Knox County Nursing Home District

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor or identify weight loss, failed to complete assessments or notify the resident's provider or dietitian of significant weight loss, failed to ensure staff adequately monitored consumption of supplements ordered for weight loss and failed to re-evaluate the resident's care plan or initiate interventions to prevent further weight loss for one resident (Resident #13), in a sample of two residents investigated for nutrition concerns. Review of the resident's weight records showed the resident experienced a seven pound (lb.) weight loss, a 5.6 percent (%) significant weight loss in 30 days. The resident had also developed a pressure ulcer. The resident experienced significant weight loss with no staff identification, evaluation, notification or intervention. The facility census was 39. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to address pain and notify the physician of effectiveness of interventions regarding pain for one resident (Resident #15), in a review of 13 sampled residents. The facility failed to administer available ordered pain medications to address the resident's pain on occasions when other medication was not effective. Staff reported the resident's increased pain was preventing him/her from sleeping and attending activities. The facility census was 39. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess limited range of motion/risk of limited range of motion and provide direction to staff or interventions such as restorative nursing services to assist three residents (Resident #5, #6, and #25) in a review of 13 sampled residents, with mobility and/or limited range of motion to ensure the resident did not develop new or worsen existing limited range of motion which could cause pain, skin issues, and decline in the resident's abilities. The facility census was 39. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were labeled in accordance with currently accepted professional standards of practice, and per facility policy, when staff failed to date a multi-use Lantus insulin pen (long-acting, injectable medication to treat diabetes (inability to regulate blood sugar) with an open date when first accessed for one resident (Resident #12), failed to date a multi-use Ozempic (injectable insulin-like medication used to treat diabetes) pen with an open date for one resident (Resident #16), when first accessed and failed to discard an open, in-use vial of Humalog insulin (rapid-acting, injectable medication used to treat diabetes) for one resident (Resident #1), per the manufacturer's recommendations for expiration and discarding time frame. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served the correct portion size of food items to residents with a physician's order for a mechanical soft diet. The facility census was 39. Review of the facility policy, Portion Control-Portion Sizes, dated 2004, showed the following:-Policy: Foods shall be served according to standard portion sizes;-Purpose: To ensure adequate servings of foods and to provide equal sized portions for those residents not requiring special dietary modification;-Procedure: Portion control equipment, such as numbered dippers/scoops, spoodles, ladles of varying ounce capacities, is used at all meals; 1. Review of a list of the residents' orders, dated 2/22/26-2/23/26, provided by the Dietary Manager, showed six residents had a physician's order for a mechanical soft diet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items to conserve flavor and appearance. The facility census was 39. Review of the facility policy, Protecting Nutrients, dated 2004, showed the following:-Policy: All food shall be prepared to protect nutrients;-Purpose: To provide a food supply containing adequate nutrients;-Standardized recipes shall be followed;-Exceptions to following recipes shall only be made by the Food Service Supervisor and/or Dietitian/Consultant;-Substitution of ingredients shall only be made by the Food Service Supervisor and/or Dietitian/Consultant;-Foods shall not be prepared or portioned too far in advance of serving. 1. Review of the Resident Council meeting minutes, dated 12/5/25, showed when asked about the menus and food, several resident said they didn't like the menus or the food. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow current infection control standards for four sampled residents (Resident #6, #25, #13 and #5) in a review of 13 sampled residents and two additional residents (Resident #12 and #29). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an adequate audible system for the residents to signal nursing staff for assistance and failed to ensure staff responded to call lights timely for three residents (Resident's #25, #9 and #20) in a sample of 13 residents. The facility census was 39. Review of the facility policy, Resident Call System, last updated December 2023, showed the following:-Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation;-Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor;-Call system communication may be audible or visual. The system may be wired or wireless;-The resident call system should always remain functional. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to convey the remaining resident balance to the state or the probate jurisdiction administering the resident's estate within 30 days of death for one resident (Resident #43) and failed to return resident funds to two discharged residents (Residents #44 and #42), within five days following discharge. The facility census was 39. Review of the undated facility policy, Resident Funds - Cash on hand, showed the following:-Any cash, up to $50, on deposit with the facility is refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction, or death as applicable;-Policy Interpretation and Implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, for two residents ( Residents #13 and #1), in a review of 13 sampled residents, within 14 days after the facility determined, or should have determined, there had been a significant change in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 39. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a copy of the Pre-admission Screening and Resident Review (PASARR) Level II assessment for one resident (Resident #5), in a sample of two residents with mental illness. The facility also failed to take information and recommendations on the resident's Level II PASARR and incorporate the information into the resident's care plan, and assessment data to adequately meet the resident's needs. The facility census was 39. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a Level 1 Pre-admission Screening and Resident Review (PASARR) screening for one resident (Resident #27) in a review of two sampled residents with mental illness. The facility census was 39. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy on assessment of wounds and pressure ulcers (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), failed to adequately assess and identify a pressure ulcer, failed to stage (measure the severity of damage caused by unrelieved pressure) a pressure ulcer correctly, failed to initiate interventions to prevent a pressure ulcer from worsening and failed to re-evaluate and attempt new interventions for one resident's (Resident #25) pressure ulcer, in a review of two resident's with pressure ulcers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #12), in a review of two sampled residents who received insulin injections, were free from significant medication errors. Staff failed to prime (remove the air from the needle and cartridge) the resident's Humalog insulin pen (prefilled pen of rapid acting insulin (medication injected under the skin used to treat diabetes) and Lantus insulin pen (prefilled pen of long-acting insulin) needle, as instructed by the manufacturer, during the preparation of the medication, potentially affecting the amount of insulin dispensed with each dose. Further observation showed staff did not hold the insulin pen against the resident's skin after the administrations for the manufacturer's suggested time to ensure the proper dose was administered. The facility census was 39. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of a pressure ulcer (a localized injury to the skin and/or underlying tissue that develops as a result of prolonged pressure on an area) for one resident (Resident #10), who was at risk for development of pressure ulcers, in a review of 10 sampled residents. Staff first identified the pressure ulcer on 8/4/25. Licensed staff failed to assess the wound or obtain treatment orders until 8/8/25 when the wound had developed into a Stage III pressure ulcer (full-thickness skin loss, where fat tissue is visible in the wound. Additionally, the facility failed to ensure nursing staff conducted a weekly skin assessment for the resident as directed in his/her care plan. The facility census was 40. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two nurse aides (NA D and NA N) of two staff reviewed completed a certified nurse aide (CNA) training program within four months of their employment in the facility. The facility census was 36. The facility did not have a specific policy on NA to CNA training. 1. Review of the facility provided list employees hired since last annual inspection showed the following: -NA D's date of hire was 08/21/23; -NA N's date of hire was 12/30/22. 2. Review of NA D's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. 3. Review of NA N's employee file showed no documentation he/she completed a nurse aide training program within four months of his/her hire date. During an interview on 02/01/24, at 3:15 P.M., the administrator said the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written statement of the individual resident's trust fund balance to the resident and/or his/her responsible party quarterly and upon request. The facility managed funds for 38 residents. The facility census was 36. Review of the facility undated policy, Accounting and Records of Resident Funds, showed the following: -Policy statement: The facility maintains accounting records of resident funds on deposit with the facility; -The business office maintains a record of all financial transactions involving the resident's personal funds on deposit with the facility; -Individual accounting ledgers are maintained in accordance with generally accepted accounting principles and include: -The resident's name and medical record number; -The name of the resident's representative (sponsor); -The date of the resident's admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to review the Nurse Aide Registry for a Federal Indicator (which would disqualify an individual from working in the facility) for four of ten newly hired employees reviewed, and facility failed to check the Family Care Safety Registry (FCSR), perform a Criminal Background Check (CBC) or check the Employee Disqualification List (EDL) according to facility policy for three of ten newly hired employees review. The facility census was 36. Review of the facility's policy, Abuse and Neglect, dated 10/11/23, showed the following: -The personnel director, or other person designated by the administrator, shall conduct employment background checks, reference checks, and Missouri Nurse Aide Registry checks on persons making application for employment with this facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing staff washed their hands and changed soiled gloves after each direct resident contact and when indicated by professional standards of practice during care for two residents (Resident #6 and Resident #18), in a review of 16 sampled residents. The facility failed to ensure procedures were implemented to address prevention of Tuberculosis (TB) for five staff members in a review of ten sampled employees reviewed, when the facility failed to ensure Tuberculin Skin Tests (TST) were completed in accordance with the requirements for TB testing for long-term care employees. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 36. 1. Review of the facility's policy, Infection Control - Antibiotic Stewardship, dated 02/13/2023 showed the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program, which is a subpart of the Infection Prevention and Control Program; -Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic resistant organisms; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses and bed rails as part of a regular maintenance program to identify areas of possible entrapment for five residents (Residents #4, #18, #23, #25 and #27) who used bed rails, in a review of 16 sampled residents. The facility census was 36. Review of the facility's policy, Proper Use of Side Rails, updated June 2023, showed the following: -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; d. [...]

Inspectors wroteBased on interview and record review, the facility failed to report injuries of unknown origin to the state survey agency for one resident (Resident #6), in a review of 16 sampled residents, who was found to have bruising on his/her body on two separate occasions. The facility census was 36. Review of the facility's policy, Abuse and Neglect, dated 10/11/23, showed the following: -All reports of resident abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the organization management, including resident to resident contact in the dementia unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate bruising of unknown origin that occurred on two separate occasions for one resident (Resident #6), in a review of 16 sampled residents, to identify the cause. The facility census was 36. Review of the facility's policy, Abuse and Neglect, dated 10/11/23, showed all reports of resident abuse, neglect, and injuries of unknown origin shall be promptly and thoroughly investigated by the organization management. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 08/16/23, showed the following: -Cognition severely impaired; -Did not reject care; -Required substantial to maximal assistance for mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff consistently implemented pressure redistribution interventions for one resident (Resident #4), in a review of 16 sampled residents, who was re-admitted to the facility with a pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) on his/her coccyx (tailbone). The facility census was 36. Review of the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages dated 2016 showed the following: -Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently evaluate, implement, and modify interventions, in accordance with current standards of practice and as necessary to reduce the risk of falls for one resident (Resident #18), in a review of 16 sampled residents. The facility also failed to complete a manual transfer with the use of a gait belt (a canvas belt applied around a resident's waist to assist in transfers and ambulation) for one resident (Resident #25). The facility census was 36. Review of the facility's policy, Fall Risk Assessment, dated 01/2024, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper care to a urinary catheter (a tube inserted into the bladder) for two residents (Resident #17 and #32), who had a history of urinary tract infections (UTIs) in a review of 16 sampled residents. The facility census was 36. Review of the facility policy Urinary Catheter Care dated 6/8/23 showed the following: The purpose of this procedure is to prevent urinary catheter-associated complications, including UTIs; Infection Control: -Be sure the catheter tubing and drainage bag are kept off the floor; -Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder. 1. Review of Resident #32's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/17/23 showed the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (Resident #22), in a review of 16 sampled residents, remained free from unnecessary drugs when the facility failed to have adequate indications for antibiotic use. The facility census was 36. Review of the facility's policy, Infection Control - Antibiotic Stewardship, dated 02/13/23, showed the following: -Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while also attempting to reduce the development of antibiotic resistant organisms; -This facility ensures the implementation of protocols to optimize the treatment of infections by ensuring that residents, who require an antibiotic, are prescribed the appropriate antibiotic; -To reduce the risk of adverse effects, including the development of antibiotic-resistant organisms; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate indication for use of an antipsychotic medication (medications used to treat symptoms of psychosis, a loss of contact with reality, typically including delusions and hallucinations), and failed to monitor residents' signs and symptoms to support the continued use of antipsychotic medications for one resident (Resident #6), in a review of 16 sampled residents. The facility census was 36. Review of the facility undated policy and procedure, Psychotropic Drug Use, showed the following: -A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic, anti-depressant, anti-anxiety, and hypnotic; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify three residents (Residents #3, #17 and #31), in a review of 16 sampled residents, or their representatives in writing of transfer to the hospital, including the reasons for the transfer. The facility census was 36. The facility did not provide a policy for written notice of transfer/discharge. 1. Review of Resident #3's face sheet showed his/her family member was his/her responsible party. Review of the resident's progress notes, dated 9/7/23 at 3:22 P.M., showed the following: -The resident was noted to have a red face and was breathing hard; -The resident said he/she was shaking and was in fact having full body shakes; -The nurse practitioner was notified and an order was obtained to send to the emergency room (ER); -911 called at 3:22 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the facility name, resident census, and total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 36. Review of the facility policy, Posting Direct Care Daily Staffing Numbers, revised 6/8/23, showed the following: -The facility will post on a daily basis for each shift nursing staffing data, including the number of nursing personnel responsible for providing direct care to residents; 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to failed to develop and implement a policy addressing Cardiopulmonary Resuscitation (CPR-process of providing rescue ventilation and chest compressions to maintain circulation of blood) requirements for staff and to ensure CPR certified staff were scheduled and present in the facility 24 hours a day, seven days a week. This failure affected seven residents who were identified as full code status (CPR required in the event of cardiac or respiratory arrest). The facility also failed to ensure staff were trained and available to provide CPR when transporting residents who requested to be full code, in the facility van. Two additional residents (Resident #7, and #37) who were a full code, were transported multiple times by the facility transporter and van driver who were not certified to perform CPR. The facility census was 40. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen range hood was free of an accumulation of grease and debris; failed to use sanitary practices when handling clean eating utensils and when touching ready to eat food items; and failed to ensure a ceiling vent over a clean dishware storage area was free of debris. The facility census was 40. Record review of the facility's policy, Proper Procedure for Glove Use, reviewed 2/19/19, showed the following: -Gloves must be worn when your hands come into contact with any food, raw meats, breads, sandwiches, cookies and cakes. We are never to touch prepared food with our bare hands; -Gloves must be changed often; -When going from one area to another, such as serving trays to washing dishes and then serving trays again. When changing gloves remember to wash hands in the proper manner; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served the correct portion sizes according to the dietary spreadsheet for residents on regular, mechanical soft, and consistent carbohydrate (CCHO)/low-concentrated sweets (LCS) diets. The facility census was 40. Record review of the facility's policy, Dietary Department Policies and Procedures, revised 2/19/19, showed the menus will meet the recommended dietary allowance, provide variety, and if food substitutions were of equivalent value. 1. Review of an undated list of residents' diets, provided by the dietary manager on 9/22/20, showed 19 residents were on a regular diet, seven residents were on a mechanical soft diet, and eight residents were on a CCHO/LCS diet. Review of the dietary spreadsheet for lunch on 9/22/20 showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at a safe and appetizing temperature. The facility census was 40. Review of the facility's policy, Dietary Department Policies and Procedures, revised 2/19/19, showed all foods will be stored, prepared and transported at appropriate temperatures and in a sanitary manner. 1. During interview on 9/22/20 at 11:25 P.M., Resident #31 said the following: -The food is cold; -He/She doesn't talk to any one about the food, because it doesn't do any good. During group interview on 9/24/20 at 10:35 A.M., residents relayed the following: -Resident #2 said the food was cold in the morning, especially when he/she ate in his/her room; -Resident #4 said if he/she ate in his/her room, he/she would just expect it to be cold for all meals. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands and changed soiled gloves after each direct resident contact and where indicated by professional standards of practice during personal care for two residents (Residents #5 and #35), in a review of 12 sampled residents; failed to appropriately clean the urine soiled floor in one additional resident's room (Resident #16); and failed to appropriately implement infection control measures while performing glucometer use for one additional resident (Resident #17). The facility census was 40. Record review of the facility's policy, Alcohol Based Hand Rub and Gloving, dated 8/12/20, showed the following: -Alcohol Based Hand Rub (ABHR); -Put product on hands and rub hands together, cover all surfaces until hands feel dry; -This should take at least 20 seconds; -Handwashing; [...]

Inspectors wroteBased on interview and record review, the facility failed to screen two new employees, in a review of seven newly hired employees, prior to employment to determine if any had a Federal indicator with the nurse aide registry that would prohibit employment at the facility. The facility census was 40. Review of the facility policy Background Checks, revised 7/2/2011 showed the following: -The facility followed state and federal requirements for conducting background checks prior to staff having direct contact with residents; -The department heads notified the business office of a potential new hire prior to offering the job; -The business office completed the Certified Nurse Aide (CNA) registry check on all employees regardless of their job title and notified the department head of the results of background checks including the CNA registry check before the person was hired; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided two residents (Residents #5 and #35) in a review of 12 sampled residents and for one additional resident (Resident #24), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 40. Review of the facility's policy, Peri Care with Disposable Wipes, dated 4/25/17, showed the following: -Steps of procedure for giving peri care to the male resident: 1. Expose perineal area. Using a circular motion, gently wash the penis with wipes and clean from the tip downward, Note: if the resident is uncircumcised, retract the foreskin, wash with disposable wipe, then pull the skin over the penis; 2. Wash the scrotum with a new disposable wipe; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and consistently implement interventions, including adequate supervision consistent with residents' needs, goals and current professional standards of practice in order to eliminate or reduce the risk of falls and accidents; and failed to update the plan of care with new interventions to prevent additional falls for two additional residents (Resident #38 and #16), who the facility had identified at risk for falls and had a history of falls. The facility census was 40. Record review of the facility's policy, Fall Prevention Policy, dated 8/18/20, showed the following: -In order to promote the safety of residents and to try and avoid falls and accidents, this facility will complete a Fall Risk Assessment on each resident at time of admission; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to prevent and treat urinary tract infections (UTIs) for one resident (Resident #25) in a review of 12 sampled residents and for one additional resident (Resident #38) who required an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine). The facility identified four residents with an indwelling catheter. The facility census was 40. Record review of the facility policy catheter care, dated 5/28/11 showed the following: -Catheter care will be given daily and as needed to all residents who have an indwelling catheter; -Wash your hands, gather equipment and take to the bedside; -Explain the procedure to the patient and provide for privacy; -Wear gloves; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's money was placed in an interest bearing account when their balance was greater than fifty dollars for one resident (Resident #7). The facility census was 40. Review of the facility policy Resident Funds dated 7/8/10 showed funds less than 50 dollars shall be placed in a non-interest bearing petty cash funds. Should the resident choose to deposit more than 50 dollars with the facility, the facility will deposit the money in a resident fund account at a local bank. This shall be an interest-bearing account. The business office manager shall calculate earned interest on balances greater than 50 dollars and generate a quarterly statement to all residents who have money in petty cash or in the resident funds account. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements in writing for all residents for whom they managed petty cash funds. The facility census was 40. Review of the facility policy Resident Funds dated 7/8/10, showed the business office manager shall calculate earned interest on balances greater than 50 dollars and generate a quarterly statement to all residents who have money in petty cash or in the resident funds account. Observation of the resident petty cash count (by the administrator) on 9/24/20 at 3:50 P.M., showed the administrator opened and counted resident money which was held in individual zipper bags. There were forty bags total with resident names and corresponding transaction sheets. Seventeen residents had cash balances. During interview on 9/24/20, the assistant office manager said the following: [...]