M., showed staff did not post required nurse staff
information, to include the total number of staff and the actual hours worked by both
licensed and unlicensed nursing staff directly responsible for resident care, per shift.
4. Record review on 6/27/19 at 5:00 P.M., of the archived posted nurse staffing
information, for the months of April, May, and (MONTH) of 2019, showed the documents did
not contain the total number of staff and the actual hours worked by both licensed and
unlicensed nursing staff directly responsible for resident care, per shift.
5. During an interview on 6/27/19 at 6:30 P.M., the administrator and the Director of
Nursing (DON) said the DON posts the staffing sheets everyday. They were not aware total
number of staff and the actual hours worked by the staff should be included on the
documentation.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 13 of 15
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 13)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures for the inspection, testing and maintenance of the facility water
systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak
of Legionnaire’s Disease (LD). The facility census was 49.
1. Review of the facility’s building maintenance, inspection and testing records, showed
the records did not contain documentation of a water management program to monitor the
facility’s water systems for the growth of waterborne pathogens and prevent LD.
During an interview on 06/26/19 at 8:57 A.M., the Maintenance Supervisor said he/she has
not had any involement in the developement or implementation of the Legionella policies
and procedures.
During an interview on 06/26/19 at 9:07 A.M., the administrator said he/she was not aware
of all the requirements for the Legionella policies and procedures. The administrator said
he/she was not aware of the requirement to complete a risk assessment in order to identify
areas at risk for the growth of waterborne pathogens in the facilities water system. The
Administrator said he/she knows maintenance checks the ice machine but was not sure if
he/she routinely tests other areas at risk for potential growth of waterborne pathogens.
Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification
(S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at
risk. Those at risk include persons who are at least [AGE] years old, smokers, or those
with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppressive.
Outbreaks have been linked to poorly maintained water systems in buildings with large or
complex water systems including hospitals and long-term care facilities. Transmission can
occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and
decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial
growth in building water systems that reduce the risk of growth and spread of Legionella
and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies
and procedures to reduce the risk of growth and spread of Legionella and other
opportunistic pathogens in building water systems. An industry standard calling for the
development and implementation of water management programs in large or complex building
water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by
American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In
(YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this
ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html).
Environmental, clinical, and epidemiological considerations for healthcare facilities are
described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management
implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,
nontuberculous mycobacteria, and fungi) could grow and spread in the facility water
system;
-Implement a water management program that considers the ASHRAE industry standard and the
CDC toolkit, and includes control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for
pathogens;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 14 of 15
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265521

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SEVILLE CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

35625 HIGHWAY 72, PO BOX 746
SALEM, MO 65560

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 TAGSUMMARY 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 14)
-Specify testing protocols and acceptable ranges for control measures, and document the
results of testing and corrective actions taken when control limits are not maintained.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265521If continuation sheet
Page 15 of 15
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