Hartville Care Center

Inspectors wroteBased on interview and record review, the facility failed to keep residents free accidents when staff failed to transfer one resident (Resident #1) per the resident's care plan and therapy assessment/direction resulting in a fall and bilateral tibia plateau fractures (break in the top of the shinbones). The facility census was 43. Review of the facility's policy titled Transfer Activities, undated, showed the following:-To transfer the resident from bed to chair, toilet, or tub safely with mechanical lift, or positioning devices, obtain assistance of another individual if necessary for safe transfer;-Obtain equipment from designated area and bring it to bedside. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was protected from potential contamination when staff failed to ensure the air gap for the ice machine had the required two inch gap between the drain in the floor and the tubing from the ice machine and when staff failed to ensure the stove top burners used to cook food for the residents were clean and free from grease. The facility census was 40. 1. Review of the 2013 Missouri Food Code showed an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. Review showed the facility did not provide a policy related to the air gap. Observation on 06/16/25, at 10:05 A.M., and 06/19/25, at 11:00 A.M., showed an ice machine located in the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary and functional environment when staff failed to keep the walk-in cooler floor maintained and cleanable. The facility census was 40. Review showed the facility did not provide a policy related to the floor of the walk-in cooler. Review of the 2013 Missouri Food Codes showed the following: -Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris; -Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material; -Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control system to control the flies when flies were present in two residents' rooms (Resident #2 and Resident #24) and in the facility kitchen. The facility census was 40. Review of the facility's policy titled, Pest Control, undated, showed the following: -Purpose was to provide an environment free of pests; -The facility will have a pest control contract which provides frequency treatment of the environment for pests. It will allow for additional visits when a problem is detected; -Monitoring the environment will be done by the facility's staff; -Pest control problems will be reported promptly. 1. Review of Resident #2's face sheet (admission data) showed an admission date of 11/05/21 and a readmisison date of 03/14/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure staff changed and stored oxygen equipment per professional standards and when staff failed to care plan oxygen usage for two residents (Resident #22 and #10). The facility census was 40. Review of the facility's Oxygen Equipment Policy, undated, showed the following: -Disposable oxygen equipment will be discarded after each use; -Humidifier must be emptied and refilled every 24 hours with distilled water; -Humidifiers are to be dated, initialed, and replaced monthly; -Tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and as needed. 1. Review of Resident #22's face sheet (a document that gives resident's basic information) showed the following: -admission date of 11/11/23; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for all residents, when staff failed to document in the medical record an injury and change of condition for one resident (Resident #36). The facility census was 40. Review of the facility's policy titled, Event Investigation, undated, showed the following: -Purpose was to investigate the cause of all marks, discoloration, skin breaks, and injuries which have not been witnessed and to identify any injuries after a resident sustains an event; -Complete a report of event form as soon as possible whenever there is an unusual, unexpected and/or unintended event; -Any staff member who discovers, witnesses, or is involved in an event should immediately report the event to the nurse in charge; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice when staff failed to keep the ice machine clean, failed to ensure the dishwasher chemicals tested at the recommended levels, and did not wear proper hair coverings. The facility census was 28. 1. Review of the 2013 Missouri Food Code showed food-contact surfaces of equipment and utensils shall be clean to sight and touch. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/23, at 8:59 AM., showed the deflector shield on the inside of the ice machine had five black spots and a black substance along most of the bottom of the deflector shield. Review of the facility's weekly cleaning schedule, dated October 2023, showed the following: -Ice machine listed as being cleaned weekly; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a sanitary environment for all residents, staff, and visitors when staff failed to ensure fans and areas around fans located in the walk-in refrigerator and the vents on the ice machine were cleaned; failed to replace a missing vent cover on the side of the ice machine; and failed to repair the vent cover broken the other side of the ice machine. The facility census was 28. 1. Review showed the facility did not provide policies related to cleaning related to the fans in the refrigerator. Observations of the kitchen on 10/30/23, beginning at 9:47 A.M., and on 10/31/2023, at 8:59 AM., showed two fans located at the back of the refrigerator had fuzzy gray lint and a build-up of lint above the fan on the left side. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report allegations of abuse to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours of staff becoming aware of the allegation of abuse when one resident (Resident #5) made allegations of physical and sexual abuse. The facility census was 28. Record review of the facility's abuse policy titled, Reporting, from Section 1 of the Abuse Prohibition Manual, undated, showed the following: -It is the policy of this facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse; -The nursing home administrator or designee will report abuse to the state agency per state and federal requirements; [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete full and timely investigations of allegations of abuse when one resident (Resident #5) made allegations of physical and sexual abuse. The facility census was 28. Record review of the facility's policy titled, Investigation, from Section 7 of the facility's, Abuse Prohibition Protocol Manual (undated) showed: -It is the policy of this facility that reports of abuse are promptly and thoroughly investigated; -When an incident or suspected incident of abuse is reported, the administrator will investigate the incident with the assistance of appropriate personnel. The investigation will include: [...]