McDonald County Living Center

Based on interview and record review, the facility failed to provide pharmaceutical services that ensured administration of all drugs to meet the needs of each resident when staff failed to have multiple medications available for administration for one resident (Resident #3) and failed to follow-up with the physician and pharmacy regarding the missed doses. The facility census was 56. Review of the facility's policy titled, Medication, Administration Guidelines, undated, showed the following: -It is the purpose of the facility that residents receive their medications on a timely basis and in accordance with established policies; -The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's order, giving the individual dose to the proper resident, and promptly recording the information;-The same person preparing the doses for administration must administer the medications;-The person administering the drugs must chart the medications immediately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure all residents were free from significant medication errors when staff administered one resident's (Resident #2) insulin to another resident (Resident #1) who did not have orders for insulin and no diagnosis of diabetes. The facility census 56. On 06/25/25, during morning medication pass, Licensed Practical Nurse (LPN A) discovered the medication. The LPN notified the Administrator, Director of Nursing (DON), physician, and family of the medication error. The LPN completed monitoring until the resident left for the hospital. The DON completed an investigation and in-service of all staff on 06/25/25. The facility corrected the non-compliance by 06/26/25. Review of the facility policy titled, Medication, Administration Guidelines, undated, showed the following:-The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's order, giving the individual dose to the proper resident, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was protected from possible contamination at all times when kitchen staff failed to air-dried bowls and pans prior to storage for use. This failure had the potential to increase the risk of food borne illness and had the potential to affect all 54 residents who resided in the facility and who received dietary services. Review of the facility's policy titled, Dishwashing and Storage, undated, showed the following: -Air-dry all items. Never use a towel to dry items. Make sure items are completely dry before stacking or storing them. Store them in a way that will protect them from contamination. 1. Observation and interview on 12/09/24, at 9:45 A.M., showed the following: -Five soup bowls stacked together that were still wet from washing and had not been allowed to fully air dry; -Cook (C) 1 said the bowls should be dry before they are stacked to help prevent contamination. Observation and interview on 12/09/24, at 9:54 A.M., showed the following: -Four pans, 6 inches by 10 inches by 6 inches deep,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed provide pressure ulcer prevention care per standards of practice when staff failed to ensure all staff were aware of a new order for placement of protective heel boots, that the intervention was consistently implemented, and that the new intervention was care planned for one of one sampled residents (Resident #23). Review of the facility's policy, Pressure Ulcer, Care and Prevention Of, undated, showed the purpose of the policy was to prevent and treat further breakdown of pressure sores. Treatment of pressure ulcers varies depending on the orders of the attending physician. The nurse was responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers. Heel protectors was one of the listed interventions. Review of the facility's policy, Positioning the Resident, undated, showed the purpose of the policy was to relieve pressure and prevent skin breakdown, to relieve pain, and to promote proper body alignment. Staff to use protective…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have a system to ensure consistent communication and collaboration of care occurred between the facility and hospice staff for one resident (Resident #39) of one resident reviewed for hospice services. Review showed the facility did not provide a policy related to coordination of hospice services. 1. Review of Resident #39's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, showed the following: -admission date of 06/09/22; -readmission date of 08/05/22; -Diagnoses included heart failure, lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), and palliative (comfort) care. Review of the resident's Minimum Date Set (MDS - a federally mandated assessment completed by facility staff), with a Assessment Reference Date (ARD) of 09/11/24, located under the MDS tab of the EMR, showed the resident was severely cognitively impaired. Review of the resident's current Care Plan, located in the EMR under the Care Plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative of the facility's bed hold policy for four residents (Residents #28, #45, #29, and #62) who were transferred out to the hospital, out of a sample of 18 residents. The facility census was 71. The facility did not provide a written policy of the Bed Hold Policy with all transfers. 1. Review of Resident #28's face sheet (brief information sheet about the resident) showed the following information: -admitted on [DATE]; -Diagnoses included: Chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid), congestive heart failure (CHF - a condition in which the heart can't pump enough blood to the body's other organs), chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an ongoing monitoring process to include accurate accountability of expired or unusable medications, including one over-the-counter medication for one resident (Resident #59), and including one over-the-counter supplement, and three topical ointments/creams, following standards of practice. The facility census was 69. Review showed no facility policy provided regarding expired medications. Review of the Centers for Disease Control and Prevention (CDC) guidance dated, August 2022, showed the following: -Every year, two million people end up in the hospital due to drug-related injuries; -This might include medication errors, adverse drug reactions, allergic reactions, or overdoses; -Safe and secure storage of prescription medicine can help avoid accidental injuries; -Check to see if any prescription medicines are expired, since taking expired medication may no longer be safe or effective; -Make sure prescription medicine is stored in the original packaging with the safety lock tightened and secured;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to keep food safe from potential contamination when food contact surfaces (dishes) were stacked wet instead of air dried, potentially causing a bacterial growth. The facility census was 69. Review of the 2013 Missouri Food Code showed the following information: -Physical facilities will ensure the rinsing of equipment and utensils after cleaning and sanitizing; -Food contact surfaces and utensils shall be clean to the sight and touch; -After being cleaned and sanitized, equipment and utensils shall be air dried; -Utensils and other eating equipment shall be in a self-draining position that allows air drying. 1. Review of the facility policy, titled Nutrition and Dining Services Manual, May 2015, showed the following information: -After the first tray of dishes is washed, pull the rack out of the machine to air dry; -After washing silverware, allow to air dry; -Trays and plate covers should be taken from carts, rinsed, and stacked in dishwasher, and allowed to air dry. Observation on 4/24/23, at 10:40 A.M.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, facility failed to ensure staff completed hand hygiene during blood glucose monitoring and insulin administration for one resident (Resident #62), during and following incontinent care for one resident (Resident #9), and following toileting for one resident (Resident #33), out of a sample of 18 residents. The facility census was 69. Review showed the facility did not provide a policy specific to hand washing. 1. Review of Resident #62's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 06/23/22; -Diagnoses included type 2 diabetes mellitus (chronic condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) without complications, aphasia (language disorder that results from damage to portions of the brain that are responsible for language) following cerebral infarction (stroke), and muscle weakness. Review of the resident's quarterly Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, observation, and record review, the facility failed to keep the kitchen area safe from potential contamination when non-food contact surfaces, such as ceiling vents and air conditioning units, were found to have a dust/debris mixture with cobwebs. The facility census was 69. Review of the 2013 Missouri Food Code showed physical facilities shall be cleaned as often as necessary to keep them in sanitary condition. Review of the facility's cleaning schedule showed the following: -There are three separate cleaning schedules, one for the cooks, one for the dishwasher, and one for the dietary aide; -Each date had two separate cleaning duties assigned to every day; -The schedule did not address cleaning the areas observed with the dust/debris/cobweb mixture, such as the air conditioning unit and vent, the metal shelf, or the ceiling vents. Review of the facility policy, titled Work Spaces and Storage, dated 05/2015, showed the following: -Rinse shelves with a clean sponge or cloth; -Use appropriate strength solution for sanitizing; -Clean on a weekly basis, or more…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the dignity of one resident (Resident #19) when staff did not place the catheter (tubing to drain the bladder) collection bag inside a dignity bag, out of a sample selection of 18 residents. The facility census was 69. The facility did not provide a policy regarding dignity. 1. Review of Resident #19's face sheet (gives basic resident profile information) showed the following: -admitted to the facility on [DATE]; -Diagnoses included left non-dominant side weakness and paralysis following a stroke, overactive bladder, urinary tract infection (UTI), urinary retention, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff), dated 03/03/23, showed the following: -Cognitively intact; -Required extensive assistance for bed mobility, transfers, mobility using a wheelchair, dressing, toileting, personal hygiene, and bathing;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide privacy during toileting for one resident (Resident #33) out of a sample selection of 18 residents. The facility census was 69. The facility did not provide a policy regarding privacy. 1. Review of Resident #33's face sheet (brief resident information profile sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included bipolar disorder (mental health disorder causing mood swings), sepsis (infection in the blood), acute upper respiratory infection, cognitive communication deficit, anxiety, urinary tract infection (UTI) caused by enterococcus(bacteria), muscle weakness, and dementia. Review of the resident's 14-day admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/02/23, showed the following: -Moderately impaired cognition skills for daily decision making; -Short and long term memory problem; -Mild depression;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure residents were free of significant medication errors when staff failed to ensure two residents (Resident #62 and #18) had a meal intake within 30 minutes of insulin administration as recommended by the manufacturer, out of a sample of 18 residents. The facility census was 69. Review of the facility policy, titled Medication Administration, dated February 7, 2013, showed the following: -Medications are given to benefit a resident's health as ordered by the physician; -Bring cart to the resident room; -Explain to resident what you are going to do; -Read the label three times before administering the medication. First when comparing label to medication sheet. Second when setting up the medication. Third when preparing to administer medication to the resident; -Administer the medication; -Record the medication given on the medication sheet. Review of the facility policy, titled Injection (Subcutaneous (under the skin)), undated, showed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.