Sarcoxie Health Care Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

noted;-Staff educated the resident on proper reporting to staff when a situation with other residents starts to escalate;-Resident #2 verbalized understanding.(Staff did not document notification of DHSS.)3. Review of the DHSS online reporting form showed a self-report from the facility was submitted on 08/23/25 at 11:11 A.M. (the day following the allegation of abuse between the residents).4. During an interview on 08/27/25, at 1:27, LPN D said the following:-On 08/22/25, at 6:00 P.M., a CNA reported there was an altercation between Resident #1 and Resident #2;-LPN D found Resident #1 lying on the floor at the end of the hall.

He/she immediately assessed Resident #1;-At 6:03 P.M., LPN D contacted the Administrator-At 6:06 P.M., LPN D contacted 911;-At 6:12 P.M., LPN D contacted Resident #1's physician;-At 6:14 P.M., LPN D contacted Resident #1;s family;-The Administrator arrived at the facility shortly after the incident-Physical altercations are reported to the State, by the Administrator, within two hours.During an interview on 08/27/25, at 1:03 P.M., Certified Nurse Aide (CNA) A said the following:-If there was an altercation between residents, he/she would report the incident to the nurse;-The nurse would have to report the incident to the State within two hours.During an interview on 08/27/25, at 1:11 P.M., Certified Medication Tech (CMT) B said the following:-Physical altercations between residents are reported to the nurse;-Administration would report the altercation to the State within two hours.During an interview on 08/27/25, at 1:30 P.M., CNA C said the following:-He/she would notify the nurse if residents got into a physical altercation;-The nurse would report the incident to the Administrator;-The Administrator reports the altercation to the State within two hours. During an interview on 08/27/25, at 1:51, Housekeeper (HK) G said the following:-Physical altercations between residents are reported to the charge nurse;-The Administrator would report the incident to the State within two hours.During an interview on 08/27/25, at 2:36 P.M., CNA E said the following:-On 08/22/25, around 6:00 P.M, CNA E was charting and heard a thump and hollering;-CNA E observed Resident #1 on the ground;-The nurse was alerted and assessed Resident #1;-The nurse would report the incident to the State immediately. During an interview on 8/27/25, at 2:56, LPN F said physical altercations are reported to the State within two hours by the Administrator.During an interview on 08/27/25, at 3:02, the Director of Nursing (DON) said the following:-Resident to resident altercations are reported to charge nurse;-The nurse will assess the resident and will report to the DON and Administrator;-The altercation is reported to the State within two hours by either the DON or the Administrator.During an interview on 08/27/25, at 3:02, the Administrator said the following:-Staff should report resident to resident alterations to the supervisor/nurse;-The nurse assesses the resident, calls the physician, next of kin, the DON, and the Administrator;-Resident contact suspected to be physical abuse has to reported to the State within two hours by the Administrator or DON;-The Administrator did not immediately report the incident as he/she did not believe the incident between Resident #1 and Resident #2 to be intentional, as Resident #1 is confused due to dementia.Complaint #2598159

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sarcoxie Health Care Center

1505 Miner Sarcoxie, MO 64862

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week. The facility census was 39.Review of the facility's Registered Nurse Policy, dated 04/30/24, showed the following information:-The facility will utilize

the services of a RN for at least eight consecutive hours per day, seven days per week;-The Director of Nursing (DON) may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents.1. Review of the facility's provided nurse schedules, dated 08/07/25 through 08/26/25, showed no RN coverage on any shift for the following dates:-08/07/25;-08/08/25;-08/09/25;-08/10/25;-08/16/25;-08/17/25;-08/25/25;-08/26/25.During an interview

on 08/27/25, at 1:03 P.M., Certified Nursing Assistant (CNA) A said he/she was unsure if a RN was on duty every day. During an interview on 08/27/25, at 1:11P.M., Certified Medication Technician (CMT) B said the following:-He/she believed the facility had daily RN coverage;-CMT B believed a RN was at the facility on

the weekends.During an interview on 08/27/25, at 1:20 P.M., CNA C said there was a RN at the facility almost every day.During an interview on 08/27/25, at 1:27 P.M., Licensed Practical Nurse (LPN) D said the following:-There was not a RN at the facility every day;-An RN was needed at the facility daily as the acuity of the residents was increasing, especially in regard to wounds and behaviors.During an interview on 08/27/25, at 2:36 P.M., the CNA E said he/she believed there was a RN at the facility every day.During an

interview on 08/27/25, at 2:56 P.M., LPN F said the following:-Typically, a RN was on duty every day;-Some days the facility has been without a RN coverage due to the change of DON;-Staff are not informed if a RN is not on duty.During an interview on 08/27/25, at 3:02 P.M., the DON said the following:-There was not 8 hours of RN coverage on 08/25/25 and 08/26/25;-Staff are made aware if there is not a RN on duty;-The DON is the only RN;-If the DON cannot work, he/she does not know who will provide RN coverage. During

an interview on 08/27/25, at 3:11 P.M., the Administrator said the following:-The DON is the only RN;-Several days the facility has been without RN coverage;-If an RN is not available, the Administrator will contact the company's nurse consultant and regional director of operations, who could assist with pulling a RN from a sister facility.Complaint #2595323

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