Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0570

Level of harm – Potential for minimal harm

Residents Affected – Many

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

reviewed CW
Based on interview and record review, facility staff failed to purchase a surety bond in
an amount sufficient to assure security of all personal funds the facility holds for 42
residents. The census was 58.
1. Review of the resident trust fund account for (MONTH) (YEAR) through (MONTH) (YEAR),
showed an average monthly balance of $16,689.55 which requires a surety bond of
$25,500.00. The current ledger amount is $17,996.12.
Review of the Department of Health and Senior Services (DHSS) database, showed the
facility has an approved non-cancelable Escrow Agreement Account in the amount of
$25,000.00.
2. During an interview on 03/29/18 at 5:46 P.M., the Business Office Manager said the
corporate office is responsible for the surety bond. He/She said it is reviewed every 6
months to a year to make sure it is sufficient.
During an interview on 03/29/18 at 6:24 P.M., the Administrator said the corporate office
reviews the bond annually to make sure it is sufficient. He/She said the Business Office
Manager and Social Worker review resident funds. He/She said they have noticed the monthly
balance increased with the census increase but would expect corporate to make sure the
bond is sufficient.

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record reviews, facility staff failed to immediately report an
allegation of resident to resident inappropriate sexual contact for one resident (Resident
#26), and an allegation of misappropriation of resident property for one resident
(Resident #37), out of 13 sampled residents, to other officials in accordance with State
law (including the State survey and certification agency). The facility census was 58.
1. Review of the facility’s policy on Reporting Abuse, dated May, (YEAR), showed staff are
directed:
-The facility will ensure that all alleged violations involving abuse, neglect,
exploitation or mistreatment, including injuries of unknown source, and misappropriation
of resident property, are reported immediately to the supervisor, who will then report to
the administrator and/or Director of Nurses (DON);
-These alleged violations are then reported immediately to the state survey agency, but
not later than two hours after the allegation is made, if the events that cause the
allegation involve abuse or result in serious bodily injury, or not later than 24 hours,
if the events that cause the allegation do not result in serious bodily injury;
-The facility will report all investigations to the administrator or designated
representative and to the state survey agency within 5 working days of the incident and if
the alleged violation is verified, appropriate corrective action will be taken.
2. Review of Resident #16’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
– Brief Interview of Mental Status (BIMS-a cognitive assessment) of 7 (severely impaired)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
-No behaviors;
-No wandering;
-Extensive assistance of one staff for ambulating in the corridor and locomotion on and
off the unit and dressing;
-Limited assistance of one staff for transfers, toileting, and personal hygiene.
Review of the resident’s care plan, last updated 01/19/18, showed staff did not update the
care plan to include sexually inappropriate behaviors after the incident occurred on
02/24/18.
Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally required resident
assessment, dated 02/10/18, showed staff assessed the resident as:
-Brief Interview of Mental Status (BIMS-a cognitive assessment) of 4 (severely impaired);
-No behaviors;
-No wandering;
-Supervision of one staff member for bed mobility, transfers, eating, and personal
hygiene;
-Independent for ambulating in his/her room, ambulating in the corridor, and locomotion on
and off the unit.
Review of nurse’s notes, dated 02/24/18, showed Licensed Practical Nurse (LPN) D saw
Resident #16 lean forward in his/her wheelchair and touch Resident #26 on the left upper
chest. LPN D documented he/she moved Resident #16 to the nurse’s station. He/She
documented the residents had no injuries, were monitored, and the family and guardian were
notified.
Review of the State Survey Agency database, showed facility staff did not report the
resident-to-resident inappropriate sexual contact.
Review of the facility’s records showed facility staff did not complete an investigation
for the allegation, and did not report the allegation to the state survey agency as
directed by the policy.
During an interview on 03/28/18 at 5:16 P.M., the DON said they did not contact the state
or the authorities about the incident on 02/24/18 because neither resident was injured or
even remembered what happened.
During an interview on 03/28/18 at 8:17 A.M., the Social Worker said he/she was made aware
of the incident between the residents after the fact and was told it was handled. He/She
said the incident happened over the weekend and he/she wasn’t made aware until the next
week. He/She said the families were notified but he/she was not sure if there was an
investigation done. He/She said the residents were supposed to be separated after the
incident and staff moved Resident #26 to a new hall a few weeks later but for another
reason. He/She said staff did not discuss the incident in any of the interdisciplinary
team meetings.
During an interview on 03/29/18 at 6:24 P.M., the Administrator and DON said they do have
a policy in place to protect their residents from abuse, neglect, and exploitation. They
said when abuse, neglect, or exploitation is reported, the accused staff member is
immediately suspended pending the outcome of the investigation. He/She said any reports of
abuse and neglect should be reported to the State Elder Abuse and Neglect Hotline within
two hours but it has not been done that way recently. The Administrator does not know why
staff did not report the resident-to-resident sexual contact to the hotline. The DON said
they did not interview other residents or complete a full investigation after the incident
but they did document the incident in the charts and contact the physician and
representatives. The DON said he/she would expect a monitoring protocol to be put in a
resident’s care plan after they have sexual behaviors. He/She said they tried to ensure
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
the safety of other residents by telling staff to keep Resident #16 in sight at all times.
The DON said the charge nurse should report allegations of abuse and neglect to the
hotline but he/she, the Administrator, or the Social Worker can report as well.
3. Review of Resident #37’s annual MDS, dated [DATE], showed staff assessed the resident
as cognitively intact.
Review of the resident’s care plan, last updated 3/5/18, showed staff are directed the
resident prefers to have his/her door locked at all times, and the key to the door is on a
hook so staff can gain entry in case of an emergency.
Review of the State Survey Agency database showed facility staff did not report the
resident’s allegation of the missing items.
Review of the facility’s records showed facility staff did not complete an investigation
for the allegation, and did not report the allegation to the state survey agency as
directed by the policy.
During an interview on 3/27/18 at 2:57 P.M., the resident said some items, including music
cd’s and hair items were taken from his/her room, but he/she thinks they got rid of the
person who did it. The resident said he/she tries to keep his/her door locked (knob
turned).
During an interview on 3/28/18 at 6:01 P.M., the administrator said an investigation was
not done. The administrator said normally an investigation would have been completed and
reported to Department of Health and Senior Services (DHSS), but he/she said we didn’t.
During an interview on 3/29/18 at 6:29 P.M., the DON said he/she or the administrator
should have reported the allegation to the state survey agency, but did not.

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record reviews, facility staff failed to initiate and complete a
thorough investigation of an alleged violation of resident to resident inappropriate
sexual contact which affected one resident (Resident #26), and an alleged violation of
misappropriation of resident property for one resident (Resident #37), of 13 sampled
residents. The facility census was 58.
1. Review of the the facility’s policy on Abuse, undated, showed the following:
-Sexual abuse is nonconsensual sexual contact of any kind with an elderly person;
-Sexual harassment includes, but is not limited to, unwanted touching, al types of sexual
assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit
photographing;
-Financial or material exploitation is the illegal or improper use of an elder’s funds,
property or assets;
-The Director of Nurses (DON) will inform the state survey, certification, and licensing
agencies of:
a. All alleged violations involving mistreatment, neglect, or abuse, including injuries
of unknown source, and misappropriation of resident property;
b. Evidence that all alleged violations are thoroughly investigated, and that further
potential abuse has been prevented while the investigation is in progress;
c. The results of all investigations within 5 working days of the incident, and if the
alleged violation verified, appropriate corrective action that was taken;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-Facility will investigate all types of abuse (physical, mental, sexual, financial,
involuntary seclusion) and report;
-Investigative documentation will include:
-Specific description of the incident;
-Names, addresses, home telephone numbers, date of birth, social security numbers, and
positions for staff involved in the incident;
-Written statements of all persons with knowledge of the incident. Statements must be
signed and dated with specific details;
– Documentation of any interviews conducted with other residents who might have been
affected, or that the involved staff person worked with to determine if there are
additional concerns;
– Documentation of any interviews conducted with persons who might have some knowledge of
the incident;
-Copy of disciplinary action taken including the date, if any action was taken;
-Summary of investigation, including corrective actions/monitoring the facility
implemented to prevent the incident from reoccurring.
2. Review of the facility’s Grievance/Complaints Policy, updated 12/2016, showed the
following:
– The resident or resident representative may file a verbal or written grievance referral
at any time. It is recommended that a written referral is completed to ensure all the
facts are investigated including the date of the referral and summary of facts regarding
the grievance or complaint;
– The date of the referral will be clearly noted and the investigation will be completed
in most cases within 5 working days of the referral date;
– The referring party will be notified of the results of the investigation and any
necessary corrective actions in writing. If the party is not satisfied with the findings
and conclusion of the investigation, the party filing the grievance will be informed that
the referral will be given to the administrator for a review of the investigation;
– The date of the referral to the administrator will be clearly noted. The investigation
will be completed within 5 working days of the referral date;
– The party filing the grievance may file a complaint with Department of Health and Senior
Services (DHSS) or the Ombudsman at any time. However, it is strongly recommended that the
facility be provided the opportunity to investigate and correct any grievance.
3. Review of Resident #16’s admission MDS, dated [DATE], showed staff assessed the
resident as follows:
– Brief Interview of Mental Status (BIMS-a cognitive assessment) of 7 (severely impaired)
-Did not display behaviors;
-Did not wander;
-Extensive assistance of one staff for ambulating in the corridor and locomotion on and
off the unit and dressing;
-Limited assistance of one staff for transfers, toileting, and personal hygiene.
Review of the resident’s care plan, last updated 01/19/18, showed staff did not update the
care plan to include sexually inappropriate behaviors after the incident occurred on
02/24/18.
Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally required
assessment, dated 02/10/18, showed staff assessed the resident as:
– Brief Interview of Mental Status (BIMS-a cognitive assessment) of 4 (severely impaired);

-No behaviors;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-No wandering;
-Supervision of one staff member for bed mobility, transfers, eating, and personal
hygiene;
-Independent for ambulating in his/her room, ambulating in the corridor, and locomotion on
and off the unit.
Review of nurse’s notes, dated 02/24/18, showed LPN D saw Resident #16 lean forward in
his/her wheelchair and touch Resident #26 on the left upper chest. LPN D said he/she moved
Resident #16 to the nurse’s station. He/She documented the residents had no injuries,
staff monitored the residents, and notified the families and guardians.
Observation on 03/29/18 at 1:29 P.M., showed Resident #16 in his/her wheelchair in the
television lounge with several other residents outside the view of the nurse’s station.
During an interview on 03/28/18 at 5:16 P.M., the DON said they did not contact the state
or the authorities about the incident on 02/24/18 because neither resident was injured or
even remembered what happened. He/She said staff updated the residents’ charts and
notified the doctor, family, and guardian.
During an interview on 03/28/18 at 8:17 A.M., the Social Worker said he/she was made aware
of the incident between the residents after the fact and was told it was handled. He/She
said the incident happened over the weekend and he/she wasn’t made aware until the next
week. He/She said staff notified the families but he/she was not sure if staff completed
an investigation. He/She said the residents were supposed to be separated after the
incident and staff moved Resident #26 to a new hall a few weeks later but for another
reason. He/She said staff did not discuss the incident in any of the team quality
improvement meetings.
During an interview on 03/29/18 at 1:16 P.M., CNA E said the resident will say
inappropriate things sometimes like sexual comments towards the aides. He/She said the
resident’s care plan does not state the resident has sexual behaviors but the staff know
about it because they talk about it during report. He/She believes Resident #16 has made
physical advances towards one other resident but no staff members.
During an interview on 03/29/18 at 1:24 P.M., CMT F said Resident #16 has no behaviors and
is quiet. He/She said the only thing he/she has heard the resident say is wow when females
walk by. He/She believes the resident has a limited vocabulary. He/She has not witnessed
the resident doing or saying anything sexual to the other residents or staff and does not
know of any time that has happened.
During an interview on 03/29/18 at 6:24 P.M., the Administrator and DON said they do have
a policy in place to protect their residents from abuse, neglect, and exploitation. They
said when abuse, neglect, or exploitation is reported, the accused staff member is
immediately suspended pending the outcome of the investigation. They said any reports of
abuse and neglect should be reported to the State Elder Abuse and Neglect Hotline within
two hours but it has not been done that way recently. The Administrator said he/she does
not know why the resident-to-resident sexual contact was not reported to the hotline. The
DON said they did not interview other residents or complete a full investigation after the
incident but they did document the incident in the charts and contact the physician and
representatives. He/She said he/she would expect a monitoring protocol to be put in a
resident’s care plan after they have sexual behaviors. He/She said they tried to ensure
the safety of other residents by telling staff to keep Resident #16 in sight at all times.
The DON said the charge nurse should report allegations of abuse and neglect to the
hotline but he/she, the Administrator, or the Social Worker can report as well.
4. Review of Resident #37’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 3/2/18, showed staff assessed the resident as cognitively intact.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
Review of the resident’s care plan, last updated 3/5/18, showed staff are directed the
resident prefers to have his/her door locked at all times, and the key to the door is on a
hook so staff can gain entry in case of an emergency.
Review of a grievance report, completed by the housekeeping supervisor on 3/8/18, showed
he/she documented the resident reported he/she was missing some personal items, and felt
that the housekeeper (HK A) who cleaned his/her room was responsible. The housekeeping
supervisor questioned the alleged employee, who became very belligerent and quit. Further
review showed the administrator signed the report on 3/12/18.
Review of the facility’s records showed staff did not complete an investigation for the
allegation.
During an interview on 3/27/18 at 2:57 P.M., the resident said some items including music
cd’s and hair items were taken from his/her room, but he/she thinks they got rid of the
person who did it. The resident said he/she tries to keep his/her door locked (knob
turned).
During an interview on 3/28/18 at 3:36 P.M., the DON said the resident alleged HK A took
some items (a cd, some Halloween thing, and maybe two other things) from his/her room, and
the DON referred the situation to the housekeeping supervisor, since it was not his/her
direct employee. The DON said when the housekeeping supervisor contacted HK A, he/she
walked out the door. The DON said the resident always locks his/her door from the inside,
but a key hangs outside the door for staff to enter if needed.
During an interview on 3/28/18 at 3:54 P.M., the administrator said HK A had already
turned in his/her notice of resignation and just left the day he/she was approached by the
housekeeping supervisor.
During an interview on 3/28/18 at 3:57 P.M., the Social Services Designee (SSD) said
he/she usually takes all grievance/complaints and forwards to the administrator, but was
told that this particular situation was already taken care of by the housekeeping
supervisor and the administrator. The SSD said normally, if a resident reports
missing/stolen items, staff considers the items missing/stolen unless proven otherwise by
an investigation. The SSD said, the resident has a lot of items and knows where everything
is in his/her room, so there might be some truth to his/her claim. He/She said regardless
of the situation, there should have been an investigation completed, and to his/her
knowledge, the administrator completed one.
During an interview on 3/28/18 at 6:01 P.M., the administrator said an investigation was
not done, and it was our fault. The administrator said normally an investigation would
have been completed, and reported to Department of Health and Senior Services (DHSS), but
we didn’t. Additionally, he/she said the facility could have tried to replace the missing
items, but staff just never investigated the situation.
During an interview on 3/29/18 at 12:52 P.M., the resident said there were 2 Boxcar(NAME)
yodel CDs (taken from the drawer), 2 clips for his/her hair, and a bottle of
lotion/perfume (taken from the top of the boxes near the window), that he/she got at the
Halloween party. He/She thinks HK A took the items when he/she cleaned the room.
During an interview on 3/29/18 at 6:29 P.M., the DON said we tried to investigate but the
alleged staff member walked out. He/She said they did not interview any additional staff
or residents about the allegation.
An attempt to contact HK A via telephone on 3/29/18 at 1:35 P.M., was unsuccessful. A
recording was received that the person is not accepting calls at this time.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to document a
complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessent
instrument) when they did not accurately code a urinary catheter (tube inserted into the
bladder to drain urine) for one resident (Resident #25), the use of a [MEDICAL CONDITION]
(a direct airway through an inscision in the trachea) for one resident (Resident #52), and
the use of grab bars for one resident (Resident #34). The facility census was 58.
1. Review of Resident #25’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 11/8/17, showed staff assessed the resident as cognitively intact, and did not have
a urinary appliance (indwelling catheter).
Review of the resident’s MDS dated [DATE] showed staff assessed the resident as
cognitively intact, and had an indwelling catheter.
Review of the resident’s care plan, last updated 2/8/18, showed staff are directed the
resident has an indwelling catheter, and to:
-Change the catheter monthly and as needed (PRN);
-Change foley bag monthly and PRN;
-Monitor and document intake per policy;
-Monitor for signs and symptoms of discomfort due to catheter.
Observation and interview on 3/27/18 at 10:59 A.M., showed the resident lay in bed, and
did not have a catheter in place. The resident said he/she did not have a foley catheter.
During an interview on 3/27/18 11:54 A.M., Licensed Practical Nurse (LPN) G said the
resident did not have a catheter for probably the past few months.
During an interview on 3/28/18 at 5:14 P.M., Certified Nurse Assistant (CNA) I said the
resident used to have a catheter, but it has been removed for a while now. The CNA said
the resident did not currently have a catheter.
During an interview on 3/28/18 6:20 P.M., LPN H said staff removed the resident’s catheter
a while ago and this should be documented in the nurses’ notes in his/her chart.
During an interview on 3/29/18 at 9:52 A.M., LPN E/charge nurse said based on the nurses’
notes, the resident’s catheter was removed prior to 12/27/17 (at least 3 months ago).
Staff did not accurately complete section H0100 on the MDS.
2. Review of Resident #34’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Unable to complete cognitive interview;
-Restraints used daily.
Review of the resident’s care plan dated 02/27/18, showed staff did not mention bed rails
or other restraints.
Observation on 03/27/18 at 11:14 A.M., showed the resident in his/her recliner. There were
no bedrails or other restraints in the resident’s room.
Observation on 03/28/18 at 1:21 P.M., showed the resident in his/her recliner. There were
no bedrails or other restraints in the resident’s room.
3. Review of Resident #52’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitivly intact;
-No [MEDICAL CONDITION] care.
Review of the resident’s Physician order [REDACTED].
Observation on 3/29/18 at 1:22 P.M., showed LPN C provided [MEDICAL CONDITION] care to the
resident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
4. During an interview on 03/29/18 at 5:35 P.M., the MDS Coordinator said he/she completes
the MDS assessments per RAI guidelines. He/She said the MDS should accurately reflect the
resident’s condition. He/She said restraints, catheters, and tracheostomies should be
correctly coded on the MDS. He/She said he/she or the DON is responsible for updating the
MDSs. He/She said the MDS is updated every three months or when there is a significant
change. He/She said he/she reviews the charts and interviews staff prior to completing the
MDS. He/She said the DON reviews the MDS for accuracy and signs off on them before they
are submitted.
6. During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the MDS
coordinator completes the MDS’s. The RN said he/she was not sure if Resident #25 currently
had a catheter, but the MDS assessment should reflect that information accurately. He/she
was not sure if Resident #34 had/used grab bars, but they would not be considered a
restraint for him/her. Resident #52 does have a trach, which should be documented on the
MDS.
7. During an interview on 3/29/18 at 6:29 P.M., the Director of Nurses (DON) said he/she
expects each resident’s MDS assessment to be completed by the RAI guidelines. The DON said
Resident #25 did not have a catheter, and once the catheter was removed, staff should
update the MDS. Resident #34 does not have/use bed rails/alarms, or any other restraint
device, so a restraint should not be documented on his/her MDS. Resident #52 has a
[MEDICAL CONDITION], which should be documented on the MDS.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff to develop measurable
goals and interventions for comprehensive care plans for two sampled residents (Residents
# 26 and #52) related to use of [MEDICAL CONDITION] (a direct airway through an inscision
in the trachea), feeding tube, and grab bars. The facility census was 58.
1. Review of the facility’s Care Plan policy, undated, showed staff are directed:
-An interdisciplinary approach to identification of problems and developing solutions
provides individualization and coordination of resident care;
-All residents must have a care plan;
-All disciplines involved in providing services to a resident should attend a Care
Planning conference to coordinate care and develop the resident Care Plan;
-The resident care plan is initiated at the time of admission;
-The interdisciplinary care plan is reviewed, revised, and updated quarterly and more
frequently if warranted by a change in resident’s condition.
2. Review of the Resident #26’s quarterly Minimum Data Set (MDS), a federally required
assessment tool, dated 02/10/18, showed staff assessed the resident as:
– Brief Interview of Mental Status (BIMS-a cognitive assessment) of 4 (severely impaired);

-No behaviors;
-No wandering;
-Supervision of one staff member for bed mobility, transfers, eating, and personal
hygiene;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-Independent for ambulating in his/her room, ambulating in the corridor, and locomotion on
and off the unit.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s care plan dated 02/08/18, showed it did not address the use of
grab bars.
Observation on 03/27/18 at 2:56 P.M., showed the resident in bed with grab bars on each
side.
Observation on 03/29/18 at 9:46 A.M., showed the resident in bed with grab bars on each
side.
3. Review of Resident #52’s MDS, dated [DATE], showed staff assessed the resident as:
-Cognitively intact;
-Used a feeding tube;
-No [MEDICAL CONDITION] care.
Review of the resident’s POS, dated 3/16/18 through 4/9/18, showed the physician ordered:
-[MEDICAL CONDITION] care daily;
-Gastrostomy tube ([DEVICE]), a tube inserted through the abdomen that delivers nutrition
directly to the stomach) care daily with cleaning warm soapy water, rinse dry and split
gauze.
Observation on 3/29/18 at 1:22 P.M., showed Licensed Practical Nurse (LPN) C entered the
resident’s room. Observation showed the resident with a [MEDICAL CONDITION] and a feeding
tube. Observation showed LPN C provided [MEDICAL CONDITION] care and feeding tube care to
the resident.
Review of the resident’s care plan, dated 3/28/18, showed staff did not document direction
to the staff for care of the resident’s [MEDICAL CONDITION] or [DEVICE].
4. During an interview on 03/29/18 at 5:35 P.M., the MDS Coordinator said he/she is
responsible for updating care plans. He/She said care plans should be updated with any
changes. He/She said nurses can update care plans too. He/She said if a nurse removes a
catheter, they should update the care plan. He/She said any falls should be documented on
the care plan. He/She said the care plan should accurately reflect the resident’s
condition. He/She said feeding tubes, [MEDICAL CONDITION] care, transfers, dentures, and
catheters should be addressed in the care plan. He/She said the care plan should be
specific about how to transfer residents and staff should follow the care plan to know how
to transfer residents. He/She said if the care plan says use a hoyer lift PRN (as needed),
it means if a resident can not bear weight staff should use a hoyer lift and the care plan
should say it in detail.
During an interview on 3/29/18 at 5:44 P.M., Certified Medication Technician
(CMT)/Certified Nurse Assistant (CNA) L said resident’s care plans should be accurate, and
he/she hopes they are. The CMT said residents have care cards (care plans) inside their
closets that directs staff on how much assistance and level of care is required.
During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the MDS
coordinator updates the care plans, but the charge nurse can update with any changes as
well. The RN said the care plan should accurately reflect the resident. The RN said
interventions for Resident #26’s grab bars, and interventions for Resident #52’s [DEVICE]
[MEDICAL CONDITION] be on his/her care plan.
During an interview on 3/29/18 at 6:22 P.M., the Director of Nursing (DON) said the MDS
Coordinator is responsible to create the care plan for residents. The DON said Resident
26’s grab bars and Resident #52’s [DEVICE] and [MEDICAL CONDITION] should be included on
their care plans.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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**
Based on observation, interview and record review, facility staff failed to ensure the
care plans were accurately updated with changes in the resident’s needs for two residents
(Resident #23, and #25), of 13 sampled residents. The facility census was 58.
1. Review of the facility’s Care Plan policy, undated, showed staff are directed:
-An interdisciplinary approach to identification of problems and developing solutions
provides individualization and coordination of resident care;
-All residents must have a care plan;
-All disciplines involved in providing services to a resident should attend a Care
Planning conference to coordinate care and develop the resident Care Plan;
-The interdisciplinary care plan is reviewed, revised, and updated quarterly and more
frequently if warranted by a change in resident’s condition.
2. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 2/5/18, showed staff assessed the resident as:
-Brief Interview of Mental Status (BIMS-a cognitive assessment): not assessed;
-Extensive assist of one person physical assist with personal hygiene and dressing;
-Extensive assist of two or more staff with transfer.
Review of the resident’s comprehensive care plan last updated 2/5/18, showed staff
documented the resident has swallowing problems related to [MEDICAL CONDITION], and
directed staff:
-Provide one staff participation with personal hygiene and oral care;
-Resident feeds self in the dining room;
-Eat only with supervision, check mouth after meal for pocketed food and debris;
-Ensure teeth are fixed in place with denture adhesive,
-Requires one staff participation to eat;
-Provide two staff participation with bed mobility, dressing, and transfers, and to use a
mechanical aid sling for transfers as needed (PRN).
The care plan did not detail specific circumstances when staff should use a mechanical
assistive device for transfers.
Observation on 3/28/18 at 12:22 P.M., showed the resident sat in his/her wheelchair at the
dining table. Observation showed the upper denture moved up and down loosely in his/her
mouth.
Observation on 3/28/18 at 12:39 P.M., showed the resident fed him/herself a pureed meal,
while the upper denture moved up and down loosely in his/her mouth.
Observation on 3/28/18 at 12:49 P.M., showed the resident attempted to eat an ice cream,
while the loose-fitting upper denture flopped around in his/her mouth. The resident used
his/her right hand and attempted to secure the denture to his/her upper gums, but the
denture remained loose and continued to move up and down loosely with each bite/chew.
Observation on 3/28/18 at 12:56 P.M., showed Certified Nurses Assistant (CNA) M approached
the resident and asked why he/she was not eating, but did not acknowledge the loosely
fitted denture in his/her mouth, and did not assist the resident to eat.
Observation and interview on 3/28/18 at 5:00 P.M., showed CNA I and CNA J placed a
gaitbelt around the resident’s waist and transferred the resident from his/her bed to the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 10)
wheelchair. Further observation showed the resident did not bear full weight, and the CNAs
pulled his/her pants to help transfer the resident to the chair. The resident sat with
his/her pants twisted to the left. CNA I said staff usually use two aides to transfer the
resident. The CNA said the resident was a little stiff, and did not bear much weight.
He/She has never used a mechanical lift to transfer the resident. The CNA said the care
cards inside the closet directs staff on how to care for each resident (transfers,
hygiene, feeding, etc.).
Review of the resident’s Condensed Care Plan/care card (inside the closet), last updated
1/31/18 showed staff are directed the resident feeds self with set-up help, provide
extensive assist with care, and transfer using a mechanical lift. Staff did not update the
care card after the comprehensive care plan was updated on 2/5/18.
During an interview on 3/28/18 at 5:10 P.M., CNA I said, I guess I should have looked at
the care card before.
During an interview on 3/29/18 at 8:57 A.M., CNA D, said the resident has only had his/her
upper denture since November, that he/she can recall, and they have always been loose. The
CNA said the denture adhesive does not work well to secure the resident’s teeth in his/her
mouth. The resident’s denture flops around in his/her mouth when eating, and could be a
choking hazard. The CNA said the resident is transferred by two staff members with a
gaitbelt, and sometimes with a hoyer lift, but staff has not used the hoyer since about
November, and some days the resident is dead weight.
3. Review of Resident #25’s quarterly MDS, dated [DATE] showed staff assessed the resident
as cognitively intact, has an indwelling catheter (tube inserted into the bladder to drain
urine), and always continent of urine.
Review of the resident’s care plan, last updated 2/8/18, showed staff are directed the
resident has an indwelling catheter, and to:
-Change the catheter monthly and as needed (PRN);
-Change foley bag monthly and PRN;
-Monitor and document intake per policy;
-Monitor for signs and symptoms of discomfort due to catheter.
Observation and interview on 3/27/18 at 10:59 A.M., showed the resident in bed, and did
not have a catheter in place. The resident said he/she did not have a foley catheter.
During an interview on 3/27/18 11:54 A.M., Licensed Practical Nurse (LPN) G, said the
resident did not have a catheter for probably the past few months.
During an interview on 3/28/18 at 5:14 P.M., CNA I said the resident used to have a
catheter, but it has been removed for a while now. The CNA said the resident did not
currently have a catheter.
During an interview on 3/28/18 6:20 P.M., LPN H said the resident’s catheter was removed a
while ago and should be documented in the nurses’ notes in his/her chart.
During an interview on 3/29/18 at 9:52 A.M., LPN E/charge nurse said based on the nurses’
notes, the resident’s catheter was removed prior to 12/2717 (at least 3 months ago).
Staff did not update the care plan after the resident’s catheter was removed.
4. During an interview on 3/29/18 at 5:44 P.M., CNA L said residents’ care plans should be
accurate, and he/she hopes they are. The CNA said residents have care cards (care plans)
inside their closets that directs staff on how much assistance and level of care is
required. The CNA said the care plan should direct staff on how many people to transfer,
and how to transfer (hoyer lift, gaitbelt, etc.), interventions for oral care, but he/she
was not sure if catheter interventions should be on the care plan.
During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the MDS
coordinator updates the care plans, but the charge nurse can update with any changes as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 11)
well. The RN said the care plan should accurately reflect the resident, and staff should
be able to walk in a room, open the closet door, and get a pretty good picture of what to
do to care for the resident. The RN said Resident #23’s oral care, assistance with
feeding, and how to transfer should be accurate on his/her care plan. Additionally, the
resident’s loose-fitting dentures could be a choking hazard if not monitored properly.
Staff should have updated Resident #25’s care plan when they removed the catheter.
During an interview on 3/29/18 at 6:29 P.M., the Director of Nurses (DON) said the MDS
Coordinator updates care plans at least quarterly, but any nurse can update the resident’s
care plan with changes, and the care plans should match the information on the MDS. The
DON said he/she expects staff to transfer Resident #23 with a mechanical lift and that
specific instruction should be on the care plan. He/She also expects staff to assist the
resident with feeding and/or provide close oversight during meals, because his/her
loose-fitting dentures creates a possible choking hazard for him/her. Resident #25 does
not have a catheter, therefore, interventions for a catheter should not be documented on
his/her current care plan.

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, facility staff failed to provide
adequate showers at least twice per week for three residents (Resident #14, #23, #29), who
are dependent on staff to bathe, out of 13 sampled residents. The facility census was 58.
1. Review of the facility’s Bath, Shower policy, undated, showed staff are directed:
-A shower will clean and refresh the resident;
-Give the resident a shower when it is required by the established shower schedule, or
indicated by the plan of care;
-Residents should receive a minimum of two showers a week, or as indicated by condition
and plan of care.
2. Review of Resident #14’s Minimum Data Set (MDS), a federally mandated assessment, dated
1/23/18, showed staff assessed the resident as:
-Cognitively intact,
-Required extensive assist of two staff with transfers;
-Set-up help with hygiene, and physical help with bathing.
Review of the resident’s care plan, updated 1/23/18, showed staff are directed to provide
assistance from two staff with transfers, avoid scrubbing, and pat dry sensitive skin with
bathing. The care plan did not indicate how often to offer the resident a shower.
Review of the facility’s shower sheets for (MONTH) (YEAR), updated by staff when a
resident is offered a shower/bed bath, and review of monthly shower tracker updated by the
Director of Nurses (DON), showed staff documented the resident received a shower/bed bath:
-2/3/18: only one shower that week;
-2/13/18 (five days after the last shower on 2/8/18): staff documented the resident
refused;
-2/23/18 (seven days after the last shower on 2/16/18): only one shower that week. The
resident received a total of six showers/bath in one month. Staff did not ensure the
resident received a minimum of two baths each week as directed by facility policy.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 12)
Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker,
showed staff documented the resident was offered a shower/bed bath:
-3/1/18 (six days after the last shower): only one shower that week;
-3/6/18 (five days after the last shower): only one shower that week;
-3/13/18 (seven days after the last shower): only one shower that week;
-Staff did not document a shower/bath for the week of 3/18/18 to 3/25/18;
-3/27/18 (14 days after the last shower). The resident only received four showers/bath in
one month. Staff did not ensure the resident received a minimum of two baths each week as
directed by facility policy.
During an interview on 3/27/18 11:04 A.M., the resident said the facility needs more
aides, because he/she does not get a shower sometimes for two weeks. He/She feels like
when staff gets to his/her name on the list, they just skip over it. He/She does not know
what days he/she is scheduled to get a shower, and told staff several times he/she needs a
shower, since the last one he/she had was about two weeks prior. The resident said he/she
really likes to feel the hot water, and it would have been nice the other night because it
got cold.
During an interview on 3/29/18 at 3:22 P.M., the resident said he/she did not really
refuse on 2/13/18, but signed the refusal sheet because staff asked him/her to. The
resident said he/she had a scheduled surgery on 2/14/18 and needed an antibacterial
cleanse prior, which staff provided the morning of 2/14/18.
3. Review of Resident #23’s MDS, dated [DATE], showed staff assessed the resident as:
-Brief Interview of Mental Status (BIMS-a cognitive assessment): not assessed;
-Physical behaviors, but no rejection of care;
-Extensive assist of one person physical assist with personal hygiene and dressing;
-Extensive assist of two or more staff with transfer;
-Total dependence of one staff for bathing and toileting.
Review of the resident’s care plan, last updated 2/5/18, showed staff are directed:
-Provide one staff participation with personal hygiene and oral care;
-Provide two staff participation with bed mobility, dressing, and transfers;
-Mechanical aid sling for transfers as needed (PRN);
-Care level: extensive assist.
The care plan did not indicate how often to offer the resident a shower.
Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker,
showed staff documented the resident was offered a shower:
-3/12/18 (12 days after the last shower);
-Staff did not document a shower was offered from 3/16/18 to 3/28/18;
-3/29/18 (14 days after the last shower on 3/15/18): only one shower that week. The
resident only received three showers in one month. Staff did not ensure the resident
received a minimum of two baths each week as directed by facility policy.
Observation on 3/27/18 at 3:15 P.M., showed the resident propelled in the hallways, with
overgrown facial hair.
Observation on 3/27/18 at 10:20 A.M., showed the resident propelled in the hallways, with
overgrown facial hair.
During an interview on 3/29/18 at 8:57 A.M., Certified Nurses Assistant (CNA) D said staff
usually shave residents when they provide their shower.
4. Review of Resident #29’s MDS, dated [DATE], showed staff assessed the resident as
cognitively intact, and required:
-Extensive assist of two or more staff with bed mobility and toilet use;
-Total dependence of two or more staff with transfer;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 13)
-Physical help with bathing.
Review of the resident’s care plan, updated 2/17/18, showed staff are directed:
-One staff assist with personal hygiene;
-Hoyer as needed for transfers, require two staff with transfers;
-Resident refuses to got to the shower room and continues to have a bed bath, encourage to
go to the shower room;
-Provide with a sponge bath when a full bath or shower cannot be tolerated;
-Require one person total care assist with bathing.
The care plan did not indicate how often to offer the resident a shower/bed bath.
Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker,
showed staff documented the resident received a shower/bed bath:
-2/4/18: only one shower that week;
-2/21/18 (six days after the last shower on 2/15/18): only one shower that week;
-Staff did not document a shower/bath was offered from 2/21/18 to 2/28/18. The resident
received a total of five showers/bath in one month. Staff did not ensure the resident
received a minimum of two baths each week as directed by facility policy.
Review of the shower sheets for (MONTH) (YEAR), and review of the monthly shower tracker,
showed staff documented the resident was offered a shower/bed bath:
-3/6/18 (13 days after the last shower on 2/21/18): only one shower that week;
-3/12/18 (six days after the last shower): only one shower that week;
-3/23/18 (10 days after the last shower): only one shower that week;
-Staff did not document a shower/bath was offered between 3/23/18 and 3/29/18, and did not
document the resident refused any showers/bath for the month. The resident only received
three showers/bath in one month. Staff did not ensure the resident received a minimum of
two baths each week as directed by facility policy.
Observation and interview on 3/28/18 at 11:00 A.M., showed the resident in bed, with
his/hair greasy. The resident said he/she does not usually go to the shower room because
they need two people to transfer him/her with a hoyer (mechanical lift), and sometimes
they don’t have enough staff to do it. The resident said there are no set days for his/her
shower or bed bath, it varies. The resident said the last bath he/she received was on
Friday, and today is Wednesday. The resident said he/she would love to have a warm shower
with running water sometimes, and get his/her hair washed.
Observation on 3/29/18 at 9:25 A.M., showed the resident in bed, with his/her hair greasy.

5. During an interview on 3/27/18 at 2:49 P.M., Resident #37 said he/she usually receives
a shower on Mondays and Fridays, but did not receive one yesterday (Monday), because staff
told him/her that the person who gave showers was not at work. The resident said this
happens often.
During an interview on 3/28/18 at 12:33 P.M., CNA M said the CNA’s provide showers to
residents based on the schedule issued daily by the DON. The CNA said the schedule is done
on a priority listing from one to five, based on the last time the resident received a
shower. The CNA said if a resident refuses his/her shower, staff completes the shower
sheet, have the resident sign the refusal, then submit the sheet to the charge nurse, who
gives it to the DON.
During an interview on 3/29/18 at 8:57 A.M., CNA D said some residents like Resident #37
receive a shower on specific days, but most residents are offered showers based on a
priority list that the DON prints out daily. The CNA said the DON is only there Monday
through Friday so the list gets followed those days, but on the weekends when there are
only two to three aides on the 400/500 halls, it is hard to get the showers done. The CNA

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 14)
said ideally if there are four to five aides (including a shower aide), the CNA’s can get
the showers done, but they are not always successful due to staffing issues. The CNA said
Resident #14 does not have specific days to get a shower, and sometimes the resident
thinks staff forgets him/her, but the CNA said that is not the case. Resident #29 does not
have specific days to get a shower/bed bath, and sometimes refuses, but usually signs the
refusal sheet.
During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said the CNA’s give
residents showers, but mostly on the day shift. The RN said if staffing permits, some
residents are offered a shower in the evenings, but that is a rarity. Resident #14
occasionally refuses his/her showers, but staff give him/her a bed bath to supplement.
Resident #29 sometimes refuses, but staff gives him/her a bed bath instead. The RN said a
female resident complained to the DON about not getting showers a couple months prior, and
said he/she thought the DON addressed it.
During an interview on 3/29/18 at 6:29 P.M., the DON said he/she expects the CNA’s to
offer residents showers from the list they receive daily. The DON said showers are offered
at least once a week, sometimes twice, and sometimes three to four times. The DON said
showers are not necessarily scheduled, but are offered on a rotating basis (day, evening,
Saturday, and Sunday), and varies based on staffing levels and resident refusals. The
CNA’s are expected to document the showers they provided on shower sheets, which are
reviewed by the charge nurse, the DON, and filed monthly.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review facility staff failed to provide an
ongoing program of activities designed to meet the residents’ interest during the weekend
and for seven sampled residents (Residents #1, #22, #27, #28, #34, # 38, and #52). The
facility census was 58.
1. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the
following:
-Saturday, 1/6/18: family time, 2 P.M. games;
-Sunday, 1/7/18: 2 P.M. First Baptist Church;
-Saturday, 1/13/18: family time, 2 P.M. games;
-Sunday, 1/14/18: 2 P.M. New Home Church;
-Saturday, 1/20/18: family time, 2 P.M. WII;
-Sunday, 1/21/18: 2 P.M. local church group;
-Saturday, 1/27/18: family time, 2 P.M. games;
-Sunday, 1/28/18: 2 P.M. Anutt Community Church.
Staff did not plan weekend activities other than church and unspecified games.
2. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the
following:
-Saturday, 2/3/18: family time, 2 P.M. WII;
-Sunday, 2/4/18: First Baptist Church, 5:30 P.M. Super Bowl;
-Saturday, 2/10/18: family time, 2 P.M. games;
-Sunday, 2/11/18: 2 P.M. New Home Church;
-Saturday, 2/17/18: family time; 2 P.M. WII;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
-Sunday, 2/18/18: 2 P.M. local church group;
-Saturday, 2/24/18: family time, 2 P.M. games;
-Sunday, 2/25/18: 2 P.M. Anutt Community Church.
Staff did not plan weekend activities other than church and unspecified games.
3. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the
following:
-Saturday, 3/3/18: family time, 2 P.M. Karaoke;
-Sunday, 3/4/18: First Baptist Church;
-Saturday, 3/10/18: family time, 2 P.M. games;
-Sunday, 3/11/18: 2 P.M. New Home Church;
-Saturday, 3/17/18: family time; 2 P.M. WII;
-Sunday, 3/18/18: 2 P.M. local church group;
-Saturday, 3/24/18: family time, 2 P.M. games;
-Sunday, 3/25/18: P.M. Anutt Community Church;
-Saturday, 3/31/18: family time, 2 P.M. WII.
Staff did not plan weekend activities other than church and unspecified games.
4. Review of Resident #1’s Minimum Data Set (MDS), a federally mandated assessment tool,
dated 12/9/17, showed staff assessed the resident as follows:
-Cognitively intact;
-Somewhat important to participate in music, group, and outdoor activities;
-Independent with bed mobility, transfers, and toileting.
Review of the resident’s care plan dated 12/9/17 showed staff are directed to do the
following:
-Encourage to attend activities;
-Receive new monthly calendar every month;
-Explain importance of social interaction;
-Encourage participation by inviting to each activity;
-Preferred activities are watching television (TV) in room like horror movies in room,
remind him/her that he/she can leave activities at any time and is not required to stay
for an entire activity.
Review of the resident’s activity note, dated 12/9/17, showed staff documented the
resident is awake mostly at night. He/She likes to watch TV, talk on the phone, and visit
with staff. Family do not visit the resident.
Review of the resident’s activity note, dated 3/7/18, showed staff documented the resident
is awake mostly at night. The resident likes to watch TV, talk on the phone, and visit
with staff. The resident’s family never visits.
Review of the resident’s medical record showed staff did not complete an Activity log for
the resident for (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR).
Observation on 3/28/18 at 12:17 P.M., showed the resident in bed. Staff did not engage the
resident in an activity.
Observation on 3/29/18 at 8:41 A.M., showed the resident in bed. Staff did not engage the
resident in an activity.
Observation on 3/29/18 at 9:48 A.M., showed the resident in bed. Staff did not engage the
resident in an activity.
5. Review of Resident #22’s activities assessment, dated 6/23/15, showed the resident
likes the following:
-Cards and games;
-Music;
-Sports;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Reading;
-Going outdoors;
-Going on trips;
-Watching TV;
-Pets;
-Gardening;
-Talking;
-Cooking.
Staff are directed the resident would like to participate in bowling, music, church,
outdoor socials, watching TV, and visiting.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Severe cognitive impairment;
-Physical and verbal behaviors;
-Total dependence on two or more staff for bed mobility, transfers, and dressing.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
Observation on 03/27/18 at 11:22 A.M., showed the resident sat up in his/her bed. Staff
did not engage the resident in an activity.
Observation on 03/28/18 at 2:40 P.M., showed the resident in bed. Staff did not engage the
resident in an activity.
6. Review of Resident #27’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severe cognitive impairment;
-No behaviors;
-Supervision for transfers, walking, and eating;
-Limited assistance of one or more staff for dressing.
Review of the resident’s care plan dated 02/14/18, showed staff are directed to:
-Provide one on one activities;
-Escort resident to activities;
-Converse with resident during activities;
-Invite resident to activities;
-Provide resident with an activities calendar;
-Thank the resident for attending activities.
Review of the resident’s undated activity evaluation showed the resident likes the
following:
-Games;
-Crafts;
-Music;
-Religious activities;
-Going outdoors;
-Gardening;
-Social events.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
Observation on 03/28/18 at 2:42 P.M., showed the resident lay in bed. Staff did not engage
the resident in an activity.
Observation on 03/29/18 at 9:49 A.M., showed the resident lay in bed. Staff did not engage
the resident in an activity.
7. Review of Resident #28’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Unable to complete the cognitive assessment;
-No behaviors;
-Supervision for walking and eating;
-Extensive assistance of one or more staff for dressing and toileting.
Review of the resident’s care plan, dated 02/17/18, showed staff are directed to:
-Engage the resident in simple structured activities;
-Provide resident with an activities calendar.
Review of the resident’s activity evaluation, dated 11/11/17, showed the resident likes
the following:
-Games;
-Crafts;
-Exercise;
-Music;
-Baking/cooking;
-Religious activities;
-Watching TV;
-Watching movies;
-Talking;
-Social events.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only two activities during the month.
Review of the (MONTH) (YEAR) activity log showed staff documented the resident attended
only one activity during the month.
Observation on 03/27/18 at 11:37 A.M., showed the resident lay in bed. Staff did not
engage the resident in an activity.
Observation on 03/28/18 at 2:45 P.M., showed the resident lay in bed. Staff did not engage
the resident in an activity.
Observation on 03/28/18 at 3:54 P.M., showed the resident lay in bed. Staff did not engage
the resident in an activity.
Observation on 03/29/18 at 9:48 A.M., showed the resident lay in bed. Staff did not engage
the resident in an activity.
8. Review of Resident #34’s activity evaluation, dated 06/18/13, showed the resident likes
the following:
-Crafts;
-Exercise;
-Music;
-Watching movies;
-Talking;
-Staff are directed the resident would like to participate in music, movies, parties,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
manicures, outdoor socials, and cooking club.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Unable to complete the cognitive assessment;
-No behaviors;
-Limited assistance of one or more staff for bed mobility, transfers, and locomotion;
-Total dependence on one or more staff for eating.
Review of the resident’s care plan, dated 02/27/18, showed staff are directed to:
-Encourage the resident to attend activities;
-Provide the resident with an activities calendar in his/her room.
Review of the resident’s medical record showed staff did not document the resident
attended any activities during (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR).
Observation on 03/27/18 at 11:14 A.M., showed the resident in his/her recliner. Staff did
not engage the resident in an activity.
Observation on 03/28/18 at 1:21 P.M., showed the resident in his/her recliner. Staff did
not engage the resident in an activity.
9. Review of Resident #38’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Cognitively impaired;
-Very important to the resident to participated in music, and outside activities;
-Somewhat important to the resident to participate in animal, favorite, and outside
activities;
-Required limited assistance of one staff for transfers, dressing, toileting, and personal
hygiene.
Review of the resident’s activity note, dated 11/30/17, showed staff documented family
visits monthly, staff does one on one activities and visits with him/her three times
weekly. Staff are directed to give reminders and assist the resident to activities of
his/her choice.
Review of the resident’s activity note, dated 2/28/18, showed staff documented family
visits monthly, staff does one on one activities and visits with him/her three time
weekly. Staff are directed to give reminders and assist the resident to activities of
his/her choice.
Review of the resident’s care plan, dated 3/2/18, showed staff are directed to do the
following;
-Encourage the resident to join activities;
-Give updated activity calendar monthly.
Review of the resident’s activity interest survey, dated 3/2/18, showed the facility staff
assessed the resident as follows:
-Current interests are playing cards, games, crafts/arts, music/singing/dancing,
reading/talking books, spiritual/religious activity, walking/wheeling outdoors,
TV/radio/movies, gardening/plants, talking, parties, pet visits.
-Religious preference Baptist but does not want to attend religious services, does attend
Bible study and church that comes to the facility;
-Likes to visit with staff, watch TV in room, music, bowling, cards, coloring, social
hour, and outdoor socials.
Review of the resident’s medical record showed an Activity log not completed for the
resident for (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR).
Observation on 3/29/18 at 8:42 A.M., showed the resident in bed. Staff did not engage the
resident in an activity.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
Observation on 3/29/18 at 9:47 A.M., showed the resident in bed. Staff did not engage the
resident in an activity.
10. Review of Resident #52’s MDS, dated [DATE], showed facility staff assessed the
resident as follows:
-Cognitively intact;
-Somewhat important to the resident to do music, favorite, and outdoors activities;
-Totally dependent on two or more staff for bed mobility, transfers, dressing, toileting,
and bathing.
Review of the resident’s Activity Evaluation, dated 3/15/18, facility staff assessed the
resident’s current interests include music, reading/audio books, baking/cooking, computer,
trips/shopping, spending time outdoors, walking/wheeling outdoors, watching TV/radio,
watching movies, talking/conversing, helping others/volunteer work, parties/social events,
and keeping up with the news.
Review of the resident’s medical record showed an Activity log not completed for the
resident for (MONTH) (YEAR).
Observation on 3/29/18 at 1:22 P.M., showed the resident in bed. Staff did not engage the
resident in an activity.
11. During an interview on 03/28/18 at 3:45 P.M., Certified Nurse Assistant (CNA) P said
staff usually do not provide activities to residents on the unit. He/She said the other
residents did Easter crafts and hung some back there but the residents who live on the
special care unit did not get to participate. He/She said the Activities Director does not
come get the residents who live on the special care unit and take them to activities in
the main part of the facility and rarely does any activities with them in the unit. He/She
said they do have books and puzzles back there but not stuff the residents can really do.
He/She thinks the residents would like crafts.
During an interview on 3/29/18 at 3:19 P.M., Resident #14 said the Activities Director
(AD) only helps Resident #17 with activities. The resident said the AD does not do much
for the dependent residents, and often times just throws the dominoes on the table,
without helping. The resident said staff does not provide anything for activities on the
weekends, and he/she felt sorry for the residents who really need the help. The resident
said at least I can move around and find something for myself to keep busy.
During an interview on 03/29/18 at 3:20 P.M., CNA Q said, Honestly, there are no
activities going on over there (the special care unit). He/She said one on one activities
would be the best because some of the residents are not able to do much.
During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said weekend
activities consist of church, music, card games, and bingo. The RN said the AD comes in on
the weekends for special occasions, but normally the nurse and the aides assist residents
to music. The RN said he/she thinks there is only one calendar for the entire building,
and did not think there was a specific activity calendar for the residents on the special
care unit.
During an interview on 3/29/18 at 6:22 P.M., the Administrator and Director of Nursing
said activities are scheduled and put on by the activity director and if the activity
director can not be there someone will fill for him/her. The Administrator said the
special care unit has some activities that the CNA can do with the residents but they are
expected to be invited to the activities. The Administrator said staff should document
activities on the activity log for each resident and if activities are not documented on
the activity log, they were not done. The Administrator said he/she is not sure why the
activities were not documented on the activity logs for each resident, and it was his/her
oversight. The Administrator said the weekend activities are church services on Sundays
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
and family time where family comes and visits the residents and the activity director is
supposed to set out activity materials for the weekend staff to initiate activities. The
administrator said if residents do not have family or if they do not want to attend
religious services the activity director is expected to provide activities for residents
to do such as WII or games/cards. The Administrator said special care unit staff should
assist those residents to attend activities outside the special care unit.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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
resident environment remained free of accident hazards. Staff failed to ensure chemicals
and disposable razors were stored behind a locked door. The facility census was 58.
1. Review of the facility’s Chemical Storage policy showed chemicals are to be stored as
follows:
-In their original container or a container with proper labeling;
-All chemicals will have a lid;
-Under lock and key when not in use.
2. Observation on 03/27/18 at 11:21 A.M., showed the soiled laundry room unlocked and
unattended. Further observation showed nine five gallon containers of laundry chemicals
marked Danger: Corrosive inside.
Observation on 03/27/18 at 3:04 P.M., showed the soiled laundry room unlocked and
unattended. Further observation showed nine five gallon containers of laundry chemicals
marked danger: corrosive inside.
Observation on 03/28/18 at 12:55 P.M., showed the soiled laundry room unlocked and
unattended. Further observation showed nine five gallon containers of laundry chemicals
marked danger: corrosive inside. There were a few residents in the hallway near the room
at this time.
Observation on 3/28/18 at 6:25 P.M., showed a spray bottle with a hand written label of
bleach, sat on a bedside table outside room [ROOM NUMBER]. Further observation showed
Resident #23 (with a cognitive assessment not completed by staff), self-propelled in
his/her wheelchair past the table.
Observation on 03/29/18 at 11:21 A.M., showed the 100 hall shower room across from the
nurses’ desk left unlocked and unattended. Further observation showed disposable razors,
shaving cream marked keep out of reach of children, and disinfectant chemicals inside.
3. During an interview on 3/29/18 at 5:44 P.M., Certified Nurses Assistant (CNA) L said
staff are expected to store sharps/chemicals in a locked area when unattended. The CNA
said the shower rooms have a cabinet that staff should use to lock away those items.
During an interview on 03/29/18 at 6:00 P.M., CNA K said sharps and chemicals should be
behind locked doors. He/She said they are stored in a cart in the shower room and it
should be locked. He/She said if staff see them unlocked they should lock them up or throw
them away.
During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said staff are
expected to store sharps and chemicals in special containers and locked away. He/She said

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 – Few

(continued… from page 21)
the cabinet in the shower room should be locked when the room is unattended by staff. The
RN said a spray bottle of bleach is unsafe to residents if left in the hallway unattended.

During an interview on 3/29/18 at 6:22 P.M., the Director of Nursing (DON) said sharps and
chemicals should be kept behind locked doors unless in someone’s hands at that moment. The
DON said there should not be chemicals in the dirty linens room.

F 0732

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Post nurse staffing information every day.

Based on observation, interview, and record review, facility staff failed to post required
nurse staffing information, which included the facility name, number of licensed and
unlicensed staff, and the actual hours worked by both licensed and unlicensed staff
directly responsible for resident care, per shift, on a daily basis. The facility census
was 58.
1. Observation on 3/27/18 at 2:26 P.M., showed the facility’s Daily Roster posted on the
wall outside the administrator’s office. The posting did not contain the facility’s name,
total number of staff, or actual hours worked by both licensed and unlicensed staff
directly responsible for resident care.
2. Observation on 3/28/18 at 9:08 A.M., showed the facility’s Daily Roster posted on the
wall outside the administrator’s office. The posting did not contain the facility’s name,
total number of staff, or actual hours worked by both licensed and unlicensed staff
directly responsible for resident care.
3. Observation on 3/28/18 at 5:23 P.M., showed the facility’s Daily Roster posted on the
wall outside the administrator’s office. The posting did not contain the facility’s name,
total number of staff, or actual hours worked by both licensed and unlicensed staff
directly responsible for resident care.
4. Observation on 3/29/18 at 8:10 A.M., showed the facility’s Daily Roster posted on the
wall outside the administrator’s office. The posting did not contain the facility’s name,
total number of staff, or actual hours worked by both licensed and unlicensed staff
directly responsible for resident care.
5. During an interview on 3/29/18 at 8:11 A.M., the administrator said the Daily Roster
was the facility’s nurse staff posting. He/She said the Director of Nurses (DON) or the
charge nurse is responsible to complete the posting.
During an interview on 3/29/18 at 5:55 P.M., Registered Nurse (RN) B said the nurse staff
posting is completed by the night nurse daily. He/She said the posting should include the
facility name, census, etc.
During an interview on 3/2918 at 6:29 P.M., the DON said he/she expects the night shift
nurse to complete and display the nurse staff posting outside the administrator’s office.
He/She expects the posting to include all the required information, such as the census,
date, facility name, total number of licensed/unlicensed staff, and the actual hours
worked, and updated at the end of each shift. The DON said he/she was not sure why staff
did not complete the posting correctly.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0732

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation and interview, facility staff failed to properly maintain the
temperature of hot foods at or above 120 degrees Fahrenheit (ºF) and cold foods at or
below 41 ºF at the time of service and failed to implement a system for monitoring food
temperatures at the time of service. Failure to properly maintain foods at the proper
temperature has the potential to affect all residents who receive room trays. The facility
also failed to provide palatable food for ten residents (Resident #1, #14, #15, #17, #20,
#21, #25, #33, #46, and #54). The facility census was 58 residents.
1. Review of the facility’s Meal Service Temperature policy showed staff are directed to:
-Ensure appropriate food temperatures and appropriate food holding temperatures during
meal service.
The Dietary Manager and Cooks are directed to:
-Cook hot foods to a temperature above 165 ºF;
-Chill cold foods to a temperature below 40 ºF;
-Monitor meal temperatures;
-Report meal temperatures on the Temperature Report Form at each meal;
-Remove, reheat, or rechill foods which register outside the acceptable range.
2. Observation on 3/28/18 at 12:54 P.M., showed staff delivered a covered hall tray to the
400 hall from the kitchen on an open cart. The temperature of the salisbury steak at the
time of delivery to the resident showed 115 ºF.
3. Observation on 3/28/18 at 5:40 P.M., showed staff delivered a covered hall tray to the
100 hall from the kitchen on an open cart. The temperature of the salisbury steak at the
time of delivery to the resident showed 95 ºF.
4. Observation on 3/28/18 at 5:49 P.M., showed staff delivered a covered hall tray to the
500 hall from the kitchen on an open cart. The temperature of the the tuna salad on a
crescent roll was 60 ºF and the temperature of the tomato soup was at 100 ºF at the time
of delivery.
5. Observation on 3/29/18 at 12:45 P.M., showed staff delivered a covered hall tray to the
500 hall from the kitchen on an open cart. The temperature of the the sliced turkey at the
time of delivery was at 105 ºF.
6. During an interview on 3/27/18 at 10:56 A.M., Resident #25 said he/she eats most meals
in his/her room, and the food is sometimes cold when it is served to him/her.
During an interview on 3/27/18 at 11:03 A.M., Resident #14 said the food is not very
tasty, and sometimes cold by the time it is served to him/her.
During an interview on 3/27/18 at 11:35 A.M., Resident #20 said he/she does not like the
food.
During an interview on 3/27/18 at 12:01 P.M. Resident #1 said he/she does not like the
food.
During an interview on 3/27/18 at 1:03 P.M. Resident #54 said the food doesn’t taste good.

During an interview on 3/27/18 at 2:12 P.M., Resident #21 said the food does not taste the
best.
During an interview on 3/27/18 at 2:31 P.M., Resident #33 said the food is not the best,
its like institutional food.
During the group interview on 03/28/18 at 10:08 A.M., Resident’s #14, #15, #17, #25, and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 23)
#46 said the food is worse since they switched companies about a year ago. The residents
said the potatoes are hard, the broccoli is hard, the meat is tough, and the room trays
are cold.
During an interview on 3/29/18 at 5:44 P.M., Certified Nurses Assistant (CNA) L said the
CNA’s are responsible to deliver resident’s room trays, but anyone can. The CNA said staff
ensure the temperature is okay by keeping the plate covered, and delivering the meal as
soon as it leaves the kitchen. If a resident complains of his/her food being cold, staff
are expected to return the meal to the kitchen and inform the dietary staff, but
microwaves are also available if needed.
During an interview on 3/29/18 at 6:02 P.M., Registered Nurse (RN) B said CNA’s deliver
room trays to residents, but anyone can deliver them. RN B said staff ensure the food
temperature is maintained by keeping the plate covered, and deliver it immediately. If a
resident complains of his/her meal being cold, staff are expected to use the microwave (on
each hall) to reheat the meal.
During an interview on 03/28/18 at 12:19 P.M., the Dietary Supervisor (DS) said the
kitchen has around 26 hall trays not counting the special care unit, for the lunch time
meal, and said it is often more than 26 hall trays for the evening meal. The DS said the
number of hall trays has increased over the past year. The DS said the kitchen does not
have anything to keep the hall trays warm once the food leaves the steam table. The DS
said if there are not enough staff to transport the hall trays, then sometimes the carts
that carry the hall trays are not delivered right away to the residents.
During an interview on 3/29/18 at 6:22 P.M., the Director of Nursing (DON) and
administrator said they expect the kitchen to fill hall trays and tell the nursing aid.
The nursing aid is expected to deliver the meal to the residents immediately, which would
keep the food at the appropriate temperatures. They said the CNA passing trays is usually
assigned by the charge nurse. The DON and administrator expect staff to take the
resident’s meal back to the kitchen and request a new tray if the food is cold. The
administrator and DON said they were not aware of complaints of cold food or food that
tasted bad.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to appropriately
sanitize a multi-use glucometer (a device for monitoring blood sugars) before and after
use for five residents (Resident #14, #19, #25, #29, and #43), to prevent the spread of
infection causing contaminants. Facility staff also failed to wash/sanitize hands at
appropriate times during medication administration for five residents (Resident #14, #25,
#27, #29, and #208), during care for two residents (Resident #13 and #23), and during meal
assistance for three residents (Resident #38, #41, and #208), to prevent the spread of
infection causing contaminants. The facility census was 58.
1. Review of the facility’s policy on Blood Glucose Monitoring, updated 2/15/18, showed
staff are directed the charge nurse will:
-Maintain a copy of each glucose monitor’s manufacturer instructions on the unit;
-Give copies of the manufacturer’s instructions to the Director of Nursing (DON) for the
policy and procedure manual;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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)
-Maintain a back-up glucose monitor to be used in the event of equipment malfunction.
There should be two monitors per sides of the building for use at all times;
-Finger stick device is used on one resident and then cleaned with bleach wipe, placed in
the plastic container where it remains until dry (approximately three minutes). DO NOT
leave device wrapped in the bleach wipe when placed in the container.
2. Observation on 3/27/18 at 11:01 A.M., showed Licensed Practical Nurse (LPN) G wore
gloves, entered Resident #14’s room and checked his/her blood glucose level. The LPN
exited the room, placed the unsanitized multi-use glucometer on top of the cart (without a
barrier), and walked away from the cart. Observation at 11:05 A.M., showed the LPN
returned to the cart, applied gloves, prepared and administered the required insulin
(medication to treat high blood glucose levels), to the resident. The LPN exited the room,
removed gloves, disposed of the needle, and pushed the cart down the hall. The LPN did not
sanitize the multi-use glucometer after use, and did not wash/sanitize his/her hands
before and after he/she administered the insulin.
Observation on 3/27/18 at 11:09 A.M., showed LPN G wore gloves, entered Resident #29’s
room, and used the unsanitized multi-use glucometer to check the resident’s blood glucose
level. The LPN exited the room, placed the unsanitized glucometer on top of the cart
(without a barrier), and went down the hall to the med room. Observation showed the LPN
returned to the cart at 11:14 A.M., gloved, prepared the insulin, entered the room, and
administered the insulin to the resident. The LPN exited the room, removed gloves,
disposed of the needle, and pushed the cart down the hall. The LPN did not sanitize the
multi-use glucometer before and after use, and did not wash/sanitize his/her hands before
and after he/she administered the insulin.
Observation on 3/27/18 at 11:17 A.M., showed LPN G wore gloves, entered Resident #25’s
room, and used the unsanitized multi-use glucometer to check the resident’s blood glucose
level. The LPN exited the room and placed the unsanitized glucometer on top of the cart
(without a barrier). The LPN gloved, prepared the insulin, entered the room, administered
the insulin to the resident, returned to the cart and proceeded down the hall. The LPN did
not sanitize the multi-use glucometer before and after use, and did not wash/sanitize
his/her hands before and after he/she administered the medication.
Observation on 3/28/18 at 11:37 A.M., showed LPN O wore gloves, entered Resident #14’s
room, placed the multi-use glucometer on the resident’s thigh (without a barrier), checked
his/her blood glucose level, and exited the room. The LPN placed the unsanitized
glucometer on top of the cart (without a barrier), sanitized hands, prepared and
administered the insulin to the resident, and sanitized hands. He/She sanitized the
glucometer with a bleach wipe and placed the glucometer back on top of the cart (without a
barrier). The LPN did not place the sanitized glucometer in a plastic container to dry, as
directed by the policy.
Observation on 3/28/18 at 4:44 P.M., showed LPN H wore gloves, entered Resident #43’s
room, placed the multi-use glucometer on the resident’s bed pad (without a barrier),
checked his/her blood glucose level, and exited the room. The LPN returned to the cart and
placed the contaminated glucometer on top of the cart (without a barrier). The LPN
sanitized hands, prepared and administered the insulin to the resident, and sanitized
hands. The LPN did not sanitize the multi-use glucometer after use.
Observation on 3/28/18 at 4:52 P.M., showed LPN O wore gloves, entered Resident #19’s room
and used the unsanitized multi-use glucometer from the cart, to check the resident’s blood
glucose level. He/She exited the room, placed the unsanitized glucometer directly on top
of cart (without a barrier), sanitized hands, and proceeded down the hall. The LPN did not
sanitize the multi-use glucometer after use.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 25)
During an interview on 3/29/18 at 5:58 P.M., RN B said staff are expected to clean the
multi-use glucometer between each resident use, and again at the end of the shift. The
glucometer should be placed on a barrier to prevent contamination, and not directly on the
resident or a bed.
3. According to the Infection Control Guidelines for Long Term Care Facilities (Section
3.0 Body Substance Precautions): *Dirty gloves are worse than dirty hands because
micro-organisms adhere to the surface of a glove easier than to the skin of your hands.
*Hand washing remains the single most effective means of preventing disease transmission;
wash hands whenever they are soiled with body substance and when each resident’s care is
completed.
Observation and interview on 3/29/18 at 8:17 A.M., showed Certified Medication Technician
(CMT) N prepared medications for Resident #208. Observation showed the CMT opened two
unidentified capsules with his/her bare hands, poured them into a plastic medication cup,
added applesauce and administered to the resident. The CMT said the capsules were
[MEDICATION NAME] and [MEDICATION NAME]. The CMT did not wear gloves to handle the
medications, and did not wash/sanitize his/her hands after handling the medications.
Further observation showed the CMT pushed the cart down the hall, pulled his/her hair back
several times while he/she prepared Resident #27’s medications, and did not wash/sanitize
his her hands.
Additional observation and interview at 8:28 A.M., showed the CMT entered the room,
administered the medications to the resident, then sanitized his/her hands. The CMT said
staff are expected to wash hands when contaminated, before they enter/leave a room, before
clean tasks, and sanitize/wash hands after a few patients when they administer
medications. The CMT said he/she was not trained to wear gloves when handling capsules
directly, but now that he/she thought about it, he/she probably should. The CMT said
he/she never really thought about sanitizing his/her hands after pulling his/her hair
back, but probably should.
During an interview on 3/29/18 at 5:58 P.M., RN B said staff are expected to wash hands
between each resident when they administer medications. Staff should wear gloves to open
capsules and wash hands after to prevent contamination, and it is not okay to pull your
hair when preparing meds without cleaning hands in between.
4. Review of the facility’s policy on Hand-Washing, undated, showed staff are directed to
wash hands:
-Before and after providing residents with personal care (dressing/undressing, and
perineal care);
-Before and after serving/assisting/feeding resident’s meal tray.
5. Observation on 3/27/18 at 11:19 A.M., showed Certified Nurse Assistant (CNA) K and CNA
P entered Resident #13’s room, did not wash hands, and applied gloves. to their hands.
Observation showed the resident incontinent of urine. Observation showed CNA P cleansed
the resident’s bottom and CNA K provided frontal perineal care to the resident.
Observation showed CNA P applied barrier cream, to the resident’s bottom with the same
soiled gloves. Observation showed CNA P changed gloves and did not wash his/her hands. CNA
K and CNA P touched the resident’s clean clothes and skin with the same contaminated
gloves. Observation showed the CNAs did not wash their hands and change gloves in a manner
to prevent the spread of bacteria.
6. Observation on 3/27/18 at 12:24 P.M., showed CNA Q served lunch trays and drinks to
multiple residents. The CNA did not wash his/her hands between residents or wear gloves
during the meal service.
7. Observation on 3/27/18 at 12:32 P.M., showed the Speech Therapy Assistant touched
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
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 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 26)
Resident #208’s bread with his/her bare hands. He/She did not wash his/her hands or wear
gloves.
8. Observation on 3/28/18 at 12:29 P.M., showed CNA R touched Resident #38’s bread with
his/her bare hands. He/She did not wash his/her hands or wear gloves to handle resident
food.
9. Observation on 3/28/18 at 12:35 P.M., showed LPN O buttered Resident #41’s bread with
his/her bare hands. The LPN did not wear gloves to handle resident food.
10. Observation on 3/28/18 at 4:56 P.M., showed CNA I washed hands, placed gloves, applied
socks to Resident #23’s feet, placed pants on his/her legs, and placed a gaitbelt around
the resident’s waist. Further observation showed CNA I and CNA J held the gaitbelt and
transferred the resident from the bed to the chair. CNA I went to the sink, cleaned the
resident’s dentures, and placed the dentures in the resident’s mouth. The CNA did not
change gloves and wash/sanitize his/her hands after he/she dressed the resident and before
he/she provided oral care to the resident.
11. During an interview on 3/29/18 at 5:44 P.M., CNA L said staff are expected to wash
hands before they enter/exit a room, when soiled, between clean and dirty tasks, and
during perineal care. Staff are also expected to change gloves and wash hands after they
dress a resident, before they clean/insert dentures, and again after they provide oral
care.
13. During an interview on 3/29/18 at 6:22 P.M., the DON staff should wash their hand or
use hands sanitizer when they enter/exit a residents room, between glove changes, between
dirty/clean tasks, every their mediation during medication pass, before eye drops, oral
medications, after touching their face/hair and before passing medications. The DON said
he/she expects staff to wear gloves when staff handle medication capsules. Staff are
expected to not touch residents’ food with their hands, and are expected to wear clean
gloves if they have to touch resident food. The DON said the glucometers should be
cleansed with the bleach wipes and staff should wait three minutes after each use and
should use the extra glucometer to perform the next blood sugar check while they wait for
the sanitizer to take effect.