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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assure the security of all personal funds of residents deposited with the facility.

Based on interview and record review, the facility failed to maintain a surety bond
sufficient to ensure protection of resident funds. The census was 63.
Review of the facility’s Resident Trust General Ledger (cash sheet) for the period of
(MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of $18,000.00,
which would require a bond of $27,000.00.
Review of the Department of Health and Senior Services approved bond list, showed the
facility had an approved bond for $25,000.00
During an interview on 11/6/18 at 10:00 A.M., the Business Office Manager said the new
bond was approved on (MONTH) 5, (YEAR) for $35,000. She was responsible for ensuring the
bond was increased.
During an interview on 11/6/18 at 10:30 A.M., the administrator said he thought he had the
bond increased back in September. The issue must have been over looked.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure hot water
temperatures reached at least 105 degrees Fahrenheit (F) for residents on three occupied
halls who complained of cool water temperatures. The census was 63.
1. Review of the maintenance work order log (a log completed by staff of items that needed
to be repaired and reviewed daily by the maintenance director), showed on 9/14/18, a staff
member wrote, the water did not get hot.
2. Observation on 11/8/18 at 7:20 A.M., of the bathroom between rooms[ROOM NUMBERS], and
shared by three residents, showed:
-The surveyor used a calibrated thermometer to take the temperature of the hot water at
the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water from the faucet reached a high temperature of 74.7 degrees F;
-At 8:06 A.M., the maintenance director re-tested the hot water from the bathroom faucet
and received a reading of 79.7 degrees F.
3. Observation on 11/8/18 at 7:25 A.M., of room [ROOM NUMBER], shared by two residents,
showed:
-The surveyor used a calibrated dial thermometer to take the temperature of the hot water
at the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for two minutes. The
water from the faucet reached a high temperature of 90 degrees F. The water was cool to
touch.
4. Observation on 11/8/18 at 7:30 A.M., of the bathroom between rooms [ROOM NUMBERS],
shared by four residents, showed:
-The surveyor used a calibrated thermometer to take the temperature of the water at the
bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water from the faucet reached a high temperature of 74.7 degrees F. During an interview, 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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
resident residing in room [ROOM NUMBER] said the water was cold and did not get warm. It
had been like this for a few weeks;
-At 8:03 A.M., the maintenance director re-tested the hot water from the bathroom faucet
and received a reading of 79.7 degrees F.
5. Observation on 11/8/18 at 7:30 A.M., of room [ROOM NUMBER], shared by two residents,
showed:
-The surveyor used a calibrated dial thermometer to take the temperature of the hot water
at the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for two minutes. The
water from the faucet reached a high temperature of 76 degrees F. The water was cool to
touch. One of the resident’s in room [ROOM NUMBER], said the hot water temperature at the
bathroom sink was not hot enough when he/she shaved. The issue with the hot water being
too cold had been going on for an extended period of time and he/she had informed the
administrator about this problem. The resident could not recall when he/she notified the
administrator.
6. Observation on 11/8/18 at 7:50 A.M., of room [ROOM NUMBER], an occupied private room,
showed:
-The surveyor used a calibrated dial thermometer to take the temperature of the hot water
at the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for two minutes. The
water from the faucet reached a high temperature of 80 degrees F. The water was cool to
touch.
7. Observation on 11/8/18 at 10:06 A.M., of the bathroom between rooms [ROOM NUMBERS],
shared by three residents, showed the maintenance director, administrator and the Regional
Nurse Consultant tested the hot water from the bathroom faucet and obtained a temperature
of 80.8 degrees F.
8. Observation on 11/8/18 at 10:10 A.M., of the bathroom between rooms [ROOM NUMBERS],
shared by four residents, showed the maintenance director, administrator and the Regional
Nurse Consultant tested the hot water from the bathroom faucet and obtained a temperature
of 79.3 degrees F.
9. During an interview on 11/08/18 at 8:23 A.M., Certified Nurse Aide (CNA) B said he/she
had noticed the water was not getting warm for a few days, but did not say anything to
anyone about it.
10. During an interview on 11/8/18 at 9:12 A.M., Resident #12 said it took a long time for
the water to get warm at the sink.
11. During an interview on 11/8/18 at 9:14 A.M., Housekeeper A said he/she cleans the
rooms on the 200/400 halls and it took the water a long time to get warm and it didn’t get
hot. He/she told maintenance about 2 months ago.
12. During an interview on 11/8/18 at 9:17 A.M., Resident #26 said it took the water about
a half hour to get hot.
13. Observation on 11/8/18 at 10:10 A.M., of the bathroom between rooms [ROOM NUMBERS],
shared by four residents showed the maintenance director, administrator, and the Regional
Nurse Consultant tested the hot water from the bathroom faucet and obtained a reading of
79.3 degrees F.
14. During an interview on 11/8/18 at 10:32 A.M., CNA C said the water on the 100 Hall got
too cold and it had been cold for awhile. The maintenance director said it was a problem
he could not fix because he needed a new part or something.
15. During a telephone interview on 11/8/18 at 9:01 A.M., a representative from the
plumbing company said the facility contacted them about the water being too cool. Their
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
service person was at the facility on 10/22/18 and the quote was sent to the facility on[DATE]. The facility had not contacted them since to have the repairs done.
16. Review of a Quotation and Agreement from the plumbing company, dated 10/24/18, showed
the following:
We hereby submit our proposal to do the following:
-1 – Thermostatic mixing valve. Replace the existing with a properly sized unit;
-1 – Hot water circulating pump. Replace the defective pump.
17. During an interview on 11/8/18 at 8:18 A.M., the maintenance director said there were
two water heaters on the 100 hall. One for the 100 hall and one for the 300 hall. A few
weeks ago, he had a plumbing company come out to the facility. Some residents had
complained about the water being too cool. The plumbing company said a new mixing valve
was needed. He had been testing the water weekly since that time and it had been alright.
He did not know if anyone had contacted the plumbing company about the mixing valve being
replaced or not. The administrator, present at the time of the interview, said a few
residents had complained and that’s why the plumbing company came in to test. He had not
contacted the plumbing company to make the repairs because the temperatures had been
alright since then.
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 interview and record review, the facility failed to adequately monitor, assess
and ensure the guidance and direction of the physician/Medical Director was obtained,
regarding a resident experiencing a change in condition. Over a four day period, staff
observed the resident with an elevated temperature, an increased heart rate and labored
breathing. On the fourth day the physician was made aware of the resident’s change, and
gave orders to send the resident to the hospital where he/she was admitted to the
intensive care unit (ICU). In addition, the facility failed to ensure adequate follow up
and physician notification regarding a resident with ongoing vaginal discharge (Residents
#202 and #201). The census was 62 residents.
Review of the facility’s policy and procedure on Change in Condition, updated 3/2017,
showed:
-Purpose: The facility will make every effort to inform the resident, consult with the
resident’s physician and notify, consistent with his or her authority, the resident
representative when there is following:
#2. A significant change in the condition, health, mental or psychosocial status, that is
a deterioration in health, mental or psychosocial status in either life threatening
conditions or clinical complications;
-Procedure:
1. If the physician cannot be reached, the Medical Director will be notified;
2. During medical emergencies, notifications will be made as soon as possible;
3. The facility will promptly notify the physician of laboratory results that fall
outside of the clinical reference ranges in accordance with Doctor parameters or
laboratory normal reference ranges;
4. Changes in condition will be evaluated for the need to complete a Significant Change
in condition MDS 3.0/RAI Assessment, in accordance to the RAI/MDS 3.0 Instruction Manual;

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 3)
5. The care plan will be updated as necessary;
-The policy did not instruct staff on what steps they should take when a resident had a
change in condition such as assessing, monitoring, taking vital signs, documenting or what
to do if the physician/Medical Director could not be reached.
1. Review of Resident #202’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/8/18, showed:
-[DIAGNOSES REDACTED].
-Severely impaired cognition;
-Clear speech;
-Usually able to make self understood and to understand others;
-Required total staff assistance for all activities of daily living (ADLs);
-Wheelchair used for mobility;
-Incontinent of bowel and bladder;
-Mechanically altered diet;
-Life expectancy of six months or less: No.
Review of the resident’s progress note, completed by the physician, dated 12/8/18, showed:
-History of multiple problems;
-Respirations (R) 16 (normal 12-16), pulse (P) 72 (normal 60-100);
-Respiratory: Lungs clear to auscultation, no respiratory distress, no oxygen use, no
wheezing;
-Medical management: Stable, dementia, depression, stroke, diabetes and increased blood
pressure.
Review of the resident’s nurse’s notes, showed:
-On 12/25/18 at 5:48 A.M.: admitted to hospital with [DIAGNOSES REDACTED].
-On 1/4/19 at 6:46 P.M.: readmitted to the facility at 3:38 P.M. Alert but does not speak.
Grunts when name is called and makes eye contact. Vital signs (VS): Blood pressure (B/P)
123/76 (normal 120/80), P 79, R 16, temperature (T) 99.7 (normal 98.6). Oxygen saturation
(O2 Sats) 96% (normal 95-100%). Tylenol given.
Review of the resident’s physician’s orders [REDACTED].
-Full code;
-No order documented for oxygen;
-Nothing by mouth (NPO);
-[MEDICATION NAME] (generic for Tylenol) 500 milligrams (mg) by mouth every six hours as
needed for elevated temperature or pain.
Review of the resident’s interim care plan, dated 1/4/19 at 3:38 P.M., showed:
-Risk for skin breakdown;
-Cognitively impaired;
-Total assistance with ADLs;
-Medications/Treatments: Oxygen;
-Medical Conditions: SOB (shortness of breath), [MEDICAL CONDITION] and [MEDICAL
CONDITIONS].
Review of the resident’s nurse’s notes, showed:
-On 1/5/19 at 5:20 A.M.: VS: T 100.0, P 100, R 18, BP 111/56, O2 Sats 94%, alert, readmit,
Tylenol given for temperature, head of bed elevated, lungs sounds clear to auscultation,
oxygen applied at 2 liters (L) per minutes for shortness of breath and comfort;
-On 1/5/19 at 3:00 P.M.: Alert but non verbal. NPO and remains on continual tube feeding
without problems. Will continue to monitor for any changes. No vital signs documented. No
further nurses note documented until 1/6/19 at 5:20 A.M.;
-On 1/6/19 at 5:20 A.M.: In bed, eyes closed, resting. Total care with ADLs, toileting 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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 4)
transfers. VS: T 99.7, P 110, R 16, B/P 118/75. O2 Sats 94% with oxygen at 2 L. No
documentation staff notified the physician of the resident’s increased pulse rate or
increased temperature;
-On 1/6/19 at 12:58 P.M.: While on break, another charge nurse reported the resident was
not looking good. VS: B/P 118/75, P 110, O2 Sats 93% on 2 L of oxygen, T 99.5, R 24 and
blood glucose of 132. Resident was SOB with slight wheezing. Call placed to the resident’s
physician, awaiting call back. Resident is a full code. [MEDICATION NAME] (medication used
to treat anxiety) administered. Will continue to monitor;
-On 1/6/19 at 3:20 P.M.: VS: B/P 122/77, O2 Sats 94%, R 18, resident still has elevated
temperature. Awaiting call back from the physician. Called times two. No pulse or
temperature documented;
-On 1/6/19 at 9:00 P.M.: No documentation regarding the resident’s vital signs or
condition nor whether the physician returned a call to the facility. The next note
documented, on 1/7/19 at 10:39 P.M.
Review of the resident’s Speech Therapy Plan of Care, dated 1/7/19, showed:
-Reason for Referral: Dysphagia (difficulty swallowing) referred for dysphasia evaluation
and treatment for [REDACTED]. Resident is NPO;
-Exam given: NPO status. Left facial droop noted, poor lip seal and labored breathing.
Recent [DIAGNOSES REDACTED]. Patient did not trigger a swallow during exam despite tactile
and verbal cues. Patient consumed a mechanical soft diet with thin liquids prior to
hospitalization .
Review of the resident’s nurse’s notes, showed:
-On 1/7/19: No day shift note for 7:00 A.M. through 3:00 P.M.;
-On 1/7/19 at 10:39 P.M.: Resident has had an active decline. Temperature unstable at
103.1, was given Tylenol and ice packs were placed to lower temperature. When nurse
returned to reassess, resident was noted to be short of breath, remained on oxygen at 2 L
per nasal cannula. Unable to obtain O2 Sats, temperature remains unstable at 101.4. Will
continue to monitor. No documentation whether the staff contacted the physician or whether
the physician returned the call from 1/6/19;
-On 1/8/19 at 1:11 A.M.: VS: T 102.0, P 107, R 22, B/P 90/54, O2 Sats not documented.
Resident short of breath, with pursed lip breathing (a breathing technique that consists
of exhaling through tightly pressed (pursed) lips and inhaling through the nose with the
mouth closed), using facial and abdominal muscles to breath, head of bed elevated. Tylenol
given for temperature. Physician called. The physician asked staff if the resident was a
hospice patient, staff replied no. Order received to send to the hospital for evaluation.
Ambulance called and gave instructions to call 911 due to resident being in respiratory
distress. Resident on O2 at 3 L, while having increased shortness of breath, color pale.
Assistant Director of Nurses (ADON) made aware. Resident transported to hospital;
-On 1/8/19 at 5:59 A.M.: admitted to the ICU with a [DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 1/8/19, showed:
-Problem: Oxygen therapy related to ineffective gas exchange, at times observed with SOB
and required oxygen;
-Interventions: Monitor for signs and symptoms of respiratory distress and report to the
physician as needed: Respirations, pulse oximetry, increased heart rate, restlessness,
diaphoresis (excessive sweating), headaches, lethargy, confusion, cough, bloody sputum,
accessory muscle usage and skin color.
During an interview on 1/8/19 at 11:16 A.M., Certified Nurse Aide (CNA) Q said he/she
works the day shift. When the resident returned from the hospital on [DATE], he/she didn’t
look well. He/she took care of the resident on 1/6/19. After breakfast, while providing
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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)
care, he/she noted the resident was short of breath and told CNA U to get the charge
nurse. Nurse D and Nurse M came to the room. Nurse D said the resident was short of
breath. Nurse D told him/her to raise the head of the bed. CNA Q believes the nurse gave
him/her a nebulizer treatment, but was not sure. When he/she made his/her last rounds, the
resident continued to have labored breathing. He/she doesn’t know if the nurse checked
him/her again. He/she didn’t get the resident up on 1/7/19, and his/her condition was
about the same.
During an interview on 1/8/19 at 11:42 A.M., Nurse M said he/she worked the day shift on
Sunday 1/6/19. While the resident’s nurse was on break, CNA Q and CNA U reported the
resident wasn’t looking good. When he/she entered the room, the resident was pursed lip
breathing and using his/her abdominal muscles to breath. The resident’s respirations were
22 to 24 and O2 Sats were 95% on 2 L of oxygen. He/she took the resident’s B/P and pulse,
but doesn’t recall what they were and didn’t document them at the time. He/she instructed
CNA Q and CNA U to stay with the resident while he/she got the resident’s nurse. He/she
was very concerned about the resident’s condition and wanted to call 911, because the
resident’s respirations were labored and his/her skin was sweaty and clammy, but he/she
wasn’t the resident’s nurse. He/she and Nurse D returned to the room to assess the
resident. He/she asked Nurse D if he/she needed any help, but he/she declined. He/she left
the room at that time, but knows Nurse D administered a [MEDICATION NAME] (antianxiety
medication) to help calm the resident down and placed a call to the physician. Nurse D
also called the ADON to make her aware. The resident’s physician didn’t call back on their
shift. He/she didn’t work on 1/7/19.
During an interview on 1/8/19 at 3:55 P.M., CNA R said he/she took care of the resident on
1/5 and 1/6/19 on the evening shift. He/she was very drowsy and responded only when he/she
provided care. The resident normally awakens easily and resists care. His/her lips were
very dry and he/she applied Vaseline to them. No one reported any changes in report.
During an interview on 1/8/19 at 4:00 P.M., Nurse T said he/she took care of the resident
on the evening shift of 1/6/19. Nurse D reported he/she had given the resident [MEDICATION
NAME] on the day shift. He/she saw the resident during rounds, and noted a decline. He/she
had pursed lip breathing which lasted 5 to 7 minutes at various times. He/she didn’t
notice the use of accessory muscles to breath. He/she saw the the resident about three
times on his/her shift. Staff didn’t report any changes and the physician didn’t return
call on his/her shift.
During an interview on 1/8/19 at 10:55 A.M., the speech therapist said she evaluated the
resident on 1/7/19, in the morning. The resident was very lethargic, had very little oral
movement and was unable to close his/her lips. He/she was short of breath with audible
breathing and sounded very congested. She was surprised to see the resident was receiving
tube feeding, because prior to hospitalization he/she received a mechanical soft diet with
thin liquids. She did not report the resident’s condition to the nursing staff.
During an interview on 1/8/19 at 1:59 P.M., Nurse D said he/she took care of the resident
on 1/5, 1/6 and 1/7/19 on the day shift. He/she doesn’t recall any problems with the
resident on 1/5/19 and no one reported any concerns. On 1/6/19, while on break, Nurse M
reported the resident was breathing hard, his/her pulse was elevated and O2 Sats and B/P
were normal. He/she assessed the resident and noted slight wheezing and an elevated
temperature of 99.5. He/she raised the HOB higher and placed a call to the physician at
about 11:00 A.M. or 12:00 P.M. He/she checked on the resident during his/her shift, but
did not document his/her condition. He/she notified the ADON and was told to call the
physician. The ADON also asked if the resident had anything for anxiety and instructed
him/her to administer it. The physician did not return the call prior to the end of
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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)
his/her shift on 1/6/19. He/she saw the resident on the morning of 1/7/19, when he/she
administered his/her medications and didn’t notice any shortness of breath at that time.
Speech therapy did not report any concerns regarding the resident. He/she was unaware the
speech therapist documented pursed lip breathing, audible wheezing, lethargy or sounds of
congestion. He/she would have expected the therapist to report any changes in his/her
condition to the nurse.
During an interview on 1/8/19 at 3:50 P.M., CNA S said he/she took care of the resident on
1/7/19, on the evening shift. He/she could see the change in the resident since his/her
return from the hospital. The resident was drooling from his/her mouth which was unusual
for him/her. He/she was drowsy and slept most of the evening. The resident normally would
be more alert.
During an interview on 1/8/19 at 2:27 P.M., the ADON said she would consider an elevated
pulse a change in condition. The nurses administered Tylenol for the temperature and did
what they were supposed to do, but the ADON was unable to state how long staff should
administer Tylenol for a elevated temperature before notifying the physician. She expected
the nurses to document in the nurse’s notes when there is a change in condition and to
document every shift until the resident is stable. She would have expected the therapist
to notify nursing immediately of any changes in the resident’s condition. The resident had
a history of [REDACTED].
During an interview on 1/8/19 at 3:10 P.M., the Administrator said he expected staff to
notify the physician anytime there is a change in the resident’s condition.
During an interview on 1/10/19 at 12:30 P.M., the resident’s physician, who was also the
facility’s Medical Director, said he expected staff to document in the medical record any
change in the resident’s condition. He would have expected the therapist to notify nursing
of any changes in the resident’s condition. Anytime a nurse had concerns and felt the
resident needed to be sent to the hospital and 911 needed to be called, he expected them
to use nursing judgement, send the resident and notify him afterward.
2. Review of Resident #201’s readmission MDS, dated [DATE], showed:
-A readmission date of [DATE];
-[DIAGNOSES REDACTED].
-Moderately impaired cognition;
-Extensive to total staff assistance for ADLs;
-Wheelchair for mobility;
-Incontinent of bowel and bladder.
Review of the resident’s progress notes, showed:
-On 1/3/19 at 2:27 P.M., CNA informed the charge nurse, while perineal care (peri-care,
cleaning of the genital and anal areas) was provided, the resident had a greenish and tan
colored vaginal discharge. The resident denied burning during urination and/or vaginal
itching at this time. Message left for the resident’s physician to contact the facility.
Awaiting return telephone call from the physician. The resident’s responsible party was
contacted and made aware of the resident’s change in condition;
-On 1/4/19 at 10:25 P.M., nursing staff administered [MEDICATION NAME] (antifungal
medication) 150 mg, one tablet, for vaginal discharge as ordered by the resident’s
physician;
-On 1/5/19 at 4:50 A.M., monitored for vaginal discharge;
-On 1/6/19 at 1:26 P.M., continues to have heavy green discharge from vaginal area.
Telephone call placed to the resident’s physician;
-On 1/8/19 at 12:10 P.M., no vaginal discharge reported today. Call placed to the
resident’s physician regarding past history of heavy vaginal drainage. New order received
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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)
for [MEDICATION NAME] 150 mg, one tablet, for one time dose;
-On 1/8/19 at 2:15 P.M., call placed to pharmacy for order of [MEDICATION NAME] to be sent
on stat (immediately) run from the pharmacy;
-No progress note found indicating the physician contacted the facility on 1/6 and/or
1/7/19 related to the resident’s vaginal drainage;
-No progress note found indicating nursing staff attempted to contact the resident’s
physician again regarding the resident’s vaginal drainage until 1/8/19.
Review of the resident’s POS, dated 1/1 through 1/31/19, showed:
-A telephone order dated 1/3/19 (no time), for [MEDICATION NAME] 150 mg, one tablet, times
one dose;
-A telephone order dated 1/8/19 (no time), for [MEDICATION NAME] 150 mg, one tablet, times
one dose.
Review of the resident’s Medication Administration Record [REDACTED] -On 1/4/19, no staff initials to indicate the administration of [MEDICATION NAME] 150 mg,
one tablet;
-On 1/8/19, staff initialed to indicate the administration of [MEDICATION NAME] 150 mg,
one tablet.
Review of the facility’s 24 hour nursing report sheet dated 1/6/19, showed staff
documented regarding the resident:
-7:00 A.M. to 3:00 P.M. shift, having green vaginal drainage, call placed to the
resident’s physician, resident leave of absence from the facility and returned;
-3:00 P.M. to 11:00 P.M. shift, no vaginal drainage this shift;
-11:00 P.M. to 7:00 A.M. shift, continues to have vaginal drainage;
-No documentation to indicate the resident’s physician called the facility back related to
the resident’s vaginal drainage;
-No documentation to indicate nursing staff attempted to contact the physician again after
contacting the physician on the 7:00 A.M. to 3:00 P.M., shift.
Review of the facility’s 24 hour nursing report sheet dated 1/7/19, showed staff
documented regarding the resident:
-7:00 A.M. to 3:00 P.M. shift, out to [MEDICAL TREATMENT] (process of filtering toxins
from the blood in individuals with kidney failure);
-3:00 P.M. to 11:00 P.M. shift, returned from [MEDICAL TREATMENT];
-11:00 P.M. to 7:00 A.M. shift, is alright;
-No documentation to indicate the resident’s physician called the facility regarding the
resident’s vaginal drainage;
-No documentation to indicate nursing staff attempted to contact the physician regarding
the resident’s vaginal drainage.
During an interview on 1/8/19 at 11:55 A.M., Nurse M verified he/she worked the day shift
on 1/6/19. He/she telephoned the resident’s physician regarding the resident’s vaginal
drainage, but had not received a telephone call back from the physician prior to him/her
leaving on 1/6/19. To his/her knowledge, the physician had not contacted the facility back
regarding the resident’s vaginal drainage. The nurse verified he/she did not receive any
information in report from the nursing staff, to indicate the physician had contacted the
facility regarding the resident’s vaginal drainage and/or staff contacted the physician
since Nurse M called the physician on 1/6/19.
During an interview on 1/8/19 at 12:00 P.M., the resident said he/she had a small amount
of vaginal drainage that day. She could not recall if nursing staff had assessed him/her
that day regarding the vaginal discharge or not. The resident denied having any pain or
discomfort.
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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)
During an interview on 1/8/19 at 12:05 P.M., Nurse M said he/she had contacted the
resident’s physician and received an order to administer [MEDICATION NAME] 150 mg one
tablet that day.
During an interview on 1/8/19 at 3:30 P.M., Nurse N verified the resident’s physician
contacted the facility during the evening shift on 1/3/19, and gave an order to administer[MEDICATION NAME] 150 mg one tablet dose. He/she placed the order for the [MEDICATION
NAME] in the computer to the pharmacy at approximately 10:30 P.M. on 1/3/19. Nurse N
verified he/she administered the resident’s [MEDICATION NAME] on 1/4/19 at approximately
7:00 P.M., but forgot to document the administration of the [MEDICATION NAME] on the
resident’s MAR.
During an interview on 1/8/19 at 2:45 P.M., the ADON said she expected nursing staff to
continue to have attempted to contact the resident’s physician regarding the vaginal
drainage when staff first contacted the physician on 1/6/19. She expected the nursing
staff to document each time they attempted to contact the resident’s physician in the
progress notes.
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 ensure hot water
temperatures remained at or below 120 degrees Fahrenheit (F) for residents on one hall,
fix the broken bathroom floor tiles for one resident, who complained of tripping over the
defective area and ensure a potentially hazardous cleanser was stored securely (Resident
#26). The census was 63.
1. Observation in 11/8/18 at 7:37 A.M., of room [ROOM NUMBER], an occupied semi-private
room, showed:
-The surveyor used a calibrated thermometer to take the temperature of the hot water at
the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water reached a temperature of 127.7 degrees F. During an interview, the resident residing
in the room said the water got too hot if you didn’t mix cold water in with it;
-At 8:10 A.M., the maintenance director tested the hot water faucet and obtained a
temperature of 117.5 degrees F.
2. Observation on 11/8/18 at 7:45 A.M., of room [ROOM NUMBER], an occupied semi-private
room, showed:
-The surveyor used a calibrated thermometer to take the temperature of the hot water at
the bathroom sink;
-The hot water faucet was turned on and the water ran continuously for three minutes. The
water reached a temperature of 127.2 degrees F;
-At 8:12 A.M., the maintenance director tested the hot water faucet and obtained a
temperature of 132.8 degrees F.
3. Observation on 11/8/18 at 8:18 A.M., of the 100 Hall shower room (one of three facility
shower rooms, but only one of two shower rooms in use), shared by 30 residents residing on
the 100 and 300 halls, showed:
-The maintenance director tested the hot water at the bathroom sink and obtained 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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 9)
temperature of 136.6 degree F;
-The maintenance director tested the hot water from the shower nozzle and the temperature
fluctuated between 120.5 and 124.5 degrees F;
-At 9:54 A.M., the maintenance director, administrator and Regional Consultant Nurse
re-tested the shower room sink and obtained a temperature of 128.7 degrees F and at the
shower nozzle and obtained a temperature of 124.7 degrees F.
4. Observation on 11/8/18 at 10:00 A.M., of room [ROOM NUMBER], an occupied semi-private
room, showed;
-The maintenance director, administrator and Regional Nurse Consultant tested the hot
water at the bathroom sink and obtained a temperature of 127.9 degrees F.
5. During a telephone interview on 11/8/18 at 9:01 A.M., a representative from the
plumbing company said the facility contacted them about the water being too cool. Their
service person was at the facility on 10/22/18 and the quote was sent to the facility on[DATE]. The facility had not contacted them since to have the repairs done. A faulty
mixing valve can not only cause the water to be too cold, but it could cause the water to
be too hot as well.
Review of a Quotation and Agreement from the plumbing company, dated 10/24/18, showed the
following:
We hereby submit our proposal to do the following:
-1 – Thermostatic mixing valve. Replace the existing with a properly sized unit;
-1 – Hot water circulating pump. Replace the defective pump.
6. During an interview on 11/8/18 at 8:18 A.M., the maintenance director said he does
random tests of the water weekly. One week he will test the front of the hall, then the
middle and then the end of the hall. He rotates those areas of the hall weekly. Hot water
temperatures should not exceed 120 degrees F. He has not recorded any hot water
temperatures. He also tests the showers every week. Review of the maintenance director
temperature log showed recordings for resident rooms, but not the shower rooms. He said he
does not record the shower rooms, but he does check them. He calibrates his thermometer
every two weeks by taking the battery out of the thermometer and putting it back in. There
are two water heaters on the 100 hall. One was for the 100 hall and one for the 300 hall.
A few weeks ago, he had a plumbing company come out to the facility. Some residents had
said the water was too cool, but he did not have any complaints about water being too hot.
The plumbing company said a new mixing valve was needed. He has been testing the water
weekly since that time and it has been alright. He did not know if anyone had contacted
the plumbing company about the mixing valve being replaced or not. The administrator,
present at the time of the interview, said a few residents had complained that the water
was too cool and that’s why the plumbing company came in to test. He had not contacted the
plumbing company to make the repairs because the temperatures had been alright since they
were here.
7. Review of Resident #26’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/20/18, showed the following:
-admitted [DATE];
-[DIAGNOSES REDACTED].
-No short/long term memory problems;
-Required extensive staff assistance for all activities of daily living.
Observation on 11/8/18 at 9:04 A.M., showed three broken laminate wood grain tiles in
front of the toilet in the bathroom between rooms [ROOM NUMBERS]. The tiles easily moved
when pushed with a foot.
During an interview on 11/8/18 at 9:17 A.M., the resident said the laminate tiles in
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 10)
his/her bathroom were broken. He/she cut his/her foot but didn’t report it to anyone. The
tiles had been broken since he/she moved to the facility. He/she has reported the broken
tiles to several staff members.
During an interview on 11/8/18 at 9:35 A.M., the maintenance director said no one reported
the broken tiles in the bathroom.
During an interview on 11/8/18 at 9:57 A.M., Housekeeper A said the laminate floor tiles
in the bathroom were broken for more than two months. He/she had reported the broken tiles
to maintenance.
Review of the facility’s maintenance log entry dated 3/26/18, showed the bathroom floor
needed repair.
8. Review of the list of residents provided by the facility who wore a wanderguard (for
residents who wander and can be confused), showed six residents that were known to wander
throughout the facility.
Observation on 11/5/18 at 6:56 A.M., during the initial tour of the facility, showed:
-An unlocked shower room on the 100 Hall with one spray bottle of Cleanser with Bleach,
sitting on a bed table next to the shower stall. The shower room remained unlocked until
12:04 P.M.;
-Review of the Cleanser with Bleach label showed: Keep out of the reach of children. Wash
hands thoroughly after handling. If in eyes, rinse continuously with water for several
minutes. If irritation persists get medical attention. If swallowed, drink a glass of
water and call a physician immediately.
Observation on the following dates and times, showed the beauty shop door open, with no
staff present, and an unlocked cabinet containing one spray bottle of Cleanser with Bleach
in an unlocked cabinet at waist height inside the beauty shop:
-11/5/18 at 7:50 A.M., 12:03 P.M. and 12:50 P.M.;
-11/7/18 at 7:27 A.M. and 8:34 A.M.
During an interview on 11/8/18 at 1:47 P.M., the administrator said the beauty shop door
and shower room doors should be locked when not in use. He was not aware the doors had
been left open. Any chemicals should be kept in a locked cabinet.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement of a supra pubic urinary catheter (a sterile tube inserted into the bladder
through the abdominal wall to drain urine) tubing and drainage bag for the only resident
the facility identified as having a suprapubic urinary catheter (Resident #23). The sample
size was 16. The census was 63.
Review of Resident #23’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff dated 8/12/18, showed:
-Severe impaired cognition;
-Total assistance with one to two persons for bed mobility, transfers, eating, hygiene 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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
bathing;
-Supra pubic catheter.
Review of the resident’s undated care plan and in use during the survey, showed:
-Problem: Supra pubic catheter related risk of urinary tract infection [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder;
-Goal: Will have reduced risk of complications related to use of supra pubic catheter;
-Interventions: Staff to determine resident’s reason for use of catheter and continued
need for catheter, provide care to prevent UTI, maintain catheter tubing below the level
of the resident’s bladder, maintain catheter tubing without kinks or twists, perform
catheter care every shift, secure catheter tubing to resident’s upper leg, cover drainage
bag with privacy bag, empty drainage collection bag every shift and as needed (PRN).
Review of the resident’s physician’s orders [REDACTED].#24 French (size)/30 milliliter
(ml) bulb (portion of the catheter is inflated with saline solution to keep the catheter
in the bladder) and catheter care every shift and PRN.
Observation of the resident during the the survey, showed:
-On 11/6/18 at 6:05 A.M., the resident lay in bed. The urinary catheter tubing looped
approximately 12 to 16 inches down and back up toward the resident’s bladder. The catheter
tubing contained cloudy, yellow colored urine with sediment (debris). No urine drained
into the drainage bag;
-On 11/7/18 at 7:25 A.M., 8:40 A.M., 9:40 A.M. and 12:50 P.M., the resident sat in a
wheelchair. The catheter tubing looped approximately 16 to 20 inches down with cloudy,
yellow colored urine with sediment. No urine drained into the drainage bag;
-On 11/8/18 at 7:00 A.M., the resident lay in bed. The urinary catheter tubing looped
approximately 12 to 16 inches down and back up toward the resident’s bladder. The catheter
tubing contained cloudy, yellow colored urine with sediment. No urine drained into the
drainage bag;
-On 11/8/18 at 9:10 A.M., the resident sat in a wheelchair. The catheter tubing looped
approximately 20 inches down with cloudy, yellow colored urine with sediment. No urine
drained into the drainage bag. The facility’s Corporate Nurse verified the resident’s
catheter tubing was positioned incorrectly.
During an interview on 11/8/18 at 9:10 A.M., the Corporate Nurse said the catheter tubing
should not be looped down and should be positioned correctly to ensure urine drained from
the tubing into the drainage bag. The catheter tubing should not be looped down and back
up toward the resident’s bladder due to infection control and prevention of UTIs. She said
the charge nurses are responsible for ensuring the resident’s catheter tubing and drainage
bag were positioned correctly.
Review of the facility’s urinary catheter care policy and procedure, dated (MONTH) (YEAR),
showed:
-Purpose: To maintain consistent and adequate hygiene standards for residents with an
indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) in
order to maintain comfort, function and prevention of infection and other complications;
-The policy failed to show staff should maintain the resident’s urinary catheter tubing
below the resident’s bladder;
-The policy failed to direct staff to check the urinary catheter tubing and drainage bag
for proper placement to ensure urine drained from the tubing into the drainage bag,
catheter tubing not looped down and back up toward the resident’s bladder.
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain an
adequate supply of Med Pass, a supplemental health drink, for residents with weight loss
or were at risk of having weight loss. The facility ran out of the supplement, failed to
notify the residents’ physicians to see if a substitution could be made until their supply
was delivered. The facility identified 27 residents as receiving the supplement. Of those
27, 10 were sampled and all 10 did not receive their ordered supplement from 11/1/18
through 11/4/18 (Residents #52, #1, #8, #18, #23, #24, #30, #32, #37 and #38). The census
was 63.
1. Review of Resident #52’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/6/18, showed:
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 6 out
of 15;
-BIMS score of 0-7, showed resident had severe impairment;
-Poor appetite occurred 2 to 6 days within the last two weeks;
-Height 63 inches, weight 123 pounds (lbs) with weight loss of 5 percent or more and not
on a physician’s prescribed weight loss regimen;
-Special treatment marked for speech therapy with start of care dated 10/3/18.
Review of the resident’s physician’s orders [REDACTED].
-An undated order, for regular diet;
-An order dated 10/19/18. to administer Med Pass (nutritional supplement) 90 milliliters
(ml) three times daily (TID) for [DIAGNOSES REDACTED].
Review of the resident’s Medication Administration Record [REDACTED] -An order dated 10/19/18, to administer Med Pass 90 ml TID (scheduled administration time
7:00 A.M., 1:00 P.M., 4:00 P.M. and 5:00 P.M.);
-From 11/1 through 11/4/18, staff documented 99 (hold see nurse’s notes).
Review of the resident’s documented weights, showed:
-4/10/18, 129.3 lbs;
-5/13/18, 132.2 lbs;
-6/1/18, 135.0 lbs;
-8/23/18, 120.6 lbs;
-8/24/18, 125.0 lbs;
-9/11/18, 129.5 lbs;
-9/25/18, 123.0 lbs;
-10/1/18, 123.0 lbs;
-11/7/18, 126.0 lbs;
-No other weights found.
Review of the facility’s Monthly Weight Report, dated (YEAR), showed the following weights
for the resident:
-May, 132.2 lbs;
-June, 135.0 lbs;
-July, 140.0 lbs, marked through as incorrect weight;
-August, 120.6 lbs;
-September, 129.5 lbs;
-October, 123.0 lbs;

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-11/7/18, 126.0 lbs;
-No other weights provided by the facility.
Review of the Registered Dietician (RD) progress notes, showed:
-On 8/29/18, the RD documented the resident’s weight is 125 lbs, one month-weight of 140
lbs, three months-weight of 132 lbs and six months-weight of 134 lbs. The resident’s
weight is decreased over one month significantly. Diet order is regular diet. Recommend
adding Med Pass 90 ml twice daily (BID). Will monitor weights and lab tests;
-On 9/19/18, the RD documented the resident’s current weight is 130 lbs. Weight fluctuates
overall. Diet order is regular with Med Pass 120 ml TID. Recommend adding multiple
vitamins with minerals. Will monitor weights and lab tests;
-On 10/18/18, the RD documented regular diet. Most recent weight of 123 lbs, height of 63
inches, recommended weight range (RWR) 104-126 lbs. Resident’s weight status within
recommended weight range. Weight changes, one month, weight of 129 lbs, three months,
weight of 140 lbs and six months, weight of 129 lbs. No significant weight and/or
insidious weight changes. Recommend increase Med Pass to 90 ml TID. Continue to monitor
weights and lab tests.
Review of the resident’s progress note, dated 11/7/18, showed nursing staff documented
resident did not receive his/her Med Pass supplement from 11/1 through 4/18. Physician
made aware. No new orders at this time. Will resume supplement as ordered.
During an interview on 11/7/18 at 10:35 A.M., the facility’s Corporate Nurse said if the
Med Pass space on the MAR indicated [REDACTED]. If nursing staff documented a 99 on the
resident’s MAR, it means nursing staff held the resident’s Med Pass and should document
the reason for the Med Pass not being administered in the progress notes.
2. Review of Resident #1’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s admission MDS, dated [DATE], showed:
-Severely impaired cognition with long and short term memory problem;
-Required total assistance from one to two persons for bed mobility, transfers, eating,
hygiene and bathing;
-Weight of 163 lbs.
Review of the resident’s POS, dated 11/1 through 30/18, showed:
-An undated order, for regular diet;
-An order dated 8/29/18, to administer Med Pass 90 ml TID (scheduled administration time
9:00 A.M., 1:00 P.M. and 5:00 P.M.) for [DIAGNOSES REDACTED].
Review of the resident’s MAR, dated 11/1 through 30/18, showed:
-An order dated 8/29/18, to administer Med Pass 90 ml TID (scheduled administration time
9:00 A.M., 1:00 P.M. and 5:00 P.M.);
-On 11/2, 11/3 and 11/4/18, staff documented 99 (hold see nurses notes) for multiple
scheduled administration times.
Review of the resident’s documented weights, showed:
-4/20/18, 142.0 lbs;
-8/23/18, 140.8 lbs;
-9/11/18, 147.5 lbs;
-9/25/18, 145.0 lbs;
-10/1/18, 149.5 lbs;
-No other weights found.
Review of the facility’s Monthly Weight Report for (YEAR), showed the following for the
resident:
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-August, 140.8 lbs;
-September, 147.5 lbs;
-October, 149.5 lbs;
-No other monthly weights provided by the facility.
Review the resident’s progress note dated 11/7/18, showed nursing staff documented
resident did not receive his/her Med Pass supplement from 11/1 through 4/18. No new orders
received at this time. Will resume supplement as ordered.
3. Review of Resident #8’s quarterly MDS, dated [DATE], showed the following:
-Short/long term memory problem;
-Total dependence of one person required for eating;
-[DIAGNOSES REDACTED].
-Weight of 139 lbs.
Review of the facility Monthly Weight Report for 10/2018, showed the resident weighed 141
lbs.
Review of the resident’s current POS, showed an order for [REDACTED].>Review of the
resident’s current MAR, showed the resident did not receive Med Pass on 11/1 through 4/18.

Review of the resident’s progress notes, dated 11/7/18 at 11:54 A.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18. Physician made aware. No new
orders given at this time. Will resume supplement as ordered.
4. Review of Resident #18’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Extensive assistance of one person required for eating;
-[DIAGNOSES REDACTED].
-Weight of 123 lbs.
Review of the facility Monthly Weight Report, showed the resident weighed 123 lbs for
9/2018 and no weight for 10/2018.
Review of the resident’s current POS, showed an order dated 9/22/16, for Med Pass
supplement 120 mls four times a day.
Review of the resident’s current MAR, showed the resident did not receive Med Pass on 11/1
through 4/18.
Review of the resident’s progress notes, dated 11/7/18 at 11:54 A.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18. Physician made aware. No new
orders given at this time. Will resume supplement as ordered.
5. Review of Resident #23’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Severely impaired cognition;
-Required total assistance with one to two persons for bed mobility, transfers, eating,
hygiene and bathing;
-Weight of 131 lbs.
Review of the resident’s POS, dated 11/1 through 30/18, showed:
-An undated order, for regular diet with nectar thickened liquids;
-An order dated 10/19/18, to administer Med Pass 90 ml BID (scheduled administration time
9:00 A.M. and 5:00 P.M.) for [DIAGNOSES REDACTED].
Review of the resident’s MAR, dated 11/1 through 30/18, showed:
-An order dated 10/19/18, to administer Med Pass 90 ml BID for weight loss (scheduled
administration time 9:00 A.M. and 5:00 P.M.) for weight loss;

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
-From 11/1 through 6/18, staff documented 99 (hold see nurses notes) for multiple
scheduled administration times.
Review of the facility’s Monthly Weight Report, dated (YEAR), showed the following for the
resident:
-May, 133.4 lbs;
-June, 128.8 lbs;
-July, 131.2 lbs;
-August, 134.2 lbs;
-September, 126.4 lbs;
-October, 125.5 lbs;
-11/9/18, 137.4 lbs.
Review of the resident’s documented weights, showed:
-5/16/18, 133.4 lbs;
-6/1/18, 128.8 lbs;
-7/13/18, 131.2 lbs;
-8/23/18, 134.2 lbs;
-9/11/18, 126.4 lbs;
-10/1/18, 125.5 lbs.
Review of the resident’s progress notes, dated 11/1 through 6/18, showed no documentation
to explain why nursing staff held the resident’s Med Pass and/or notification to the
resident’s physician of why the Med Pass was held and not administered.
6. Review of Resident #24’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Extensive assistance of one person required for eating;
-[DIAGNOSES REDACTED].
-Weight of 74 lbs.
Review of the facility Monthly Weight Report for 10/2018, showed the resident weighed 70
lbs.
Review of the resident’s current POS, showed an order for [REDACTED].
Review of the resident’s current MAR, showed the resident did not receive Med Pass on 11/1
through 4/18.
Review of the resident’s progress notes, dated 11/7/18 at 11:55 A.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18. Physician made aware. No new
orders given at this time. Will resume supplement as ordered.
7. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Limited assistance of one required for eating;
-[DIAGNOSES REDACTED].
-Weight of 146 lbs.
Review of the facility Monthly Weight Report for 10/2018, showed the resident weighed
150.5 lbs.
Review of the resident’s current POS, showed an order for [REDACTED].
Review of the resident’s current MAR, showed the resident did not receive Med Pass on 11/1
through 4/18.
Review of the resident’s progress note dated 11/7/18 at 11:54 A.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18. Physician made aware. No new
orders given at this time. Will resume supplement as ordered.
8. Review of Resident #32’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Extensive assistance of one person required for eating;
-[DIAGNOSES REDACTED].
-Weight of 162 lbs.
Review of the facility Monthly Weight Report for 10/2018, showed the resident weighed
153.5 lbs.
Review of the resident’s current POS, showed an order for [REDACTED].
Review of the resident’s current MAR, showed the resident did not receive Med Pass on 11/1
through 4/18.
Review of the resident’s progress notes, dated 11/7/18 at 11:54 A.M., showed the resident
did not receive Med Pass supplement from 11/1/18 through 11/4/18. Physician made aware. No
new orders given at this time. Will resume supplement as ordered.
9. Review of Resident #37’s POS, dated 11/1 through 30/18, showed an order for [REDACTED].
Review of the resident’s MAR, dated 11/1 through 30/18, showed he/she didn’t receive Med
Pass on 11/5/18.
Review of the resident’s progress note, dated 11/7/18 at 2:43 P.M., showed the resident
did not receive Med Pass supplement from 11/1 through 4/18.
10. Review of Resident #48’s POS, dated 11/1 through 30/18, showed an order for[REDACTED].
Review of the resident’s MAR, dated 11/1 through 30/18, showed he/she didn’t received Med
Pass on 11/3 through 5/18.
11. During an interview on 11/5/18 at 8:43 A.M., Certified Medication Technician C said
the facility ran out of Med Pass the past weekend, 11/3 and 4/18. There was very little
Med Pass on Saturday 11/3/18 and none on Sunday 11/4/18. He/she notified the charge nurse.

12. During an interview on 11/9/18 at 8:25 A.M., the facility’s Corporate Nurse said
nursing staff should have documented why the resident’s Med Pass was held from 11/1
through 6/18 in the nurse’s notes. It is very important for nursing staff to administer
the Med Pass supplement for nutritional needs such as nutritional deficiency, maintain
nutritional parameters and prevent weight loss.
13. During an interview on 11/09/18 at 8:26 A.M., the Director of Nurses said their sister
facility (about one mile away) does have Med Pass 2.0. Her staff know to call them if they
run out of anything to see if it can be borrowed. If their sister facility does not have
enough to loan, staff know they can go to the local grocery or drug store and buy what
they need or a comparable substitute until their supply is delivered. She does not know
why staff failed to do this.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments and ongoing monitoring for residents who received [MEDICAL TREATMENT] services. The facility identified three residents who received [MEDICAL TREATMENT]. Of
those three, one was selected for the sample and problems were identified (Resident #37).
The sample size was 16. The census was 63.
Review of Resident #37’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 9/22/18, showed:

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-[DIAGNOSES REDACTED].
-Short/long term memory problem;
-Extensive staff assistance for bed mobility, transfers, dressing and eating;
-Total staff assistance for toilet use, personal hygiene and bathing;
-Special treatments: [MEDICAL TREATMENT].
Review of the resident’s care plan, updated 10/23/18, showed:
-Problem: Receives [MEDICAL TREATMENT] (kidney [MEDICAL TREATMENT]);
-Approach: Access resident’s [MEDICAL TREATMENT] port/shunt for signs and symptoms of
bleeding every shift and when he/she returns from [MEDICAL TREATMENT].
Review of the resident’s medical record, showed he/she received [MEDICAL TREATMENT] on
Tuesday, Thursday and Saturday.
Review of the resident’s progress note, dated 11/1/18, showed he/she was sent from the[MEDICAL TREATMENT] center to the hospital due to a clogged [MEDICAL TREATMENT] port.
Review of the resident’s hospital discharge orders, dated 11/3/18, showed the following:
-[DIAGNOSES REDACTED].
-Medication: [MEDICATION NAME] (medication used to prevent blood clots) 5000 units per
injection two times per day.
Review of the resident’s progress notes, dated 11/3 through 6/18, showed staff failed to
thoroughly assess and monitor the resident’s [MEDICAL TREATMENT] port.
Observation during a skin assessment on 11/9/18 at 8:00 A.M., showed the resident’s[MEDICAL TREATMENT] port was intact with a clean dressing to the right groin (area where
the thigh and leg meet).
During an interview on 11/9/18 at 8:15 A.M., Nurse D said the nurses are to document in
the nurse’s notes regarding the resident’s [MEDICAL TREATMENT] port. The resident’s[MEDICAL TREATMENT] port had been located in his/her arm, but he/she was unsure of where
the [MEDICAL TREATMENT] port was located currently. The resident goes to [MEDICAL
TREATMENT] on Tuesday, Thursday and Saturday. He/she worked on Tuesday, 11/6/18, but
failed to assess or document in the nurse’s note. He/she would have documented in the
progress note if the computer had prompted him/her to do so.
Review of the nurse’s note for Tuesday 11/6/18, showed no documentation regarding resident
going to [MEDICAL TREATMENT] or his/her return or whether the dressing to the port was
intact and clean.
During an interview on 11/9/18 at 8:28 A.M., the facility’s corporate nurse said she would
expect staff to know the location of the resident’s [MEDICAL TREATMENT] shunt/port and
document each shift regarding the appearance and whether it is dry and intact. She would
also expect staff to document regarding the resident’s recent hospitalization for [MEDICAL
TREATMENT] port complications.
During an interview on 11/9/18 at 8:52 A.M., the Director of Nurses said she would expect
staff to document at least daily regarding a resident who receives [MEDICAL TREATMENT].
She would expect staff to know the location of the shunt/port and to assess and document
when the resident returns from [MEDICAL TREATMENT].
Review of the facility’s Policy and Procedure Care of [MEDICAL TREATMENT] Resident,
updated 8/19/17, showed the following:
-Purpose: To ensure the needs of the resident receiving [MEDICAL TREATMENT] are met by
both the facility and the [MEDICAL TREATMENT] center. Resident receiving [MEDICAL
TREATMENT] are transported routinely out of the facility. Communication is essential for
continuity of care;
-Procedure: External Catheters: Care should be taken so the external catheter is not
pinched poked, bent or pulled. A smooth clamp should be kept at the bedside for emergency
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
situations. Avoid getting catheter wet during bathing. You may cover with plastic wrap
during bathing. Replace dressing if it comes off or becomes wet. Cleanse the area with
cleanser and apply new sterile dressing.
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain
physician’s orders and properly assess two sampled residents that used bed rails.
(Residents #8 and #38). In addition, the facility identified 24 residents who used bed
rails and the facility did not assess them or obtained physician orders. The census was
63.
1. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/23/18, showed the following:
-Rarely/never understood/understands;
-Total dependence of one person for bed mobility and transfers;
-[DIAGNOSES REDACTED].
-Bed rails not used.
Observation on 11/6/18 at 5:59 A.M., showed the resident lay in bed. The bed was
positioned against the wall. The exit side of the bed had one quarter length bed rail
raised.
Review of the resident’s medical record, showed no physician’s order or assessment for the
bed rail.
2. Review of Resident #38’s quarterly MDS, dated [DATE], showed the following:
-Usually understood/understands;
-Total dependence of one person for bed mobility and transfers;
-[DIAGNOSES REDACTED].
-Bed rails not used.
Observation on 11/6/18 at 5:31 A.M., showed the resident lay in bed. The bed was
positioned against the wall. The exit side of the bed had one quarter length bed rail
raised.
Review of the resident’s medical record, showed no physician’s order or assessment for the
bed rail.
3. During an interview on 11/9/18 at 9:19 A.M., the maintenance director said he is
responsible for checking bed rails monthly. He does not complete safety assessment form
for each resident using a bed rail and he does not document the assessment has been done.
4. During an interview on 11/9/18 at 10:56 A.M., the Regional Nurse Consultant said the
facility had 24 residents that used bed rails and none of those 24 had physician’s orders.
Assessments should be completed on admission and quarterly thereafter. The last time
assessments were completed were 3/2018.
5. Review of a Restraint – Physical (Quarterly/Annual Evaluation) form, showed the
assessment did not address safety factors such as the risk of entrapment in the bed rail
or between the bed rail and the mattress.

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0713

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide or arrange emergency care by a doctor 24 hours a day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the physician, who was
also the facility Medical Director, responded timely to nursing staff calls. This affected
three residents, one regarding a change in condition, in which after four days the
resident was sent to the hospital and admitted to the Intensive Care Unit, another
resident with ongoing vaginal discharge and a newly admitted resident in need of admission
order approval (Residents #202, #201 and #203). The census was 62 residents.
Review of the Medical Director Independent Contractor Agreement, signed by the Medical
Director on 2/28/17, showed:
-Services and Qualifications:
-Physician specifically acknowledged and affirms that Physician is an independent
contractor and understands the duties and responsibilities resulting from such status;
-Physician shall comply with all facility and medical staff bylaws, including, without
limitation, those relating to the conduct, standards of medical care and record
compliance;
-Physician shall at all times comply with all state and federal laws and regulations with
respect to the operations of the facility and physician services provided hereunder;
-Specific Responsibilities:
-Assure availability of physician services 24 hours a day in case of emergency;
-Develop and maintain systems to ensure that other licensed practitioners who may perform
physician-delegated tasks act within regulatory requirements and within the scope of
practice as defined by state law;
-Develop procedures and general clinical guidance for facility staff regarding when to
contact practitioners, including information that should be gathered prior to contacting
the practitioners regarding a clinical issue, question, or change in condition;
-Develop mechanisms for communicating and resolving issues related to medical care.
1. Review of Resident #202’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/8/18, showed:
-[DIAGNOSES REDACTED].
-Severely impaired cognition;
-Required total staff assistance for all activities of daily living (ADLs);
-Incontinent of bowel and bladder;
-Mechanically altered diet;
-Life expectancy of six months or less: No.
Review of the resident’s nurse’s notes, showed:
-Readmitted to the facility on [DATE] at 3:38 P.M. Alert but does not speak. Grunts when
name is called and makes eye contact. Vital signs (VS): blood pressure (B/P) 123/76
(normal 120/80), pulse (P) 79 (normal 60 – 100), respiration (R) 16 (normal 12 – 16),
temperature (T) 99.7 (normal 98.6). oxygen saturation (O2 Sats) 96% (normal 95 – 100%).
Tylenol given;
-1/5/19 at 5:20 A.M.: VS: T 100.0, P 100, R 18, B/P 111/56, O2 Sats 94%, alert, readmit,
Tylenol given for temperature, head of bed elevated, lungs sounds clear to auscultation
(the action of listening to sounds from the heart, lungs, or other organs, typically with
a stethoscope, as a part of medical diagnosis), oxygen applied at 2 liters (L) per minute
for shortness of breath (SOB) and comfort;
-1/6/19 at 5:20 A.M.: VS: T 99.7, P 110, R 16, B/P 118/75. O2 Sats 94% with oxygen at 2 L;

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0713

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)

-1/6/19 at 12:58 P.M.: While on break, another charge nurse reported the resident was not
looking good. VS: B/P 118/75, P 110, O2 Sats 93% on 2 L of oxygen, T 99.5, R 24 and blood
glucose of 132. Resident was SOB with slight wheezing. Call placed to the resident’s
physician (also the facility Medical Director), awaiting call back. Resident is a full
code;
-1/6/19 at 3:20 P.M.: VS: B/P 122/77, O2 Sats 94%, R 18, resident still has elevated
temperature. Awaiting call back from the physician. Called times two;
-1/6/19 at 9:00 P.M.: No documentation whether the physician returned the call to the
facility;
-1/7/19 at 10:39 P.M.: Resident has had an active decline. Temperature was unstable at
103.1, was given Tylenol and ice packs were placed to lower temperature. When nurse
returned to reassess, resident was noted to be SOB, remained on oxygen at 2 L per nasal
cannula. Unable to obtain O2 Sats, temperature remains unstable at 101.4. No documentation
whether the staff contacted the physician or whether the physician returned the call from
1/6/19;
-1/8/19 at 1:11 A.M.: VS: T 102.0, P 107, R 22, B/P 90/54. Resident was SOB, with pursed
lip breathing (a breathing technique that consists of exhaling through tightly pressed
(pursed) lips and inhaling through the nose with the mouth closed), using facial and
abdominal muscles to breath, head of bed elevated. Tylenol given for temperature.
Physician called. The physician asked staff if the resident was a hospice patient, staff
replied no. Order received to send to the hospital for evaluation. Ambulance called and
gave instructions to call 911 due to resident being in respiratory distress. Resident on
O2 at 3 L, while having increased SOB, color pale. Resident transported to the hospital.
During an interview on 1/8/19 at 11:42 A.M., Nurse M said he/she worked the day shift on
Sunday 1/6/19. While the resident’s nurse was on break, Certified Nurse Aide (CNA) Q and
CNA U reported the resident wasn’t looking good. When he/she entered the room, the
resident was pursed lip breathing and using his/her abdominal muscles to breath. The
resident’s respirations were 22 to 24 and O2 Sats were 95% on 2 L of oxygen. He/she was
very concerned about the resident’s condition and wanted to call 911, because the
resident’s respirations were labored and his/her skin was sweaty and clammy, but he/she
wasn’t the resident’s nurse. He/she and Nurse D returned to the room to assess the
resident. He/she left the room at that time, but knows Nurse D placed a call to the
physician. The resident’s physician didn’t call back on their shift.
During an interview on 1/8/19 at 1:59 P.M., Nurse D said while on break during the day
shift on 1/6/19, Nurse M reported the resident was breathing hard, his/her pulse was
elevated and O2 Sats and B/P were normal. He/she assessed the resident and noted slight
wheezing and an elevated temperature of 99.5. He/she raised the HOB higher and placed a
call to the physician at about 11:00 A.M. or 12:00 P.M. He/she notified the Assistant
Director of Nurses (ADON) and was told to call the physician. The physician did not return
the call prior to the end of his/her shift on 1/6/19.
During an interview on 1/8/19 at 4:00 P.M., Nurse T said he/she took care of the resident
on the evening shift of 1/6/19. He/she saw the resident during rounds and noted a decline.
He/she had pursed lip breathing which lasted 5 to 7 minutes at various times. The
physician didn’t return the call on his/her shift.
During an interview on 1/8/19 at 2:27 P.M., the ADON said she expected staff to continue
to try to reach the physician and document it in the medical record.
During an interview on 1/8/19 at 3:10 P.M., the Administrator said he expected staff to
notify the physician anytime there is a change in the resident’s condition.

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0713

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
2. Review of Resident #201’s medical record, showed:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes, showed:
-On 1/3/19 at 2:27 P.M., CNA informed the charge nurse, while perineal care (peri-care,
the cleaning of the genital and anal areas) provided, the resident had a greenish and tan
colored vaginal discharge. Message left for the resident’s physician (also the facility
Medical Director) to contact the facility. Awaiting return telephone call from the
physician;
-On 1/4/19 at 10:25 P.M., nursing staff administered [MEDICATION NAME] (antifungal
medication) 150 milligram (mg) one tablet for vaginal discharge as ordered by the
resident’s physician;
-On 1/6/19 at 1:26 P.M., resident continues to have heavy green discharge from her vaginal
area. Telephone call placed to the resident’s physician;
-On 1/8/19 at 12:10 P.M., no vaginal discharge reported today. Call placed to the
resident’s physician regarding past history of heavy vaginal drainage. New order received
for [MEDICATION NAME] 150 mg, one tablet for one time dose;
-No progress note found regarding the physician contacted the facility on 1/6 and/or
1/7/19 related to the resident’s vaginal drainage.
Review of the facility’s 24 hour nursing report sheet dated 1/6/19, showed:
-7:00 A.M. to 3:00 P.M. shift, nursing staff documented the resident having green vaginal
drainage, call placed to the resident’s physician;
-11:00 P.M. to 7:00 A.M. shift, staff documented resident continues to have vaginal
drainage;
-No documentation indicating the resident’s physician called the facility back related to
the resident’s vaginal drainage.
Review of the facility’s 24 hour nursing report sheet dated 1/7/19, showed no
documentation indicating the resident’s physician called the facility related to the
resident’s vaginal drainage.
During an interview on 1/8/19 at 11:55 A.M., Nurse M said he/she worked the day shift on
1/6/19. He/she telephoned the resident’s physician regarding her vaginal drainage, but had
not received a telephone call back from the physician prior to him/her leaving on 1/6/19.
The nurse said to his/her knowledge, the physician had not contacted the facility back
regarding the resident’s vaginal drainage. The nurse verified he/she did not receive any
information in report from the nursing staff, regarding the physician contacting the
facility regarding his/her 1/6/19 message about the resident’s vaginal drainage.
3. Review of Resident #203’s hospital medical records dated 11/15/18 at 2:03 P.M., showed:
-admission date of [DATE];
-Chief complaint of weakness, fatigue and [DIAGNOSES REDACTED] (low blood sugar);
-[DIAGNOSES REDACTED].
-11/14/18 at 2:38 P.M.: Glucose (sugar) level 28 (critical), normal range 70 – 199;
-11/18/18 at 2:55 P.M.: Glucose level 69 (low);
-11/18/18 at 3:10 P.M.: Glucose level 46 (critical).
Review of the resident’s admission face sheet, showed:
-Original admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s nurse’s progress notes, showed:
-12/11/18 at 5:24 A.M., this nurse started calling the resident’s physician (also the
facility Medical Director) at 11:30 P.M. on 12/10/18 to verify hospital orders. Message
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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 0713

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
left with no return call from physician. Called Physician O (not the resident’s physician
and not a colleague of the resident’s physician/Medical Director) and no return call.
Message left to call facility, urgent, still no reply. Resident has several Diagnoses:[REDACTED]. Both hands have 4+ pitted [MEDICAL CONDITION] (pressure is applied to the skin
and the 4+ is the number of seconds the skin takes for depression to vanish). At 5:30
A.M., still no answer from the resident’s physician;
-12/11/18 at 5:34 A.M., resident has [MEDICAL TREATMENT] catheter in left arm. Will be
going to [MEDICAL TREATMENT] for [MEDICAL CONDITION];
-12/11/18 at 6:08 A.M., called placed to the resident’s physician, no reply;
-12/11/18 at 6:11 A.M.: Physician O returned call and stated he is not the Medical
Director and to keep calling the Medical Director. Explained to Physician O that attempts
had been made to call the resident’s physician/Medical Director all night and the
resident’s orders needed to be verified;
-No other documentation if the facility was able to contact the resident’s physician.
During a telephone interview on 1/10/19 at 1:45 P.M., a representative from the facility
pharmacy confirmed they received the resident’s admission orders [REDACTED].M.
4. During an interview on 1/8/19 at 3:30 P.M., Nurse N said he/she had problems several
times with the Medical Director not contacting the facility back in a timely manner when
called about resident issues and/or concerns.
5. During an interview on 1/8/19 at 2:20 P.M., the ADON said she had been employed at the
facility since (MONTH) (YEAR). Since her employment, they have had a problem with the
Medical Director returning their calls promptly. Not all the time, but some of the time.
She had not mentioned this to the administrator and did not know if anyone else had.
6. During an interview on 1/8/19 at 3:10 P.M., the Administrator said he had heard in
general, that there were times the staff were waiting for the Medical Director to return
their calls. He was not under the impression the wait times were that long though.
Resident #203’s case was unacceptable.
7. During a telephone interview on 1/9/19 at 12:30 P.M., the Physician/Medical Director
said he spoke to the facility administration on 1/8/19, about him not responding promptly
to the nurses’ phone calls. He always tries to return the facility calls as quickly as
possible, but admitted there may be instances when that does not happen. To correct the
problem, he will now have two of his colleagues that can be contacted if he is
unavailable, or the staff can contact an exchange number. Those alternatives were not
available prior to 1/8/19.
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed ensure serving trays used for meal
service were dry prior to use, use proper sanitizing practices when wiping down counters
and clean the thermometer used to test the temperature of the food. This had the potential
to affect residents who ate from the facility’s kitchen. The census was 63.
Observation of the kitchen on 11/5/18, showed:
-8:09 A.M., dietary staff used five wet serving trays during meal service;
-8:13 A.M., the dietary manager wiped counters with a white cloth towel. There was no
sanitizer water made in the kitchen;

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:

265757

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

11/09/2018

NAME OF PROVIDER OF SUPPLIER

BENTWOOD NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

1501 CHARBONIER ROAD
FLORISSANT, MO 63031

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 – Some

(continued… from page 23)
-8:25 A.M. and 12:43 P.M., the dietary manager used a digital thermometer to take the
temperature of the food on the steam table and used a white towel to clean the thermometer
between food items;
-1:07 P.M. to 1:14 P.M., dietary staff used 14 wet serving trays during the meal service.
During an interview on 11/7/18 at 10:03 A.M., the dietary manager said the serving trays
should air dry after coming out of the dishwasher and a sanitizer bucket should be use
when wiping down counters. An alcohol wipe should be used on the thermometer between food
items when testing the temperature. This is done to prevent unsanitary and cross
contamination issues.
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