Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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

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 staff
maintained all areas in the facility in a clean, comfortable, and home like manner. The
facility census was 64.
1. Observation on 07/24/18 at 2:25 PM showed the following:
– Smoke barrier doors to 200 hall black scuff marks wood chipped on bottom and sides;
-Room door 202 wood chipped and scuffed marks;
-room [ROOM NUMBER] no light fixture cover on ceiling light bulbs exposed part hanging
down;
-room [ROOM NUMBER] door wood chipped on sides and scuff marks on bottom;
-Shower door on 200 hall wood chipped throughout and black scuff marks along the bottom;
-room [ROOM NUMBER] door wood chopped along edges;
-Dust all around air intake on ceiling in hallway by room [ROOM NUMBER];
-Dust all around air intake in hallway by room [ROOM NUMBER];
-room [ROOM NUMBER] door wood chipped black scuff marks on door;
-Mechanical room door by exit on 400 hall chunks of wood missing and chipped;
-Cracking across length of tile flooring between smoke doors by social service office
cracked tiles and small pieces missing.
Observation on 07/25/18 at 8:25 AM showed the following:
– room [ROOM NUMBER] ceiling cracking and flaking around light fixture;
-room [ROOM NUMBER] door wood chipped and cracked;
-room [ROOM NUMBER] black scuff marks on bottom of door;
-Utility room door wood cracked and chipped throughout;
-Bath door on 100 hall door black scuff marks on bottom and wood chipped;
-room [ROOM NUMBER] corner of wall by sink cracked and chipped and exposed metal;
-3 foot long and 2 foot wide of black gorilla tape on the floor in front of exit door on
the 200 hall.
During an interview on 7/27/18 at 10:00 A.M., Maintenance Director said someone put the
gorilla tape on the floor a long time ago to keep a resident from going out the door. He
does environmental rounds on a quarterly basis.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to administer eye drops,
inhalers, medications and oxygen correctly which affected three of 27 sampled residents
(Resident # 19, #15, and #17. The facility census was 64.
1. Review of the facility’s ophthalmic medication administration procedures, revised
1/1/09, showed, in part:
– Instillation of medication: steady your hand with the dripper by resting it lightly
against the resident’s forehead. With your other hand, gently pull down the lower lid of
the affected eye and instill the drop into the conjunctival sac along the margin of the
eyelid;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 – Some

(continued… from page 1)
– Pressure should be applied to the inner canthus for one minute, or if able, have the
resident gently close their eyes for three minutes after administration.
Review of the website. www.drugs.com., showed:
– To apply the eye drops: tilt your head back slightly and pull down your lower eyelid to
create a small pocket. Hold the dropper above the eye with the tip down. Look up and away
from the dropper and squeeze out a drop;
– Close your eyes for two or three minutes with your head tipped down, without blinking or
squinting;
– Gently press your finger to the inside corner of the eye for about one minute, to keep
the liquid from draining into your tear duct.
2. Review of Resident #19’s physician order [REDACTED].
– an order for [REDACTED].
Review of the resident’s electronic Medication Administration Record [REDACTED]
– Start date 1/3/18: [MEDICATION NAME] drops 1%, one drop to each eye twice daily for
allergic [MEDICAL CONDITION].
Observation on 7/25/18, at 9:25 A.M., showed:
– Licensed Practical Nurse (LPN) A washed his/her hands and applied gloves;
– The resident tilted his/her head back slightly;
– LPN A administered one drop in the resident’s right eye and applied lacrimal pressure
for 27 seconds;
– LPN A administered one drop in the resident’s left eye and applied lacrimal pressure for
25 seconds.
3. Review of the facility’s medication administration policy, revised, 1/1/09, showed, in
part:
– When all medication for that resident is prepared, administer the medication and observe
the resident taking the medication;
– When measuring liquids, use the appropriate measuring device and read the medication cup
at eye level.
4. Review of the facility’s metered dose inhaler administration policy, revised, 1/1/09,
showed, in part:
– Have the resident tilt head back slightly and breathe out;
– Open mouth with inhaler one – two inches away and place the inhaler in the mouth;
– Press down on the the inhaler to release medication as the resident starts to breathe in
slowly for three – five seconds;
– Have the resident hold breath for ten seconds to allow medication to reach deeply into
lungs;
– Repeat puffs as directed, waiting approximately one minute between puffs of either the
same or different medication;
– The resident should be allowed to rinse their mouth and spit after corticosteroid
inhalation to help prevent thrush.
Review of the instructions on the [MEDICATION NAME] HFA ([MEDICATION NAME] sulfate)
inhaler box, showed, in part:
– Follow these steps every time you use [MEDICATION NAME] HFA inhaler: Shake the inhaler
well between each spray; Breathe out through your mouth and push as much air from your
lungs as you can; put the mouthpiece in your mouth and close your lips around it; push the
top of the canister all the way down while you breathe in deeply and slowly through your
mouth; after the spray comes out, take your finger off the canister. After you have
breathed in all the way, take the inhaler out of your mouth and close your mouth; hold
your breath for about ten seconds, or for as long as is comfortable. Breath out slowly as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 – Some

(continued… from page 2)
long as you can; if your healthcare provider has told you to use more sprays, wait one
minute and shake the inhaler again.
Review of the website, www.drugs.com, for [MEDICATION NAME] showed:
– To apply the eye drops: tilt your head back slightly and pull down your lower eyelid to
create a small pocket. Close your eyes for two or three minutes with your head tipped
down, without blinking or squinting. Gently press your finger to the inside corner of the
eye for about one minute, to keep the liquid from draining into your tear duct.
5. Review of Resident #15’s POS, dated, 6/26/18 – 7/26/18, showed:
– Start date: 5/5/18: [MEDICATION NAME] powder, 17 grams in eight ounces water daily for
constipation;
– Start date: 5/5/18: ProAir HFA, [MEDICATION NAME] sulfated aerosol inhaler, 90
micrograms (mcg.), two puffs four times daily for [MEDICAL CONDITIONS], a chronic [MEDICAL
CONDITION] lung disease that obstructs airflow from the lungs;
– Start date: 7/7/18: [MEDICATION NAME] 0.25%, one drop each eye three times daily for
chronic allergic [MEDICAL CONDITION].
Review of the resident’s EMAR, dated, 7/1/18 – 7/26/18, showed:
– [MEDICATION NAME] 17 grams in eight ounces water daily for constipation;
– ProAir HFA ([MEDICATION NAME] sulfate) 90 mcg, two puffs four times a day for [MEDICAL
CONDITION];
– [MEDICATION NAME] 0.25 %, one drop in each eye three times a day for dry eyes.
Observation and interview on 7/25/18, at 8:43 A.M., showed:
– LPN A poured one tablespoon of [MEDICATION NAME] in the plastic mediation cup then
emptied it in a 360 milliliter (ml.) white styrofoam cup and filled it up half way with
apple juice;
– LPN A said the resident liked it mixed with apple juice;
– LPN A gave it to the resident and he/she drank a little less than half of it and placed
it on his/her table and left the room.
Observation on 7/25/18, at 9:16 A.M., showed:
– LPN A gave the resident the bottle of [MEDICATION NAME] and the resident;
– The resident administered one drop in the right eye but did not hold lacrimal pressure
for one minute;
– The resident administered one drop in the left eye and did not apply lacrimal pressure;
– LPN A held lacrimal pressure in the left eye for 28 seconds;
– LPN A did not instruct the resident about the lacrimal pressure.
Observation and interview on 7/25/18, at 9:19 A.M., showed:
– LPN A shook the inhaler and handed it to the resident and said the resident liked to
administer it him/herself;
– The resident placed the inhaler in his/her mouth and administered one spray, took two
deep breaths and administered another spray and took two more deep breaths;
– LPN A gave the resident a cup of water and the resident used it to rinse and spit;
– LPN A did not give the resident any instructions on how to use the inhaler;
– The resident did not shake the inhaler between the inhalations and did not wait one
minute between inhalations.
Observation on 7/25/18, at 9:49 A.M., showed:
– The cup of [MEDICATION NAME] remained on the resident’s table and it remained a little
less than half full.
During an interview on 7/26/18, 11:32 A.M., LPN A said:
– Not all of the orders say how much water to mix the [MEDICATION NAME] with. The white
styrofoam cups hold 360 ml. so he/she filled it about half way full;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 – Some

(continued… from page 3)
– He/she should have made sure the resident drank all of the [MEDICATION NAME];
– He/she should have applied lacrimal pressure for one minute;
– He/she should have made sure the resident used the inhaler correctly.
During an interview on 7/27/18, at 9:04 A.M., the Director of Nursing (DON) said:
– Staff should not leave medication at the bedside, unless there are physician’s orders
[REDACTED].
– Staff should have stayed with the resident and made sure the resident finished the
[MEDICATION NAME] and should have verified the resident had taken it before he/she signed
it off;
– Staff should follow the the physician’s orders [REDACTED].
– Staff should correct the resident or instruct the resident on how to apply lacrimal
pressure or use the inhaler;
– After staff administer the eye drop, they should apply lacrimal pressure for one minute
or if not, the resident should keep their eye closed for three minutes;
– Staff should use lacrimal pressure with medicated and non medicated eye drops;
– Staff should try to make a pouch and open the resident’s eye wide so the entire
medication is inserted.
6. Record review of resident #17’s admission MDS, dated [DATE] showed:
-admission date of [DATE];
-Cognitively intact;
-[DIAGNOSES REDACTED].
-Resident on oxygen therapy.
Review of residents POS dated (MONTH) (YEAR) showed:
-Oxygen 2 liters nasal cannula (NC), to keep oxygen saturation greater than 90 percent.
Review of residents care plan dated 5/9/18 showed:
-Resident is on oxygen at two liters per NC continuous, I get short of air with exertion;
-I wear oxygen continuous.
Observation on 7/25/18 from 12:26 P.M., to 1:10 P.M. showed resident #17 sat in the dining
room eating lunch with oxygen on, but the oxygen tank was empty and in the red.

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 observations, interviews, and record review, the facility failed to ensure staff
provided proper and complete perineal care for three of 27 sampled residents, (Residents
#12, #40 and #42). The facility census was 64.
1. Review of the facility’s undated competency sheet for perineal care to female resident,
showed, in part:
– Gently wash the inner legs and outer peri area along the outside of the perineal folds.
NOTE: Use a clean area of he wash cloth for each wipe of peri are per care plan;
– Wash the outer skin folds from front to back;
– Wash the inner perineal folds from front to back;
– Gently open all skin folds and wash the inner area from the front to back;
– Wash and dry the anal area.
Review of the facility’s undated competency sheet for perineal care to male resident,
showed, in part:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 4)
– Use a circular motion, gently wash the perineal fold by lifting it and cleaning from the
tip downward. Rinse and dry;
– Wash and rinse the perineal folds;
– Wash and rinse the other skin areas between the legs;
– Wash and rinse the anal area.
2. Review of Resident #42’s care plan for urinary incontinence, revised, 6/13/18, showed:
– The resident was incontinent of bladder at times and had cognition problems;
– Toilet every two hours and as needed, especially before and after meals;
– Assist with peri care with each incontinent episode and as needed.
Review of the resident’s significant change in status Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 6/22/18, showed:
– Cognition severely impaired;
– Limited assistance of one staff for bed mobility;
– Required extensive assistance of two staff for transfers and toilet use;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 7/26/18, at 10:39 A.M., showed:
– Certified Nurse Aide (CNA) C cleaned fecal material from the resident’s buttocks;
– CNA A and CNA C turned the resident onto his/her back;
– CNA C wiped down each side of the groin with a different wipe each time;
– CNA C used the same area of the wipe and cleaned different areas of the perineal folds.
During an interview on 7/26/18, at 1:37 P.M., CNA C said:
– He/he should not have used the same area of the wipe to clean different areas of the
skin.
3. Review of Resident #40’s care plan, revised, 6/19/18, showed:
– The resident had recurrent urinary tract infections (UTI’s), an infection in the urinary
system;
– Frequently incontinent of urine;
– Change each incontinent pad with each incontinent episode and as needed;
– Make sure staff provide appropriate peri care.
Review of the resident’s admission MDS, dated , 6/20/18, showed:
– Cognition severely impaired;
– Limited assistance of one staff for transfers and toilet use;
– Frequently incontinent of bladder;
– [DIAGNOSES REDACTED].
Observation on 7/26/18, at 7:59 A.M., showed:
– The resident laid in bed and had been incontinent of urine and the fitted sheet was wet
from just below the resident’s shoulders, almost down to the resident’s knees;
– CNA D provided incontinent care to the front perineal folds;
– CNA D and Nurse Aide (NA) A turned the resident on his/her side;
– CNA D provided incontinent care to the buttocks but did not clean all areas of the skin
where urine had touched.
During an interview on 7/27/18, 10:00 A.M., CNA D said:
– He/she should have cleaned all areas of the skin where urine had touched.
During an interview on 7/27/18, at 9:04 A.M., the Director of Nursing (DON) said:
– Staff should clean all areas of he skin where urine had touched and are encouraged to
clean up the resident’s back, and down their legs to their knees;
– Staff are taught to use one wipe, one swipe;
– Staff should not use the same area of the wipe to clean different areas of the skin
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 5)
4. Review of Resident #12’s quarterly MDS dated [DATE], showed:
– Cognitively intact;
– Required staff assistance for hygiene and toileting;
– Occasionally incontinent of bladder;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 7/25/18 at 10:08 A.M. of CNA E and CNA F providing perineal care for the
resident showed:
– Using gloved hands, CNA E cleaned the resident’s rectal area which was soiled with fecal
material.
– Without washing hands and chanting gloves, CNA E cleaned the resident’s rectal area back
to front.
– With washing hands and changing gloves, CNA E cleaned the front of the resident’s groin.
– CNA E did not separate the resident’s perineal folds and clean between the folds.
During an interview on 7/25/18 at 10:10 A.M. CNA E said:
– He/she should have washed his/her hands and changed gloves when going from soiled to
clean tasks.
– He/she should have always clean front to back.
– He/she should always separate the resident’s perineal folds and clean between the folds.
During an interview on 7/27/18 at 10:00 A.M. the DON said:
– Staff should always wash their hands and change their gloves if their gloves become
soiled.
– Staff should always clean front to back.
– Staff should always separate the resident’s perineal folds and clean between the folds.

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 observations, interviews and record review, the facility failed to ensure staff
used proper techniques to reduce the possibility of accidents or injuries during the use
of a mechanical lift, which affected two out of 27 sampled residents, (Residents #34 and
#50), and during the use a gait belt (a safety device and mobility aide used to provide
assistance during transfers, ambulation or repositioning), which affected three residents
(Residents #21, #40 and #41). The facility census was 64.
1. Review of the undated facility policy on the use of mechanical lifts showed:
– Prior to lifting the resident staff should lock the casters.
– Staff should never close the left legs while transporting a resident.
Review of the facility’s, undated Invacare Lift manufacture’s manual, for use of the
mechanical lift showed:
– Staff must always be kept in the open position during lifting and transfers.
– Staff should not lock the rear casters during lifting and transporting.
2. Review of Resident #50’s quarterly Minimum Data Set, a federally mandated assessment
instrument completed by facility staff, dated, 6/6/18, showed:
– Cognitively intact;
– Required extensive assistance of two staff for bed mobility and toilet use;
– Dependent on two staff for transfers;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 6)
– Lower extremities impaired on both sides;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 7/18/18, showed:
– He/she transferred with the Hoyer (mechanical lift).
Observation on 7/26/18, at 7:37 A.M., showed:
– Licensed Practical Nurse (LPN) D moved the lift away from the bed and Certified
Medication Technician (CMT) A guided the resident to his/her electric wheelchair;
– LPN D locked the rear caster on the mechanical lift;
– LPN D lowered the resident into his/her wheelchair;
– LPN D and CMT A unhooked the resident from the lift sling, LPN D unlocked the rear
casters and moved the lift away.
During an interview on 7/27/18, at 9:04 A.M., the Director of Nursing (DON) said:
– The rear casters should be unlocked when lowering the resident into the wheelchair.
During a telephone interview on 7/27/18, at 10:59 A.M., LPN D said:
– The rear casters should be locked when lowering the resident down.
3. Review of Resident #34’s care plan, dated 5/4/18 showed staff must transfer the
resident using a mechanical lift.
Review of the resident’s significant change in condition MDS, dated [DATE], showed:
– Cognitively impaired;
– Total dependence upon staff for transfers;
– [DIAGNOSES REDACTED].
Observation on 7/26/18 at 11:40 A.M. of Certified Nurse Aide (CNA) D and Nurse Aide (NA) A
showed:
– CNA D and NA A locked the casters while lifting the resident.
– CNA D and NA A unlocked the casters to transfer the resident.
– CNA D and NA A locked the casters to lower the resident.
During an interview on 7/26/18 at 11:40 A.M. CNA D and NA A said they thought they were
supposed to lock the casters when raising and lowering a resident.
During an interview on 7/27/18 at 10:00 A.M. the DON said staff should not lock the
casters when raising or lowering a resident.
4. Review of Resident #40’s admission MDS, dated , 6/20/18, showed:
– Cognition severely impaired;
– Limited assistance of one staff for transfers;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised, 7/11/18, showed:
– The resident required assistance of one staff with the use of a gait belt to ambulate.
Observation on 7/26/18, at 8:09 A.M. showed:
– NA A placed the gait belt around the resident’s upper abdomen;
– NA A and CNA D reached under the resident’s arm and grabbed the side of the gait belt
and grabbed the back of the gait belt with their other hand and stood the resident up;
– The gait belt slid up between the resident’s shoulder blades and CNA D and NA A’s hand
was under the resident’s arm pit bearing the resident’s weight;
– CNA D and NA A transferred the resident into his/her wheelchair and removed the gait
belt.
During an interview on 7/27/18, at 10:00 A.M., CNA D said:
– The gait belt should not have slid up under the resident’s arm pit;
– He/she placed his/her hands on the side of the gait belt and on the back of the gait
belt.
During an interview on 7/27/18, at 10:35 A.M., NA D said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 7)
– The gait belt should not slide up, it should have been adjusted;
– His/her hands should not have been under the resident’s arm pits;
– He/she placed one hand on the side of the resident’s arm pit and the other hand on the
back of the gait belt.
3. Review of Resident #41’s admission MDS, dated , 6/28/18, showed:
– Cognitively intact;
– Limited assistance of one staff for bed mobility, transfers, dressing and toilet use;
– Upper extremity impaired on one side;
– Lower extremity impaired on both sides;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised, 6/28/18, showed:
– Transfer with assistance of one staff with the use of a gait belt and hemi cane (walker
used to assist resident with limited mobility).
Observation on 7/26/18, at 6:48 A.M., showed:
– CNA A entered the resident’s room and assisted the resident to sit on the side of the
bed;
– CNA A placed the hemi cane beside the resident’s bed and locked the brakes on the
wheelchair;
– CNA A placed his/her arm under the resident’s arm pit and the resident rocked
him/herself but was unable to stand up;
– CNA A kept his/her arm under the resident’s arm pit and the resident rocked him/herself
and stood up with the assistance of CNA A and transferred him/her into the wheelchair.
During an interview on 7/26/18, at 1:26 P.M., CNA A said:
– He/she should probably have used a gait belt to transfer the resident;
– He/she should not have lifted under the resident’s arm pit.
4. Review of Resident #21’s care plan, dated 2/20/18 showed two staff must transfer the
resident using a gait belt.
Review of the resident’s quarterly MDS dated [DATE] showed:
– Cognitively impaired;
– Required extensive staff assistance for transfers;
– [DIAGNOSES REDACTED].
Observation on 7/26/18 at 11:03 A.M. of CNA D ad NA A transferring the resident using a
gait belt showed:
– They applied a gait belt around the resident’s waist.
– NA A grasped the resident under his/her left arm pit and the resident’s left shoulder
rose with the transfer.
During an interview on 7/26/18 at 11:05 A.M. NA A said he/she should only grasp the
resident’s gait belt.
5. During an interview on 7/27/18, at 9:04 A.M., the Director of Nursing (DON) said:
– The gait belt should be snug and not slide up. If it did, staff should sit the resident
down and readjust it;
– The staff’s hands should not be under the resident’s arm pit;
– Staff should place one hand on the front of the gait belt and one hand on the back of
the gait belt.

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
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 8)
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interview, and record review, the facility failed to ensure staff
provided proper catheter (sterile tube inserted into the bladder to drain urine) care in a
manner to prevent a urinary tract infection (UTI, an infection of the urinary system), or
the possibility of a UTI, which affected two of 27 sampled residents, ( Resident #48 and
#50). The facility census was 64.
1. Review of the facility’s indwelling catheter drainage bag/leg bag policy, revised
1/19/15, showed, in part:
– The catheter drainage bags will be emptied at the end of the each shift and the output
documented; – – Gloves should be worn, changed and hands washed between each resident;
– The catheter bag and/or tubing must not touch the floor at any time to prevent
contamination and decrease the possibility of a UTI.
Review of the facility’s undated competency sheet for giving peri care with catheter,
showed, in part:
– Separate the perineal folds, and gently wash around the opening of the urethra with soap
and warm water;
– Wash the catheter tubing from the opening of the urethra outward four inches or farther
if needed. Do not pull on the catheter;
– Using a fresh wash cloth, continue washing and rinsing the peri area. Dry the perineal
area.
2. Review of Resident #50’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 6/6/18, showed:
– Cognitively intact;
– Lower extremities impaired on both sides;
– Had a Foley catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised 7/18/18, showed:
– The resident had an indwelling Foley catheter and it put the resident at a greater risk
for UTI’s;
– Give good peri/catheter care each shift and as needed;
– When in bed drainage bag to be in pink tub under bed with dignity cover on it.
Observation on 7/26/18, at 7:01 A.M., showed:
– The resident laid in bed with the drainage bag hanging on the side of the bed and did
not have a cover over it.
– Certified Nurse Aide (CNA) A wiped down each side of the groin with a different wipe
each time;
– CNA A wiped down the middle of the perineal folds;
– CNA A wiped down the catheter tubing toward the insertion site;
– CNA A did not provide peri care to the buttocks.
During an interview on 7/26/18, at 1:26 P.M., NA A said:
– He/she should have wiped away from the insertion site;
– He/she should have provided peri care to the buttocks.
3. Review of Resident #48’s care plan, revised 5/9/18, showed:
– The resident had a history of [REDACTED].
– Provide proper peri care with incontinent episodes and as needed.
Review of the resident’s quarterly MDS, dated , 6/27/18, showed:
– Cognition severely impaired;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 9)
– Required extensive assistance of one staff for transfers and toilet use;
– Upper extremities impaired on both sides;
– Always incontinent of bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s urinalysis (UA, a test to analyze urine contents), results,
dated, 6/28/18, showed:
– The presence of bacteria indicative of a possible UTI.
Review of the resident’s urine culture and sensitivity (C & S, identifies the amount
and type of bacteria present and the medications appropriate to treat the infection)
report, dated, 6/28/18, showed:
– The presence of organisms indicative of a UTI.
Review of the resident’s physician order [REDACTED].
– Start date: 6/28/18; end date 7/1/18: Bactrim DS 800/160 milligrams (mg.) tablet, one
twice daily for UTI;
– Start date: 7/1/18; end date 7/2/18: [MEDICATION NAME] one gram injection daily for UTI;
– Start date: 7/2/18; end date 7/4/18: [MEDICATION NAME] one gram injection daily for UTI.
Observation on 7/26/18, at 1:10 P.M., showed:
– CNA B transferred the resident onto the toilet;
– CNA B removed the resident’s wet incontinent pad;
– After the resident had used the toilet, CNA B assisted the resident to stand;
– CNA B wiped once from front to back;
– CNA B wiped the rectal area, placed a clean incontinent pad on the resident, pulled up
his/her pants and transferred the resident into his/her wheelchair.
During an interview on 7/26/18, at 1:18 P.M., CNA B said:
– He/she should have cleaned all areas of the skin where urine had touched.
4. Review of Resident #45’s annual MDS, dated [DATE], showed:
– Cognitively impaired;
– Required staff assistance for toileting and hygiene;
– Had a urinary catheter;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 7/26/18 at 7:19 A.M. CNA C proving perineal care to the resident showed:
– He/she emptied the resident’s leg drainage bag.
– Without washing hands and changing gloves, he/she started catheter care.
– He/she cleaned around the base of the resident’s catheter.
– He/she did not clean the catheter tubing.
During an interview on 7/26/17 at 7:20 A.M. CNA C said:
– He/she should have washed his/her hands and changed gloves, prior to providing catheter
care.
– He/she should have cleaned the resident’s catheter tubing from the body out
approximately four inches.
During an interview on 7/27/18 at 9:04 A.M. and 10:00 A.M. the Director of Nursing said:
– Staff must always wash their hands and apply fresh gloves prior to performing catheter
care.
– Staff must always clean a resident’s catheter tubing starting at the insertion out (away
from) three to four inches.
– Staff should clean all areas of the skin where urine had touched;
– Even if the resident was standing, staff should still separate and thoroughly clean all
the perineal folds.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 10)
– Catheter care should include complete peri care;

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview the facility failed to ensure that as needed (PRN)
[MEDICAL CONDITION] drugs were limited to 14 days without physician document rationale for
extending any PRN [MEDICAL CONDITION] drugs past 14 days. This affected three out of 27
residents (Resident #9, #19, #52). The facility census was 64.
1. Review of Resident #19’s face sheet showed:
– admitted : 1/27/17;
– [DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 5/16/18, showed:
– Cognitively intact;
– Had four anti-anxiety medication in the last seven days.
Review of the resident’s care plan, revised, 7/19/18, showed:
– The resident used [MEDICAL CONDITION] drugs and was anxious at times;
– Approaches included pharmacy consultant review, review for continued need at least
quarterly, try gradual dose reduction yearly after first year unless contraindicated.
Review of the resident’s physician’s orders [REDACTED].
– an order for [REDACTED].
Review of the resident’s electronic chart (Echart) showed:
– No documentation or rationale from the physician to continue the use of PRN anti-anxiety
medication after 14 days.
2. Record review of resident #9’s quarterly MDS, dated [DATE] showed:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of residents POS dated (MONTH) (YEAR) showed:
-[MEDICATION NAME] .25 mg (for anxiety) every 8 hours as needed, start date of 2/4/18.
Review of residents medical record showed no documentation of rationale from the physician
to continue use of PRN anti-anxiety medication after 14 days.
3. Review of Resident #52’s quarterly MDS, dated ,[DATE], showed:
– Cognitively intact;
– Received antidepressant medications;
– [DIAGNOSES REDACTED].
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order dated 7/27/18 with an
end date open ended for [MEDICATION NAME] (used to treat anxiety), 0.25 milligrams every
eight hours as needed.
Review of the resident’s progress notes, showed the resident’s physician did not provide a
rationale for use of the medication beyond 14 days.
Review of the resident’s consultant pharmacist monthly drug regimen review for 8/1/17
though 7/12/18 showed the consultant pharmacist did not address the resident’s as needed
[MEDICATION NAME].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
During an interview on 7/25/18 at 8:25 A.M., the Director of Nurses said she had not put a
system in place for the physician to discontinue or document a rationale to continue the
use of PRN [MEDICAL CONDITION] medication after 14 days.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to ensure staff
administered medications (med) with a less than 5% medication error rate. Facility staff
made three medication errors out of 32 opportunities for error resulting in a medication
error rate of 9.38%. This affected three of 27 sampled residents (Resident #41, #26, #58)
The facility census was 64.
1. The facility policy on med administration, dated 1/9/2009, showed:
– Staff must follow manufacture’s recommendations for mixing medications.
– Staff must always administer the right dose of a medication.
– Staff must always administer medications at the right time.
2 Review of the [MEDICATION NAME] package insert, date 7/2/18, showed:
– The medication was used to treat constipation.
– The medication must be mixed with four to eight ounces of fluid.
Review of Resident #58’s physician order [REDACTED].
Observation on 7/25/18 at 10:00 A.M. of Certified Medication Technician (CMT) B showed
he/she mixed the medication with an unmeasured amount of water and gave the medication to
the resident.
Observation on 7/25/18 at 10:05 of CMT B showed he/she measured the water and found the
glass held three ounces.
During an interview on 7/25/18 at 10:05 A.M. CMT B said he/she should have placed the
[MEDICATION NAME] in at least four ounces of water.
3. Review of the package insert for Humalog insulin, dated 2012, showed:
– The medication was a fast acting insulin.
– The medication should be administered no more than 15 minutes before or immediately
after a meal.
– The most common side effect of the medication was low blood sugar which could be
life-threatening.
Review of Resident #26’s POS, dated (MONTH) 2019, showed an order for [REDACTED].
Observation on 7/25/18 of Licensed Practical Nurse (LPN) C showed:
– At 11:52 A.M. he/she administered to the resident Humalog 10 u sq.
– The resident then went to the dining room but did not receive any food or caloric
fluids.
– At 12:17 staff served the resident a glass of lemonade.
During an interview on 7/25/18 at 12:30 P.M. LPN C said he/she should have ensured the
resident ate within 15 minutes of administering Humalog.
4. Review of the package insert from Novalog flex pen, dated (YEAR), showed after applying
the needle to the Novalog Flex pen and before administering the medication to the
resident, staff must prime the needle with 2 u of insulin to clear the air from the
needle.
Review of Resident #41’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Observation on 7/25/18 at 12:09 P.M. of LPN administering medication to the resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
showed:
– He/she checked the resident’s blood sugar and found his/her blood sugar 114.
– Without priming the Novalog Flex pump, administered 40 u sq to the resident.
During an interview on 7/25/18 at 12:10 P.M. LPN D said he/she should have primed the pump
with 2 u before administering the insulin to the resident.
5. During an interview 7/27/18 at 10:00 A.M. the Director of Nursing said:
– Staff must always mix Miraralax in four to six ounces of water.
– Staff must always ensure resident eat within 15 minutes of administering short-acting
insulin.
– Staff must always prime the insulin needle before administering the insulin.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 observations, interviews, and record review, the facility failed to ensure staff
properly stored controlled substances (substances with a high probability abuse) which
affected two of 27 sampled residents, (Resident #6 and #48). The facility was 64.
1. Review of the facility’s stability and storage of medications policy, revised, 1/1/09,
showed:
– It did not address how staff should handle narcotic pain medication when the bubble pack
(a package enclosing medications in transparent dome-shaped plastic on a flat cardboard
backing), had been punctured.
2. Observation and interview on 7/24/18 at 2:34 P.M., of the north hall medication cart,
showed:
– Resident #48 had a bubble pack of [MEDICATION NAME] 5-325 milligrams (mg.), one every
four hours as needed during the night for pain;
– The bubble pack had four tablets which had been taped on the back with puncture holes
noted;
– The Quality Assurance (QA) Nurse said some of the staff have long fingernails and they
puncture the bubble pack, so the staff tape the back of the bubble pack.
3. Observation on 7/24/18 at 2:14 P.M. of Certified Medication Technician (CMT) B and CMT
C counting controlled substances showed Resident #6’s bubble pack of [MEDICATION NAME] (a
narcotic pain reliever) 5 milligrams (mg) / 325 mg with blister #19 torn the with of the
tablet inside.
During an interview on 7/24/18 at 2:15 P.M. both CMTs said they should discard any
medications behind torn blisters.
4. During an interview on 7/27/18, at 9:04 A.M., the Director of Nursing (DON) said:
– If the bubble pack had been punctured, staff should write it up to be destroyed;
– If it was a small hole, staff should get a second person to verify the medication and
put a colored sticker on it;

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 – Many

Based on observation and interview the facility failed to ensure they stored and prepared
food under sanitary conditions when staff stored food on the floor, failed to keep food
sealed, labeled, dated. Additionally, staff did not wash hands during meal service and
failed to wear beard nets when preparing and serving food. The facility census was 64.
1. Review of facility food storage policy, dated 11/2/2016 showed:
-All food will be stored on shelves;
– No food will be stored directly on any floor surface;
-All opened or prepared foods will be stored in air tight/sealable containers;
-All containers will be labeled and dated.
Observation on 07/24/18 at 9:06 AM in the kitchen showed the following:
-Walk in freezer had open bags of chicken strips and hash brown patties not dated;
– 3 bags of french fries, 2 bags of hash browns, and garlic bread used and not dated;
-Two large cans of applesauce on floor in pantry;
-Large fan covered in dust turned on and pointed in direction where clean dishes come out
of dishwasher.
Observation on 07/25/18 at 12:08 PM showed Dietary Aide A;
– Brought a food cart to north dining room;
– Without washing hands, applied gloves and picked up a grilled cheese and cut in halves;
-Handled plates, bread, and meal cards;
-Gave four crackers to resident and touched resident hands;
-Used tongs in one hand and other hand to scoop salad in individual bowls for residents;
-Grabbed buttered bread and put on plate;
– Continued to handle food throughout the meal service with the same pair of gloves and
without washing hands.
Observation on 7/25/18 at 9:45 A.M. showed the following:
-Dietary cook with a beard and goatee preparing lunch with no beard net;
-Fan still covered in dust blowing on clean dishes;
-Food still undated, not sealed, not labeled and used bag of chicken breast not dated in
walk in freezer;
-Back wall over three compartment dink and dishwashing area covered in various rust stains
and dust;
-Cook dishing plates for main dining room with beard and goatee and no beard net.
Observation on 7/26/18 at 7:08 AM showed Dietary manager dishing breakfast plates behind
steam table had a beard and no beard net on.
During an interview on 7/27/18 at 9:35 A.M., Dietary Supervisor said food should be off
the floor, sealed, dated. They have a weekly cleaning schedule, and maintenance is
responsible for cleaning the fan. They do have beard nets, but the cook since the cooks
beard was trimmed, did not need beard net.
During an interview on 7/27/18 at 10:16 A.M., Dietary Manager said food should be sealed,
labeled, and dated, and nothing stored on the floor. They have beard nets, but was told by
someone as long as their beard is not longer than eyebrow length, they do not need to wear
them.

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**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 14)
Based on observations, interviews, and record reviews, the facility failed to ensure staff
used proper hand washing techniques when going from soiled to clean tasks. This affected
four of 27 sampled residents (Residents #12, #41 #45 and #50). The facility also failed to
use proper infection control when using an insulin pen which affected one resident
(Resident #41). The facility census was 64.
1. Review of Resident #12’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/25/18, showed:
– Cognitively intact;
– Required staff assistance for hygiene and toileting;
– Occasionally incontinent of bladder;
– Frequently incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 7/25/18 at 10:08 A.M. of Certified Nurse Assistant (CNA) E and CNA F
providing perineal care for the resident showed:
– Using gloved hands, CNA E cleaned the resident who was soiled with fecal material.
– Without washing hands and changing gloves, he/she assisted the resident into his/her
wheelchair.
During an interview on 7/25/18 at 10:10 A.M. CNA E said he/she should have washed his/her
hands and changed gloves when going from soiled to clean tasks.
2. Review of Resident #45’s annual MDS, dated [DATE], showed:
– Cognitively impaired;
– Required staff assistance for toileting and hygiene;
– Had a urinary catheter (a sterile tube inserted into the bladder to provide for drainage
of urine);
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 7/26/18 at 7:19 A.M. CNA C providing perineal care to the resident showed:
– He/she emptied the resident’s catheter leg drainage bag.
– Without washing hands and changing gloves, he/she started catheter care.
– After providing catheter care and perineal care, without washing hands and changing
gloves, he/she applied barrier cream to the resident’s buttocks.
During an interview on 7/26/18 at 7:20 A.M. CNA C said:
– He/she should have washed his/her hands and changed gloves after emptying the resident’s
leg drainage bag.
– He/she should have washed his/her hands and changed gloves before starting catheter
care.
– He should have washed his/her hands and changed gloves before applying barrier cream to
the resident.
3. Review of the package insert for Novalog Insulin Flex Pen, dated 2008, showed prior to
inserting a needle on the rubber [MEDICATION NAME], staff must wipe off the [MEDICATION
NAME] with alcohol.
Observation on 7/25/18 at 11:55 A.M. Licensed Practical Nurse (LPN) D administering
insulin to Resident #41 using a Novalog Insulin Flex pen showed, without wiping the rubber
[MEDICATION NAME] with alcohol, he/she applied the needle and administered the resident’s
dose of insulin.
During an interview on 7/25/18 at 11:55 A.M. LPN D said when using the Novalog Insulin
Flex pen, he/she should have wiped the rubber [MEDICATION NAME] with alcohol prior to
inserting the needle.
During an interview on 7/27/18 at 10:00 A.M. the Don said staff should always wipe off the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 15)
rubber [MEDICATION NAME] of a Novalog Flex pen with alcohol before putting on the needle.
4. Review of Resident #41’s admission MDS, dated , 6/28/18, showed:
– Cognitively intact;
– Upper extremity impaired on one side;
– Lower extremity impaired on both sides;
– Occasionally incontinent of bladder;
– [DIAGNOSES REDACTED].
Observation on 7/26/18, at 6:48 A.M., showed:
– CNA A entered the resident’s room, did not wash his/her hands and did not apply gloves;
– CNA A uncovered the resident, placed the resident’s shoes and socks on him/her;
– CNA A assisted the resident to sit on the side of the bed;
– CNA A assisted the resident to transfer into his/her wheelchair;
– CNA A did not wash his/her hands and applied gloves, emptied the resident’s urinal,
removed gloves and did not wash his/her hands and left the resident’s room and entered
Resident #50’s room.
5. Review of Resident #50’s quarterly MDS, dated , 6/6/18, showed:
– Cognitively intact;
– Lower extremity impaired on both sides;
– Had a Foley catheter (sterile tube inserted into the bladder to drain urine);
– [DIAGNOSES REDACTED].
Observation on 7/26/18, at 7:01 A.M., showed:
– CNA A entered the resident’s room, did not wash his/her hands and applied gloves;
– CNA A removed pillows from between the resident’s legs, applied tube grip socks and
turned the resident onto his/her back;
– CNA A removed gloves, did not wash his/her hands and applied gloves;
– CNA A disconnected the drainage bag and connected the leg bag (a device used to hold and
collect urine), cleaned the catheter tubing (sterile tube inserted into the bladder to
drain urine);
– CNA A removed gloves, did not wash his/her hands and applied gloves;
– CNA A provided catheter care, applied [MEDICATION NAME] powder (topical powder used to
treat skin infections caused by yeast), and applied dry wipes to the resident’s groin,
removed gloves, did not wash his/her hands and applied gloves, placed the lift pad under
the resident, removed gloves, did not wash his/her hands and left the room.
During an interview on 7/26/18, at 1:26 A.M., CNA A said:
– He/she should have washed his/her hands when he/she entered the resident’s room, between
glove changes, before you leave the room and between clean and dirty tasks.
During an interview on 7/27/18, at 9:04 A.M. and 10:00 A.M., the DON said:
– Staff should sanitize when they entered the resident’s room, staff should wash their
hands if gloves are visibly soiled or if cleaning fecal material;
– Staff can sanitize between glove changes;
– Upon leaving the resident’s room, staff should hand sanitize or wash their hands.
– Staff should always hands and change gloves when going from soiled to clean tasks.
– Staff should always wash their hands and change gloves after emptying a resident’s
drainage bag.
– Staff should always wash their hands and change gloves before performing catheter care.
– Staff should always wash their hands and change gloves before applying barrier cream.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265800

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

07/27/2018

NAME OF PROVIDER OF SUPPLIER

GOWER CONVALESCENT CENTER, INC

STREET ADDRESS, CITY, STATE, ZIP

PO BOX 170, 323 SOUTH HIGHWAY 169
GOWER, MO 64454

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 0881

Level of harm – Potential for minimal harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program that includes antibiotic use protocols and a system to monitor
antibiotic use. This deficient practice had the potential to affect all residents in the
facility. The facility census was 64.
1. Record review showed the facility had not developed or implemented an Antibiotic
Stewardship Program that should include:
– Protocols to optimize the treatment of [REDACTED].
– Procedure to reduce the risk of adverse events, including the development of
antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use;
– Procedure to promote and implement a facility-wide system to monitor the use of
antibiotics including a system of reports related to monitoring antibiotic usage and
resistance data;
– Designated appropriate facility staff accountable for promoting and overseeing
antibiotic stewardship;
– Accessing pharmacists and others with experience or training in antibiotic stewardship;
– Implementation of a policy or practice to improve antibiotic use;
– Regular reporting on antibiotic use and resistance to relevant staff such as prescribing
clinicians and nursing staff;
– Educate staff and residents about antibiotic stewardship.
During a joint interview on 7/25/18 at 8:25 A.M., the Director of Nurses said she had a
thick stack of forms from Antibiotic Stewardship webinars, but had not yet gone through
and pulled out what she wanted to use for the facility. The Administrator said there was
no formal Antibiotic Stewardship policy in place for the facility, it is a work in
progress.