Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document the resident’s
choice of code status accessible to staff in the event of an emergency, failed to obtain
signed code status forms, failed to obtain a physician’s orders[REDACTED].#39) out of a
sample of 16 residents. The facility census was 42.
Record review of the facility’s policy and procedure titled, Social Services Policies and
Procedures Advanced Directives, from the Centers for Medicare and Medicaid (CMS) dated[DATE], showed the following:
-The policy is a general guideline. The facility will comply with state laws governing
advance directives and will honor such forms in accordance with applicable state and
federal regulations;
-The facility will recognize each patient’s/resident’s right to self-determination and
their right to accept or discontinue medical or surgical treatment, to participate in or
refuse to participate in experimental research, the right to choose to receive
cardiopulmonary resuscitation (CPR), and the right to execute (or not execute) advanced
medical records such as Living Wills, agent designations, do-not-resuscitate directives,
etc. The purpose of this Policy of Practice is to provide instruction to the facility for
obtaining, honoring and implementing advance directives to the fullest extent of the law;
-Advance Care Planning is a process of communication between individuals and their
healthcare agents to understand, reflect on, discuss and plan for future healthcare
decisions for a time when individuals are not able to make their own healthcare decisions;

-An advanced directive is a written instruction, such as a living will or durable power of
attorney for healthcare, recognized under state law, related to the provision of health
care when the individual is incapacitated;
-Physicians Orders for Life Sustaining Treatment (POLST). A form designed to improve
patient care by creating a portable medical order form that records patient treatment
wishes so that emergency personnel know what treatments the patient wants in the event of
a medical emergency;
-The facility recognizes the following advanced directives;
A. Do-Not-Resuscitate (DNR) Identifications and orders;
B. Living Will, or similar declaration;
C. Power of Attorney for Health Care, or similar declaration;
D. Organ Donations;
E. Physicians Orders for Life Sustaining Treatment (POLST) and Medical Order for Life
Sustaining Treatment (MOLST);
-Upon admission to the facility, the Admission Coordinator will provide each
patient/resident and/or their legal representative with a copy of the facility’s policy
and state requirements for advanced directives and each patient/resident and/or their
representative will then sign an acknowledgement confirming receipt of this. Interview
each patient/resident or their legal representative/family members to determine whether or
not the patient/resident has executed an advance directive of any type. If the
patient/resident has executed an advanced directive, copies are obtained and disseminated
to the medical record, the financial record, Social Service Director, and to the Attending
Physician;
-The facility will determine Decision Making Capacity at the time of admission and as

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
necessary throughout the patient/residents’ stay. Social Services will review the medical
record and interview each patient/resident or responsible party again to discuss advanced
directives and inform them of their rights to complete advanced directives. If a
patient/resident has not executed an advance directive and would like to do so the Social
Service Director shall obtain the necessary forms and assist the patient/resident with
completing these forms. Once executed, copies are obtained and disseminated as noted
above. The facility will review the residents existing choices with resident or
responsible party periodically and with significant decline or improvement.
1. Record review of Resident #39’s medical record showed the following information:
-Date of admission [DATE];
-[DIAGNOSES REDACTED].
-Court appointed public administrator as the resident’s legal guardian;
-Admission sheet showed no code status;
Record review of the (MONTH) (YEAR) and (MONTH) (YEAR) physician order [REDACTED].
Record review of the resident’s medical record did not have a green sheet (which indicated
full code), red sheet (which indicated DNR), or an outside the hospital DNR sheet.
Record review of the resident’s care plan, dated [DATE], did not indicate the resident’s
code status.
During an interview on [DATE], at 9:07 A.M., the social service director (SSD) said
he/she assists with code status documentation for residents. He/she did not realize the
resident did not have his/her code status in his/her medical record. The SSD said medical
records should audit for a resident’s code status within 24 hours after the resident’s
admission and ensure each medical record lists the resident’s code status.
During an interview on [DATE], at 9:25 A.M., Medical Records (MR) staff said he/she just
started back at the facility last Thursday so he/she is still trying to organize medical
records. He/she said a resident’s code status should be the first item in a resident’s
medical record. If a resident had a red sheet in the front of the medical record, it would
show a resident to be a DNR and if there was a green sheet, it would show a resident to be
a full code. If the resident or resident representative selected a DNR code status, the
facility would have the resident or resident representative sign an outside the hospital
DNR as well. The resident’s code status should also be on the face sheet, admission
paperwork, and care plans. The MR staff agreed the resident did not have a code status
listed in his/her chart and he/she said in an emergency there is not time for staff to go
through a chart to see if the resident was a DNR or full code. He/she said the resident
had been admitted over a month ago and should have had a code status in his/her chart.
During an interview on [DATE], at 2:03 P.M., the director of nursing (DON) said every
resident at the facility should have a red, green, or purple sheet in the front of his/her
medical record to show the resident’s code status. Medical Records and Social Services
handle this.
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to develop a baseline care plan
within 48 hours of admission to the facility for six residents (Resident #45, #97, #39,
#3, #23, #40, #44) and failed to date one partially completed baseline care plan and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
failed to ensure the resident received a copy or summary of the baseline care plan for one
resident (Resident #39). A sample of 16 residents was selected for review out of a
facility census of 42.
1. Record review of Resident #45’s face sheet showed the following information:
-Date of admission 6/15/18;
-Diagnoses included dementia, irregular heart flutters, [MEDICAL CONDITION] with
metastasis (cancer that has spread to other parts of the body) to the bone, Foley catheter
(a flexible tube passed through the urethra into the bladder to pass urine), depression,
anxiety, high blood pressure, weight loss with anorexia (a lack or loss of appetite for
food), [MEDICAL CONDITION], pressure ulcer to coccyx;
-Severe cognitive impairment;
-[MEDICAL CONDITION].
Record review of the resident’s medical record showed the facility had not completed a
baseline care plan.
2. Record review of Resident #97’s face sheet showed the following information:
-Date of admission 7/3/18;
-Diagnoses included failure to thrive, heart failure, depression, and anxiety;
-admitted on Hospice;
Record review of the resident’s medical record did not show any admission Minimum Data Set
(MDS), a federally mandated comprehensive assessment instrument, completed by facility
staff, to determine cognitive status.
Record review of the resident’s medical record showed the facility had not completed a
baseline care plan for the resident.
3. Record review of Resident #39’s face sheet showed the following information:
-Date of admission 6/13/18;
-Diagnoses included [MEDICAL CONDITION], lung disease, and nicotine dependence;
-Cognitively intact;
-Resided on the memory care unit due to history of elopement from previous facility.
Record review of the resident’s medical record showed an undated partially completed
baseline care plan.
During an interview on 7/11/18, at 2:45 P.M., the resident said he/she had not been given
a copy of his/her baseline care plan.
4. Record review of Resident #3’s face sheet showed the following information:
-Date of admission 2/15/18;
-Diagnoses included high blood pressure, diabetes, dementia (a brain disorder),
depression, [MEDICAL CONDITIONS] and pain.
Record review of the resident’s quarterly MDS, dated [DATE], showed no cognitive status
listed. Staff marked the resident could be understood.
Record review of the resident’s medical record showed the facility had not developed or
completed a baseline care plan for the resident.
5. Record review of Resident #23’s face sheet showed the following information:
-Date of admission 5/20/18;
-Diagnoses included secondary malignant neoplasm (cancer) of the brain, muscle weakness,
dysphagia, cognitive communication deficit and assistance with personal care.
Record review of the resident’s 14 day MDS, dated [DATE], showed the following
information:
-admitted [DATE];
-Diagnoses included malignant neoplasm (cancer) of the brain and lung, generalized muscle
weakness, other abnormalities of gait and mobility, cognitive communication deficit and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
need for assistance with personal care;
-Cognitive impairment and staff indicated the resident can be understood;
-No rejection of care;
-Extensive assistance from staff for bed mobility, transfers, dressing, toileting,
bathing, and personal hygiene;
-Resident not steady during transfers and was only able to stabilize with assistance
during moving from seated to standing position, moving on and off toilet, and surface to
surface transfers;
-The resident used a wheelchair for mobility
Record review of the resident’s medical record showed the facility had not developed or
completed a baseline care plan for the resident.
6. Record review of Resident #40’s face sheet showed the following information:
-Date of admission 6/19/18;
-Diagnoses included acute kidney failure, chronic respiratory disease, type 2 diabetes,[MEDICAL CONDITION], high blood, [MEDICAL CONDITION] disorder, and chronic pain.
Record review of the resident’s admission MDS, dated [DATE], showed the following
information:
-admitted [DATE];
-No cognitive impairment;
-Supervision for bed mobility, transfers, eating, walking, and personal hygiene;
-Limited assist with toileting and bathing;
-Marked for no assistive devices;
-No [DIAGNOSES REDACTED].
Record review of the resident’s medical record showed the facility had not developed or
completed a baseline care plan for the resident.
7. Record review of Resident #44’s face sheet showed the following information:
-Date of admission 6/25/18;
-Diagnoses included [MEDICAL CONDITION] (abnormal brain development or injury that effects
muscle movement), [MEDICAL CONDITION] disorder, quadriplegic (loss of movement of all four
limbs), stage III pressure ulcer and difficulty swallowing.
Record review of the resident’s admission MDS, dated [DATE], showed the following
information:
-admitted [DATE];
-No cognitive status marked;
-Total dependence for bed mobility, transfers, personal hygiene, toileting and bathing;
-Limited assist with eating;
-Uses a wheelchair for mobility;
-Diagnoses marked as [MEDICAL CONDITION], generalized muscle weakness, difficulty
swallowing, and cognitive communication deficit.
Record review of the resident’s medical record showed the facility had not developed or
completed a baseline care plan for the resident within 48 hours.
8. During an interview on 7/17/18, at 9:37 A.M., the MDS Coordinator said he/she was
responsible for completing the baseline care plans. He/she said had not been taught about
baseline care plans and what should be on them. He/she did not know about a baseline care
plan form that lists the areas that needed to be covered. He/she did not know the baseline
care plan had to be completed within 48 hours, or that a copy had to be provided to the
resident or resident’s representative.
9. During an interview on 7/17/18, at 2:03 P.M., the Director of Nursing (DON) said she
did not know a baseline care plan had to be completed in 48 hours or that a copy must be
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
given to the resident or resident’s representative.
F 0684

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to properly
assess, monitor, and treat a resident’s wound when admitted with a negative-pressure wound
therapy (NPWT) device, otherwise known as a wound V.A.C. (Vacuum Assisted Closure)(a
therapeutic technique using a vacuum dressing to promote healing in acute or chronic
wounds and enhance healing of second- and third-degree burns), for one resident (Resident
# 21) resulting in the resident requiring surgery in order to remove the foam dressing
material from the wound. The facility failed to assure competency of the staff to maintain
the wound V.A.C. device per facility policy. The facility staff failed to report and
document a previously undocumented skin finding to the physician and DON when discovered.
The facility staff also failed to follow proper hand hygiene practices during the wound
dressing change per professional standards, and the facility failed to update their wound
care policies and procedures to include those standards. This practice affected one
resident out of a sample of 16. The facility census was 42.
Record review of the facility’s wound care policy, dated (MONTH) 2011, showed the
following information:
-Weekly skin checks should be performed and documented by licensed staff on all residents;
-The facility should have a system in place for daily observation of wounds which may
include the following:
-An evaluation of the status of the dressing such as being intact and dated, and for
observable drainage or leakage;
-Status of the surrounding skin;
-It is recommended that nursing progress notes reflect the nurse’s observation and
management of wounds from shift to shift perspective and with each dressing change. At a
minimum, weekly documentation is recommended to provide a review of the wound;
-Weekly documentation should include the following:
-Date observed;
-Location with staging/depth description for non-pressure wounds (i.e. partial thickness,
full thickness);
-Measurements (length, width, depth) and the presence and location of any extent of
undermining (undermining occurs when the tissue under the wound edges becomes eroded,
resulting in a pocket beneath the skin at the wound’s edge), tunneling or sinus tract (a
sinus tract is blind-ended tract that extends from the skin’s surface to an underlying
abscess cavity or area. The biggest difference between sinus tracts or tunneling and
undermining is that tunneling and sinus tracts are unidirectional, whereas undermining may
occur in more than one direction) measured per facility protocol;
-Presence, type, color, odor, appearance, and approximate amount of any exudate
(drainage);
-Presence, nature, and frequency of pain;
-Wound bed characteristics (color, type of tissue i.e. granulation tissue (new vascular
tissue in granular form on an ulcer or the healing surface of a wound.), slough (dead
tissue that can be yellow and stringy), or eschar (dark, dry scab) which give evidence to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 5)
healing or non-healing);
-Description of wound edges and surrounding skin as appropriate (i.e. rolled edges,
redness, induration (hardened area), maceration (softening and breaking down of skin
resulting from prolonged exposure to moisture) ;
-If the wound does not show some evidence of progress towards healing within two to four
weeks, the wound and the resident’s overall clinical condition should be reevaluated.
Reevaluation of the treatment plan and modification of the current interventions may also
be indicated. Documentation of any rationale for continuing present treatments when there
is little or no healing is required by the clinicians.
Record review of the facility’s N.P.W.T. (E.G. Vacuum Assisted Closure (V.A C.) units and
dressings) policy, dated (MONTH) 2011, showed the following information:
-N.P. W. T. negative pressure is applied to a porous dressing positioned in the wound
cavity or over a flap or graft. This porous dressing distributes negative pressure to the
wound and helps remove interstitial fluids (fluids that surround cells) from the wound;
-The vendor will provide initial facility based training and certification/competency;
-Facility N.P.W.T. trained staff that has demonstrated proficiency with the N.P.W.T. will
provide subsequent facility staff training;
-The facility will have an individual who is N.P.W.T. trained in-house, or available to
come in whenever there is a unit in use;
-physician’s orders [REDACTED].W.T. will meet the following criteria prior to initiation:
-Type of filler dressing (s) foam (s) to use;
-Wound bed preparation, if any with non-adherent, or impregnated dressings;
-N.P.W.T. pressure settings millimeters of mercury (mm/Hg) pressure/continuous vs.
intermittent pressure);
-Frequency of dressing changes;
-Orders for pain medication;
-Competency:
-All N.P.W.T. users (those who are applying the device and dressings) will be evaluated
for competency use for the individual N.P.W.T. units (and dressings) the location is
using, using the attached form. This competency will be kept in the individual’s personnel
file.
-Procedures:
-Follow manufacturer’s guidelines and physician’s orders [REDACTED].P.W.T. unit,
dressings, or any components of the system;
-Utilize existing wound care policies and procedures;
-Explain the procedure to the resident;
-Remove old dressing if present;
-Cleanse wound of drainage, debris, and foam residue;
-Evaluate and measure the wound;
-Replace filler/foam dressing per manufacturer’s guidelines and physician’s orders[REDACTED].>-Apply cover dressings and tubing per manufacturer’s guidelines and attach
to unit;
-Set N.P.W.T. unit pressure settings per manufacturer’s guidelines and physician’s orders[REDACTED].>-Document all procedures performed and the resident’s response.
Record review of the facility’s licensed nurse skin checks policy, dated (MONTH) 2011,
showed the following information:
-All residents will have a thorough weekly skin evaluation performed by a licensed nurse;
-Weekly, the licensed nurse performs a head to toe check of the resident’s skin, paying
particular attention to the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 6)
-The surfaces of the skin that come in contact with any orthotic device, tube, brace, or
positioning device;
-The nurse observes for redness, rashes, bruising, and open areas;
-Any significant abnormal findings are reported to the resident’s physician and resident
contact person;
-Documentation that the check was performed is denoted on the medication administration
form (MAR), the treatment administration record form (TAR), or the weekly skin
documentation form;
-Abnormal findings are to be documented in the nurse’s note or to be documented on the
back of the TAR if space allows;
-Document the actions taken in the nurse’s note along with a summary of all persons who
were notified and their responses.
Record review of the World Health Organization’s (WHO) recommendations for hand hygiene
and glove use showed the following information:
-Summary of the recommendations on glove use:
-When an indication for hand hygiene follows a contact that has required gloves, hand
rubbing or hand washing should occur after removing gloves;
-When an indication for hand hygiene applies while the health-care worker is wearing
gloves, then gloves should be removed to perform hand-rubbing or handwashing;
-In no way does glove use modify hand hygiene indications or replace hand hygiene action
by rubbing with an alcohol-based product or by handwashing with soap and water;
-When wearing gloves, change or remove gloves in the following situations: during patient
care if moving from a contaminated body site to another body site (including a mucous
membrane, non-intact skin or a medical device within the same patient or the environment);
-Clean your hands as soon as the task involving an exposure risk to body fluids has ended
(and after glove removal);
-Situations when this applies:
-When the contact with a mucous membrane and with non-intact skin ends;
-After removing any form of material offering protection (napkin, dressing, gauze,
sanitary towel, etc.).
Record review of the facility’s wound care policy and procedure titled, performing a
dressing change, dated (MONTH) 2011, showed the following information:
-A dressing change will follow specific manufacturer’s guidelines and general infection
control principles;
-Wash hands before and after donning gloves;
-Don gloves;
-Remove old dressing and packing (if present) (change gloves);
-Cleanse the wound of drainage, debris, or dressing/filler residue (change gloves);
-Assess the wound (measuring done here) (change gloves);
-Pack the dead space of large wounds (change gloves-if needed);
-Apply a cover dressing;
-Date and initial cover dressing, place time reference on it (remove gloves, discard
waste);
-The policy did not follow the WHO’s recommendations for using hand hygiene and glove use
after touching a contaminated body site or non-intact skin.
Record review of the facility’s hand hygiene policy, dated September, 2011, showed the
following information:
-Hand hygiene/hand washing is completed:
-Before taking part in a medical or surgical procedure;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 7)
-After contact with soiled or contaminated articles, such as articles contaminated with
body fluids;
-Hand washing may not be necessary until the completion of the procedure such as changing
from clean gloves to sterile gloves per specific standards of practice;
-The policy did not show to perform hand hygiene between glove use after handling
potentially contaminated items or body fluids.
1. Record review of Resident # 21’s face sheet (general resident information) showed the
following information:
-admission date of [DATE];
-[DIAGNOSES REDACTED]. (The [DIAGNOSES REDACTED].
Record review of the admission data tool, completed by facility staff, dated 3/11/18,
showed no notes pertaining to a wound V.A.C. or wounds present on admission.
Record review of the admission physician orders, dated 3/11/18, the date of admission,
showed the following:
-No orders that pertained to the resident’s wound V.A.C.;
-No orders for the air boot with directions of use or frequency of monitoring skin to the
feet.
Record review of the (MONTH) (YEAR) treatment administration record (TAR) showed the
following information:
-Treatment start date of 3/11/18: Air boots to be worn at all times. Only remove to
inspect the skin. 7A.M.-7 P.M. (treatment on TAR did not show how often to inspect the
skin);
-Treatment start date of 3/11/18: Abdominal wound V.A.C. continuous at 125 mm/HG, 7 A.M.
to 7 P.M.
Record review of the (MONTH) (YEAR) nurses’ progress notes showed the following
information:
-On 3/11/18, at 4:41 P.M., the resident refused a skin assessment. Staff did not document
the presence of a wound V.A.C.
-On 3/11/18, at 1:00 A.M., the resident refused a skin assessment. Staff did not document
the presence of a wound V.A.C.
-On 3/13/18, the resident had an abdominal wound with a wound V.A.C.
Record review of the resident’s current care plan, dated 3/13/18, showed the following
information:
-Skin integrity: at risk; turn and reposition;
-The care plan did not show information that pertained to the condition of the resident’s
skin or of any wounds the resident had.
-The care plan did not show any information related to a wound V.A.C. system.
Record review of the (MONTH) (YEAR) daily skilled nurse’s notes which showed areas (boxes)
for each shift to mark checkmarks and /or document nursing notes on, showed the following:
-Dated 3/14/18: Night shift noted a rash to the abdomen under the skin assessment (no
further documentation of skin or wounds);
-Dated 3/15/18: Night shift noted a rash to the abdomen under the skin assessment (no
further documentation of skin or wounds);
-Dated 3/16/18: Night shift noted a rash to the abdomen under the skin assessment (no
further documentation of skin or wounds);
Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated
comprehensive resident assessment instrument, completed by facility staff, dated 3/16/18,
showed the following information:
-Cognitively intact;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 8)
-Resident had a surgical wound;
-At risk for pressure ulcers.
Record review of the (MONTH) (YEAR) treatment administration record (TAR) showed the
following information:
-Treatment start date of 3/11/18: Air boots to be worn at all times. Only remove to
inspect the skin. 7A.M.-7 P.M. (treatment on TAR did not show how often to inspect the
skin);
-Treatment start date of 3/11/18: Abdominal wound V.A.C. continuous at 125 mm/HG, 7 A.M.
to 7 P.M.;
-Staff initialed completion of the treatments for dates, 3/12/18 through 3/31/18, with the
exception of 3/27/18;
-Staff did not document completion of any weekly skin assessments;
-The TAR did not include any orders to change the wound V.A.C. dressing.
Record review of the resident’s care plan, dated 3/13/18, showed the following
information:
-Skin integrity: at risk; turn and reposition;
-The care plan did not show information that pertained to the condition of the resident’s
skin or of any wounds the resident had.
-The care plan did not show any information related to a wound V.A.C. system;
-Staff did not any document any revision of the care plan after 3/13/18, date of admission
to the facility.
Record review of the resident’s medical record did not show any wound treatments, progress
records, or weekly skin integrity assessments completed by staff during (MONTH) (YEAR).
Record review of the (MONTH) (YEAR) nurses’ progress notes showed the following
information:
-On 3/31/18, the wound V.A.C. was intact with green watery drainage;
-Staff did not document any other refusals of skin assessments or of any wound assessments
in (MONTH) (YEAR).
Record review of the (MONTH) (YEAR) daily skilled nurse’s notes which showed areas (boxes)
for each shift to mark checkmark and/or document nursing notes on, showed the following
information:
-On 3/31/18, day shift noted a surgical wound and open lesion without a location noted,
along with a skin tear, and pressure ulcer, and night shift noted a surgical wound and an
open lesion without location noted.
Record review of the (MONTH) (YEAR) nurses’ progress and skilled nursing notes showed no
documentation of any wound V.A.C. changes.
Record review of the (MONTH) (YEAR) physician order [REDACTED].
-Staff handwrote an order, dated 3/2/18, (nine days prior to the resident’s admission) to
change the wound V.A.C. Monday, Wednesday, and Friday. The order did not include any
specific information regarding the time of day staff should change the wound V.A.C. The
order did not include what type of foam or other supplies to be used, or of what type of
cleanser, if any, was to be used. The physician signed the physician order [REDACTED].
-The medical record did not contain any hand written, verbal, or telephone order to
indicate when the order to change the wound V.A.C. on Monday, Wednesday, and Friday was
obtained from the physician.
Record review of the resident’s (MONTH) (YEAR) TAR showed an order, dated 4/9/18, to
perform weekly skin assessments on Mondays;
-Staff initialed and circled the dates of 4/2/18 and 4/9/18 indicating skin assessment not
completed. Staff did not document why the weekly skin assessment had not been completed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 9)
-The TAR contained an undated, hand written order in the treatment area to change the
wound V.A.C. Monday, Wednesday, and Friday at 8:00 P.M.;
-Staff initialed the wound V.A.C. dressing as changed on 4/4/18, 4/6/18, and 4/9/18. Staff
circled the date, 4/11/18, indicating the dressing change as not completed. Staff did not
document why the dressing change was not completed;
-(Order dated 3/11/18), abdominal wound V.A.C. continuous at 125 mm/HG showed staff
initialed completion of the wound V.A.C. (4/1/18 through 4/5/18, 4/7/18 through 4/9/18,
and on 4/12/18), with the exception of 4/6/18, 4/10/18, 4/11/18, and 4/13/18. The
treatment had a line marked through it that showed the wound clinic discontinued it on
4/13/18.
Record review of the (MONTH) (YEAR) daily skilled nurse’s notes showed the following
information:
-On 4/1/18 and 4/2/18, the evening and night shifts had noted a surgical wound with a
wound V.A.C. (no other wound description);
-On 4/3/18, night shift noted a surgical wound (no other description of wound or mention
of wound V.A.C.;
-On 4/4/18, night shift noted a surgical wound with a wound V.A.C. Notes had been written
on the back of the form that showed wound V.A.C. applied to cleansed area-operating well.
(No description of the wound, the foam, and if and how many pieces of foam had been
removed and/or replaced into the wound bed. No description of the wound V.A.C. drainage in
the tubing had been documented;
-On 4/5/18, night shift noted a surgical wound with a wound V.A.C. (no other description
of the wound documented);
-On 4/6/18, Night shift noted a surgical wound with wound V.A.C.;
-On 4/7/18, day shift and night shift noted a surgical wound with a wound V.A.C. The 7
A.M. to 7 P.M. shift documented the wound V.A.C. had a small amount of green watery
drainage;
-On 4/8/18, 4/9/18, and 4/10/18, night shift documented the resident had a surgical wound
with a wound V.A.C. (No other description of the wound documented);
Record review of the (MONTH) (YEAR) nurses’ progress notes showed the following
information:
-From 4/1/18 through 4/10/18, staff did not document any difficulty changing the wound
V.A.C. Staff did not document any description of the wound V.A.C. dressing change, or of
the wound bed.
-On 4/10/18, the nurse from the physician’s office called to schedule a surgical consult
for 4/12/18.
Record review of the (MONTH) (YEAR) daily skilled nurses’ notes showed the following
information:
-On 4/11/18, surgical wound noted by day shift (no further description of the wound or
documentation of the wound V.A.C. being present);
-On 4/12/18, day shift and night shift noted a wound V.A.C. An additional note on the back
of the form timed 11:30 A.M. showed the wound V.A.C. was intact with serous and green
colored output. The resident left by ambulance to the hospital;
-On 4/13/18, night shift noted the resident had a wound V.A.C. (No other description of
the wound documented);
Record review of a physician’s telephone order, dated 4/13/18, showed the following
information:
-Wound care to left upper quadrant (of abdomen) (LUQ), clean with normal saline and gauze,
apply wet to dry saline moist gauze twice a day (BID). Follow up with physician at wound
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 10)
clinic on 4/23/18.
Record review of the (MONTH) (YEAR) TAR showed the following order:
-On 4/13/18, LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline
moist gauze twice daily (BID) A.M. and P.M.
Record review of the (MONTH) (YEAR) daily skilled nurses’ notes showed the following
information:
-On 4/14/18, day and night shifts documented wet to dry dressing to left upper quadrant
(LUQ) (of abdomen). Additional note on back of the form, timed 10:30 A.M. showed the wet
to dry dressing was changed to the LUQ abdominal wound. (No description of the wound
documented);
-On 4/15/18, day and night shifts noted wet to dry dressing to LUQ (no other description
of wound documented);
-On 4/16/18, day and night shifts noted surgical wound to LUQ. An additional note timed
10:00 P.M. showed the dressing had been changed to the abdomen, and purulent light green
drainage had been noted;
-On 4/17/18, night shift noted a surgical wound and other open lesion. An additional note
timed 1:30 P.M. showed after the resident showered, the skin assessment had been
completed, and a wet to dry dressing to the LUQ continued;
-On 4/18/18, night shift noted a surgical wound and an open lesion. An additional note
added in the night shift portion of the notes, and untimed, showed the resident refused
the treatment to the wound V.A.C. site;
-On 4/19/18, night shift noted surgical wound (no further description of wound documented
by any shift;
-On 4/20/18, night shift noted surgical wound (no further description of wound
documented);
-On 4/21/18, day shift and night shift noted LUQ abdominal wound. (No further description
of wound documented);
-On 4/22/18, night shift noted surgical abdominal wound; An additional untimed note on the
day shift portion showed wet to dry dressing treatment continued, but was not changed;
-On 4/23/18, (date of surgical removal of foam dressing), Night shift noted surgical wound
to abdomen. Additional note timed 8:30 A.M. showed the resident transferred to the
hospital for incision and drainage of gastric tube site, and returned from the hospital at
5:05 P.M. The physician continued the wet to dry dressing with normal saline moistened
gauze. The resident had a follow-up appointment 5/3/18;
-On 4/24/18, night shift noted surgical wound to abdomen. (No other description of wound
documented);
-On 4/25/18, night shift noted surgical wound to abdomen. (No other description of wound
documented);
-From 4/26/18 to 4/30/18, night shift noted surgical wound to abdomen. (No other
description of wound documented);
-The (MONTH) (YEAR) daily skilled nursing notes showed staff did not document a wound
description.
Record review of the (MONTH) (YEAR) TAR showed the following order:
-On 4/13/18, LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline
moist gauze twice daily (BID) A.M. and P.M.
Record review of a physician’s telephone order dated 4/16/18, showed staff to perform a
weekly skin assessment on Mondays.
Record review of the (MONTH) (YEAR) TAR showed staff recorded the weekly skin assessment
as completed on 4/16/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 11)
Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following
information:
-No weekly skin integrity form completed for 4/16/18 as noted on the TAR.
Record review of the (MONTH) (YEAR) TAR showed the following order (order dated 4/13/18
for LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline moist gauze
twice daily (BID) A.M. and P.M.);
-On 4/17/18, the A.M. shift did not document completion of the LUQ dressing change;
-On 4/18/18, the A.M. shift did not document completion of the LUQ dressing change. On the
P.M. shift, staff circled the dressing change and marked it as refused.
-On 4/22/18, on the P.M. shift, staff circled the dressing change to indicate dressing not
completed. Staff did not document why staff did not complete the treatment.
Record review of the (MONTH) (YEAR) TAR showed staff recorded the weekly skin assessment
as completed on 4/23/18.
Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following
information:
-On 4/23/18, staff documented wound number three indicated as gastric tube site, incision
and drainage. Revision on gastric (stomach) tube site this date. Wet to dry dressings
continued. No description of wound documented;
-No other weekly skin integrity forms completed for (MONTH) (YEAR).
Record review of the (MONTH) (YEAR) TAR showed the following order (order dated 4/13/18
for LUQ abdomen: Clean with normal saline and gauze. Apply wet to dry saline moist gauze
twice daily (BID) A.M. and P.M.);
-On 4/29/18 of the A.M. shift, staff did not document completion of the LUQ dressing
change. On the P.M. shift, staff did not document completion of the LUQ dressing change;
-On 4/30/18 of the A.M. shift, staff did not document completion of the LUQ dressing
change.
Record review of the resident’s hospital wound clinic discharge records, dated 4/23/18,
showed the following information:
-Resident had a surgical procedure of abdominal incision and drainage dated 4/23/18;
-Resident required intubation for the procedure;
-Resident received general anesthesia;
-Antibiotics were administered;
-The wound V.A.C. sponge was ellipsed (oval-shaped incisions to remove objects) out in its
entirety using cautery (an agent or device used for scarring, burning, or cutting the skin
or other tissues by means of heat, cold, electric current, ultrasound, or caustic
chemicals) down to good healthy tissue;
-Continue wet to dry dressings twice a day (normal saline with moist gauze) to LUQ
abdominal wound;
-Brief pre-operative Diagnosis: [REDACTED].C. sponge and left upper abdominal wound;
-Post op Diagnosis: [REDACTED].
-Specimen: Retained sponge;
-Indications for procedure: The resident is a quadriplegic whom the hospital had
previously operated on for a gastric tube (tube that enters the stomach used for
nutrition) fistula (permanent abnormal passageway between two organs in the body or
between an organ and the exterior of the body, in this case caused by a previous gastric
tube) tract. The hospital treated the site with a wound V.A.C. and sent the resident to a
nursing facility at which point the nursing facility did not remove the wound V.A.C.
sponge, and only changed the outer dressing. The abdominal wound had granulated into the
sponge and it was unable to be removed. The resident was brought back to our office for
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 12)
evaluation. There was no way to get the foam out without taking the resident to surgery
for [REDACTED].
Record review of the wound treatment and progress record for the month of (MONTH) (YEAR)
showed the following information:
-On 4/25/18, left upper quadrant wound measured 4.7 centimeters (CM) Length (L) by 7.4 CM
width (W) by 3.2 CM depth (D). Staff did not document any further description of the wound
or of any drainage present;
-Staff did not document any other wound assessments during the month of (MONTH) (YEAR),
including while the resident had the wound V.A.C.
Record review of the (MONTH) (YEAR) daily skilled nurses’ notes showed the following
information:
-From 5/1/18 to 5/3/18, night shift noted surgical wound to abdomen. (No documentation of
wound description).
Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following
information:
-On 5/1/18, staff documented a treatment was in place: The areas marked on diagram had
been the LUQ, along with the toes and left lower extremity (LLE). No descriptions of the
skin or marked areas had been documented.
Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed the
following information:
-On 5/1/18, measurements 6.9 CM L by 4.8 CM W by 2.0 CM D. No further description of the
wound was documented.
Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following
information:
-On 5/8/18, staff documented a treatment was in place. The areas marked on the diagram had
been the LUQ, along with the toes and LLE. No descriptions of the skin or marked areas had
been documented.
Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed the
following information:
-On 5/8/18, 7.1 CM L by 3.9 CM W by 2.1 CM D. No further description of the wound was
documented.
Record review of the (MONTH) (YEAR) physician order [REDACTED].
-Order dated 4/13/18 for LUQ abdomen, clean with normal saline and gauze. Apply wet to dry
saline moist gauze twice daily (BID) A.M. and P.M. continued until order changed on
5/14/18;
-On 5/14/18, change wound care orders to Calcium Alginate with Silver (a sterile,
non-woven calcium alginate dressing composed of an ionic silver complex (silver sodium
hydrogen zirconium [MEDICATION NAME]), which releases silver ions in the presence of wound
exudate). Cover with Filacare (type of dressing cover). Measure wound with dressing
changes. Change every five days.
Record review of the (MONTH) TAR showed on 5/14/18, staff applied the dressing per the new
treatment order, dated 5/14/18.
Record review of the (MONTH) (YEAR) weekly skin integrity form showed on 5/14/18, staff
documented an open area to the left abdominal wall, and the LUQ had been noted on the
diagram. Staff documented a new treatment had been in place. No description of the skin or
marked area on the diagram had been documented.
Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed on
5/14/18, 7.0 CM L by 3.5 CM W by 1.8 CM D. No further description of the wound was
documented.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 13)
Record review of the (MONTH) (YEAR) TAR showed the staff changed the dressing again on
5/18/18.
Record review of the (MONTH) (YEAR) weekly skin integrity form showed on 5/21/18, staff
documented an open area to the left abdominal wall, and the LUQ had been marked on the
diagram. No further description of the marked area had been documented.
Record review of the (MONTH) (YEAR) TAR showed staff changed the dressing on 5/22/18.
Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed the
following information:
-On 5/22/18, 5.2 CM L by 2.6 CM W by 1.4 CM D. Progress documented as granulation present,
decreased size, decreased depth of undermining, and no tunneling depth. No other
description of the wound was documented; No signature had been found of the staff that
performed the assessment.
Record review of the (MONTH) (YEAR) weekly skin integrity form showed the following
information:
-On 5/28/18, staff documented treatment in place. The areas marked on diagram had been the
LUQ. Staff did not document any description of the skin or wounds.
Record review of the (MONTH) (YEAR) TAR showed staff changed the dressing on 5/29/18
(seven days later).
Record review of the (MONTH) (YEAR) weekly wound treatment and progress record showed on
5/29/18, 5.0 CM Length by 2.6 CM W by 1.5 CM. No other description of the wound had been
documented.
Record review of the (MONTH) (YEAR) nurses’ progress notes showed no documentation of the
description of the surgical wound site to the LUQ of the abdomen.
Record review of the (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the (MONTH) (YEAR) TAR showed the following information:
-Order (dated 4/16/18), skin assessment check and record weekly on Monday;
-Staff documented completion of the skin assessment check on 6/5/18 and 6/18/18.
-Staff did not document completion of the skin assessments on any other date in (MONTH)
(YEAR).
Record review of the (MONTH) (YEAR) weekly skin integrity assessments showed facility
staff did not complete any assessments on the forms.
Record review of the resident’s (MONTH) (YEAR) nursing progress notes showed no
description of the LUQ abdominal wound.
Record review of the resident’s (MONTH) (YEAR) wound treatment and progress record showed
the following information:
-On 6/6/18, 4.5 CM L by 2.5 CM W by 0.4 CM D in center of wound and 0.3 CM at edges of
wound. The wound had been draining serosanguineous (means containing or relating to both
blood and the liquid part of blood (serum). It usually refers to fluids collected from or
leaving the body) drainage. No other descriptions of the wound had been documented, and
the form had not been signed by staff;
-On 6/9/18, 4.0 CM L by 2.5 CM W by 0.3 CM D. with serosanguineous drainage. No other
description of the wound had been documented, and the form had not been signed by staff;
-On 6/19/18, (ten days since prior wound assessment), 4.0 CM L by 1.2 CM W by 0.2 CM D. No
other descriptions of the wound had been documented, and the form had not been signed by
staff;
-On 6/24/18, 4.0 CM L by 3.0 CM W by 0.2 CM D. No other descriptions of the wound had been
documented;
-On 6/26/18, 3.6 CM L by 1.8 CM W by 0.0 CM D. No other descriptions of the wound, and no
signature by staff.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 14)
Record review of the (MONTH) (YEAR) physician’s orders [REDACTED].
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess,
monitor, and consistently document skin and pressure ulcer assessments. The facility
failed to report abnormal findings in a pressure ulcer to the physician timely per
facility policy and failed to follow professional standards for infection control
guidelines for one resident (Resident # 46), out of a sample of 16. The facility failed to
update their Handwashing Policy and Wound Care Policy per professional standards for glove
and hand hygiene guidelines. The facility census was 46.
Record review of the facility’s Wound Care Policy, dated (MONTH) 2011, showed the
following information:
-Weekly skin checks should be performed and documented by licensed staff on all residents;
-The facility should have a system in place for daily observation of wounds which may
include the following:
-An evaluation of the status of the dressing such as being intact and dated, and for
observable drainage or leakage;
-Status of the surrounding skin;
-It is recommended that nursing progress notes reflect the nurse’s observation and
management of wounds from shift to shift perspective and with each dressing change. At a
minimum, weekly documentation is recommended to provide a review of the wound;
-All documentation should include the following:
-Date observed;
-Location with staging/depth description for non-pressure wounds (i.e. partial thickness,
full thickness);
-Measurements (length, width, depth) and the presence and location of any extent of
undermining, tunneling or sinus tract tunneling (a sinus tract is blind-ended tract that
extends from the skin’s surface to an underlying abscess cavity or area. The biggest
difference between sinus tracts or tunneling and undermining is that tunneling and sinus
tracts are unidirectional, whereas undermining may occur in more than one direction)
measured per facility protocol;
-Presence, type, color, odor, appearance, and approximate amount of any exudate
(drainage);
-Presence, nature, and frequency of pain;
-Wound bed characteristics (color, type of tissue i.e. granulation tissue (new vascular
tissue in granular form on an ulcer or the healing surface of a wound), slough (dead
tissue that can be yellow and stringy), or eschar (dark, dry scab) which give evidence to
healing or non-healing);
-Description of wound edges and surrounding skin as appropriate (i.e. rolled edges,
redness, induration (hardened area), maceration (softening and breaking down of skin
resulting from prolonged exposure to moisture) ;
-If the wound does not show some evidence of progress towards healing within two to four
weeks, the wound and the resident’s overall clinical condition should be reevaluated.
Reevaluation of the treatment plan and modification of the current interventions may also
be indicated. Documentation of any rationale for continuing present treatments when there
is little or no healing is required by the clinicians.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-The facility should have a system in place for daily observation of pressure
ulcer/wounds;
-It is recommended that the nursing progress notes reflect the nurse’s observation and
management of wounds from a shift to shift perspective and with each dressing change. At a
minimum, weekly documentation is recommended to provide a review of the wound. Weekly
documentation should include the data observed and:
-Wound bed characteristics (color, type of tissue i.e. granulation tissue (new vascular
tissue in granular form on an ulcer or the healing surface of a wound), slough (dead
tissue that can be yellow and stringy), or eschar (dark, dry scab) which give evidence to
healing or non-healing);
-Description of wound edges and surrounding skin as appropriate (i.e. rolled edges,
redness, induration (hardened area), maceration (softening and breaking down of skin
resulting from prolonged exposure to moisture) ;
-If the wound does not show some evidence of progress towards healing within two to four
weeks, the wound and the resident’s overall clinical condition should be reevaluated.
Reevaluation of the treatment plan and modification of the current interventions may also
be indicated. Documentation of any rationale for continuing present treatments when there
is little or no healing is required by the clinicians;
-Documenting and staging pressure ulcer:
-In 2007, the National Pressure Ulcer Advisory Panel (NPUAP) redefined the definition of
pressure ulcers;
-Stage I pressure ulcer: Intact skin with non-blanchable redness of a localized area
usually over a bony prominence.
-Stage II pressure ulcer: Partial thickness loss of dermis (skin) presenting as a shallow
open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or
open/ruptured serum-filled blister. Presents a shiny or dry shallow ulcer without slough
or bruising. This stage should not be used to describe skin tears, tape burns, perineal
(the region between the scrotum and the anus in males, and between the posterior vulva
junction and the anus in females) [MEDICAL CONDITION] ([MEDICAL CONDITION] condition of
the skin in the perineal area, upper part of the thigh, and buttocks that is commonly
associated with incontinence. It is manifested by various degrees of skin injury, ranging
from redness to areas of denuded skin. ), maceration (softening and breaking down of skin
resulting from prolonged exposure to moisture), or excoriation (damage to the skin
surface);
-Stage III pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible,
but bone, tendon, or muscle is not exposed. Slough may be present, but does not obscure
the depth of tissue loss. (MONTH) include undermining and tunneling;
-Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or
eschar may be present on some parts of the wound bed. Often include undermining
(undermining occurs when the tissue under the wound edges becomes eroded, resulting in a
pocket beneath the skin at the wound’s edge) and tunneling (narrow opening or passageway
underneath the skin that can extend in any direction through soft tissue and results in
dead space with potential for abscess formation). Stage IV ulcers can extend into muscle
and/or supporting structures such as fascia (a thin sheath of fibrous tissue enclosing a
muscle or other organ.), tendon, or joint capsule;
-Necrotic wounds: Qualified staff should identify and document the presence of devitalized
tissue (necrotic tissue) when evaluating wounds;
-Necrotic tissue is evaluated for and identified for color, consistency, and adherence to
the wound bed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-Necrotic tissue is described as the following:
-Slough-usually yellow to tan, mushy or stringy material which indicates less severity
than eschar and is in the process of separating from the viable portions of the body;
-Eschar-may be black, gray, or brown in color. It usually adheres firmly to the wound
edges and wound bed
-Determine the percentage of wound with necrotic tissue present;
-Visually divide the wound into quarters or four pie-shaped quadrants to help determine
percentage of the wound involved;
-Document findings on the appropriate form (s).
Record review of the Wound Care Policy and Procedures: Licensed Nurse Skin Checks, dated
(MONTH) 2011, showed the following information:
-All residents will have a thorough weekly skin evaluation performed by a licensed nurse;
-Weekly skin checks should be performed and documented by licensed staff on all residents
paying particular attention to:
-The surfaces of the skin that come in contact with the bed and chair;
-Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.)
-The surfaces of the skin that come in contact with each other and any orthotic device,
tube, brace, or positioning device;
-All significant abnormal findings/changes should be reported to the resident’s primary
care provider by the licensed nurse per facility protocol. Documentation of primary care
provider notification, orders received, family notification, and resident response to any
treatment should follow facility protocol as well.
Record review of the World Health Organization’s (WHO) recommendations for hand hygiene
and glove use showed the following information:
-Summary of the recommendations on glove use:
-When an indication for hand hygiene follows a contact that has required gloves, hand
rubbing or hand washing should occur after removing gloves;
-When an indication for hand hygiene applies while the health-care worker is wearing
gloves, then gloves should be removed to perform hand-rubbing or handwashing;
-In no way does glove use modify hand hygiene indications or replace hand hygiene action
by rubbing with an alcohol-based product or by handwashing with soap and water;
-When wearing gloves, change or remove gloves in the following situations: during patient
care if moving from a contaminated body site to another body site (including a mucous
membrane, non-intact skin or a medical device within the same patient or the environment);
-Clean your hands as soon as the task involving an exposure risk to body fluids has ended
(and after glove removal);
-Situations when this applies:
-When the contact with a mucous membrane and with non-intact skin ends;
-After removing any form of material offering protection (napkin, dressing, gauze,
sanitary towel, etc.).
Record review of the facility’s Wound Care Policies and Procedures: Performing a Dressing
Change; dated (MONTH) 2011, showed the following information:
-A dressing change will follow specific manufacturer’s guidelines and general infection
control principles;
-Wash hands before and after donning gloves;
-Apply gloves;
-Remove old dressing and packing (if present) (change gloves);
-Cleanse the wound of drainage, debris, or dressing/filler residue (change gloves);
-Assess the wound (measuring done here) (change gloves);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-Pack the dead space of large wounds (change gloves-if needed);
-Apply a cover dressing-date and initial cover dressing, place time reference on it
(Remove gloves, discard waste);
-The policy did not follow the WHO’s recommendations for using hand hygiene and glove use
after touching a contaminated body site or non-intact skin.
Record review of the facility’s Hand Hygiene Policy, dated September, 2011, showed the
following information:
-Hand hygiene/hand washing is done:
-Before taking part in a medical or surgical procedure;
-After contact with soiled or contaminated articles, such as articles contaminated with
body fluids;
-Hand washing may not be necessary until the completion of the procedure such as changing
from clean gloves to sterile gloves per specific standards of practice;
-The policy did not show to perform hand hygiene between glove use after handling
potentially contaminated items or body fluids.
1. Record review of Resident # 46’s face sheet (general resident information) showed the
following information:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s comprehensive care plan, dated 10/25/17, showed the
following information:
-Problem: Wound infection (no site indicated); Approaches:
-Keflex (antibiotic) 500 milligrams (mg) three times daily (TID) as ordered;
-Monitor for changes in drainage, amount, and notify physician if treatment is
ineffective;
-The care plan did not address or provide interventions for the Stage IV pressure ulcer to
any area of the body, and staff did not update the care plan since 10/25/17.
Record review of the (MONTH) (YEAR) physician order [REDACTED].
-On 3/17/18, the physician ordered Santyl (enzymatic [MEDICATION NAME] ointment that
possesses the unique ability to digest collagen in necrotic tissue) ointment 30 grams:
Apply topically once daily to ischium (the curved bone forming the base of each half of
the pelvis) pressure ulcer. The physician discontinued the order on 5/23/18.
Record review of the (MONTH) (YEAR) treatment administration record (TAR) showed the
following information:
-Undated treatment for [REDACTED].
-Staff documented completion of the skin assesment on 5/3/18 as indicated by staff
initials.
Record review of the weekly skin assessment forms showed no weekly skin or wound
assessments completed on 5/3/18.
Record review of the (MONTH) (YEAR) TAR showed staff documented completion of the skin
assesment on 5/10/18 as indicated by staff initials.
Record review of the facility’s Weekly Wound Assessment form, dated 5/10/18, showed the
following information:
-Staff did not document any stage of the pressure ulcer or measurements of the ulcer;
-Pressure Ulcer circled yes as present;
-Color pink;
-Minimal drainage (no description or color documented);
-No odor or infection;
-Comments: Treatment to right ischial area.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-Continued area with slow healing. Granulation noted.
Record review of the (MONTH) (YEAR) TAR showed staff documented completion of the skin
assesment on 5/17/18 indicated by staff initials.
Record review of the weekly skin assessment forms showed no weekly skin or wound
assessments completed on 5/17/18.
Record review of the (MONTH) (YEAR) POS showed the following information:
-On 5/23/18, the physician ordered staff to clean with Vashe (wound cleanser that contains
hypochlorous (weak acid obtained in solution along with [MEDICATION NAME] acid by reaction
of chlorine with water and used as a disinfectant for wounds) solution), apply Santyl to
the wound bed, collagen (derived from animal sources) pad, and cover with silicone
adhesive bandage.
Record review of the (MONTH) (YEAR) TAR showed the following information:
-Staff did not document/carry over the treatment ordered by the physician written on
5/23/18 for staff to cleanse the pressure ulcer with Vashe, apply Santyl to the wound bed,
collagen pad, and cover with silicone adhesive bandage.
-The 3/17/18 santyl ointment treatment had a line drawn through it with a handwritten
discontinued over it dated 5/23/18.
Record review of the (MONTH) (YEAR) TAR showed staff documented completion of the skin
assesment on 5/24/18 indicated by staff initials.
Record review of the facility’s Weekly Wound Assessment form, dated 5/24/18, showed the
following information:
-Staff did not document any stage, measurement, color, or drainage of the ulcer;
-Comments: Treatment changed to right ischial area. Granulation noted.
Record review of the resident’s wound care clinic’s notes, dated 5/30/18, showed the
following information:
-Right ischium wound; Resident is on hospice services; admitting [DIAGNOSES REDACTED]. as
the sacrum )ulcer;
-Wound Measurements: 2.5 centimeters (CM) L by 1.4 CM W by 0.4 CM W;
-Wound #1: Pressure ulcer injury right ischium; Not healed; Quality of tissue improved;
Granulation tissue red and 100%; Moderate amount of serosanguineous (relating to both
blood and the liquid part of blood (serum)) drainage; Maceration present;
-Clean with hypochlorous acid 0.01 % and spray directly in wound. Don’t rinse. Don’t use
with silver; Apply Santyl for enzymatic debridement; ; Apply skin prep to periwound (skin
surrounding the wound) ; Dressing to be changed by staff every other day and as needed for
soiling.
Record review of the (MONTH) (YEAR) TAR staff documented completion of the skin assesment
on 5/31/18 indicated by staff initials.
Record review of the facility’s Weekly Wound Assessment form, dated 5/31/18, showed the
following information:
-Staff did not document any stage, measurement, color, or drainage of the ulcer;
-Comments: Treatment changed to right ischium every other day. Area filling in with good
granulation noted.
Record review of the (MONTH) (YEAR) TAR showed the following information:
-Treatment order dated, 6/4/18, for staff to complete weekly skin assessment on Thursdays;
-Staff documented the weekly skin assessment as completed on 6/6/18 as indicated by staff
initials.
Record review of the Weekly Skin Integrity (assessment) form, 6/6/18, showed staff did not
document completion of the skin assessment form.
Record review of the Weekly Wound Assessment form, dated 6/7/18, showed staff did not
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
document any staging of the ulcer, measurements, color, or drainage amount. Staff
documented skin in good condition. Treatment continued to right ischium.
Record review of the resident’s wound care clinic’s notes, dated 6/13/18, showed the
following information:
-Status: not healed; Quality of tissue deteriorated: Wound status deteriorated;
-Wound measurements: 3.0 CM L (0.5 CM longer than previous assessment) by 1.7 CM W (0.3 CM
wider than previous assessment) by 0.4 CM D;
-No eschar or slough present; moderate serosanguineous exudate; Maceration present;
-Notes: Grey, brown, colored tissue;
-No change in wound treatment orders.
Record review of the (MONTH) (YEAR) TAR showed staff documented the weekly skin
assessments as completed on 6/15/18 as indicated by staff initials.
Record review of the (MONTH) (YEAR) Weekly Skin Integrity (assessment) form, dated
6/15/18, showed staff documented right ischium with treatment. Staff did not document any
other skin assessment information.
Record review of the (MONTH) (YEAR) physician’s orders [REDACTED]. Apply Santyl to the
wound bed and cover with absorptive silicone dressing daily.
Record review of the (MONTH) (YEAR) TAR showed the following information:
-Treatment order, dated 6/21/18, for staff to cleanse pressure ulcer with hypochloric
acid. Apply Santyl to wound bed, cover with absorptive silicone dressing;
-Documentation on the TAR showed staff had not initialed the treatment as completed on
6/21/18, 6/22/18, 6/29/18, and 6/30/18. Staff did not document a reason for why staff did
not complete the treatments.
Record review of the (MONTH) (YEAR) TAR showed staff did not initial the date of 6/22/18
to indicate staff completed the treatment. Staff left the date blank.
Record review of the (MONTH) (YEAR) Weekly Skin Integrity (assessment) form, dated
6/22/18, showed staff did not document completion of the skin assessment form.
Record review of the (MONTH) (YEAR) TAR showed staff documented the weekly skin
assessments as completed on 6/28/18 as indicated by staff initials.
Record review of the (MONTH) (YEAR) Weekly Skin Integrity (assessment) form, dated
6/28/18, showed staff documented treatment to the right ischium. Staff did not document
any other skin assessment information.
Record review of the (MONTH) (YEAR) Weekly Wound Assessment form, dated 6/28/18, showed
staff did not document any staging, measurements, color, or drainage amount. Staff
documented treatment continued to right ischium.
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
resident assessment instrument, completed by facility staff, dated 6/30/18, showed the
following information:
-At risk for pressure ulcers;
-The resident had one Stage II pressure ulcer;
-The resident had slough;
-Staff did not document the presence of a Stage IV pressure ulcer.
Record review of the (MONTH) (YEAR) Weekly Wound Assessment form, undated, showed staff
did not document any staging, measurements, color, or drainage amount for the pressure
ulcer. Staff documented treatment continued to right ischium.
Record review of Weekly Skin Integrity (assessment) form, dated 7/5/18, showed staff
documented treatment in place. Staff did not document any further description of the
resident’s skin.
Record review of the (MONTH) (YEAR) physician’s orders [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
-On 7/12/18, the physician ordered to change hypochlorous acid to 0.0033% per wound
cleansing per wound clinic protocol;
-Continuing order dated 3/17/18, the physician ordered Santyl ointment 30 grams: Apply
topically once daily.
Record review of the (MONTH) (YEAR) TAR showed the following:
-Treatment order date 7/12/18 showed staff to clean the ulcer with hypochloric acid. Apply
to skin. Skin prep (liquid that when applied to the skin forms a protective film or
barrier) to periwound. Apply hypochlorous acid 0.033% to wound, apply Santyl for enzymatic
for enzymatic debridement debridement. Cover with silicone dressing daily by staff and as
needed. Allow hypochlorous to dry;
-Treatment documented as completed by staff 7/12/18 through 7/17/18;
-Treatment order with start date 3/17/18 showed staff to apply Santyl ointment 30 grams:
Apply topically to the ulcer once daily;
-Staff did not apply the Santyl ointment to the ulcer on 7/2/18, 7/6/18, 7/11/18, and
7/12/18. Staff did not document a reason for why staff did not complete the treatment.
Record review of (MONTH) (YEAR) Weekly Skin Integrity (assessment) forms showed staff did
not complete any further weekly skin Integrity forms for (MONTH) (YEAR) after 7/5/18.
Record review of the (MONTH) (YEAR) Weekly Wound Assessment forms showed staff did not
complete any pressure ulcer assessments for (MONTH) (YEAR).
During an interview on 7/10/18, at 4:16 P.M., Resident # 46 said his ulcer occasionally
got infected. He/she had osteo[DIAGNOSES REDACTED], so the ulcer would never heal, but it
had been better than it was, and was a lot smaller now. He/she had the ulcer for [AGE] years. He/she was on hospice now, and the wound physician requirements had changed, so the
wound physician no longer treated his/her ulcer.
During an observation and interview, on 7/13/18, at 9:18 A.M., showed Registered Nurse
(RN) I and Licensed Practical Nurse (LPN) J entered the resident’s room to change the
pressure ulcer dressing. RN I gathered the supplies which were a silicone super absorbent
dressing, sure prep, hypochloric wound cleanser placed in a plastic cup, dry gauze placed
in a plastic cup, measuring tape, and Santyl ointment placed in a cup. The nurse placed
the items on a sterile cover sheet. RN I removed a pair of scissors from his/her pocket
and sat them on a box of gloves on the bedside table. RN I washed his/her hands. LPN J
placed the supplies on a sterile drape on the resident’s bedside table. LPN J washed
his/her hands and applied gloves. LPN J said he/she was not performing the wound care, but
only helping position the resident. Staff assisted the resident with turning to his/her
left side. RN I put gloves on, and removed a blue dressing dated 7/11/18 (two days old).
The dressing had a moderate amount of tan-colored drainage on it. The wound was deep,
long, and wide, with what appeared to be pink granulation tissue in the center of the
wound. A dark area of skin, about 0.5 CM round was observed around 7:00 o’clock, with
surrounding macerated skin. A dark are of skin around 1 CM long was observed in the wound
bed extending into the perimeter of the wound around 5:00 o’clock. RN I cleansed the
periphery of the wound with wound cleanser. RN I removed the gloves and applied new ones.
RN I touched the resident’s wound at the 7:00 o’clock area, and the site bled, and
continued to ooze a stream of blood. The ulcer had an odor at that time. RN I blotted the
wound bed with the wound cleanser. RN I changed his/her gloves. RN I had not used hand
hygiene between glove changes. RN I applied skip prep to the periwound area. LPN J said
the wound clinic no longer saw the resident due to a hospice [DIAGNOSES REDACTED]. RN I
blotted the blood that oozed into the resident’s periarea from the wound with a gauze
sponge. RN I changed gloves without using hand hygiene. RN I reapplied new gloves. RN I
applied Santyl ointment to the periphery of the wound edges, and covered it with a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
silicone dressing. RN I dated the dressing. RN I removed his/her gloves and bagged the
used supplies. RN I picked up the scissors from the resident’s bedside table, which
appeared dirty with food and liquid debris. RN I placed the scissors in his/her pocket
without sanitizing them. RN I told the resident he/she would return and clean his/her
bedside table.
During an interview on 7/13/18, at 3:16 P.M., Resident # 46 said he/she was running a
temperature now, and was concerned about his/her ulcer since the wound clinic no longer
attended to his/her ulcer.
Record review of the resident’s nurses’ progress notes, on 7/13/18, at 4:00 P.M., showed
staff did not document any description of the pressure ulcer or notification to the
Director of Nursing (DON) or the physician of the ulcer drainage, odor, or darkened areas
of the ulcer.
During an interview on 7/17/18, at 8:20 P.M., RN G said the following:
-RN G had worked at the facility as needed (PRN) for about six months. He/she had worked
one to five days per month. He/she hadn’t worked for five or six weeks. He/she had worked
back in March, April, and (MONTH) (YEAR). All licensed staff should complete the weekly
skin assessments. It looked like the DON had taken over the skin assessments now. The
weekly skin assessments are head to toe assessments. The facility used a corporate form.
Staff should document bruising, open areas, and dry red areas. Those areas should be
circled on the diagram. Those areas can also be described in the paragraph area on the
form. If wounds were pressure areas, he/she would contact the physician, and have the
wound consult company come there to see the resident. Another flow sheet is used for wound
assessments that are supposed to be filled out at least weekly for pressure ulcers. Those
forms should be filled out with description of the wounds such as the measurements i.e.
length, width, depth, drainage, color of the wound, and changes to the wound. For wound
care, he/she would gather supplies, check the orders to verify the treatment, wash his/her
hands, put gloves on, get a bag for dirty supplies, and change the gloves after removing
dirty gloves. He/she just swapped out gloves and didn’t use hand hygiene between glove
uses. RN G didn’t use hand hygiene unless the gloves got super disgusting. RN G would not
touch a dressing with his/her bare hands if it was to be applied directly to the wound
bed. RN G wouldn’t touch the clean gauze with his/her bare hands as well. RN G had his/her
own scissors, and would sanitize them before use. RN G would use antibacterial wipes to
sanitize the scissors. She would clean a wound bed with gauze sponges from the top to the
bottom of the wound. RN G would not re-swipe the wound bed. He/she would use a different
wipe to clean the periphery of the wound. He/she was not comfortable with staging wounds,
and just described them. As for Resident # 46, his/her wounds are cleansed. His/her wounds
come and go, and appear like shearing at first. The facility obtained a wound clinic
consult for Resident # 46.
During an interview on 7/17/18, at 6:59 P.M., the DON said the following:
-Weekly skin assessments should be performed every seven days. They use a form to describe
the skin areas such as bruising or sores, and treatment should be recorded on them as
well. The dates on the resident’s TARs should match the dates of the weekly skin
assessments documented. Pressure ulcers and sores should be noted without details about
them on the weekly skin assessments, but those wounds should be described on the wound
assessment forms weekly. On the wound assessment forms, staff should chart the wound
width, depth, and length, the wound bed description, any wound odor, exudate and amount
such as small, medium, and large amounts, and note any necrotic tissue or slough, for
example, 50 % slough present. The wound assessments should be completed weekly. The
facility did not have designated wound nurse. Day shift divides up the duty, and the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
charge nurse would be responsible for them, both the weekly skin and the weekly wound
assessments. She would expect changes in a wound to be reported to her. The TAR should
match the date the weekly skin assessments had been completed if completed. The last time
she knew of, staff should wash hands after using gloves anytime. When gloves were removed,
they should use hand sanitizer between uses. If hand sanitizer had been used three times,
staff should wash their hands. Scissors should be wiped with alcohol before and after use.
Staff can place scissors in their pockets as long as they have been sanitized. For wound
care, staff should wash their hands and put on gloves. Staff should remove the old
dressing and discard it in a plastic bag. Staff should cleanse the wound from inside to
outside. All areas under the bandage should be cleansed. Staff should visualize the wound.
Staff could use a sterile cotton swab or pick up a corner of dressing with it to place the
dressing in the wound bed. Staff should use clean gloves, and not touch dressings or gauze
pads with their bare hands. All RNs should stage wounds at the facility. Wounds should be
staged upon a resident’s admission and weekly as well with the measurements. Resident # 46
had had his/her wound forever and a day. The last wound report she had seen had shown the
wound was at a stage III. She had not seen the wound since the resident had been put on
hospice. The facility had not obtained measurements on Resident # 46’s wound for two
weeks. Staff had not reported anything like odor, drainage, slough, or black areas in the
wound to her. She would have expected staff to report those findings to her.
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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, the facility failed to document post
fall nursing monitoring, including neurological checks (check for level of consciousness),
on two residents (Resident #3 and Resident #36 ), who sustained unwitnessed falls or hit
their heads during falls. The facility also failed to ensure a mattress fit the bed frame
appropriately for one resident (Resident #97) when staff placed a bariatric mattress of
the bed frame and failed to use the extensions on the bed so the mattress was
appropriately supported. The mattress hung off the bed frame approximately 10 to 12 inches
and could contribute to the resident falling from bed. A sample of 16 residents was
selected out of a facility census of 42.
1. Record review of Resident #97’s medical record showed the following information:
-Date of admission 7/3/18;
-[DIAGNOSES REDACTED].
-Hospice.
Record review of the resident’s (MONTH) (YEAR) physician order [REDACTED].
Record review of a nurse’s note, dated 7/4/17, showed a nurse witnessed the resident crawl
out of bed. The bed was in a low position and the resident continued to lay on the fall
mats and crawled around on the floor multiple times. The nurse documented talking to the
Hospice nurse who told staff the resident always crawled around on the floor and slept on
the floor at home prior to his/her admission.
Record review of a nurse’s note, dated 7/5/18, showed the resident refused to lay in bed
or sit in his/her chair and continued to crawl on the floor and lay on his/her fall mats
all shift.
Record review of a nurse’s note, dated 7/10/18, showed the facility notified the physician

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 – Some

(continued… from page 23)
the resident refused to lay in bed and continued to crawl on the floor.
Record review of a nurse’s note, dated 7/10/18, showed the resident refused to lay in bed
and continued to lay on the fall mats on the floor.
Observation of the resident’s room on 7/11/18, at 11:44 A.M., showed the resident had a
bariatric mattress on a twin size bed frame. The mattress hung over the edge of the bed
frame 10 to 12 inches. The resident had a bed in a lower position and fall mats on either
side of the bed.
Observation and interview on 7/13/18, at 2:58 P.M., showed the mattress remained too large
for the bed frame. Staff had placed fall mats on either side of the bed. Observation of
the resident showed the resident on the floor crawling around. The resident showed no
signs of distress and denied falling. The resident said he/she was okay and denied any
injuries.
During an interview on 7/17/18, at 8:25 A.M., Certified Nursing Assistant (CNA) H said if
he/she saw a mattress that did not fit a bed frame he/she would report this to the charge
nurse and maintenance staff. He/she would also look to see if the bed frame had extensions
for a bariatric mattress. He/she had not seen the bed frame and mattress for this resident
since he/she had not worked on the resident’s hall since the resident’s admission to the
facility.
During an interview on 7/17/18, at 8:50 A.M., the maintenance director said he inspected
the mattresses in the facility to ensure appropriate size and that the mattress was in
good condition and had no low spots. He said he had not checked the mattress in the
resident’s room since the resident was a new admission. He said he would have inspected
the mattress prior to the resident’s admission. He said the mattress should fit the bed
frame. He went and looked at the mattress and bed frame and said staff had placed a
bariatric mattress on a regular sized bed frame and had not pulled out the extensions on
the frame to properly support the mattress.
During an interview on 7/17/18, at 2:03 P.M., the director of nursing (DON) said a
resident’s mattress should fit the bed frame. She said the resident had a bariatric bed
frame on a regular size bed frame and staff failed to pull out the extensions on the bed
frame so the mattress had the proper support. She said staff should have used the
extensions on the bed frame so the mattress had the proper support. She said no staff had
reported the mattress did not fit the bed frame.
During an interview on 7/17/18, at 8:55 A.M., the administrator said she would expect a
mattress to fit the bed frame. If the mattress was too large for the frame, she would
expect staff to adjust the extensions on the bed frame or to report to maintenance and the
nurse that the mattress did not fit the frame. She said no one had reported this as far as
she knew. The administrator said she would consider a mattress that hung over the bed
frame a fall risk.
2. Record review of the facility’s policy, titled Nursing Policies and Procedures: Fall
Management, dated as a complete revision 7/1/16 , showed the following information:
-The purpose of the policy was to identify each resident who is at risk for falls and will
care plan and implement interventions to manage falls;
-Qualified staff evaluates all patients/residents for fall risk at a minimum upon
admission, quarterly, with significant change and post fall;
-If a fall occurs, qualified staff evaluates the resident for injury from the fall and
determines what may have caused or contributed to the fall;
-Any unwitnessed fall will have neurologic checks completed regardless of the resident’s
cognitive status at the time of the incident;
-The physician and family are promptly notified and an incident report is completed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 – Some

(continued… from page 24)
Record review of the facility’s form, titled Neurologic Flow sheet, showed the following
information:
-The form directed staff to use this flow sheet at the following interval for events with
possible head injury (witnessed and/or non-witnessed);
-Any change in condition would require a phone call to the primary care physician;
-The form directed staff to do an initial assessment on the resident, followed by
assessments every 15 minutes for the first hour, then every 30 minutes for an hour, then
hourly for two hours, the every shift for the rest of the 72 hour monitoring;
-The assessments included orientation of the resident, eye opening response, handgrip
strength, arm and leg strength, vital signs, and then pupil size and response to light.
3. Record review of Resident’s #3’s face sheet (information sheet) showed the following
information:
-admitted on [DATE] with [DIAGNOSES REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument, completed by facility staff, dated 2/21/18, showed the following
information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
-Cognitive impairment and indicated the resident is not understood;
-Required extensive assistance from staff for bed mobility, transfers, dressing,
toileting, and personal hygiene;
-Resident not steady during transfers and was only able to stabilize with assistance
during moving from seated to standing position, moving on and off toilet, and surface to
surface transfers;
-The resident used a wheelchair for mobility;
-The resident had a fall with injury prior to admission.
Record review of the resident’s medical record did not show any care plan developed at
that time.
Record review of the nurses’ notes, dated 2/18/18 and 2/19/18 showed the resident was up
for meals and went out for smoke breaks.
Record review of a SBAR Communication Form, dated 2/26/18, indicated a fall at 2:00 P.M.
The form instructed the staff to evaluate the resident and obtain vital signs (heart rate,
blood pressure, temperature, respiratory rate, blood glucose level (if indicated) and
Oximetry (level of oxygen in blood)) before calling the physician;
-The form is a fill in the blank and check mark form;
-[DIAGNOSES REDACTED].
-Vital signs listed as blood pressure 160/90, heart rate 90 and temperature 97.7;
-Staff documented no change in respiratory status or abdomen;
-Staff did not document blood glucose or blood oxygen level;
-Staff did not document a response to a change in mental status;
-Staff did not document a change in functional status other than fall;
-Staff documented a request to monitor vital signs, for the resident to be in view of
staff until put to bed. Staff documented the resident had been in his/her room in the
wheelchair. The resident had been found on the floor on his/her right side with a raised,
red/purple area on the right side of the forehead;
-Staff documented a message was left in the folder for the physician to inform him of the
fall.
Record review of the nurses’ notes showed no documentation entry on 2/26/18.
Record review of the resident’s medical record did not show a neurologic assessment flow
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 – Some

(continued… from page 25)
sheet for the fall on 2/26/18.
Record review of the nurses’ note, dated 2/27/18, showed the nurse called the physician at
7:10 A.M. to report the resident complaints of pain and limited range of motion. Orders
obtained for an x-ray and pain medication. Staff did not document any neurological
assessment follow up assessments for day, evening, or night shifts.
Record review of the nurses’ notes showed no staff documentation from 2/28/18 to 3/2/18.
Record review of an untimed nurse’s note, dated 5/15/18, showed the following:
-The resident wheeled his/herself to his/her room;
-The resident attempted to self transfer and fell to the floor. Staff documented a staff
member was in the room but did not document if a staff member actually saw the fall;
-Staff documented no redness, skin tears, or pain at the time of the fall;
-Staff did not document if the resident did or did not hit his/her head;
-Staff did not document notification of family or physician contact;
-Staff did not document any neurological checks;
-Staff did not document any further follow up assessments.
Record review of the nurses’ notes, dated 5/16/18, at 12:10 A.M. showed staff documented
the resident rested quietly and neurological checks were within normal limits. Staff did
not provide further documentation for 5/16/18.
Record review of the resident’s care plan showed the following information:
-Problem start date 5/16/18: The resident has behavioral symptoms and is allowed to sit
him/her self on the floor if he/she so desires. Related to frustration when not getting
what he/she wants/needs. Family and nursing staff aware.
Record review of the resident’s medical record did not show a neurologic flow sheet sheet
for the fall on 5/15/18.
Record review of the nurses’ notes showed no staff documentation from 5/17/18 to 6/10/18.
Record review of the resident’s nurses’ note dated, 6/14/18, at 9:30 A.M. showed the
following information:
-The resident had an injury from the fall;
-The nurse documented the resident had been outside smoking in his/her wheelchair and
attempted to transfer him/her self. The resident fell to the sidewalk striking his/her
head. Staff documented a large abrasion and indention on right side of forehead above
right eye. Staff documented a small skin tear to the right outer hand.
-Staff cleaned the areas and applied bandages;
-Staff documented neurological checks within normal limits, notification of the nurse
practitioner, and family notified.
Record review of the resident’s medical record did not show a neurologic flow sheet for
the fall on 6/14/18.
Record review of the resident’s nurses’ note, dated 6/14/18, showed the staff did not
complete neurological checks or follow up assessments during the day, evening or night
shifts.
Record review of the resident’s care plan showed the following information:
-Problem start date 6/15/18: Resident to have bed in lowest position at all times and a
fall mat on the ground next to the bed;
-Family requested the bed be placed against the wall.
4. Record review of Resident #36’s face sheet showed the following information:
-The resident admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].)
Record review of the resident’s 14 day admission MDS, dated [DATE], showed the following
information:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 – Some

(continued… from page 26)
-Staff did not list a [DIAGNOSES REDACTED].
-Required extensive assistance with bed mobility, transfers, toileting, and personal
hygiene;
-The resident used a wheelchair for mobility;
-No falls prior to admission.
Record review of the resident’s nurses’ notes showed the following information:
-On 7/11/18, untimed, staff documented the resident’s right eye as red with yellow
drainage. The nurse practitioner (NP) notified and orders for antibiotic eye drops
received.
Record review of the telephone physician order [REDACTED].
Observation on 7/13/18, at 1:30 P.M., showed the resident up in a wheelchair, self
propelling through the main television area, both eyes noted to be red/red rimmed and left
arm in an over the shoulder sling.
Record review of the resident’s nurses’ notes showed the following information:
-On 7/15/18, at 12:45 P.M., the nurse documented the resident had a raised red area with
light bruising, measuring 3.5cm x 3.5 cm, and a small laceration, measuring .5 cm, and
scabbed over. No complaints of pain or discomfort. The resident said he/she fell out of
the wheelchair and got into bed. The resident said after the call light was on, the DON
came into his/her room and touched the resident’s nose and said it’s not broken. The nurse
documented he/she called the physician and no new orders received. Family was unable to be
notified. The nurse documented vital signs and a neurological checks were within normal
limits. The nurse failed to document the location of the injury.
-On 7/15/18, from 1:00 P.M. to 10:45 P.M., the nurse did not document fall follow-ups. The
nurse did not document a neurologic assessment of the resident;
-On 7/15/18, at 11:00 P.M., the nurse documented a fall follow up and neurological checks
within normal limits. Denies pain or discomfort at this time;
Observation on 7/16/18, at 10:00 A.M., showed the resident up in his/her wheelchair by the
nurses’ station. The resident had a large bruised area around and above the left eye.
Small scabbed area noted to the bridge of the nose.
Record review of the resident’s nurses’ notes showed the following information:
-On 7/16/18, at 9:20 P.M., the nurse documented the resident’s neurological checks were
within normal limits and the resident was alert and oriented. Bruising continued above the
left eye and small laceration with scabbing to the bridge of the nose. No complaints of
pain at this time.
-No further documentation noted in regard to fall follow up assessments.
During an interview on 7/16/18, at 3:50 P.M., Licensed Practical Nurse (LPN) J said he/she
did not document on and could not locate a neurologic flow sheet for a fall on 7/14/18 or
7/15/18. The LPN said Registered Nurse (RN) G worked Saturday and Sunday and would know
more about an incident.
During an interview on 7/17/18, at 2:00 P.M., RN G said he/she did not document on and
could not locate a neurologic flow sheet for the fall on 7/14/18 or 7/15/18.
During an interview on 7/17/18, at 5:00 P.M., CNA B said the following:
-When a resident has fallen, you immediately get the charge nurse to assess the resident;
-After the charge nurse has assessed the resident for injuries and determined it is safe
to move the resident, then you can assist the resident up with either the gait belt or the
lift;
-If staff witness the fall, and the resident did not hit their head, the aide obtains
vital sign every 15 minutes for the first hour, then two in an hour, then once an hour
later;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 – Some

(continued… from page 27)
-If no one witnesses the fall or the resident hit their head, then we add the neurologic
assessments and go by the facility flow sheet;
-CNA B said he/she is familiar with the resident;
-The resident is oriented, but confused at times. The resident was able to verbalize
his/her needs. The resident required assist with transfers, but was non-compliant;
-CNA B said the resident has fallen more than one time, but is aware of the most recent
fall. The resident had bruising on one side of the face;
-The CNA said he/she was not here at the time of the most recent fall and the resident is
not on the list for vital signs.
During an interview on 7/17/18, at 7:00 P.M., the DON said the following:
-When a resident falls, she expected the nurses to assess the resident head to toe,
including a neurologic assessment if it was an unwitnessed fall or the resident hit their
head;
-The nurses then should notify the physician, family, and on-call nurse;
-The DON said the nurses should fill out the event form;
-The nurses should initiate follow-up documentation for 72 hours, and if the resident hit
their head or the fall was unwitnessed, the nurses should initiate the neurologic flow
sheet;
-The follow-up documentation should include the injuries sustained in the fall, including
bruising and skin tears. If the injuries remain at the end of the 72-hour documentation
period, the nurses should continue documenting on those injuries until resolved;
-The DON said she could not locate the neurologic flow sheet for a fall on 7/14/18 or
7/15/18;
-The DON said a Resident incident/accident investigation worksheet (an internal document)
had been completed.
Record review of the Resident Incident/Accident Investigation worksheet provided by the
facility, is an internal document, showed RN I filled out the form on 7/15/18, at 2:00
P.M. Date and time of the actual incident was not marked. The type of incident and injury
the nurse indicated as unknown with bruising and a skin tear. The form showed the NP as
notified at 2:30 P.M. on 7/15/18. The vital signs listed were within normal limits. The
nurse documented the resident to have light blue and pink bruising to the left side of the
forehead over the left eyebrow with a raised area measuring 3.5cm x 3.5 cm. A small
laceration, measuring 0.5cm, and scabbed over on the bridge of the nose. Documentation
showed no complaints of pain or discomfort. The resident said he/she fell out of the
wheelchair and got into bed. The resident said after the call light was on the DON came
into his/her room and touched the resident’s nose and said it’s not broken. The form
indicated signatures of the DON on 7/16/18 and the administrator on 7/17/18.
During an interview on 7/17/18, at 7:50 P.M., the DON said the following:
-Resident #36 fell at approximately 10:30 P.M., on the evening of 7/14/18;
-The DON said a CNA came to get her to report the resident had fallen. The DON went to the
resident’s room, the resident had put himself/herself in the bed. The DON said she told
the CNA to get vital signs and then turned the resident’s care over to the shift’s charge
nurse;
-The DON said he/she did not initiate the neurologic assessment sheet;
-The DON does not recall seeing the cut on the resident’s nose;
-The DON said she informed the charge nurse to complete the resident’s neurologic
assessment sheet. The charge nurse did not complete the charting.
-The nurses failed to document any nurses’ notes for night shift on 7/14/18 that should
have included fall follow-up and neurologic assessments;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 – Some

(continued… from page 28)
-The nurses failed to document any nurses’ notes for day shift on 7/15/18 at 12:00 P.M.
that should have included fall follow-up and neurologic assessments;
-The nurses failed to document any nurses’ notes for day shift on 7/16/18 that should have
included fall follow-up and neurologic assessments;
-The DON said she had not been aware of Resident #3’s fall with injury.
During an interview on 7/17/18, at 8:15 P.M., RN G said the following:
-Expects the CNA/staff to report it to him/her immediately;
-When a resident falls, the nurse is to perform an assessment on the resident, consisting
of neurologic assessment if the resident hit their head or if the fall was unwitnessed, as
well as assessment of any injuries, and range of motion;
-The nurse was then to notify the physician, resident’s responsible party, and on-call
nurse, initiate a nurse’s note, and 72 hour follow up charting;
-If the resident hit their head, or the fall was unwitnessed, the nurse should also
initiate the neurologic flow sheet that would continue for 72 hours;
-The charge nurse should document the resident’s injuries sustained in the fall, including
bruising, cuts, and skin tears. If those injuries remain past the 72-hour follow-up
documentation period, the nurse should continue to document on the injuries until those
injuries are resolved.
Record review of the resident’s medical record did not show a neurologic flow sheet for
the fall on 7/14/18.
F 0727

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 eight consecutive hours per day, seven days a week. The
facility census was 42.
1. Record review showed the facility did not provide an RN staffing policy.
Record review of the facility’s daily schedule (posted staffing sheets) for 5/17/18
through 7/17/18 showed the following:
-No RN scheduled/worked on 5/26/18, 5/27/18, 5/28/18, 6/3/18, 6/9/18, 6/10/18, 6/16/18,
6/17/18 and 7/4/18.
During an interview on 7/17/18, at 6:00 P.M., the administrator said staffing is better
than it was. The administrator said any nurse that applies, the facility tries to be very
accommodating but cannot compete with the other pay rates in the area. The administrator
said the facility is actively recruiting registered nurses.
During an interview on 7/17/18, at 6:50 P.M., the DON said they lost their assistant
director of nursing (ADON) at the end of June. She said she has been at the facility part
of every day, in one way or another, since she started in March. The DON said the facility
is actively seeking more registered nurses.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure food was
stored and served in accordance with professional standards for food safety when a working
thermometer was not kept in a refrigerator, temperatures were not logged and
expired/undated food was kept in a refrigerator containing resident food. This could lead
to contamination of food and to foodborne illness potentially affecting all residents. The
facility had a census of 42.
According to the Missouri Food Code, published 2013 refrigerated, potentially hazardous
food prepared and held for more than 24 hours shall be clearly marked to indicate the date
or day by which the food shall be consumed on the premises or discarded when held at a
temperature of forty-one degrees Fahrenheit (41 degrees F) or less for a maximum of seven
days or when held at a temperature of forty-five degrees Fahrenheit (45 degrees F) or less
for a maximum of four days.
1. Record review of the facility’s policy titled, Food Safety in Receiving and Storage,
dated [DATE] showed the following:
-Keep a thermometer in each refrigerator and freezer unit;
-Check and record the refrigerator temperatures at least two times per day. Temperatures
not in the appropriate range are reported to the Nutrition Director or to maintenance;
-Maintain the ambient temperature of refrigerators at 34 to 38 degrees.
2. Record review of the facility’s policy titled Food Safety in Receiving and Storage
dated [DATE], showed the following:
-Refrigerated, ready to eat foods are properly covered, labeled, dated with a use-by date
and refrigerated immediately. Mark them clearly to indicate the date by which the food
shall be consumed or discarded. Discard after three days unless otherwise indicated.
3. Record review of the facility’s policy titled Safe Handling of Food Brought In by
Family/Friends for Resident Consumption, dated [DATE], showed the following:
-Foods are labeled to identify the resident’s name, container contents, and the date it
was prepared. Food items are stored in disposable, tightly covered containers, or sealable
plastic bags. Items will be stored for three days. Expired and unlabeled items will be
discarded.
4. Record review of the facility Monthly Temperature Log dated May, (YEAR), for the
nursing unit refrigerator showed staff did not document a temperature check 49 out of 62
times (two times per day) for the nursing unit refrigerator.
Record review showed no June, (YEAR), nursing unit refrigerator temperature log.
Record review showed no July, (YEAR), nursing unit refrigerator temperature log.
Observation on [DATE] at 2:00 P.M., showed the interior thermometer of the nursing unit
refrigerator was not readable, the mercury was broken up/fragmented and the temperature
could not be determined. There was no exterior thermometer. No temperature log for (MONTH)
(YEAR) was observed on the refrigerator.
5. Observation on [DATE] at 2:00 P.M., of the nursing unit refrigerator showed the
following:
-The freezer section contained an open, undated carton of ice cream;
-The door shelf had a dried, brown sticky substance the length of the shelf;
-Three small bowls of applesauce, covered with plastic wrap, were undated and stuck to the
dried substance;
-Three over-ripe, brown bananas, marked with a resident’s name;
-An unsealed, dried out container of yogurt with a resident’s name, dated [DATE] and
manufacturer’s best by date of [DATE];
-One bowl of unsealed vanilla pudding, marked 26.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
6. During an interview on [DATE] at 1:50 P.M., Dietary Manager (DM) said resident food was
stored in the nursing unit refrigerator. The nursing staff log the temperatures for the
refrigerator.
7. During an Interview on [DATE] at 1:55 P.M., Licensed Practical Nurse (LPN) A said the
nursing unit refrigerator was used to store food brought in for specific residents, food
used for medication administration and the staff’s food. He/She removed the June, (YEAR)
temperature log today and gave the log to the Director of Nursing.
8. During an interview on [DATE] at 3:00 P.M., Certified Nurse Assistant (CNA) B said the
nursing unit refrigerator was used for resident’s food and staff’s food. The nursing staff
or housekeeping staff are responsible for logging the refrigerator temperatures.
Housekeeping staff used to check the refrigerator for cleanliness but he/she is not sure
who monitors for cleanliness at this time.
9. During an interview on [DATE] at 03:07 P.M., Certified Medication Technician (CMT) C
said he/she is new to the facility and the nursing unit refrigerator was for resident
food. He/she obtains individual containers of applesauce from dietary for medication
administration. He/she disposes of unused applesauce.
10. During an interview on [DATE] at 03:18 P.M., the Housekeeping Supervisor said she has
been in the supervisor position for three weeks. The housekeeping staff have not logged
temperatures or cleaned the nursing unit refrigerator.
11. During an interview on [DATE] at 3:30 P.M., Director of Nursing (DON) said the
following:
-The nursing unit refrigerator was used for resident’s food and food for the medication
passes, such as applesauce;
-The nursing staff are responsible for the refrigerator;
-Nursing staff check for and dispose of expired foods;
-She tries to clean it every Friday;
-The nursing staff should log the refrigerator temperatures daily;
-She does not have temperature logs and does not know who keeps the them.
-She expects the staff to dispose of partially used applesauce after each (individual)
resident use.
11. During an interview on [DATE] at 4:50 P.M., Administrator said the following:
-The nursing staff should check for expired foods in the refrigerator and that has not
been completed correctly;
-She directed staff to dispose of all items in the nursing unit refrigerator;
-A thermometer should be in the nursing unit refrigerator;
-Nursing staff are responsible for logging the temperatures and checking for expired foods
in the refrigerator and that has not been completed correctly;
-She directed staff to dispose of all items in the nursing unit refrigerator.
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 record review and interview, the facility failed to ensure a Two-Step [MEDICATION
NAME] (TB-a contagious and potentially fatal lung disease) test was completed for three
residents (Resident #14, #21, and #39) and failed to do an annual TB or a signs and
symptoms screening for one resident (Resident #17). Five residents out of a sample of 16
residents was selected for review for the TB immunizations. The facility failed to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 31)
properly disinfect glucometers between resident use for three residents (Resident # 13, #
40, and # 198) and failed to ensure a glucometer disinfection policy was in place. A
sample of 16 residents was selected for review out of a facility census of 42.
Record review of 19 CSR 20-20.100 showed the following requirements for TB testing and
monitoring of long-term care residents:
-Within one month prior to or one (1) week after admission, all residents new to long-term
care are required to have the initial test of a Mantoux PPD ([MEDICATION NAME] sensitivity
test, tool for screening for TB and for TB diagnosis) two (2)-step [MEDICATION NAME] test;
-If the initial test is negative, the second test can be given after admission and should
be given one to three weeks later;.
-All skin test results are to be documented in millimeters (mm) of induration;
-Residents with a negative, zero to nine millimeters Mantoux PPD two-step test need not be
routinely retested unless exposed to infectious [MEDICAL CONDITION] or they develop signs
and symptoms which are compatible with [MEDICAL CONDITION] disease;
-All long-term care facility residents shall have a documented annual evaluation to rule
out signs and symptoms of [MEDICAL CONDITION] disease.
1. Record review of Resident #14’s medical record showed the following information:
-Date of admission 10/26/17;
-[DIAGNOSES REDACTED].
Record review of the resident’s immunization record showed no records the resident had
received the first or second TB test.
2. Record review of Resident #21’s medical record showed the following information:
-Date of admission 3/11/18;
-[DIAGNOSES REDACTED].
Record review of the resident’s immunization record showed no records the resident had
received the first or second TB test.
3. Record review of Resident #39’s medical record showed the following information:
-Date of admission 6/13/18;
-[DIAGNOSES REDACTED].
Record review of the resident’s immunization record showed no records the resident had
received the first or second TB test.
4. Record review of Resident #17’s medical record showed the following information:
-Date of admission 8/22/16;
-[DIAGNOSES REDACTED].
Record review of the resident’s immunization record showed no records the resident had
received an annual signs and symptoms screening or an annual one step TB test.
5. During an interview on 7/17/18, at approximately 4:00 P.M., the medical records staff
said he/she looked through the residents’ thinned medical records and did not find any
records the TB test had been administered for the requested residents. He/she said if the
immunization form did not list the TB test then the residents must not have received the
TB test or the annual screening for TB.
6. During an interview on 7/17/18, at 7:55 P.M., the director of nursing (DON) said
residents newly admitted to the facility should be given a Two-step TB test. The first TB
test should be read 48-72 hours later. The second TB test should be given 7-10 days later
and then read 48-72 hours later. Residents who are not new admissions should be offered an
annual TB test. She did not know the TB test for the requested residents had not been
done.
7. The Centers for Disease Control and Prevention (CDC) report blood glucometers approved
for use for more than one person must be cleaned and disinfected. The CDC investigated
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 32)
multiple outbreaks of [MEDICAL CONDITIONS] residents in long-term care (LTC) communities
that were attributed to shared devices and other breaks in infection-control practices
related to blood glucose monitoring devices. When blood glucose monitoring devices are
shared between individuals there is a risk of transmitting [MEDICAL CONDITIONS] other
blood borne pathogens.
Record review of the American Society of Consultant Pharmacists Summary of Glucometer
Cleaning Guidelines, dated (MONTH) 2010, showed the following information:
-If the manufacturer does not provide specific cleaning recommendations, or as a
conservative approach to infection control for glucometer with minimal cleaning
requirements, facilities may want to consider cleaning glucometer with high-level
disinfectants;
-Be familiar with the amount of time the disinfectant solution is supposed to contact the
equipment or how long active cleaning should be performed to ensure complete disinfection.
For example, simply wiping equipment with a disinfectant-soaked swab (like an alcohol prep
pad) may not be adequate.
8. Observation on 7/12/18, at 11:23 A.M., showed Licensed Practical Nurse (LPN) D applied
hand gel and applied gloves. LPN D obtained a glucometer from the medication drawer. LPN D
entered Resident # 198’s room with the glucometer and other supplies to perform the
glucometer finger stick test. LPN D obtained the blood glucose test results and exited the
room. LPN D sat the used glucometer on top of the medication cart directly, without a
protective barrier. LPN D removed his/her gloves, and disposed of other used supplies.
Record review of Resident # 198’s admission Minimum Data Set (MDS), a federally mandated
resident assessment instrument, dated 3/8/18, completed by facility staff, showed the
resident had been admitted on [DATE], and had a [DIAGNOSES REDACTED].
Observation on 7/12/18, at 11:30 A.M., showed LPN D picked up the unclean, used
glucometer, along with other supplies, and entered Resident # 40’s room. LPN D obtained a
paper towel and sat it on the resident’s bedside table. LPN D sat the glucometer on the
paper towel, then washed his/her hands and applied gloves. LPN D obtained the blood
glucose test on the resident. LPN D removed his/her gloves and washed his/her hands. LPN D
exited the resident’s room. LPN D disposed of the used supplies, and sat the glucometer
directly on the medication cart without a protective barrier. LPN D administered insulin
to the resident. LPN D removed his/her gloves and applied hand gel.
Record review of Resident # 40’s face sheet (general resident information) showed the
resident admitted to the facility on [DATE], and had a [DIAGNOSES REDACTED].
Observation on 7/12/18, at 11:42 A.M., showed LPN D obtained supplies needed to administer
a blood glucose test on Resident # 13. LPN D picked up the unclean, used glucometer and
entered the resident’s room. LPN D obtained a paper towel and sat it on the resident’s
bedside table, and sat the supplies and glucometer on the paper towel. LPN D washed
his/her hands, and applied gloves. LPN D obtained the blood glucose results. LPN D left
the resident’s room, and disposed of the used supplies. LPN D placed the glucometer on the
medication cart. LPN D had not disinfected the glucometer. LPN D placed the unclean, used
glucometer in the top drawer of the medication cart.
Record review of Resident # 13’s quarterly MDS, dated [DATE], showed the resident had been
admitted on [DATE], and had a [DIAGNOSES REDACTED].
9. During an interview on 7/17/18, at 8:20 P.M., Registered Nurse (RN) G said the
following:
-RN G would clean glucometers with an antibacterial wipe after resident use, and leave wet
for three minutes. He/she had learned this practice when working at other facilities.
10. During an interview on 7/17/18, at 6:59 P.M., the Director of Nursing said the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 33)
following:
-She expected staff to disinfect glucometers after resident use by wiping them off with
alcohol, and letting them sit for 90 seconds before using on another resident. This
practice was based on previous in-services she had received in the past. The facility
didn’t have a glucometer cleaning policy.
11. During an interview on 7/17/18, at 6:50 P.M., the administrator said she did not have
a glucometer cleaning policy.
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to offer the pneumococcal
vaccine to five residents (Resident #6, #14, #17, #21, #39) following the residents’
admission to the facility. Five residents were selected for review out of a sample of 16
residents. The facility census was 42 residents.
Record review of the US Department of Health and Senior Services Centers for Disease
Control (CDC) Pneumococcal Vaccine Timing for adults, dated 11/30/15, showed the following
information:
-Two pneumococcal vaccines are recommended for adults: 13-valent pneumococcal conjugate
vaccine (PCV13; Previnar 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine(PPSV23;[MEDICATION NAME] 23);
-One dose of PPSV23 was recommended for adults [AGE] years and older, regardless of
previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was
given at age of [AGE] years or older, no additional doses of PPSV23 should be
administered;
-For those age 65 or older who had not received any pneumococcal vaccines, or those with
unknown vaccination history administer one dose of PCV13. Administer one dose of PPSV23 at
least one year later for most adults or at least 8 weeks later;
-For those age [AGE] years or older who previously received one dose of PPSV23 and no
doses of PCV13 administer dose of PPSV13 at least one year after the dose of PPV23 for all
adults regardless of their medical condition.
1. Record review of Resident #6’s medical record showed the following information:
-Date of admission 3/09/18;
-[DIAGNOSES REDACTED].
-No consent forms to authorize the pneumococcal vaccines.
Record review of the resident’s immunization record showed no records the resident had
been offered either pneumococcal vaccines and no previous history the resident had ever
received either pneumococcal vaccine.
2. Record review of Resident #14’s medical record showed the following information:
-Date of admission 10/26/17;
-[DIAGNOSES REDACTED].
-No consent forms to authorize the pneumococcal vaccines.
Record review of the resident’s immunization record showed no records the resident had
been offered either pneumococcal vaccines and no previous history the resident had ever
received either pneumococcal vaccine.
3. Record review of Resident #17’s medical record showed the following information:
-Date of admission 8/22/16;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265410

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/17/2018

NAME OF PROVIDER OF SUPPLIER

BENTONVIEW PARK HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

410 WEST BENTON STREET
MONETT, MO 65708

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
-[DIAGNOSES REDACTED].
-No consent forms to authorize the pneumococcal vaccines.
Record review of the resident’s immunization record showed no records the resident had
been offered either pneumococcal vaccines and no previous history the resident had ever
received either pneumococcal vaccine.
4. Record review of Resident #21’s medical record showed the following information:
-Date of admission 3/11/18;
-[DIAGNOSES REDACTED].
-No consent forms to authorize the pneumococcal vaccines.
Record review of the resident’s immunization record showed no records the resident had
been offered either pneumococcal vaccines and no previous history the resident had ever
received either pneumococcal vaccine.
5. Record review of Resident #39’s medical record showed the following information:
-Date of admission 6/13/18;
-[DIAGNOSES REDACTED].
-No consent forms to authorize the pneumococcal vaccines.
Record review of the resident’s immunization record showed no records the resident had
been offered either pneumococcal vaccines and no previous history the resident had ever
received either pneumococcal vaccine.
During an interview on 7/17/18, at 7:55 P.M., the director of nursing (DON) said the staff
should send out a consent form for the resident, guardian, or resident representative to
sign for authorization to administer the pneumococcal vaccine. The DON said she did not
know there were two pneumococcal vaccines that should be offered. She said the facility
had not been offering the pneumococcal vaccines since she had been at the facility.
F 0919

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that a working call system is available in each resident’s bathroom and
bathing area.

Based on observation and interview, the facility failed to provide a switch in all toilet
rooms which would activate the resident call light system when activated by omitting the
switches in two toilet rooms located near the front entrance and one toilet room near the
north side nurses’ desk. This deficient practice had the potential to affect all
residents, staff, and visitors who might need to use the toilets and would need staff
assistance. The facility had a capacity of 120 with a census of 42.
1. Observation on 7/10/18, at 10:30 A.M., showed two public toilet rooms located at the
front entrance and a public toilet room located near the north side nurses’ desk. All
three toilet rooms remained without a call light activation switch.
During an interview on 7/10/18, at 3:45 P.M., the administrator said she thought since the
toilet rooms were public use only they did not need a call light activation switch.

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