Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Immediately tell the resident, the resident’s doctor, and a family member of situations
(injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to immediately inform a
resident’s responsible party after the resident fell and sustained an injury for one
sampled resident (Resident #2) out of three sampled residents. The facility census was 54.
Review of the facility policy for Event Investigation, dated 3/2016, showed in part:
-Procedure for completing the Report of Event Form: description of the event – describe
the event and include pertinent comments made by the person involved and any witness
comments, primary diagnoses, cognitive state, exact location of the event, type of event,
observations, exact location of the injury, vital signs, mental and neurological status,
range of motion, complaints of pain, first aid given, seen by the physician, transferred
to the hospital, notification of the physician (must be documented in the medical record),
notification of the responsible party (must be documented in the medical record), actions
taken to prevent recurrence – what was done immediately to prevent event from happening
again.
1. Review of Resident #2’s medical record showed a letter of incapacitation (a letter
signed by two physicians who have determined the resident has lost his/her decisional
capacity and invoking the power of attorney) dated 11/28/17.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 6/5/18, showed staff assessed the resident as:
-Alert with some confusion;
-Required limited assistance of one with transfers and ambulation;
-Occasionally incontinent of urine, continent of bowel;
-[DIAGNOSES REDACTED].
-One fall with fracture.
Review of the resident’s fall event report, dated 6/12/18 at 2:32 A.M. and signed by
Licensed Practical Nurse (LPN) D, showed:
-The resident was observed on the floor;
-No pain, bruising or hematoma present and unable to complete range of motion (ROM), no
rotation, deformity or shortening of extremities noted;
-Alert, speech clear;
-Contributing factors to fall: orthopedic condition;
-Receives antihypertensives and antipsychotic medication;
-Interventions: rest;
-Outcome of interventions: effective and resident stated his/her understanding of the call
light;
-Physician and family notified;
-Care plan reviewed.
Review of the nurses’ note, dated 6/12/18, showed staff did not document the fall or that
they notified the resident’s physician or responsible party at the time of the fall.
Review of the nurses’ note, dated 6/12/18 at 9:51 A.M. and signed by LPN A, showed:
-Resident doing well at this time. Received reply from nurse practitioner related to fall
and he/she advised that the resident should be seen at the emergency room (ER) for a head
CT (computed tomography) scan if he/she would go. The nurse spoke with the resident again
about this and the resident stated I’m doing ok, I don’t need to go. The nurse contacted
the responsible party who stated that he/she would come and check on the resident.
Review of the telephone order, dated 6/12/18, showed:
-Send the resident to ER for evaluation post fall, head injury and left hand bruising and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
pain.
During an interview on 7/5/18 at 3:30 P.M., Licensed Practical Nurse (LPN) A said:
-He/she was the day shift nurse on 6/12/18;
-The off-going nurse faxed the physician notifying him/her of the resident’s fall, but did
not notify the responsible party (RP);
-The RP was very involved with the resident’s care and would have wanted to be notified;
-He/she notified the RP of the resident’s fall at 9:51 A.M.;
-The RP came to the facility and took the resident to the hospital;
-The resident returned from the hospital with a sprained wrist and orders to do neuro
checks (to monitor for a head injury) due to bruising to the resident’s face.
During an interview on 7/5/18 at 4:00 P.M., the RP said:
-He/she was not notified of the resident’s fall on 6/12/18 until the day shift came on
duty;
-He/she came to the facility and took the resident to the hospital for an evaluation;
-He/she is the power of attorney and should have been notified at the time of the fall.
During an interview on 7/6/18 at 10:00 A.M., LPN D said:
-He/she was the nurse on duty when the resident fell on [DATE];
-The resident slid off the bed;
-He/she tried to talk the resident into going to the hospital, but the resident refused;
-The resident’s hand was bruised and he/she complained of pain in the hand;
-He/she faxed the physician informing him/her of the fall;
-He/she did not try to call the physician;
-He/she did not call the family, because he/she did not want to wake them up;
-He/she told the day shift nurse to notify the family.
During an interview on 7/10/18 at 8:45 A.M., the Medical Director said:
-The resident was unable to make health care decisions;
-The resident’s Power of Attorney had been invoked;
-The RP should have been notified at the time the fall occurred.
During an interview on 7/10/18 at 4:00 P.M., the Administrator said:
-The RP was very involved with the resident’s care;
-The RP wanted to be notified of any incidents or accidents involving the resident;
-The nurse should have notified the RP of the resident’s fall when it occurred.
MO 8

F 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to voice grievances without discrimination or reprisal and
the facility must establish a grievance policy and make prompt efforts to resolve
grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents’ grievances
were fully addressed and failed to maintain complete documentation of grievances received,
steps taken to resolve the grievance, notification of the residents of the results of the
grievance and follow up with the residents to ensure the problem/concern was resolved for
three sampled residents (Resident #8, #9 and #20). The facility census was 55.
Review of the facility’s undated policy for Grievance Protocol showed:
-The purpose of the Grievance/Complaint Report and Grievance Log is to provide a written
record of each resident and family concern and to ensure proper follow-up through the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
appropriate discipline;
-The Social Service Director (SSD) is responsible for the program, although the
Administrator is ultimately responsible for the proper implementation of the program;
-The SSD informs the Administrator of each incident;
-Any member of the Social Service staff can complete the Grievance Complaint Report;
-The appropriate situations for use of the Grievance Complaint Report are: resident
articles that are lost or cannot be located, continued concern of lost resident items;
resident care or personal hygiene issues that cannot be immediately resolved; resident or
family concerns with dietary issues; any resident or family concern with a staff member;
or any resident or family issue that would require a resolution;
-The SSD will obtain the original grievance complaint report; record the grievance on the
monthly grievance log; inform the Administrator of the grievance and forward a copy of the
grievance to the appropriate discipline;
-The Administrator and SSD evaluate the monthly grievance log for trends or patterns and
devise an action plan to correct the issues;
-A new grievance log should be completed each month and presented at the Quality Assurance
meeting quarterly.
1. Review of Resident #20’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by staff, dated 5/26/18 showed:
-BIMS of 15 – alert and oriented and able to make decisions;
-Extensive assistance of two staff members for Activities of Daily Living (ADL’s);
-[DIAGNOSES REDACTED].
Review of a typed written summary, dated 6/18/18 and signed by the SSD, showed:
-The resident sought out the SSD related to a complaint against Certified Nurse Aide (CNA)
A. The resident said that he/she and CNA A had a round three to four weeks ago. He/she
wanted to lay down and CNA A entered the room and threw papers on his/her bed. According
to CNA A, he/she said What do you want?. The resident stated he/she wanted to lay down.
He/she said CNA A didn’t like it by the look on his/her face. On (MONTH) 17, (YEAR), the
resident stated he/she wanted to lay down to nap and if it was CNA A, he/she would be mad
and he/she was. The resident said CNA A had a book and slammed it against the bedrail
making a loud noise. According to the resident, the resident said to CNA A: If you
wouldn’t get so God damned mad, people wouldn’t act the way they do. The resident said
that CNA A said it was not him/her but if the facility would only hire more people. The
resident said CNA A always seemed mad and he/she hated to call for anything when CNA A was
working, he/she was afraid of CNA A;
-SSD spoke with CNA A who denied throwing papers on the resident’s bed and denied having a
book in his/her hand. CNA A admitted to being frustrated related to being the only aide on
the floor and the residents seem to want to get up or lay down all at the same time;
-SSD encouraged CNA A to remain calm and to act professionally towards the residents;
-SSD spoke with several other residents who voiced no concerns related to CNA A;
-In-service held for all staff on 6/18/18 regarding dignity and respect.
During an interview on 8/23/18 at 10:10 A.M., the resident said:
-He/she could not walk and needed help with transferring;
-CNA A came into his/her room several weeks ago and threw papers when he/she asked to be
laid down;
-CNA A was very rude and short tempered with him/her;
-He/she reported to the SSD that CNA A was rude and short tempered, but nothing was done;
-CNA A continued to be short tempered and rude when the resident asked for help;
-He/she was afraid of CNA A.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
2. Review of Resident #8’s quarterly MDS, dated [DATE], showed:
-BIMS of 12 – alert and able to make decisions;
-Extensive assistance with ADL’s;
-[DIAGNOSES REDACTED].
During an interview on 8/23/18 at 9:45 A.M., the resident said:
-He/she needed help transferring;
-CNA A was very rude towards him/her;
-He/she cringed when CNA A answered his/her call light;
-CNA A made him/her feel bad when he/she came into his/her room;
-He/she did not want CNA A taking care of him/her, but there was no other staff;
-He/she told the SSD about CNA A but nothing has been done.
During an interview on 8/23/18 at 12:40 P.M., Licensed Practical Nurse (LPN) B said:
-He/she has worked with CNA A for several years;
-Several residents and families have complained about CNA A’s attitude toward them;
-He/she has reported the concerns to the Administrator and the SSD;
-The resident has requested that CNA A not come in his/her room and take care of him/her;
-He/she has written statements for the Administrator and the SSD in the past about CNA A’s
attitude and rudeness towards the residents, but nothing has been done.
Observation on 8/23/18 at 1:00 P.M., showed CNA A hurriedly going from room to room laying
the residents down and answering their call lights.
During an interview on 8/23/18 at 1:00 P.M., CNA A said:
-He/she did not have time to talk with the surveyor, he/she had work to do;
-Staffing had gotten better, but there were many times he/she was the only aide on the
floor.
3. Review of Resident #9’s quarterly MDS, dated [DATE], showed:
-BIMS of 12 – able to make decisions;
-Independent with ADL’s.
During an interview on 8/23/18 at 3:20, Resident #9 and Family Member A said:
-CNA A has been very rude and grouchy with them in the past;
-The family has complained to the Administrator and the SSD about CNA A’s attitude, but
nothing has been done.
4. During an interview on 8/24/18 at 9:30 A.M., the SSD said:
-No residents have issued any complaints recently regarding CNA A;
-She spoke with CNA A in (MONTH) about Resident #20’s concerns;
-CNA A denied throwing papers;
-She held an in-service for all staff regarding dignity and respect in June;
-CNA A was not suspended or issued any counseling after the incident in June;
-Grievance forms were not available to the staff, residents or families to complete;
-She made rounds and visits with the residents to see if there were any concerns;
-She typed a narrative of any concerns and discussed the concerns with the Administrator
and department managers;
-The grievances/concerns are kept on a log;
-There are no forms or documentation from the individual departments about
grievances/concerns;
-She should follow-up on the concerns in two or three weeks.
During an interview on 8/24/18 at 9:45 A.M., the Director of Nursing said:
-She received a couple of complaints from the residents regarding CNA A’s attitude;
-She does not remember if anything was done about the concerns.
During an interview on 8/24/18 at 10:30 A.M., the Administrator said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-The SSD addressed any concerns or grievances that were brought to her attention;
-The SSD wrote up a narrative of the concerns of grievances and the Administrator reviewed
the concerns/grievances;
-There was a form that the staff, residents or families could fill out, but it was not
being used (it is unknown why they are no longer using the form);
-The SSD followed up with any concerns;
-CNA A has been employed at the facility for several years;
-She has talked with CNA A about his/her attitude in the past;
-She was unaware of any new concerns regarding CNA A’s attitude and rudeness towards the
residents.
MO 7

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to update the comprehensive
care plan after falls with the causes of the falls and new interventions to prevent future
falls for three sampled residents (Residents #2, #3 and #4) out of 11 sampled residents.
The facility census was 54.
Review of the facility policy for Care Plans, dated 3/15, showed:
-An individualized comprehensive care plan that includes measurable goals and time frames
will be developed to meet the resident’s highest practicable physical, mental and
psychosocial well-being;
-The interdisciplinary care plan team with the input from the resident, family, and/or
legal representative will develop and maintain a comprehensive care plan for each resident
that identifies the highest level of functioning the resident may be expected to attain;
-The comprehensive care plan will be based on a thorough assessment that includes, but is
not limited to, the Minimum Data Set (MDS), a federally mandated assessment instrument
completed by staff;
-Assessment of each resident is an ongoing process and the care plan will be revised as
changes occur in the resident’s condition;
-A well developed care plan will be oriented to: preventing avoidable declines in
functioning or functional levels; managing risk factors to the extent possible or
indicating the limits of such interventions; addressing ways to try to preserve and build
upon resident strengths; applying current standards of practice in the care planning
process; evaluating treatment of [REDACTED]. abilities; involving the resident, resident’s
family and other resident representatives as appropriate; assessing and planning for care
to meet the resident’s medical, nursing, mental and psychosocial needs; involving the
direct care staff with the care planning process relating to the resident’s expected
outcomes; addressing additional care planning areas that are related to meeting the
resident’s needs in the long-term care setting;
-The interdisciplinary care plan team is responsible for the periodic review and updating
of the care plans when a significant change in the resident’s condition has occurred, at
least quarterly and when changes occur that impact the resident’s care.
1. Review of Resident’s #2 medical record showed the resident was admitted to the facility
on [DATE] after sustaining a fractured right clavicle (collar bone) while walking through

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
a set of double doors from the Residential Care Facility (RCF) to the Skilled Nursing
Facility (SNF).
Review of the resident’s care plan for falls, dated 4/13/18, showed:
-At risk for falls related to weakness and shortness of air (SOA) with history of falls
with a [MEDICAL CONDITION] clavicle;
-Goal to remain free from any major injury through next review with a goal date of
7/13/18;
-Approaches: assist to keep environment free of clutter; assist with proper footwear or
non skid socks as needed; assist with eyeglasses; encourage to ask for assistance with
transfers; encourage to assume a standing position slower; use walker with transfers and
wheel chair for distance related to SOA; compliant with therapy; follow the facility’s
protocol with falls; keep personal items and frequently used items within reach.
Review of the nurses’ note, dated 4/16/18, showed the resident had an unwitnessed fall in
his/her room and sustained a fractured pelvis.
Review of the resident’s care plan for falls, updated 4/16/18, showed staff documented the
resident had an unwitnessed fall on 4/16/18, but did not document the cause of the fall or
any new interventions put in place to prevent further falls.
Review of the Johns Hopkins Fall Risk Assessment Tool (a tool used to determine if a
resident is at risk for falls), dated 5/22/18, showed staff assessed the resident at high
risk for falls.
Review of the risk meeting notes, dated 5/25/18, showed staff documented to continue with
current care plans and interventions for the resident related to falls.
Review of the comprehensive MDS, dated [DATE], showed staff assessed the resident as:
-Alert with some confusion;
-Required limited assistance of one staff member for transfers and ambulation;
-Occasionally incontinent of urine;
-[DIAGNOSES REDACTED].
-Had one fall with major injury;
-Received antipsychotic and antidepressant medications.
Review of the resident’s Event Report, dated 6/12/18, showed staff documented:
-The resident had an unwitnessed fall in the resident’s room at 2:42 A.M. The resident had
bruising/hematoma, was unable to complete range of motion (ROM). Contributing factor to
the fall was previous orthopedic condition. Interventions for rest and encourage the
resident to use the call light.
During an interview on 7/6/18 at 10:00 A.M., Licensed Practical Nurse (LPN) D said:
-The resident slid off the bed;
-The resident had his/her own bed from home;
-The interventions used to prevent falls were to check on him/her frequently and encourage
him/her to use the call light;
-No new interventions were put in place after the fall.
Review of the nurses’ note, dated 6/12/18 at 2:34 P.M., showed the resident returned from
the emergency room (ER) with orders to wear an ace wrap to left wrist and hand for 24
hours and continue neuro checks (to check for a head injury).
Review of the resident’s care plan for falls showed staff did not document the cause of
the fall on 6/12/18 and did not document new interventions put in place to prevent further
falls.
Review of the social services notes, dated 6/13/18 at 3:00 P.M., showed:
-Responsible party requested a pressure pad for the resident at night due to falls;
-The pressure pad was put on the resident’s bed on 6/13/18.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
Review of the nurses’ note, dated 6/14/18 at 2:30 A.M., showed:
-Resident observed on floor at 1:00 A.M., face down with a dinner plate size amount of
blood surrounding his/her face. The resident was alert to person and place. Hand grips
were weak bilaterally. Blood coming from nose and upper gum with a two inch size gash
inside of his/her mouth. The resident complained of hand pain, bilateral hip pain and left
shoulder pain. Emergency personnel arrived at 1:22 A.M. and transported the resident to
the hospital.
During an interview on 7/6/18 at 12:30 P.M., Family Member (FM) A said:
-He/she told the facility after the 6/12/18 fall that the family wanted a bed alarm placed
on the resident’s bed to alert the staff when the resident was getting out of bed;
-The resident’s falls occurred during the night shift;
-The facility did not put any other interventions in place to help prevent the resident
from falling.
During an interview on 7/6/18 at 2:00 P.M., LPN C said:
-The resident’s family requested that a bed alarm be put on the residents bed;
-The interventions in the care plan to prevent falls were to encourage the resident to use
the call light and to monitor frequently;
-The resident did not always remember to use the call light.
During an interview on 7/10/18 at 11:45 A.M., the Social Services Director (SSD) said:
-The family insisted that a bed alarm be put on the residents bed after the fall on
6/12/18;
-The facility put a bed alarm on the resident’s bed on 6/13/18.
During an interview on 7/10/18 at 3:05 P.M. Certified Nurse Aide (CNA) I said:
-The resident had frequent falls;
-The care plan interventions were to check on him/her frequently and to encourage the
resident to use the call light;
-The resident was confused during the night and did not remember to use the call light;
-The family requested the bed alarm be put on the bed.
2. Review of Resident #3’s annual MDS, dated [DATE], showed staff assessed the resident
as:
-Alert with confusion;
-Required limited assistance of one person with transfers;
-[DIAGNOSES REDACTED].
-No history of falls.
Review of the resident’s care plan for falls, dated 5/2/18, showed:
-History of falling related to weakness;
-Goal to remain free from injury;
-Approaches – assist the resident to keep the environment free of clutter; encourage the
resident to keep the door open; encourage to assume a standing position slowly; assist of
one person with transfers at all times; keep the call light within reach at all time;
obtain therapy consult per physician orders; fall prevention program per facility
protocol.
Review of the nurses’ note dated 7/2/18 at 8:40 P.M., showed:
-Resident witnessed on the floor in his/her room beside the bed on his/her right side. The
resident said he/she slipped on water on the floor while trying to get out of bed. The
resident said he/she hit his/her head on the floor. Large blue bruise to the back of the
right hand from the fall. No bumps or bruising noted to the head, but a reddened area
noted to the right side of the head.
Review of the resident’s care plan for falls showed staff did not document the cause of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
the fall or document new interventions to prevent further falls.
3. Review of Resident #4’s quarterly MDS, dated [DATE], showed staff assessed the resident
as:
-Alert with confusion;
-Required extensive assistance of two people with transfers;
-[DIAGNOSES REDACTED].>-No history of falls.
Review of the resident’s fall care plan dated, dated 6/22/17, showed:
-At risk for falling related to decreased mobility, history of fractured left hip. Will
attempt to transfer self often related to wanting to be independent and does not like to
ask for help;
-Goal: Remain free from injury;
-Approaches: assist to keep the environment free of clutter; do not leave unattended on
the toilet; encourage and assist with proper well-maintained footwear; assist of two to
transfer; keep call light within reach at all times; keep personal items and frequently
used items within reach at all times; fall prevention program; assist to bed at bedtime;
assist to the bathroom after meals and lay down after meals; toilet frequently and as
requested; check on resident often; toilet every morning when sitting up; fall mat at
bedside; staff not to leave resident alone in the bathroom; use mat on the floor when in
bed; toilet after getting up in the morning before breakfast.
Review of the nurses’ note, dated 6/28/18 at 12:20 P.M., showed staff documented:
-The resident found on the floor in front of the wheelchair and end table. Laceration on
the left side of the head.
Review of the care plan for falls showed staff did not document the cause of the fall or
new interventions for the prevention of further falls.
4. During an interview on 7/6/18 at 9:45 A.M., the Administrator said:
– LPN B was the MDS coordinator until the end of (MONTH) (YEAR). LPN E was hired to take
LPN B’s place, but he/she has not had the time to work with him/her on care plans;
-LPN E has worked the floor multiple times and has not had training on care plans or
completion of the MDS.
During an interview on 7/10/18 at 8:40 A.M., LPN E said:
-He/she was the MDS coordinator and began work at the facility the week of 6/12/18;
-He/she has not had any training to do the care plans;
-He/she has worked the floor as a nurse.
During an interview on 7/10/18 at 2:15 P.M., the Administrator and Quality Assurance Nurse
said:
-Care plans should be updated with new interventions after each fall;
-Each fall should be investigated for the cause and interventions put in place.
MO 8

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews and record reviews, the facility failed to assure staff
followed acceptable standards of practice for two additionally sampled residents (Resident
#7 and #40) when staff recorded [MEDICATION NAME] (narcotic pain medication) and
[MEDICATION NAME] (an anti-anxiety medication in the benzodiazepine family), scheduled

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
controlled medications in the medication administration record (MAR) as administered and
recorded the medications in the narcotic controlled log (a book used by staff to account
for controlled medications) and subtracted the medications from the count prior to the
medications being administered to the residents. The facility census was 58.
Review of the facility policy, dated (MONTH) (YEAR), titled Storage of Medications,
showed:
-Purpose: To ensure residents receive their medications on a timely basis and in
accordance with all laws and regulations governing such acts;
-Medications may not be prepared in advance and must be administered within one hour of
preparation;
-The person administering the drugs must chart medications immediately following the
administration;
-The date, time administered, dosage, etc must be entered in the medical record and signed
by the person entering the data.
1. Review of Resident #40’s (MONTH) (YEAR), physician’s order sheet (POS) showed:
-[MEDICATION NAME] 1 milligram (mg) tablet orally four times daily for a [DIAGNOSES
REDACTED].
Observation on 5/3/18, at 11:15 A.M., showed:
-Resident #40 walked up to the nurses’ desk and reported to Licensed Practical Nurse (LPN)
B that he/she was having a panic attack and required his/her medication;
-LPN B then asked the resident to wait by the desk and he/she informed the resident that
he/she would obtain the scheduled medication;
-LPN B left the desk, went to the medication room, unlocked the medication cart and
obtained Resident #40’s medication card of [MEDICATION NAME] 1 milligram (mg) then popped
the medication into a medication cup;
Review of the MAR at the same time as the observation showed LPN B had already signed the
12:00 P.M. dosage and 4:00 P.M., as administered to the resident.
Review of the controlled medication log at the same time as the observation showed the
12:00 P.M. dosage of [MEDICATION NAME] had already been signed out as administered and
subtracted from the count and the 4:00 P.M., dosage of [MEDICATION NAME] had already been
signed out as administered and subtracted from the count.
2. Review of Resident’s #7’s (MONTH) (YEAR), POS showed:
-[MEDICATION NAME] 5 mg one tablet four times daily for a [DIAGNOSES REDACTED].
Review of Resident #7’s MAR on 5/3/18, at 11:25 A.M., showed;
-The resident’s 12:00 P.M., and 4:00 P.M., dose of [MEDICATION NAME] 5 mg was initialed by
LPN B which indicated the medication had already been administered.
Review of the controlled medication log for this resident showed the 12:00 P.M., dosage of
[MEDICATION NAME] had already been signed out as administered and subtracted from the
count and the 4:00 P.M., dosage of [MEDICATION NAME] had already been signed out as
administered and subtracted from the count.
3. During an interview on 5/3/18, at 11:30 A.M., LPN B said:
-He/she is the nurse responsible for administering Residents #7’s and # 40’s medications;
-Staff are expected to sign the MAR after the medication is administered if the medication
is considered to be a controlled medication then staff should record the medication in the
controlled medication log and subtract the medication to ensure the count is accurate;
-He/she was aware that it is not acceptable to sign the MAR prior to a medication being
administered or pre-sign and subtract medications from the controlled medication log;
-He/she signed the MAR and narcotic accountable log sheets prior to the doses of
medications being administered for Resident #7 and #40 in an effort to save time and be
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
efficient as he/she is required to assist the aide on the hall.
During an interview on 5/3/18, at 4:15 P.M., the Director of Nursing (DON) said:
-She expects staff to follow the facility policy and medications may not be prepared in
advance and documentation should not be completed in advance;
-Staff should never pre-sign the MAR or controlled medication log these are to be
completed immediately after the medication is administered.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided complete perineal care (cleaning the genital and rectal areas) to three
dependent, incontinent residents (Resident #6, #36 and #38) out of 15 sampled residents,
failed to assure they had a sufficient number of staff to provide at least two showers a
week and assure residents who preferred to be shaven were shaved for four sampled
residents (Resident #23, #37, #39 and #51). The facility census was 58.
1. Review of the facility’s policy on perineal care, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Purpose: to cleanse the perineum and to prevent infection and odor;
– Lie the resident on his/her back, wet the washcloth, make a mitt with it, and apply soap
lightly;
– Use one hand to stabilize and separate the perineal folds, with the other hand, wash
from front to back, rinse and pat dry.
– Does not address how many times to fold and reuse the washcloth;
– If uncircumcised, pull back the perineal fold, wash, dry and return to the normal
position;
– Turn the resident on his/her side, use a new washcloth, wash around the rectum, rinse
and dry.
2. Review of Resident #6’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 4/29/18, showed:
– [DIAGNOSES REDACTED].
– Required extensive assistance of two staff for all activities of daily living (ADLs);
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, updated on 4/30/18, showed:
– Problem: Risk for pressure ulcers related to [MEDICAL CONDITION] and decreased mobility
[MEDICAL CONDITION] of bowel and bladder;
– Provide perineal care after each incontinent episode;
– Need two assist with cares: mechanical lifting, transferring, dressing, toileting,
perineal care and repositioning.
Observation on 4/30/18, at 12:30 P.M., showed:
– Nurse Aide (NA) A opened a wet brief, wiped across the resident’s supra pubic area once,
wiped each groin once, retracted the perineal fold and cleaned around the skin folds, and
repositioned the perineal fold;
– Wiped under the perineal fold and rolled the resident onto his/her side, and wiped a
large amount of fecal material away from the rectum;
– Did not wash the buttocks, upper thighs, or all areas wet with urine.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
3. Review of Resident #36’s quarterly MDS, dated [DATE], showed:
– [DIAGNOSES REDACTED].
– Did not ambulate and required extensive assistance of two staff for all ADLs;
– Indwelling urinary catheter and frequent incontinence of bowel.
Review of the resident’s care plan, updated on 3/23/18, showed:
– Problem: ADL function related to limited ability for self-care: administer perineal care
often and as needed.
Observation on 5/1/18, at 6:45 A.M., showed:
– NA A entered the resident’s room to perform perineal care, washed his/her hands, and
gloved;
– NA A wiped each groin once, down the inner perineal fold twice, rolled the resident onto
his/her right side, wiped once on each buttock, and once over the rectum;
– Did not clean the entire suprapubic, frontal perineal area, all the buttocks, or
anterior or posterior thigh areas.
During an interview on 5/2/18, at 2:30 P.M., NA A said he/she should clean all areas
during perineal care.
4. Review of Resident #38’s quarterly Minimum Data Set (MDS), a federally mandated
assessment completed by facility staff, dated 3/15/18 showed:
– Severe cognitive impairment;
– Totally dependent on two staff for bed mobility, transfers, toileting, eating, and
personal hygiene;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation and interview on 5/1/18 at 5:36 A.M., of NA A and NA B showed:
– Resident #38 in bed resting with eyes closed;
– Both staff entered the resident’s room washed their hands and reported that they planned
to get the resident up for the day;
– NA B uncovered the resident and the resident was fully dressed except for his/her shoes;
– Staff used the mechanical lift and assisted him/her from the bed to the wheelchair;
– Staff did not check the resident’s brief to ensure the brief was clean and dry;
– NA B washed the resident’s hands and face and provided oral care;
– NA A said the resident is dependent on staff for care and he/she is incontinent of bowel
and bladder;
– NA A said he/she changed the resident’s brief approximately 30 minutes ago and
pre-dressed the resident as he/she was one of the residents that should be gotten up
early;
– NA A he/she was recently hired and he/she was unsure why this resident was scheduled to
get up at this time;
– Residents who require transfer with the mechanical lift require two staff and they are
pre dressed about 4:30 A.M., each day;
– NA A said he/she works 6:00 P.M., to 6:00 A.M., on the 400 and 500 hall;
– Usually there are three aides scheduled for the night shift, one for each hall and one
aide acts as the float and covers for breaks however, this night there were only two
aides;
– NA B said he/she works 6:00 A.M., to 6:00 P.M., and he/she came in early today to assist
the overnight shift;
– Both staff exited the resident’s room and the resident sat in his/her wheelchair with
eyes closed and appeared to be sleeping.
5. Review of Resident #23’s annual MDS, dated [DATE], showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
– No cognitive impairment;
– Totally dependent on two staff for bed mobility, transfers, toileting, and personal
hygiene;
– Indwelling urinary catheter and always incontinent of bowel.
Review of the resident’s care plan last updated 3/5/18, showed:
– Staff assistance with ADLs due to a [DIAGNOSES REDACTED]. A contracture occurs when a
joint becomes permanently fixed in a bent or straightened position, which can impact the
function and range of motion of the joint);
– Catheter and perineal care every shift and as needed.
Observation on 4/30/18, at 2:10 P.M., showed a strong urine odor coming from Resident
#23’s room that could be smelled in the hallway outside of the resident’s room as he/she
sat in his/her wheelchair watching television.
Observation on 5/1/18, at 7:45 A.M., showed:
– Certified Nurse Aide (CNA) B and NA D entered the resident’s room to provide catheter
and incontinent care as the resident lay in bed.
– The resident was unable to flex or straighten his/her legs as CNA B used multiple hand
towels to cleanse the resident’s perineal skin folds.
– CNA B had difficulty thoroughly cleansing all perineal skin folds.
During an interview on 5/1/18, at 8:45 A.M., with Resident #23 he/she said:
– He/she had a catheter however, he/she experiences urinary incontinence and wears a
brief;
– The facility staff provide one shower weekly but he/she feels that he/she required more
than one shower weekly and his/her hair was oily and needed to be washed;
– He/she would like at least two showers weekly.
During an interview on 5/1/18, at 11:24 A.M., CNA B said:
– It is very difficult to cleanse between Resident #23’s legs and perineal skin folds as
the resident was not able to straighten or spread his/her legs;
– Providing a shower for this resident is the best way to cleanse the perineal skin folds;
Observation on 5/1/18, at 1:00 P.M., showed:
– Resident #23’s sat in his/her wheelchair in a common area in the facility the resident’s
hair was oily and was not brushed;
– The resident did not appear well-groomed and continued to have an odor of urine and body
odor.
Observation on 5/2/18, at 9:50 A.M., showed Resident #23’s hair remained oily and was not
brushed. The resident did not appear well-groomed and continued to have an odor of urine
and body odor.
During an interview on 5/3/18, at 10:05 A.M., NA A said:
– He/she worked yesterday and was unable to provide all the scheduled showers.
6. Review of Resident #37’s medical record showed the resident was severely cognitive
impaired.
Review of the current care plan showed the resident preferred to shave twice a week. The
plan did not show any shower preferences.
Review of Resident #37’s shower sheets showed the resident was offered showers on the
following dates: 3/9/18, 3/16/18, 3/24/18, 3/28/18, 4/4/18, 4/6/18, 4/8/18, 4/10/18,
4/15/18, 5/3/18.
Observation of the resident from 4/30/18 to 5/3/18, showed the resident had ¼ inch plus
whiskers.
During an interview on 5/3/18, at 9:00 A.M., Resident #37’s spouse said he/she does not
get all his/her showers and did not live his/her life with those whiskers.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
7. Review of Resident #51’s medical record showed the resident was cognitively intact.
Review of the resident’s care plan showed no shower preferences.
Review of Resident #51’s shower sheets showed the resident was offered showers on the
following dates: 3/10/18, 3/14/18, 3/28/18, 4/4/18, 4/8/18.
Observation of the resident on 5/2/18, at 6:00 P.M., at supper showed the resident had ¼
inch plus whiskeys. During an interview at that time the resident’s spouse said his\her
spouse liked to be clean shaven.
8. Review of Resident #39’s significant change in condition MDS assessment, dated 1/25/18,
showed:
-Two assist for transfers and toileting;
-One assist for dressing, hygiene, and bathing;
-[DIAGNOSES REDACTED].
Review of resident’s care plan, dated 3/29/18, showed:
-Needs two assist with peri-care;
-Need two to transfer with mechanical lift;
-Chosen Hospice for palliative care start date of 3/29/18;
-Needs assist with all ADL care due to confusion and health decline.
Review of resident’s comprehensive shower sheets showed:
-Shower documented on 3/6/18;
-Shower documented on 3/19/18;
-No documentation given to show any showers in-between that time.
During an interview on 5/3/18, at 11:15 A.M., a family member said showers do not get
done. They have aides try to do it and they just don’t have time. Staff do not show up for
the evening shift, and there was one nurse for the whole building, one night last week.
One nurse and one aide per hall is what you typically see on evening shift, it is a
skeleton crew.
9. During an interview on 5/1/18, at 12:47 P.M., Restorative Aide (RA) A said there was no
specific shower aide. They took turns and sometimes evening shift gave showers. They do
not all get done. He/she was also the restorative aide. He/she was mostly pulled to work
the floor.
During an interview on 5/2/18 at 3:55 P.M., Licensed Practical Nurse (LPN) B said:
– He/she is the nurse responsible for the 100, 200, and 300 hall;
– Currently there is one aide and him/herself for all three halls;
– Frequently, he/she was required to assist the aides in proving direct patient care;
– These three halls have a total of 28 residents;
– Of these 28 residents, nine residents require two staff for transfers;
– 19 of the 28 residents are incontinent and require to be toileted or changed every two
hours;
– 25 of the 28 residents are dependent on staff for their ADLs;
– It was not possible today to provide all the scheduled showers and frequently showers
are not always provided as planned.
During an interview on 5/2/18, at 4:15 P.M., LPN A said:
– He/she is the nurse responsible for the 400 and 500 hall;
– These two halls have a total of 28 residents;
– Of these 28 residents, nine residents require two staff for transfers, seven of them
being a mechanical lift transfer, with two being a two-person gait belt transfer;
– 12 of the 28 residents are incontinent and require to be toileted or changed every two
hours;
– 14 of the 28 residents are dependent on staff for their ADLs.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
– Showers do not always get done if there is only one aide on each hall;
– When there are two aides for both halls, staff attempt to provide showers but often all
the showers are not provided;
– If a resident is on hospice services then hospice staff provide the showers;
– The facility was aware that when a resident was on hospice that the facility was too
also be providing showers;
– He/she comes in on his/her days off to provide showers.
During an interview on 5/3/18 at 4:15 P.M., the Director of Nursing (DON) said:
– Several departments have staff that are cross trained to assist with the staffing
issues.
– All laundry staff are cross-trained as CNAs.
– She attempts to have an adequate number of staff to meet the needs of the residents;
– It has been a struggle to get the showers done;
– Due to staffing issues, the Restorative Aide (RA) is frequently pulled to work the floor
so we improvised and now activity staff provides restorative nursing;
– If she had enough staff, she would have a designated shower aide that would only do
showers.
– She has been working nights and worked on 4/13/18, 4/15/18, 4/18/18, and 4/19/18.
– On the 4/13/18, she was here overnight with one CNA and one NA.
– They do at least one aide per hall, and have had enough staff on night shift lately.
– They used to have a full time shower aide, but he/she left in March.
– She expected staff to clean the whole perineal area which included the legs, buttocks
and thighs.

F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

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 observations, interviews and record review, the facility failed to assure staff
used proper techniques and follow their facility policy to reduce the possibility of
accidents and injuries during mechanical lift transfers. This affected two of 15 sampled
residents (Resident #6 and Resident #36). The facility census was 58.
Review of the facility’s policy on Hydraulic Lifts, Nursing Guidelines Manual, (MONTH)
(YEAR), showed:
– Open the lift legs to the widest point, at the closest location to the resident (bed or
chair);
– Position the sling under the resident and move the lift with the base under the bed;
– Attach the S hooks to the overhead bar and raise the resident, when the resident has
been lifted clear of the bed, grasp the bar, and move to the chair;
– Position the wheelchair and lock the wheelchair brakes.
Review of the facility’s manufacturer’s instructions on the battery operated mechanical
lift, dated 12/3/12, showed:
– Operating instructions: Open the base legs, move the lift slowly towards the resident,
and position the overhead bar over the resident’s chest;
– Attach the sling and lift the resident above the bed using the hand control;
– Pull lift away from the bed, move the resident over the wheelchair (chair wheels locked)
opening the base for stability and fit, and lower the resident into the wheelchair.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 – Immediate jeopardy

Residents Affected – Few

(continued… from page 14)
1. Review of Resident #6’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 4/29/18, showed:
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, updated on 4/30/18, showed:
– Problem: Risk for falls related [MEDICAL CONDITION] right sided [MEDICAL CONDITION];
– Two staff assistance with mechanical lift.
Observation and interview on 4/30/18, at 12:30 P.M., showed:
– Nurse’s Aide (NA) A and NA D moved a mechanical lift into the resident’s room and washed
their hands.
– NA D pushed the mechanical lift under the resident’s bed, did not open the lift legs,
attached the sling, and raised the resident off the bed.
– NA D struggled to pull the lift back, did not open the lift legs, and tried to turn the
lift.
– Staff said the right back lift wheel did not work properly and NA D struggled to turn
the lift.
– NA A traded places with NA D and pushed the lift across the room, did not open the lift
legs, reached the resident’s wheelchair, and then opened the lift legs.
2. Review of Resident #36’s quarterly MDS, dated [DATE], showed:
– [DIAGNOSES REDACTED].
– Did not ambulate and required extensive assistance of two staff for all activities of
daily living (ADLs).
Review of the resident’s care plan, updated on 3/23/18, showed:
– Problem: Risk for falling related to weakness and not bearing weight consistently;
– Two person assist with mechanical lift for transfers.
Observation on 5/1/18, at 6:45 A.M., showed:
– Certified Nurse Aide (CNA) C and NA A pushed the mechanical lift into the resident’s
room, washed and gloved their hands.
– CNA C pushed the lift under the bed and did not open the lift legs.
– Staff attached the lift sling and raised the resident off the bed.
– CNA C pulled the lift back from the bed, turned the lift, did not open the lift legs,
and moved it several feet to the wheelchair.
– CNA C then opened the lift legs, did not lock the wheelchair brakes, and lowered the
resident into the wheelchair.
During an interview on 5/1/18, at 10:30 A.M., CNA C said:
– The mechanical lift should be able to turn or move without difficulty.
– Lift legs should be opened when raising or lowering a resident.
– Wheelchair brakes should be locked when lowering the resident into the wheelchair.
During an interview on 5/2/18, at 2:30 P.M., showed Nurse’s Aide (NA) A said:
– Mechanical lift legs should be opened, if you can.
– Lift legs should be opened when the lift is moved across the room.
– Wheelchair brakes should be locked when raising or lowering the resident into the
wheelchair.
During an interview on 5/3/18, at 4:15 P.M., the Director of Nurses (DON) said:
– For stability, mechanical lift legs should be open when raising or lowering a resident
and moving the lift across the room;
– Wheelchair brakes should be locked when a resident is raised from a wheelchair or
lowered into one.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 – Immediate jeopardy

Residents Affected – Few

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 observations, interviews, and record reviews, the facility failed to provide care
to prevent urinary tract infections (UTIs) for residents with a suprapubic catheter (a
urinary catheter that is inserted into the abdominal wall and into the bladder), and an
indwelling catheter. This affected three of 15 sampled residents (Residents #14, # 23 and
#36). The facility census was 58.
Review of the facility policy on catheter care, dated (MONTH) (YEAR), showed:
– Purpose: To prevent infection and reduce irritation;
– Use a warm water and soap to cleanse all perineal skin folds;
– Use one area of the washcloth for each downward, cleansing stroke and change the
position of the washcloth with each downward stroke;
– Change the position of the washcloth and cleanse at the insertion site; do not allow the
washcloth to drag on the resident’s skin or bed linen;
– With a clean washcloth, rinse with warm water using the above technique;
– Use a clean wash cloth with warm water and soap to cleanse and rinse the catheter from
insertion site to approximately four inches outward;
– Ensure that the catheter remains secured utilizing a leg strap;
– Check drainage tubing and bag to ensure that the catheter is draining properly;
– Discard disposable items; remove gloves and wash hands.
1. Review of Resident #23’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/1/18, showed:
– No cognitive impairment;
– Totally dependent on two staff for bed mobility, transfers, toileting, and personal
hygiene;
– Indwelling urinary catheter and always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan last updated 3/5/18, showed:
– Staff assistance with activities of daily living (ADLs) due to a [DIAGNOSES REDACTED]. A
contracture occurs when a joint becomes permanently fixed in a bent or straightened
position, which can impact the function and range of motion of the joint);
– At risk for UTIs related to having a catheter;
– Catheter and perineal care every shift and as needed.
Observation on 5/1/18, at 7:45 A.M., showed Certified Nurse Aide (CNA) B and Nurse Aide
(NA) D entered the resident’s room to provide catheter and incontinent care as the
resident lay in bed and staff did the following:
– Both staff washed their hands and put on clean gloves.
– CNA B cleansed the resident’s frontal perineal skin folds with a hand towel then removed
his/her gloves and did not wash his/her hands before he/she informed NA D that he/she
needed to leave the resident’s room to obtain additional disposable gloves as he/she did
not have any more gloves in his/her pockets.
– CNA B exited the resident’s room without washing his/her hands;
– CNA B returned shortly, did not wash his/her hands before reaching into his/her pocket
to obtain a pair of disposable gloves and he/she put on the clean gloves without washing
his/her hands.
– CNA B cleansed the resident’s buttock with a hand towel and did not remove his/her

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 – Some

(continued… from page 16)
gloves and wash his/her hands before assisting the resident to turn onto his/her back.
– CNA B touched the clean brief with dirty gloves and both staff secured the clean brief
on the resident.
– CNA B did not remove his/her gloves and wash his/her hands before holding the supra
pubic catheter at the insertion site with a dirty glove and he/she cleansed the tubing
with hand towel wiping downwards.
– CNA B did not remove his/her gloves and wash his/her hands before he/she continued to
assist NA D with dressing the resident.
During an interview on 5/1/18, at 11:24 A.M., CNA B said:
– Staff should wash their hands after glove removal and staff should not touch clean items
with dirty hands.
2. Review of Resident #14’s quarterly MDS , dated 2/15/18, showed:
– Severe cognitive impairment;
– Dependent on one staff for bed mobility, transfers, toileting, and personal hygiene;
– Always continent of bowel and bladder;
– The MDS assessment did not indicate the resident had an indwelling urinary catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan last updated 2/25/18, showed:
– Staff assistance with ADLs due to a [DIAGNOSES REDACTED].
– Catheter related to [DIAGNOSES REDACTED].
Observation on 4/30/18, at 10:20 A.M., showed:
– The resident sitting in his/her room;
– CNA A entered the resident’s room, did not wash his/her hands, picked up a dignity bag
from the floor near the resident’s bed and placed it on the urinary drainage bag as it
hung on the resident’s walker;
– CNA A did not wash his/her hands prior to exiting the resident’s room.
During an interview on 5/1/18, at 7:39 A.M., CNA A said:
– He/she normally works in housekeeping and several staff are cross trained;
– Hands should be washed before and after providing care.
– He/she should have washed his/her hands when he/she entered the resident’s room and upon
exiting the resident’s room.
– He/she picked the dignity bag off the floor because residents that have catheters should
always have a dignity bag.
3. Review of Resident #36’s quarterly MDS, dated [DATE], showed:
– [DIAGNOSES REDACTED].
– Indwelling urinary catheter and frequent incontinence of bowel.
Review of the resident’s care plan, updated on 3/23/18, showed:
– Problem: Suprapubic catheter (a catheter inserted through the abdomen into the bladder
and used to drain urine) related to neuromuscular dysfunction of the bladder and
incontinent of bowel at times;
– Position the catheter bag below the level of the bladder and manipulate the tubing as
little as possible during care;
– Do not allow tubing or any part of the drainage system to touch the floor;
– Store catheter bag inside a protective dignity pouch;
– Report any complications (e.g. confusion, foul odor, blood in urine, dislodgement of
catheter) to the charge nurse.
Observation on 5/1/18, at 6:45 A.M., showed CNA C did the following:
– Entered the resident’s room to perform catheter care, washed and gloved his/her hands;
– Emptied the catheter into a graduate (measured container used to measure the amount of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 – Some

(continued… from page 17)
urine), did not place a barrier under the graduate;
– Did not use alcohol to clean the catheter spigot after he/she drained the urine and
before he/she placed it back into the port;
– The catheter bag and privacy bag sat on the floor while CNA C performed catheter care.
During an interview on 5/1/18, at 10:30 A.M., CNA C said:
– He/she should have used a paper towel as a barrier to set the graduate on and should
have used alcohol to clean the spigot when finished emptying the catheter bag.
4. During an interview on 5/3/18, at 4:15 P.M., the Director of Nurses (DON) said:
– Staff should not put a catheter and a dignity bag on a floor;
– Staff should put a barrier on the floor for the graduate and wipe the spigot off with
alcohol before replacing back into the port.
– Staff should wash their hands when entering a resident’s room and upon exiting a
resident’s room;
– Staff should wash their hands before and after glove removal;
– Staff should wash their hands and apply gloves before they start catheter care and
anytime the gloves were soiled;
– Staff should remove gloves when soiled, wash their hands, and put on clean gloves before
performing clean tasks;
– Suprapubic sites should not be cleaned with soiled gloves;
– No item should be used after it had been on the floor and staff should have obtained a
clean dignity bag and placed it on Resident #14’s urinary drainage bag.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
dated multi-dose bottles of [MEDICATION NAME] (a mediation used to treat anxiety and often
used during end of life) and [MEDICATION NAME] (narcotic pain medication) when opened for
two out of fifteen sampled residents (Resident #56 and #210). The facility census was 58.
Review of the facility policy, dated (MONTH) (YEAR), titled Storage of Medications,
showed:
-Staff are directed to record the expiration date based on date opened on the label of
medication with shortened expiration dates and follow manufacturer medication
administration guidelines.
-Medications may not be prepared in advance and must be administered within one hour of
preparation;
-The person administering the drugs must chart medications immediately following the
administration;
-The date, time administered, dosage, etc must be entered in the medical record and signed
by the person entering the data.
Review of the package insert provided by the facility for [MEDICATION NAME] showed to
discard opened bottle 90 days after opening the bottle.
1. Review of Resident #210’s (MONTH) (YEAR), physician order sheet (POS) showed:
-[MEDICATION NAME] 2 mg/ml (milligrams/milliliters), give ,[DATE] ml orally every every
four hours as needed for anxiety;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-[MEDICATION NAME] sulfate 100/mg per 5 ml, give ,[DATE] ml orally every hour as needed.
Observation on [DATE], at 6:58 A.M., of the facility’s medication storage refrigerator, in
the medication storage room for the 400 and 500 hall showed:
– Resident #210’s opened bottle of liquid [MEDICATION NAME] and [MEDICATION NAME];
– Both bottles did not contain a date showing when staff opened the bottles.
During an interview on [DATE], at 7:15 A.M., Licensed Practical Nurse (LPN) A said:
– Resident’s #210’s liquid medications should have a date written on the bottles when
staff opened the bottles to ensure the medications are not expired.
2. Review of Resident #56’s (MONTH) (YEAR), POS showed:
-[MEDICATION NAME] 2 mg/ml (milligrams/milliliters), give 0.25 ml-0.5 ml every 4 hours as
needed for shortness of air.
Observation on [DATE], at 7:07 A.M., of the facility’s medication storage refrigerator, in
the medication storage room for the 100, 200, and 300 hall showed:
– Resident #56’s opened bottle of liquid [MEDICATION NAME];
– The bottle did not contain a date showing when staff opened the bottle.
During an interview on [DATE], at 7:10 A.M., Registered Nurse (RN) A said:
– Resident #56’s liquid [MEDICATION NAME] should have a date written on the bottle when
staff opened the bottle to ensure the medication is not expired;
-Liquid [MEDICATION NAME] expires 30 days after the date it was opened.
3. During an interview on [DATE], at 4:15 P.M., the Director of Nursing (DON) said:
– Medications should be dated when opened, because the expiration date of medications can
change once opened;
– Liquid [MEDICATION NAME] should be discarded 90 days after opening;
– All nursing staff should be checking to ensure all medications are dated when opened.

F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure meals and snacks are served at times in accordance with resident’s needs,
preferences, and requests. Suitable and nourishing alternative meals and snacks must be
provided for residents who want to eat at non-traditional times or outside of scheduled
meal times.

the west side parked by the nurses’ station with the evening snacks. One resident sat at a
table in the area and ate his/her snack.
During an interview on 5/2/18, at 7:50 P.M., RN A said the aide was supposed to pass the
snacks.
During an interview on 5/2/18, at 8:00 P.M., Family Member A said no snacks were passed to
their mother/father.
Based on observation, record review and interview, the facility failed to ensure all
residents were offered an evening snack. This affected all residents that were unable to
go to the snack cart and get their own snacks. The facility census was 58.
Review of the facility’s bedtime snack policy dated March, (YEAR), showed an aide assigned
will take the hydration cart and bedtime snacks to each resident room and offer each
resident a snack and drink.
During a group resident interview on 4/30/18, at 10:10 A.M., all 10 of the residents in
attendance said the facility did not pass evening snacks room to room.
During an interview on 5/2/18, at 7:30 P.M., Dietary Aide A said they had already taken
the snacks to each nurses’ station.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

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 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
Observation on 5/2/18, at 7:35 P.M., showed the snack cart at the east nurses’ station had
seven bags of chips and the rest of the snacks on the cart consisted of only saltine and
graham crackers. During an interview at that time, Registered Nurse (RN) A said one of the
residents sometimes passed out the snacks.
Observation on 5/2/18, at 7:45 P.M., showed the snack cart full of graham and saltine
crackers on

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
followed infection control protocols to prevent the spread of infection, when staff did
not change gloves and wash their hands when going from a soiled to a clean task, which
affected three of 15 sampled residents (Resident #6, #19, and #23). The facility also
failed to change nebulizer tubing monthly which affected residents (Resident #13 and
Resident #39). The facility census was 58.
Review of the facility’s policy on Handwashing, Nursing Guidelines Manual, (MONTH) (YEAR),
showed:
– Purpose: To reduce transmission of organisms from resident to resident, nursing staff to
resident, and resident to nursing staff.
Review of the facility’s policy on Gloves, Nursing Guidelines Manual, (MONTH) (YEAR),
showed:
– Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, wound drainage oral
secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or a
person with a rash.
– Gloves must be changed between residents and between contacts with different body sites
of the same resident.
– Gloves are not a cure-all. They should reduce the likelihood of contaminating the hands,
but gloves cannot prevent injuries due to needles or sharp objects.
– Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of
a glove easier than to the skin on your hands. Handling medical equipment and devices with
contaminated gloves is not acceptable.
– Change gloves between contacts (as defined above) with different residents or with
different body sites of the same resident.
1. Review of Resident #6’s Minimum Data Set (MDS), a federally mandated assessment
completed by facility staff, dated 4/29/18, showed:
– Required extensive assistance of two staff for all activities of daily living (ADLs);
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, updated on 4/30/18, showed:
– Risk for pressure ulcers related to [MEDICAL CONDITION] (weakness or inability to move
one side of the body) from a [MEDICAL CONDITION] ([MEDICAL CONDITION] or stroke) and
incontinence of bowel and bladder;
– Frequently incontinent, provide care after each incontinent episode.
Observation on 4/30/18, at 12:30 P.M., showed Nurse Aide (NA) A did the following:
– Opened a wet brief, wiped across the resident’s suprapubic area with a washcloth; folded
it, wiped the right groin once; folded the washcloth again, wiped the left groin; folded

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
the washcloth a third time; did not get a clean washcloth, retracted the perineal fold and
cleaned around the skin, folded the soiled washcloth a forth time, repositioned the
perineal fold, and used the soiled washcloth a fifth time to clean under the perineal
folds.
– Rolled the resident onto his/her side, used a new washcloth, and wiped a large amount of
fecal material away from the rectum, and folded and reused the washcloth;
– Grabbed a new washcloth and continued to wipe, fold, and reuse the washcloth with fecal
material on it several times, did not remove his/her soiled gloves.
– Touched the new brief, clean bed pad, resident and resident’s gown without removing
his/her soiled gloves and washing his/her hands.
During an interview on 5/2/18, at what time? NA A said:
– He/she was not sure how many times to fold and reuse a washcloth;
– When cleaning the rectal area, if there is fecal material on the washcloth, staff should
use a washcloth once and get a clean one;
– He/she should have removed his/her soiled gloves and washed his/her hands after cleaning
fecal material or soiled areas.
2. Review of Resident #19’s annual MDS, dated [DATE], showed:
– Moderate cognitive impairment;
– Totally dependent on two staff for bed mobility, transfers, toileting, and personal
hygiene;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan last updated 3/1/18, showed:
– Staff assistance with activities of daily living (ADLs) due to a [DIAGNOSES
REDACTED].>- Provide perineal care after each incontinence and as needed.
Observation on 5/1/18, at 5:53 A.M., showed NA A and NA B provided incontinent care as the
resident lay in bed and did the following:
– Both staff washed their hands and put on clean gloves before starting incontinent care.
– The resident had a cloth between his/her legs; NA A removed the wet cloth and handed it
to NA B who placed it in a plastic bag.
– NA A made one downward swipe on the resident’s right frontal perineal skin folds; folded
the washcloth and made one downward swipe down the left frontal perineal skin fold; then
folded the washcloth again and made one downward swipe down the front perineal skin fold.
– NA A handed the soiled washcloth to NA B who put it in a plastic bag.
– NA A did not remove his/her gloves and wash his/her hands before he/she obtained two
clean pads from the resident’s chair and set them both at the foot of the bed.
– With dirty gloves, both staff assisted the resident to roll onto his/her side and NA A
used a washcloth to cleanse the resident’s rectal area, removing fecal material.
– NA A folded the same washcloth four times, removing fecal material as the resident was
having a bowel movement;
– NA A handed the washcloth covered with fecal material to NA B who placed it in a plastic
bag; NA B then removed his/her gloves and washed his/her hands and put on clean gloves.
– NA A did not remove his/her gloves and wash his/her hands before he/she touched the
clean pad and both staff assisted the resident with positioning as they slid one of the
pads under the resident.
– NA A did not remove his/her gloves and wash his/her hands before he/she picked up the
other clean pad from the foot of the bed and placed it in the resident’s chair next to
his/her bed.
– The pad touched the resident’s clean clothing as it lay in his/her chair.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
– NA A removed his/her gloves and washed his/her hands.
– Both staff continued with care to include securing a clean brief on the resident,
assisted with dressing, and transferred the resident to his/her wheelchair with the
mechanical lift.
During an interview on 5/1/18, at 6:15 A.M., NA A and NA B said:
– Staff should wash their hands after glove removal and staff should not touch clean items
with dirty hands.
– NA A said it is probably not the best idea to fold a washcloth multiple times during
incontinent care however, there is a limited supply of washcloths.
– Staff should not touch clean items with dirty hands.
3. Review of Resident #23’s annual MDS, dated [DATE], showed:
– No cognitive impairment;
– Totally dependent on two staff for bed mobility, transfers, toileting, and personal
hygiene;
– Indwelling urinary catheter and always incontinent of bowel.
Review of the resident’s care plan last updated on 3/5/18, showed:
– Staff assistance with ADLs due to a [DIAGNOSES REDACTED]. A contracture occurs when a
joint becomes permanently fixed in a bent or straightened position, which can impact the
function and range of motion of the joint);
– At risk for urinary tract infections related to having a catheter;
– Catheter and perineal care every shift and as needed.
Observation on 5/1/18, at 7:45 A.M., showed Certified Nurse Aide (CNA) B and NA D entered
the resident’s room to provide catheter and incontinent care as the resident lay in bed
and staff did the following:
– Both staff washed their hands and put on clean gloves;
– CNA B cleansed the resident’s frontal perineal skin folds with a hand towel then removed
his/her gloves and did not wash his/her hands before he/she informed NA D that he/she
needed to leave the resident’s room to obtain additional disposable gloves as he/she did
not have any more gloves in his/her pockets.
– CNA B exited the resident’s room without washing his/her hands.
– CNA B returned shortly, did not wash his/her hands before reaching into his/her pocket
to obtain a pair of disposable gloves and he/she put on the clean gloves without washing
his/her hands.
– CNA B cleansed the resident’s buttock with a hand towel, did not remove his/her gloves
and wash his/her hands before assisting the resident to turn onto his/her back.
– CNA B touched the clean brief with dirty gloves and both staff secured the clean brief
on the resident.
– CNA B did not remove his/her gloves and wash his/her hands before holding the suprapubic
catheter at the insertion site with a dirty glove and he/she cleansed the tubing with a
hand towel wiping downwards.
– CNA B did not remove his/her gloves and wash his/her hands before he/she continued to
assist NA D with dressing the resident.
– CNA B removed his/her gloves, did not wash his/her hands and informed NA D that he/she
needed to go get the resident’s electric wheelchair then CNA B left the resident’s room
without washing his/her hands.
– CNA B returned with the electric wheelchair, did not wash his/her hands and put on clean
gloves; both staff used the mechanical lift and transferred the resident from his/her bed
to the electric wheelchair.
– Both staff removed their gloves and washed their hands and exited the resident’s room.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265807

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

05/03/2018

NAME OF PROVIDER OF SUPPLIER

CRESTVIEW HOME

STREET ADDRESS, CITY, STATE, ZIP

1313 SOUTH 25TH ST, PO BOX 430
BETHANY, MO 64424

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
During an interview on 5/1/18, at 11:24 A.M., CNA B said:
– Staff should wash their hands when entering a resident’s room and prior to exiting a
resident’s room.
– Staff should wash their hands after glove removal.
– Staff should not touch clean items with dirty hands.
4. Review of Resident #39’s (MONTH) (YEAR), physicians’ order sheet dated (POS), showed:
-[MEDICATION NAME]/[MEDICATION NAME] (oral inhalation is used to prevent wheezing,
shortness of breath, coughing, and chest tightness in people with [MEDICAL CONDITIONS]; a
group of diseases that affect the lungs and airways) solution 0.5 milligrams (mg)/3 ml,
one vial via nebulizer every six hours for a [DIAGNOSES REDACTED].
Observation on 5/2/18, at 11:30 A.M., showed Certified Medication Technician (CMT) A
administered an [MEDICATION NAME]/[MEDICATION NAME] 0.5 mg/3 ml breathing treatment to
Resident # 39. The nebulizer tubing was dated that it was changed on 3/10/18.
5. Review of Resident #13’s (MONTH) (YEAR), POS showed:
– [MEDICATION NAME] Solution 2.5 mg/3 ml, use one vial per nebulizer twice daily for a
[DIAGNOSES REDACTED].
Observation on 4/30/18, at 10:14 A.M., showed Resident’s #13’s nebulizer tubing was dated
2/12/18, which indicated the tubing was changed on 2/12/18.
6. During an interview on 5/2/18, at 11:40 A.M., CMT A said:
– Staff change the nebulizer tubing monthly and as needed.
– Staff write the date on a piece of tape and secure it with to the tubing;
– Nebulizer tubing is changed monthly on the 10th of the month;
– Resident #13’s and #39’s nebulizer and tubing should have been changed on 4/10/18.
7. During an interview on 5/3/18, at 4:15 P.M., the Director of Nursing (DON) said:
– Staff should wash their hands when entering a resident’s room and upon exiting a
resident’s room.
– Staff should their wash hands before and after glove removal.
– Staff should wash their hands and apply gloves before they start catheter care and
anytime the gloves were soiled.
– Staff should remove their gloves when soiled, wash their hands, and put on clean gloves
before performing clean tasks.
– Suprapubic sites should not be cleaned with soiled gloves.
– Nebulizers and the tubing are to be changed once monthly.
– During perineal care, she expected staff should clean the whole perineal area which
included legs, buttocks, and thighs.