Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed to ensure staff
cared for residents in a dignified manner when they administered nasal sprays and an
inhaler in the dining room which affected three of 16 sampled residents, (Resident #2, #4
and #35). The facility census was 61.
1. Review of the facility’s social services policy, revised 5/1/18, showed, in part:
– Quality of life begins with the preservation of a sense of dignity and individuality.
2. Review of Resident #2’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/16/19, showed:
– Cognitive skills for daily decision making intact
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED]., for allergies [REDACTED].>Observation on 5/8/19, at 8:11
A.M., showed:
– The resident sat in his/her wheelchair in the dining room with other residents;
– Certified Medication Technician (CMT) B shook the bottle of [MEDICATION NAME] and
administered two sprays in each nostril of the resident.
4. Review of Resident #35’s admission MDS, dated [DATE], showed:
– Cognitive skills for daily decision making intact.
Review of the resident’s POS, dated (MONTH) 2019, showed:
– an order for [REDACTED].
Observation on 5/8/19, at 7:43 A.M., showed:
– The resident sat in the dining room at the table with another resident and other
residents also in the dining room;
– CMT A administered the nasal spray in the dining room.
5. Review of Resident #4’s quarterly MDS, dated [DATE], showed:
– Cognitive skills for daily decision making intact.
Review of the resident’s POS, dated (MONTH) 2019, showed:
– an order for [REDACTED].>Observation on 5/8/19, at 8:14 A.M., showed:
– The resident sat at the dining room table in his/her wheelchair with other residents in
the dining room;
– CMT B handed the resident his/her inhaler and instructed him/her to rinse his/her mouth
after use;
– The resident used his inhaler, took a drink of water, swished it around in his/her mouth
and swallowed it.
6. During an interview on 5/8/19, at 2:03 P.M., CMT A said:
– He/she should not administer the nasal sprays in the dining room;
– He/she should have administered it when the resident was in his/her room.
During an interview on 5/8/19, at 2:12 P.M., CMT B said:
– He/she should not administer inhalers or nasal sprays in the dining room;
– He/she should have administered them in the resident’s room.
During an interview on 5/9/19, at 3:09 P.M., the Director of Nursing (DON) said:
– Staff should not administer inhalers or nasal sprays in the dining room;
– Staff administer them in the resident’s room.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to and the facility must promote and facilitate resident
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to create an
environment respectful of the rights of a resident to make choices about significant
aspects of his/her life. The facility did not provide one of 16 sampled residents
(Resident #59) with 2XL (extra-extra large) size briefs to fit comfortably and made an
agreement with the resident for him/her to pay for 2XL briefs and the facility would pay
for cleansing wipes when the facility did not feel that briefs were a necessary item for
the resident to use for toileting. The facility census was 61.
1. Review of the facility’s Self-Determination policy dated 5/1/18, showed:
– To assure that the resident’s personal dignity, well-being, and self-determination is
maintained and to educate residents with respect to their rights and responsibilities in
this regard.
– The facility has established the Patient’s/Resident’s Bill of Rights and
Responsibilities in accordance with State and Federal regulations.
– The Patient’s/Resident’s Bill of Rights and Responsibilities will be communicated to the
residents in a language and/or by means of communication that ensures that the resident
understands these rights and will be recognized and supported by all facility staff
members at all times and will document that the information was provided.
– The facility will ensure residents can exercise his/her rights without interference,
coercion, discrimination, or reprisal from the facility.
– The facility must treat each resident with respect and dignity and care for each
resident in a manner that promotes, maintains, or enhances his/her quality of life,
recognizing each resident individually.
– On admission, each resident is informed of his/her rights and responsibilities and the
rules and regulations governing resident conduct and responsibilities orally and in
writing; the receipt of which will be acknowledged by the resident’s signature or legal
guardian’s signature.
2. Review of Resident #59’s care plan last updated on 2/13/19, showed:
– At risk for constipation related to history of constipation;
– Will have at least one soft formed stool every three days through the next review;
– Medications as ordered;
– Encourage food and fluids;
– Monitor and document bowel movements (BM) every shift;
– Provide incontinent care after each incontinent episode;
– Risk of bladder and bowel incontinence due to mobility and receipt of multiple bowel
medications;
– Provide urinal as needed, keep urinal clean and within reach;
– Required assist to safely meet activities of daily living (ADLs);
– Will have ADLs safely met with staff assist and risk of decline in ADLs will be
minimized;
– Provide assistance as needed to safely meet ADLs and toileting needs.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/23/19, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– Extensive assist of two or more staff for bed mobility and transfers;
– Extensive assist of one staff for toileting and personal hygiene;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
– Assist of one staff with transferring to bathe;
– Wheelchair;
– Steady at all times when moving from seated to standing position and for surface to
surface transfers;
– Moving on and off the toilet did not occur;
– Continent of urine and bowel;
– No diagnoses listed.
Review of the physician’s orders [REDACTED].
– [MEDICATION NAME] suppository 10 milligrams (mg), one rectally daily PRN (as needed) for
constipation;
– [MEDICATION NAME] 5 mg tablet, two tablets daily at bedtime (HS) for constipation;
– [MEDICATION NAME] sodium 100 mg, one tablet BID (twice daily) for constipation;
– Milk of magnesia suspension, 400 mg/5 milliliter (ml), 30 ml daily PRN for constipation;
– Diagnoses included: Muscle wasting, history of falls, abnormal gait and constipation;
– admitted : 1/14/19.
During an interview on 5/6/19, at 10:00 A.M., the resident said:
– He/she had always had problems with constipation.
– He/she did not use the toilet in his/her room because he/she had very large bowel
movements (BMs) and would clog the toilet each time.
– When he/she lived in the community, he/she would drive to the local hospital and use the
toilet in the waiting area because the toilets were powerful enough to flush the BM.
– He/she used briefs for toileting.
Review of a facility-generated Request for Incontinence Brief Exception, dated 5/8/19, and
written by Central Supply (CS) staff showed:
– Weight 368 pounds;
– Circumference of girth (of the waist) for appropriate sizing verification: 64 inches;
– Brief requested: 2XL briefs
– No diagnosis listed for use of briefs;
– Has the resident been trialed on a toileting program: Resident used the urinal; said
he/she leaks urine at times; used briefs to have BM because they are too large to go down
the toilet; offered a bariatric (obese) commode (larger than normal commode for bariatric
residents) but refused and said briefs were how he/she chose to have a BM.
During an interview on 5/7/19, at 3:26 P.M., the CS staff said:
– The facility orders briefs for residents in sizes small, medium, and large.
– The facility did not provide 2XL size briefs for Resident #59.
– In order to purchase bariatric (2XL) briefs, he/she had to go through the corporate
office to order those, and a continence form needed to be filled out for the resident.
– The resident complained about the facility not providing the briefs a lot.
– The resident is not incontinent and did not qualify for use of briefs for just BMs.
– The resident would not use the toilet because his/her BMs clog the toilet.
– Staff offered him/her a bariatric commode but he/she did not want to use the bedside
bariatric commode.
– The facility provided XL briefs but the resident said the briefs did not fit and caused
pain when he/she wore them.
– The facility provided briefs for all other residents who needed briefs.
– Corporate said the resident needed to fill out a continence form but it was not filled
out at the time of admission.
– The facility did not order the 2XL size because he/she did not meet the criteria for the
questions of incontinence.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
– Corporate said they would not order the briefs.
– He/she did not have documentation of an incontinence questionnaire for the resident.
During an interview on 5/7/19, at 4:00 P.M., the Community Liaison said:
– She and other administrative staff look at the needs of a resident when the facility
received a referral for admission.
– At the time of the resident’s admission, he/she was not getting out of bed; he/she is
more active now.
– He/she is now covered by Medicaid and Medicaid paid for stay, medications, and personal
health items.
– The facility paid for briefs.
– She spoke with the resident about a bigger size of brief, but he/she wore a different
type than the facility ordered and he/she said he/she would take care of buying the
briefs.
– The facility would not deny to pay for briefs for the resident.
– The facility did not have what he/she wanted to wear.
– She did not know about an incontinence sheet that needed to be completed before briefs
were purchased for residents.
– Briefs are not a medical necessity.
– If he/she needed a larger size of brief, the facility should provide, but he/she wanted
a specific type of brief that the facility could not order.
During an interview on 5/7/19, at 4:45 P.M., the resident said:
– He/she bought Tena 2XL briefs to use.
– The facility was supposed to have the right brief for him/her when he/she admitted .
– The briefs they provided were too small, too tight and hurt him/her; he/she just could
not wear them.
– The facility said they only buy the ones they gave him/her and would not buy any other
briefs.
– He/she would be willing to try briefs the facility purchased in they were large enough
(2XL) and fit him/her.
– He/she had a bladder leakage problem and used the urinal but would dribble.
– He/she had a bowel problem and chronic constipation with horrendous amounts of BM that
plugs up a toilet.
– He/she never filled out a form related to use of briefs.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing (DON) said:
– The facility provided briefs for all residents who require them.
– Briefs should be provided if a resident needed them.

F 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to organize and participate in resident/family groups in the
facility.

Based on observation, record review and interview, the facility failed to consider
concerns and recommendations of the resident council members and failed to communicate
with the council regarding concerns as reported by all 13 residents who participated in a
group interview. This had the potential to affect all residents of the facility. The
facility census was 61.
1. Review of the facility’s Complaints and Grievances Process policy, dated 5/1/18,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
showed:
– The facility’s leadership will support the resident’s right to voice
complaints/grievances to the facility or other agencies or entity that hears grievances
regarding concerns they have about services and treatment received including but not
limited to treatment, care, failure to follow advanced directives, failure to provide
information related to returning to the community, funds, lost articles, behavior of other
residents and staff, violation of rights and environmental issues.
– The facility will identify a Grievance Official who is responsible for overseeing the
grievance process, receiving and tracking grievances through their conclusion and leading
the investigation, maintaining confidentiality of all information associated with the
grievance.
– Honor the right to obtain a written decision regarding the grievance.
– After receiving the grievance/complaint, the facility’s leadership will promptly seek a
problem resolution and will keep the resident informed of the progress toward resolution.
2. During the Resident Council meeting and interview with surveyors on 5/7/19, at 1:26
P.M., all residents said:
– Staff did not report back with answers/resolutions to concerns which the council members
presented at monthly council meetings.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing (DON) said:
– Resident council members complain about many things.
– Staff have to be invited to their meetings.
– If there is a concern, the concern was addressed with the department involved.
– She was not sure if her fixes were being communicated back to the resident council
members after she gave them to the Activity Director (AD).
– All department heads give their answers to the AD to report, but she does not get the
information to the members.

F 0577

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on observation, record review and interview, the facility failed to post the most
recent survey results in a prominent place readily accessible to residents. This had the
potential to affect all residents. The facility census was 61.
1. Review of the Federal regulation ?483.10 (g) (10) showed:
– The resident has the right to examine the results of the most recent survey of the
facility conducted by Federal or State surveyors and any plan of correction in effect with
respect to the facility.
During the Resident Council meeting and interview with surveyors on 5/7/19, at 1:26 P.M.,
all residents said:
– They were not aware of a book that posted the most recent facility survey results.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing said:
– The results of the last survey are in a notebook kept in the sitting room at the front
of the facility.
– Residents should be able to access the book if they go to the front of the facility.
During the exit conference on 5/9/19, at 5:00 P.M., the Administrator said:
– The survey results are kept in a book in the front sitting area of the facility.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0577

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– The residents would have a long way to travel to get to the front sitting room to look
at the survey results.

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
documented transfer information to include why a resident was transferred, physician and
responsible parties notified, contact information for the practitioner and responsible
parties, and other pertinent information to the receiving facility which affected three of
16 sampled residents (Resident #7, #21 and #112) when they were transferred to the
hospital. This had the potential to affect all residents of the facility. The facility
census was 61.
1. The facility did not provide a policy to show needed documentation in the medical
record when a resident was transferred to a hospital.
2. Review of Resident #21’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/28/18, showed:
– Short- and long-term memory problems;
– Severely impaired cognition, not able to make own decision;
– Extensive assist of two or more staff for bed mobility, transfers, eating, and
toileting;
– Wheelchair;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of a progress note, dated 2/8/19 showed:
– No documentation of information sent with resident to the hospital when he/she was
admitted for chest pain; transfer sheet, medication record, Advanced Directive if any, or
bed hold
Review of a Progress Note, dated 2/22/19, at 4:08 P.M., showed:
– PEG tube (surgically inserted tube into the stomach to provide liquid nourishment,
fluids, and medications), draining liquid that smelled like fecal material;
– Son requested resident to be sent to the hospital regardless of what the physician said;
– Sent to hospital at 5:15 P.M. by ambulance;
– No documentation of information sent with resident to the hospital, transfer sheet,
medication record, Advanced Directive if any or bed hold letter to the son;
– No call to the receiving facility with pertinent information documented.
3. Review of Resident #112’s demographic sheet showed:
– admitted [DATE].
Review of a progress note, dated 4/22/19, at 5:20 P.M., showed:
– Resident had large amount of emesis (vomiting of stomach contents) three times;
– Orders to send to the emergency room ;
– No documentation of information sent with resident to the hospital; transfer sheet,
medication record, Advanced Directive if any, or bed hold letter;
– admitted with pneumonia, fluid to lungs, [MEDICAL CONDITION], elevated lab values, low
potassium level, and a urinary tract infection [MEDICAL CONDITION].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
Review of the readmission MDS, dated [DATE], showed:
– A Brief Interview for Mental Status (BIMS) score of 14, which indicated he/she made
his/her own decisions;
– Urinary catheter (a sterile tube inserted into the urinary bladder to drain urine);
– Antibiotics for three days;
– [DIAGNOSES REDACTED]. UTI was not listed as a diagnosis.
4. Review of Resident #7’s progress note, dated 1/12/19, at 1:41 P.M., showed:
– Suctioned large amount thick white mucous from resident.
Review of a progress note, dated 1/12/19, at 2:45 P.M., showed:
– Sent to the emergency room for decrease loss of consciousness, oxygen saturation (oxygen
in the blood stream) 64% (normal 96-100%), respiratory distress, and heart rate 120 beats
per minute (normal 80-88);
– No documentation of information sent with resident to the hospital; transfer sheet,
medication record, Advanced Directive if any, or bed hold letter.
Review of a hospital consult note, dated 1/12/19, showed:
– admitted for choking, and gram positive cocci bacteremia (bacterial infection of the
lungs);
– Currently on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics).
Review of the five-day MDS, dated [DATE], showed:
– Medically complex conditions, high blood pressure, pneumonia, dementia, and depression;
– Short- and long-term memory problems;
– Severely impaired cognition, not able to make own decisions.
5. During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing (DON) said:
– Staff should document why a resident was sent to the hospital, note medical information
sent with resident to the hospital and a bed hold letter should be sent with the resident.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided written notice of transfer or discharge to residents or their responsible party
and the reasons for the transfer in writing in a language they understood. The facility
must send a copy of the notice to a Representative of the Office of the State Long-Term
Care Ombudsman. This affected three of 16 sampled residents (Resident #7, #21 and #112).
The facility census was 61.
1. Review of the facility’s policy and State requirements for a temporary leave/bed-hold,
dated September, 2009, showed:
– If a resident leaves the facility on a temporary basis for medically necessary inpatient
hospitalization or therapeutic leave (visits home with family or friends), the resident or
his/her legal representative may ask the facility to hold the resident’s bed open and the
facility will hold the bed as outlined herein bed-hold.
– The resident and/or his/her representative will be given a copy of the facility’s
bed-hold policy before the resident actually leaves for his/her temporary leave or
hospitalization .
– In the case of an emergency hospitalization , the bed hold policy may accompany the
resident to the hospital or it will be given to the resident or his/her representative

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
within 24 hours of the resident’s hospitalization .
Review of the Social Services Policies and Procedures Bed-Hold policy, dated 5/1/18,
showed:
– Facility staff will provide each resident or their legal representative with the
facility’s written bed-hold policy at the time of admission and each time the resident
leaves the facility for hospitalization or therapeutic leave.
– The facility will re-admit the resident according to the facility’s bed-hold policy and
applicable State and Federal guidelines.
– Written notice of the facility’s bed-hold is provided on admission and at the actual
time of the transfer for hospitalization or therapeutic leave.
– In the case of an emergency hospitalization , the bed hold policy may accompany the
resident to the hospital or it will be given to the resident or his/her representative
within 24 hours of the resident’s hospitalization .
2. Review of Resident #21’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/28/18, showed:
– Short- and long-term memory problems;
– Severely impaired cognition, not able to make own decision;
– Extensive assist of two or more staff for bed mobility, transfers, eating, and
toileting;
– Wheelchair;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of a progress note, dated 2/8/19, showed:
– No documentation of the bed-hold letter sent with the resident when he/she was admitted
to the hospital with [REDACTED].
Review of a progress note, dated 2/22/19, at 4:08 P.M., showed:
– PEG tube (surgically inserted tube into the stomach to provide liquid nourishment,
fluids, and medications), draining liquid that smelled like fecal material;
– Son requested resident to be sent to the hospital regardless of what the physician said;
– Sent to hospital at 5:15 P.M. by ambulance.
3. Review of Resident #112’s demographic sheet showed:
– admitted [DATE].
Review of a progress note, dated 4/22/19, at 5:20 P.M., showed:
– Resident had large amount of emesis (vomiting of stomach contents) three times;
– Orders to send to the emergency room ;
– admitted with pneumonia, fluid to lungs, [MEDICAL CONDITION], elevated lab values, low
potassium level, and a urinary tract infection [MEDICAL CONDITION];
– No documentation of the bed-hold letter sent with the resident.
Review of the readmission MDS, dated [DATE], showed:
– A Brief Interview for Mental Status (BIMS) score of 14, which indicated he/she made
his/her own decisions;
– Urinary catheter (a sterile tube inserted into the urinary bladder to drain urine);
– Antibiotics for three days;
– [DIAGNOSES REDACTED]. UTI was not listed as a diagnosis.
4. Review of Resident #7’s progress note, dated 1/12/19, at 1:41 P.M., showed:
– Suctioned large amount thick white mucous from resident.
Review of a progress note, dated 1/12/19, at 2:45 P.M., showed:
– Sent to the emergency room for decrease loss of consciousness, oxygen saturation (oxygen
in the blood stream) 64% (normal 96-100%), respiratory distress, and heart rate 120 beats
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
per minute (normal 80-88);
– No documentation of the bed-hold letter sent with the resident.
Review of a hospital consult note, dated 1/12/19, showed:
– admitted for choking, and gram positive cocci bacteremia (bacterial infection of the
lungs);
– Currently on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics).
Review of the five-day MDS, dated [DATE], showed:
– Medically complex conditions, high blood pressure, pneumonia, dementia, and depression;
– Short- and long-term memory problems;
– Severely impaired cognition, not able to make own decisions.
5. During an interview on 5/9/19, at 8:33 A.M., previous Social Service Designee (SSD) A
said:
– She was the SSD from February, 2019, until two weeks ago.
– She was never told to send letters to the resident or the responsible party about the
reason for the transfer/discharge to the hospital or bed-hold policy.
– She was never told these letters and bed-hold policy needed to be sent to the State
Ombudsman’s office.
– She never sent any letters to the resident or responsible party or the State Ombudsman’s
office related to any transfers/discharges of residents when they were sent to the
hospital or for therapeutic leave.
During an interview on 5/9/19, at 9:08 A.M., the Administrator said:
– He learned about the 30 day bed-hold letter with transfers/discharges last week.
– He was in the process of instituting this process, but it had not been initiated by
staff at this time.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing (DON) said
– The 30 day bed-hold letters should go out to the resident/responsible party and the
Ombudsman.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff completed a
Level I (indicated for any individual who may have an intellectual disability (ID),
developmental disability (DD), or mental illness (MI)).The affected two of 16 sampled
residents (Resident #60 and #11). The facility census was 61.
1. Review of the facility’s PASARR (Preadmission Screening and Resident Review, a federal
requirement to help ensure that individuals are not inappropriately placed in nursing
homes for long term care) Documentation policy, dated 5/1/18, showed:
– PASARR is a federal requirement to help ensure that individuals who have a mental
disorder or intellectual disability are not inappropriately placed in nursing facilities
for long-term care.
– PASARR requires that all applicants to a Medicaid-certified facility be evaluated for a
serious mental disorder and/or ID; be offered the most appropriate setting for their needs
(in the community, a nursing facility, or acute care setting); and receive the services
they need in those settings.
– Any individual seeking admission to a Medicaid certified facility receives a PASARR
Level I screening for any ID, DD, or MI diagnosis, follows the state-specific process for

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
completion of the Level II evaluation.
– If the Level II evaluation confirms the ID, DD, or MI diagnosis, the facility
collaborates with local resources when special services are necessary or required.
– If special services are required, the facility will coordinate services per State policy
and develop a care plan that addresses specific needs.
2. Review of Resident #11’s medical record showed:
– Payer source: Medicare and Medicaid;
– [DIAGNOSES REDACTED].
– No Level I PASARR in the record.
Review of the care plan, dated 3/10/19, showed:
– [MEDICAL CONDITION] drug use;
– At risk for adverse consequences related to [MEDICAL CONDITION] medications for
treatment of [REDACTED].
– Assess/record effectiveness of drug treatment, monitor and report adverse signs and
symptoms related to the medications;
– Monitor mood and response to medications;
– Monitor for restlessness and/or increased agitation.
During an interview on 5/7/19, at 3:50 P.M., the Business Office Manager said:
– She did not have a Level I PASARR for Resident #11 and did not know why.
– She did not know all Medicaid recipients should have a Level I PASARR when admitted .
– Resident #11’s payer source was Medicare/Medicaid.
– He/she came from another facility and they should have sent the PASARR.
– She never asked them to send a copy for the resident.
3. Review of Resident #60’s medical record showed:
– Pay source: Medicaid and Medicare;
– [DIAGNOSES REDACTED].
– Did not have a Level I PASARR in the medical record.
Review of the resident’s care plan, revised 4/25/19, showed:
– The resident was admitted from a behavior unit, status [REDACTED].
– At risk for adverse consequences related to receiving antipsychotics with [DIAGNOSES
REDACTED].
– Quantitatively and objectively document the resident’s mood. Monitor for crying,
delusions, agitation, self-isolation and increased pacing;
– Assess and record effectiveness of drug treatment.
During an interview on 5/7/19, at 3:50 P.M., the Business Office Manager (BOM) said:
– The resident came from another facility and she did not know where the resident’s PASARR
was located;
– She should have asked for it from the other facility but did not.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 observation, interview and record review, the facility failed to ensure staff
developed, implemented and updated a comprehensive, person centered care plan that
included measurable objectives to meet the resident’s needs, conditions, and risks for
three of 16 sampled residents (Resident #23, #60 and #112). The facility census was 61.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Some

(continued… from page 10)
1. Review of the facility’s Person Centered Care Plan Process policy, dated 7/1/16,
showed:
– The facility will develop and implement a baseline and comprehensive care plan for each
resident that includes the instructions needed to provide effective and person centered
care of the resident that meet professional standards of quality care.
– The care plan should include measurable objectives and timeframes to meet a resident’s
medical, nursing, and mental and psychosocial needs that are identified in the
comprehensive assessment.
– The care plan will include: Date; problem; resident goal for admission and desired
outcomes; time frames for achievement, interventions, discipline specific services and
frequency; refusal of services, evaluation of resident’s decision making capacity,
educational attempts, attempts to find alternative means to address the identified
risk/need; discharge plans, preference and potential for future discharge, desire to
return to the community and any referrals to local contact agencies and/or other
appropriate entities for this purpose; and resolution/goal analysis.
2. Review of Resident #23’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/19/18, showed:
– No cognitive status recorded;
Wandering not exhibited;
– Locomotion on unit supervision of one staff;
– Walk in room and in corridor, supervision of one staff;
– Wheelchair;
– [DIAGNOSES REDACTED].
– Care Area Assessments (CAAs, assessment of care areas needed to be care planned) did not
include behavior of wandering.
Review of a nursing progress note, dated 4/3/19, at 5:40 A.M. showed:
– Resident had repeatedly been wandering without his/her walker; encouraged to use walker
for safety reasons;
– Easily redirected.
Review of a nursing progress note, dated 4/7/19, at 6:43 A.M., showed:
– Two short incidences of wandering without his/her walker;
– Easily redirected.
Review of a nursing progress, note dated 5/2/19, at 6:49 P.M., showed:
– Resident continued to be exit seeking, opened exit doors;
– Redirected with fair results.
Review of a nursing progress note, dated 5/8/19, at 2:01 A.M., showed:
– Resident roaming hallways with coat on, looking for a way to leave facility at 1:30
A.M.;
– Redirected to room, toileted, and clothing changed without difficulty;
– Resident out of room roaming the hallway again and headed to the 300 hallway looking for
a door to leave according to the resident;
– Administered [MEDICATION NAME] and a snack with a drink;
– Currently sitting in TV area by 100 nurses’ desk.
Review of the care plan last updated on 5/5/19, by the Director of Nursing (DON) showed:
– Resident will ambulate throughout the facility with the use of a walker daily;
– Impaired decision making;
– No care plan for wandering, roaming hallways, or exit seeking.
During an interview on 5/7/19, at 3:50 P.M., the MDS/Care Plan Coordinator said:
– The resident did not wander and she did not record it on the most up to date MDS.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Some

(continued… from page 11)
During an interview on 5/9/19, at 3:06 P.M., the DON said:
– Wandering should be care planed for the resident.
3. Review of Resident #112’s admission MDS, dated [DATE], showed:
– A Brief Interview of Mental Status (BIMS) score of 14 which indicated he/she made his
her own decisions;
– Extensive assist of two or more staff for bed mobility and transfers;
– Extensive assist of one staff for toileting;
– Balance during transition and walking- steady at all times with seated to standing
position and surface to surface transfers (bed to chair);
– Oxygen therapy;
– [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], pneumonia, and urinary tract infection
[MEDICAL CONDITION], elevated lab values, and low potassium level were not addressed as
noted in last hospitalization of 4/24/19.
Review of a nursing progress note, dated 4/22/19, showed:
– Contacted the emergency room for resident status;
– admitted for pneumonia, [MEDICAL CONDITIONS], elevated lab values, low potassium level,
and UTI.
Review of the care plan last updated on 5/6/19, showed:
– Care plan did not address use of the gait belt with transfers;
– Did not address pneumonia, UTI, [MEDICAL CONDITIONS], elevated lab values or low
potassium level.
During an interview on 5/8/19, at 3:56 P.M., the MDS Coordinator said:
– She was responsible for updating care plans quarterly, annually, and with a significant
change.
– Nurses can update with issues when they occur and she would add to the care plan as
necessary.
3. Review of the resident’s care plan, revised 4/25/19, showed:
– The resident was at risk for decreased cardiac output related to changes in [MEDICAL
CONDITION] contractility due to [DIAGNOSES REDACTED].
– Monitor oxygen saturation as needed;
– The care plan did not address the use of oxygen.
Review of the physician order [REDACTED].
– The resident did not have an order for [REDACTED].>Observation and interview on
5/6/19, at 9:42 A.M., showed:
– The oxygen concentrator was turned on at 3 liters per nasal cannula (L/NC);
– The resident said he/she used the oxygen during the night.
During an interview on 5/9/19, at 7:37 A.M., Certified Nurse Aide (CNA) A said:
– The resident mainly used his/her oxygen during the night.
During an interview on 5/9/19, at 2:21 P.M., the MDS Coordinator said:
– The resident should have an intervention for oxygen on his/her care plan.
During an interview on 5/9/19, at 3:09 P.M., the DON said:
– The care plan should address if the resident used oxygen.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
Based on observation, interview and record review, the facility failed to ensure staff
developed and updated a care plan consistent with a resident’s specific condition and
needs which affected one of 16 sampled residents (Resident #24). The facility census was
61.
1. Review of the facility’s Person Centered Care Plan Process policy, dated 7/1/16,
showed:
– The facility will develop and implement a baseline and comprehensive care plan for each
resident that includes the instructions needed to provide effective and person centered
care of the resident that meet professional standards of quality care.
– The care plan should include measurable objectives and timeframes to meet a resident’s
medical, nursing, and mental and psychosocial needs that are identified in the
comprehensive assessment.
– The care plan will include: Date; problem; resident goal for admission and desired
outcomes; time frames for achievement, interventions, discipline specific services and
frequency; refusal of services, evaluation of resident’s decision making capacity,
educational attempts, attempts to find alternative means to address the identified
risk/need; discharge plans, preference and potential for future discharge, desire to
return to the community and any referrals to local contact agencies and/or other
appropriate entities for this purpose; and resolution/goal analysis.
2. Review of Resident #24’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/4/19, showed:
– A Brief Interview for Mental Status (BIMS) score of 12, which indicated supervision
needed for decision making;
– At risk for pressure ulcer (PU) development;
– One Stage III (a full thickness skin break into the subcutaneous tissue, but does not go
into the muscle or bone);
– No record of a wound to the right third toe.
Review of the care plan last updated on 4/5/19, by the MDS coordinator, showed:
– 2/3/19: PU to the right ankle [MEDICAL CONDITION] (a bacteria resistant to antibiotics
and hard to heal);
– 2/3/19: Bactrim DS (an antibiotic) for treatment of [REDACTED].>- Right third toe PU
not care planned.
Review of the physician’s orders [REDACTED].
– No order for Bactrim DS.
Review of the previous wound team’s note, dated 5/2/19, showed:
– Wound to right third toe is eschar covered full thickness and has received a status of
not healed.
Review of the new wound clinic’s notes, dated 5/8/19, showed:
– Right third toe: 0.2 centimeters (cm) long x 0.4 cm wide x 0.1 cm deep;
– Right lateral ankle: 0.8 cm long x 0.6 cm wide x 0.1 cm deep.
During an interview on 5/8/19, at 2:59 P.M., the Director of Nursing (DON) said:
– There have been changes in the resident’s wound and wound care.
During an interview on 5/8/19, at 3:25 P.M., the MDS Coordinator said:
– The resident’s wound gets better then worsens.
– He/she saw wound team last week and was sent to vascular surgeon today.
– Vascular surgeon said the wound is not vascular and sent him/her to the hospital wound
clinic for further treatment.
– New orders received.
– The wound to the right third toe is healing.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
– She needed to update the care plan with wound and treatment information.
– The resident no longer [MEDICAL CONDITION] in the wound, but the infection was never
care planned and should have been.
During an interview on 5/9/19, at 3:06 P.M., the DON said:
– Wounds, wound changes, and treatments should be care planned.

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 observations, interviews and record review, the facility failed to ensure staff
provided services that meet professional standards of quality when staff failed to
administer [MEDICATION NAME] nasal spray (used to treat seasonal allergies [REDACTED].#2
and #35) and preset medications. The facility census was 61.
1. Review of the facility’s medication policy, dated 11/1/17, showed, in part:
– The facility will provide medication administration in accordance with accepted
professional standards and principles including the various practice regulations in each
state, and current commonly accepted health standards established by national
organizations, boards, and councils;
– The authorized staff member or licensed nurse will only prepare one resident’s
medications at a time;
– Pre-pouring medications is NOT an acceptable or safe practice.
2. Review of the manufacturer’s guidelines for [MEDICATION NAME] nasal spray showed, in
part:
– Blow your nose to clear your nostrils;
– Close one nostril. Tilt your head forward slightly and keeping the bottle upright,
carefully insert the nasal applicator into the other nostril;
– Start to breath in through your nose, and while breathing in press firmly and quickly
down once on the applicator to release the spray;
– Repeat in the other nostril.
3. Review of Resident #2’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/16/19, showed:
– Cognitive skills for daily decision making intact.
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED]., for allergies [REDACTED].>Observation on 5/8/19, at 8:11
A.M., showed:
– The resident sat in his/her wheelchair in the dining room;
– Certified Medication Technician (CMT) B shook the bottle of [MEDICATION NAME] and
administered two sprays in each nostril of the resident;
– CMT B did not have the resident blow his/her nose and did not hold one side of the
resident’s nostril.
During an interview on 5/8/19, at 2:12 P.M., CMT B said:
– He/she should follow the manufacturer’s guidelines or what is on the prescription label
for the [MEDICATION NAME].
4. Review of Resident #35’s admission MDS, dated [DATE], showed:
– Cognitive skills for daily decision making intact.
Review of the resident’s POS, dated (MONTH) 2019, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 14)
– an order for [REDACTED].
Observation on 5/8/19, at 7:43 A.M., showed:
– The resident held one side of his/her nostril and CMT A administered one squirt into the
resident’s nostril and repeated in the other nostril;
– CMT A did not shake the bottle and did not have the resident blow his/her nose.
During an interview on 5/8/19, at 2:03 P.M., CMT A said:
– He/she was not taught to have the resident blow his/her nose or to follow the
manufacturer’s guidelines.
5. Observation on 5/8/19, at 7:41 A.M., showed;
– CMT A opened the top drawer of his/her medication cart and had a clear plastic
medication cup with multiple pills in the cup with a resident’s first name written on the
side of the cup with a black marker;
– CMT A administered medications to other residents and left the cup in the top drawer
during the medication pass.
During an interview on 5/8/19, at 2:03 P.M., CMT A said:
– He/she should not have pre set the medications.
6. During an interview on 5/9/19, at 3:09 P.M., the Director of Nursing (DON) said:
– Staff should not pre pop or pre set medications.
– She expected staff to follow the manufacturer’s guidelines when administering nasal
sprays.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation, interview and record review, the facility failed to ensure dependent
residents who were unable to carry out activities of daily living (ADLs) received the
necessary services to maintain good personal hygiene when staff did not provide complete
perineal care, which affected one of 16 sampled residents (Resident #163). The facility
census was 61.
1. Review of the facility’s perineal care/incontinent care policy, revised 7/1/16, showed,
in part:
– Staff will perform perineal/incontinent care with each bath and after each incontinent
episode;
– Separate the skin folds and wash downward from the pubic area toward rectum in one
smooth stroke;
– Use a separate section of cloth for each stroke;
– Retract skin fold from thigh, washing carefully in skin folds from perineum to rectum;
repeat on opposite side using separate section of wash cloth;
– Assist the resident to assume side lying position;
– Clean anal area by first wiping off excessive fecal material with toilet paper or
disposable wipes (for females, wash by wiping from vagina toward anus with one stroke).
Discard soiled wipes;
– Cleanse skin with incontinent wipe or perineal cleanser and cloths until skin is clear
of fecal material.
2. Review of Resident #163’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/2/19, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Few

(continued… from page 15)
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility, transfers and toilet use;
– Upper and lower extremities impaired on one side;
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, revised 5/7/19, showed:
– The resident experienced bladder incontinence related history of stroke and dependent on
staff for ADLs and transfers;
– Provide incontinence care after each incontinent episode.
Observation on 5/8/19, at 9:54 A.M., showed:
– Certified Nurse Aide (CNA) A and CNA B used the mechanical lift and transferred the
resident from his/her wheelchair to the bed;
– CNA A and CNA B pulled the resident’s pants down and the wet incontinent brief between
the resident’s legs;
– CNA A wiped across the abdominal folds twice with a different wipe each time;
– CNA A pulled up but did not separate the perineal folds and wiped down the middle six
times with a different wipe each time;
– CNA A and CNA B turned the resident on his/her side;
– CNA A wiped down the right side of the buttocks with one wipe;
– CNA A used a new wipe and wiped down the resident’s leg;
– CNA A used a new wipe and wiped down the right buttock again;
– CNA A used a new wipe and wiped the rectal area;
– CNA A and CNA B turned the resident to the other side;
– CNA B removed the wet incontinent brief;
– CNA A and CNA B put a clean brief on the resident;
– CNA A and CNA B did not clean all areas of the skin where urine had touched and wiped in
the wrong direction.
During an interview on 5/8/19, at 3:00 P.M., CNA A said:
– When cleaning the buttocks, should have cleaned from the cleanest to the dirtiest;
– He/she should have wiped up and away from the perineal area;
– He/she should have cleaned both sides of the buttocks.
During an interview on 5/9/19, at 3:09 P.M., the Director of Nursing (DON) said:
– Staff should clean all areas of the skin where urine or fecal material has touched the
skin;
– Staff should wipe from front to back.

F 0689

Level of harm – Minimal harm or potential for actual harm

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 ensure staff
used proper techniques to reduce the possibility of accidents and injuries when
transferring one of 16 sampled residents (Resident #163) during the use of a mechanical
lift and during a gait belt (a safety device and mobility aid used to provide assistance
during transfers, ambulation or repositioning) transfer, which affected two sampled
residents (Resident #54 and #112). The facility census was 61.
1. Review of the facility’s mechanical lift policy, revised 7/1/16, showed:
– Residents will be assisted with their activities of daily living (ADLs) per facility

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Few

(continued… from page 16)
standard, utilizing lifts according to manufacturer’s guidelines.
Review of the facility’s Gait Belt policy, dated 7/1/16, showed:
– Each resident will be issued a gait belt at admission when the resident requires hands
on assistance to ambulate or transfer and will be kept in the resident’s room.
– Each nursing employee will be trained in proper use of the gait belt.
– Properly place wheelchair, chair, etc., at angle close to bed on unaffected side, remove
foot pedals of wheelchair, lock or brace chair or other seating device to prevent slippage
during transfer.
– Always use gait belt when the resident requires hands on assistance to ambulate or
transfer.
– Always place belt around waist in soft tissue, with buckle in front, and never over the
ribs, hip bones, or breasts with buckle at front of resident.
– Always have belt applied snugly so there is no possibility of it sliding up over ribs,
never loosely.
– Always place belt over clothing or some type of covering, never on bare skin.
– Bed to chair transfers: Always assist the resident from the affected side.
– Have resident come to a sitting position.
– Grasp belt with both hands; one on each side to the resident’s waist.
– Brace the resident’s knees with your knees as necessary; brace feet at the same time.
– Instruct resident to grasp wheelchair arm and lean forward slightly.
– Stand up by pushing up from chair.
– Firmly guide resident as necessary and allow resident to gain balance.
– Have resident to pivot toward bed or chair.
– Assist resident to sit, remove belt and assist to a comfortable position
Review of the manufacturer’s guidelines for the Joerns Hoyer lift, showed, in part:
– When lifting, the castors should be left free and un-braked;
– The lift will then be able to move to the center of gravity of the lift;
– If the brakes are applied, it is the resident that will swing to the center of gravity
and this may prove disconcerting and uncomfortable.
2. Review of Resident #163’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/2/19, showed:
– Cognitive skills for daily decision making intact;
– Required extensive assistance of two staff for bed mobility, transfers and toilet use;
– Upper and lower extremity impaired on one side;
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, revised 5/7/19, showed:
– The resident was at risk for falling related to bilateral weakness and history of
stroke;
– Transfers with the Hoyer lift.
Observation on 5/8/19, at 9:54 A.M., showed:
– Certified Nurse Aide (CNA) A and CNA B entered the resident’s room with the mechanical
lift;
– CNA B opened the legs of the lift and placed it around the resident’s locked wheelchair
and locked the right rear brake on the mechanical lift;
– CNA B used the mechanical lift and transferred the resident to his/her bed;
– CNA B locked the right rear brake on the mechanical lift and lowered the resident onto
the bed;
– After CNA A and CNA B provided incontinent care, CNA B placed the mechanical lift under
the resident’s bed and locked the right rear brake;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Few

(continued… from page 17)
– CNA B transferred the resident to his/her unlocked wheelchair, locked the right rear
brake and lowered the resident into his/her wheelchair.
During an interview on 5/8/19, at 3:00 P.M., CNA B said:
– The mechanical lift should bed locked when stationary;
– He/she locked the right side of brake when raising and lowering the resident.
During an interview on 5/9/19, at 3:09 P.M., the Director of Nursing (DON) said:
– Staff should not lock the rear casters on the mechanical lift.
3. Review of Resident #54’s admission MDS, dated [DATE], showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility and transfers;
– Limited assistance of two staff for toilet use;
– Lower extremity impaired on one side;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 4/3/19, showed:
– The resident is limited in ability to transfer self related to bilateral weakness and
fracture of right tibia;
– The resident is dependent on staff for ADLs, transfers, and bed mobility;
– Provide assistance for transfers;
– Remind resident not to transfer without assistance.
Observation on 5/8/19, at 9:04 A.M., showed:
– The resident sat in his/her wheelchair with a brace on his/her right knee and lower leg;
– CNA A placed the resident’s wheelchair in the doorway to his/her bathroom and locked the
brakes;
– CNA A stood behind the wheelchair while the resident stood and pivoted on one foot,
pulled his/her pants down and sat down on the toilet;
– CNA A left the resident’s room;
– At 9:19 A.M., CNA B entered the resident’s room, applied gloves and moved the wheelchair
from the doorway;
– The resident stood up, CNA B provided incontinent care, left the resident standing and
brought the wheelchair into the bathroom doorway locking the brakes on the wheelchair;
– CNA A and CNA B did not use a gait belt to transfer the resident.
During an interview on 5/8/19, at 3:00 P.M., CNA A said:
– The resident is just stand by assist and does not need a gait belt;
– The resident has been toe-touch weight bearing.
During an interview on 5/8/19, at 3:46 P.M., CNA B said:
– He/she did not use a gait belt on the resident;
– If the resident had started to fall, he/she would move the wheelchair out of the way
real quick and try to slide the resident to the floor.
Observation on 5/8/19, at 2:16 P.M., showed:
– The resident sat in his/her wheelchair with the brakes locked;
– Certified Medication Technician (CMT) A and Licensed Practical Nurse (LPN) A placed the
gait belt around the resident’s upper abdomen;
– LPN A grabbed the back of the gait belt with one hand;
– CMT A grabbed the back of the gait belt with one hand and the front of the gait belt
with the other hand;
– LPN A and CMT A assisted the resident to transfer from his/her wheelchair to the side of
the bed and the gait belt slid up under the resident’s arm pit during the transfer;
– The resident sat on the side of the bed and CMT A removed the gait belt;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Few

(continued… from page 18)
– LPN A and CMT A assisted the resident to lay down.
During an interview on 5/8/19, at 2:03 P.M., CMT A said:
– The gait belt should not have slid up under the resident’s arm pits;
– The gait belt should have been adjusted.
During an interview on 5/8/19, at 2:48 P.M., LPN A said:
– The gait belt should not be under the resident’s arm pit, it should have been moved and
adjusted.
During an interview on 5/9/19, at 3:09 P.M., the DON said:
– The gait belt should not slide up under the resident’s arm pits, it should be snug;
– The staff should adjust the gait belt if it was loose;
– Staff should not stand behind the wheelchair while the resident is transferring by
him/herself, the staff should have a gait belt on the resident.
4. Review of Resident #112’s admission MDS, dated [DATE], showed:
– Extensive assist of two or more staff for bed mobility and transfers;
– Extensive assist of one staff for toileting;
– Indwelling urinary catheter (a sterile tube inserted into the urinary bladder to drain
urine);
– Oxygen therapy;
– Balance during transition and walking- steady at all times with seated to standing and
surface to surface transfers;
– Hospice;
– Anti-depressants (used to treat depression), anti-anxiety medications (used to treat
anxiety), hypnotics (used for sleep), administered in last seven days;
– Opioids (narcotic pain medications) administered in last three days;
– [DIAGNOSES REDACTED]. Did not address pneumonia, urinary tract infection, [MEDICAL
CONDITION], or [MEDICAL CONDITION] as noted from most recent hospitalization on [DATE].
Review of the care plan last updated on 5/6/19, showed:
– Resident limited in ability to transfer self, related to weakness, increased anxiety
when transferring, and requires staff assistance with transfers;
– Provide assistance with transfers;
– Resident not to transfer without assistance from staff;
– Resident at risk for falls related to bilateral lower extremity weakness, used walker,
increased anxiety when transferred, indwelling urinary catheter, and depends on staff for
assistance;
– Will remain free from injury.
During an observation and interview on 5/8/19, at 8:53 A.M., CNA D and CNA C did and said:
– CNA D did not place a gait belt around the resident’s waist.
– CNA D placed his/her hands under the resident’s blouse and place his/her hands on the
resident’s waist.
– Helped the resident to stand from the wheelchair and assisted the resident to pivot and
sit on the bed.
– The resident was weak and his/her knees were slightly bent during the pivot.
– The resident sat very near the edge of the bed and CNA C and CNA D assist the resident
to lie down on the bed.
– CNA D said he/she should have used a gait belt on the resident but the resident did not
like to use the gait belt.
– The resident wanted to do things for him/herself.
– CNA D touched the resident’s sides gently to help and the resident did the transfer by
him/herself.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 – Few

(continued… from page 19)
– CNA D said he/she should use a gait belt with all transfers.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing (DON) said:
– Gait belts should be used if needed.
– Care plans should show if gait belt needed.
– CNAs should not make the decision as to whether to use a gait belt or not on a resident.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided complete catheter (a sterile tube inserted into the bladder to drain urine) care
in a manner to prevent infection or the possibility of infection which affected two of 16
sampled residents (Resident #47 and #112). The facility census was 61.
1. Review of the facility’s undated Indwelling Catheter Care policy showed:
– Perform hand hygiene and apply clean gloves.
– Provide privacy by closing curtains around bed and closing door.
– Position resident for care.
– Provide perineal care and perform hand hygiene.
– Apply clean gloves.
– Female: Gently open the large skin folds and expose the urinary opening and catheter.
– Male: Retract the skin fold to clean.
– Wipe catheter gently for about four inches from insertion site to attachment to the
drainage bag tubing.
– Avoid pulling on the catheter.
– Apply leg strap to anchor catheter.
– Ensure drainage is below the level of the bladder.
2. Review of Resident #112’s nursing progress note, dated 4/22/19, showed:
– Staff contacted the hospital emergency room and the resident was admitted for pneumonia,
[MEDICAL CONDITIONS].
Review of a nursing progress note, dated 4/24/19, showed:
– Returned from hospital stay,
Review of the resident’s re-admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/1/19, showed:
– Entered from an acute hospital;
– Extensive assist of one staff for toileting;
– Urinary catheter;
– Frequently incontinent of bowel;
– Antibiotics for three days;
– No diagnoses for a urinary tract infection [MEDICAL CONDITIONS], and pneumonia, [MEDICAL
CONDITION], elevated lab values, and low potassium.
Review of the care plan last updated on 5/6/19, showed:
– Indwelling urinary catheter;
– Catheter care managed appropriately as evidenced by not exhibiting signs of infection or
urinary opening trauma;
– Position drainage bag below level of bladder;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
– Report signs and symptoms of a UTI, urgency, acute confusion, frequency, bladder spasms,
burning, pain, difficulty urinating, nocturia (night time urination), low back and kidney
area pain, malaise, nausea/vomiting, chills, fever, foul odor to urine, concentrated
urine, blood in urine).
During an observation and interview on 5/8/19, at 8:53 A.M., Certified Nurse Aide (CNA) C
and CNA D did and said:
– Provided perineal and catheter care to the resident;
– Both CNAs washed their hands and put on gloves;
– CNA D wiped each groin front to back;
– CNA D wiped front to back down the middle of the perineal area, but did not open the
large skin folds and fecal material was noted to the wipe;
– Wiped both thighs back to front;
– Did not change gloves or wash his/her hands;
– Wiped the catheter drainage bag tubing from the attachment site down to the drainage
bag;
– Wiped the catheter tubing from insertion site to drainage bag attachment site;
– Rolled the resident to his/her right side;
– Wiped each buttock from front to back;
– Wiped the rectal area from front to back and cleaned fecal material from the resident
two times with two wipes;
– Wiped the rectal area again back to front two times with two wipes;
– Removed his/her gloves and washed his/her hands;
– CNA C assisted CNA D during catheter care;
– CNA D said he/she should wash front to back all areas, should change gloves and wash
his/her hands after cleaning fecal material and before performing clean tasks, and he/she
should not have wiped the drainage bag tubing and then the catheter without changing
his/her gloves and washing his/her hands.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing said:
– She expected staff to clean all areas of the skin during perineal or catheter care.
– She expected staff to clean the areas from front to back.
– Staff should change gloves when going from dirty to clean tasks.
– Staff should change gloves and wash hands after cleaning fecal material.
3. Review of Resident #47’s urinalysis (UA, a test to analyze urine contents), dated
3/26/19, showed the presence of bacteria indicative of a possible UTI.
Review of the resident’s urine culture and sensitivity (UA with C&S, identifies the
amount and type of bacteria present and the medications appropriate to treat the
infection), dated 3/30/19, showed the presence of organisms indicative of a possible UTI.
Review of the resident’s prescription order, dated 3/30/19, showed:
– an order for [REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility, transfers and toilet use;
– Had a Foley catheter (sterile tube inserted into the bladder to drain urine);
– Frequently incontinent of bowel.
Review of the resident’s care plan, revised 4/15/19, showed:
– The resident required a supra pubic catheter (enters the bladder through the lower
abdomen) related to a [MEDICAL CONDITION] bladder (a dysfunction that results from
interference with the normal nerve pathways associated with urination) and [MEDICAL
CONDITION] (a progressive deteriorating nervous system disease that results in a gradual
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
loss of muscle function);
– The resident had a history of [REDACTED].
Observation on 5/8/19, at 3:52 P.M., showed:
– During catheter care, Licensed Practical Nurse (LPN) B held onto the catheter tubing
where it connected to the drainage bag and wiped down the tubing three times with a
different wipe each time.
During an interview on 5/8/19, at 4:07 P.M., LPN B said:
– He/she should have anchored the catheter tubing at the insertion site.
During an interview on 5/9/19, at 3:09 P.M., the DON said:
– Staff should anchor the catheter tubing close to the body so it does not get pulled out.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided proper respiratory care when staff failed to properly clean oxygen concentrator
filters, which affected one of 16 sampled residents (Resident #27), failed to date oxygen
and nebulizer tubing for three sampled residents (Resident #4, #27 and #60) and failed to
date a humidified water bottle for Resident #60. The facility census was 61.
1. Review of the facility’s equipment change policy, revised 4/1/17, showed, in part:
– The facility shall have a schedule for changing disposable equipment at regular
intervals as determined by manufacturer recommendations and local community policies;
– Nasal cannula: change on an as needed basis or per state regulations;
– Nebulizer set up: between treatments on the same resident, disinfect, rinse with sterile
water and air dry. For small volume medication nebulizers, place in clean, dry plastic
bag. Label with resident’s name and if possible, leave at resident’s bedside;
– The policy did not address dating the tubing, nebulizer tubing, the humidified water
bottle or cleaning the concentrator’s filters.
2. Review of Resident #4’s care plan, revised 6/20/18, showed:
– The resident used oxygen to keep oxygen saturation above 90%;
– Administer oxygen as ordered.
Review of the resident’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/27/19, showed:
– Cognitive skills intact.
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].>- an order for [REDACTED].>- An order to change oxygen
tubing once a day on Sunday;
– An order to clean oxygen concentrator filter once a day on Sunday.
Observation on 5/6/19, at 9:42 A.M., showed:
– The oxygen tubing was not dated.
3. Review of Resident #27’s quarterly MDS, dated [DATE], showed:
– Cognitive skills intact.
Review of the resident’s care plan, revised 4/9/19, showed:
– The resident used oxygen due to chronic [MEDICAL CONDITION];
– Administer oxygen as ordered.
Review of the resident’s POS, dated (MONTH) 2019, showed:
– an order for [REDACTED].>- An order to change nebulizer tubing weekly on Sunday,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
11:00 P.M. – 7:00 A.M. shift;
– An order to change oxygen tubing every Sunday, 10:00 P.M. – 6:00 A.M. and as needed;
– an order for [REDACTED].
Observation on 5/6/19, at 8:38 A.M., showed:
– The resident sat in his/her wheelchair with oxygen at 3 L/NC and the oxygen tubing was
not dated;
– The filter on the oxygen concentrator was covered in gray lint;
– The resident had a canister of portable oxygen on the back of his/her wheelchair and the
tubing was not dated;
– The nebulizer tubing was not dated.
4. Review of Resident #60’s quarterly MDS, dated [DATE], showed:
– Cognitive skills intact.
Review of the resident’s care plan, dated 4/25/19, showed:
– The resident was at risk for decreased cardiac output related to [MEDICAL CONDITION];
– Monitor oxygen saturation as needed.
Review of the resident’s POS, dated, (MONTH) 2019, showed:
– an order for [REDACTED].
Observation on 4/6/19, at 9:42 A.M., showed:
– The oxygen concentrator was on at 3 L/NC;
– The oxygen tubing was not dated;
– The humidified water bottle was not dated.
5. During an interview on 5/9/19, at 3:09 P.M., the Director of Nursing (DON) said:
– The oxygen and the nebulizer tubing should bed changed every week, staff should put the
new one in a bag with the resident’s name on it and the date;
– The humidified water bottle should be dated;
– The filters should be cleaned weekly.

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Some

Post nurse staffing information every day.

Based on observation, record review and interview, the facility failed to ensure staff
posted nurse staffing data in a prominent place, readily available to all residents and
visitors on a daily basis at the beginning of each shift. The facility census was 61,
1. Review of the facility’s Human Resources Planning Posting of Licensed and Unlicensed
Direct Care Staff policy, dated 11/1/17, showed:
– The Director of Nursing (DON) or designee shall post the direct care staffing on a daily
basis.
– Purpose: To post the direct care staff, both licensed and unlicensed, that are directly
responsible for resident care that may include but is not limited to giving medications,
performing nursing assessments, and assisting with activities of daily living.
– Data requirements include: Facility name, current date, total number and actual hours
worked by the registered nurses (RN), licensed practical or vocational nurses (LPN/LVN),
and certified nurse’s aides (CNA), and the resident census.
– The nurse staffing data must be posted on a daily basis at the beginning of each shift.
– Data must be in a clear and readable format and in a prominent place readily accessible
to residents and visitors.
During the resident council interview meeting on 5/7/19, at 1:26 P.M., all 13 residents

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0732

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 23)
said:
– They did not know nursing staffing data needed to be posted for all residents and
visitors to access.
– They did not know where the data was posted.
– Traveling to the front hall was a long way to walk or self-propel to see the data.
– The data needed to be posted closer to the hallway they lived on.
Observation on all days of the survey, 5/6/19 through 5/9/19, at various times during the
day, showed:
– The nursing staffing data was posted on the front hall of the facility in a glassed box
on the wall next to the Administrators office.
– The hall had offices and closed doors to another hall which was being renovated and no
visitors or residents used the front hall to any extent.
– The data was not easily visible/accessible for visitors or residents.
– Residents would have to travel long distances to access the staffing data.
During an interview on 5/9/19, at 11:00 A.M., the DON said:
– The Payroll/Human Resources staff posted the staffing data up at the front of the
facility.
– The staffing data was not posted anywhere else in the facility.
During an interview on 5/9/19, at 11:11 A.M., Payroll/Human Resources staff said:
– She posted the staffing data daily in the front hall and it included the number of staff
and hours worked as she knew the information to be from the staffing schedule.
– The next day she discarded the original sheet and filled out another sheet with actual
numbers of staff worked and hours worked that she received from staff.
– Numbers of staff and hours worked are based on a daily census.
– Numbers of staffing may change because of call-ins and that is why she created another
sheet the next day.
– She only posts the data in the front hall, in the glassed case and did not post on each
unit for easy accessibility for residents and visitors.
– She did not know it needed to be posted to be more accessible.

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 observations, interview and record review, the facility failed to ensure staff
dated an opened vial of [MEDICATION NAME] purified protein derivative (skin test used to
help diagnose [MEDICAL CONDITION] infection), failed to date an opened vial of [MEDICATION
NAME] (used to treat anxiety), failed to document when a new bottle of [MEDICATION NAME]
was received from the pharmacy and failed to ensure it had a pharmacy label on it, and
failed to ensure two [MEDICATION NAME] pens had pharmacy labels on them to indicate who
they belonged to and failed to ensure an inhaler had a pharmacy label to indicate who it
belonged to; and did not follow their policy to label eye drops with an opening date and
discarding the eye drops after 28 days or sooner dependent upon requirement of the
manufacturer which affected two of 16 sampled residents (Resident
#7 and #23). The facility census was 61.
1. Review of the facility’s policy for medication administration, dated 11/1/17, showed,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 24)
in part:
– The authorized staff member or licensed nurse verifies information documented on the
Medication Administration Record (MAR). This includes, but is not limited to medication
and label match and the label and physician’s orders [REDACTED].>- The authorized staff
member or licensed nurse read the label on the medication three times to verify accuracy.
The label is read: when removing the medication from the drawer, before pouring the
medication, and after pouring the medication;
– If the medication or prescription label is missing or illegible, the medication should
not be administered and the item should be replaced;
– Once any multi-dose packaged mediation or biological is opened, nursing will mark
multi-dose products (e.g. inhalers, insulin, ophthalmics, otics and the like) with the
date opened and discard and replace after 28 days (or sooner if required by the
manufacturer, i.e. mix insulins);
– As needed (PRN) multi-dose inhalers will be marked with the date opened and discarded
and replaced after 28 days;
– Facility staff may record the calculated expiration date based on date opened on the
medication container.
Review of the facility’s General Guidelines for Storage of Medication and Biologicals,
dated 11/1/17, showed:
– Once any multi-dose packaged medication or biological is opened, nursing will mark
multi-dose products such as inhalers, insulin, eye drops (gtts) and others with the date
opened and discard and replace after 28 days or sooner if required by the manufacturer.
2. Observation and interview on 5/8/19, at 10:21 A.M., of the 100 hall medication room
showed:
– A clear plastic bag with a pharmacy label on it with two [MEDICATION NAME] pens inside
the clear plastic bag which did not have a label to indicate which resident it belonged to
once it was removed from the bag;
– Licensed Practical Nurse (LPN) A said the insulin pens should have a pharmacy label on
them;
– An opened vial of [MEDICATION NAME] (TB) purified protein derivative which did not have
a date when it was opened;
– LPN A said the vial of TB should be dated when it was opened;
– An opened vial of [MEDICATION NAME] which did not have a date when it was opened;
– A narcotic sheet for [MEDICATION NAME] was not filled out when it received from the
pharmacy and the opened bottle of [MEDICATION NAME] did not have a pharmacy label on it to
indicate which resident it belonged to and did not have a date when it was opened;
– LPN A said the bottles of [MEDICATION NAME] should be dated when opened, have a pharmacy
label on it and the narcotic count sheet should have been filled out when it was received
from the pharmacy;
– An opened Breo Ellipta inhaler (used to treat chronic obstructive pulomonary
disease/[MEDICAL CONDITION], obstruction of air flow that interferes with normal
breathing), did not have a pharmacy label on it to indicate which resident it belonged to.
During an interview on Certified Medication Technician (CMT) B said:
– The Breo Ellipta inhaler should have a pharmacy label on it.
During an interview on 5/9/19, at 3:09 P.M., the Director of Nursing (DON) said:
– The vial of TB should be dated when opened;
– Individual insulin pens should have a pharmacy label on them;
– The [MEDICATION NAME] should have a label on the bottle and on the box and should be
dated when opened;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 25)
– Staff should fill out the narcotic count sheet and sign for it when it is received;
– The inhaler should have a pharmacy label on the box and on the inhaler.
3. During an observation of the 100/300 hall medication cart and interview on 5/7/19, at
9:00 A.M., CMT A did and said:
– [MEDICATION NAME] eye gtts for Resident #7 was opened and dated as 2/2/19.
– [MEDICATION NAME] eye gtts for Resident #23 was opened and dated as 1/4/19.
– He/she did not know but thought the eye gtts needed to be discarded on the expiration
date printed on the bottle.
During an interview on 5/7/19, at 9:10 A.M., the Director of Nursing (DON) said:
– Eye gtts should be discarded one month after opening and should be dated with the
opening date.
– She would provide copy of the policy.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to serve food to residents who ate
in their rooms at a preferable temperature or the required minimum of 120? Fahrenheit (F).
This had the potential to affect residents who ate their meals in their rooms. The
facility census was 61.
The facility did not provide a printed policy regarding food temperatures at time of
service to the residents.
1. During the group meeting on 5/7/19 at 1:26 P.M., residents said food is sometimes cold
on hall trays and staff have said that sometimes there were not enough staff to pass
trays.
During an interview on 5/8/19, at 9:45 A.M., Resident #54 said the meals are late,
especially if you have to have a room tray and the meals are cold or barely warm.
2. Observation of the kitchen tray line on 5/9/19, at 8:05 A.M., showed:
– Dietary Cook A (DC A) plating one of the last of breakfast trays to the dining room
while staff placed beverage containers on the top of an insulated food cart which had
already been loaded with hall trays.
– At the request of the surveyor, the dietary manager (DM) asked DC A to plate a test tray
of the breakfast meal to be placed in the insulated cart.
– DC A served regular portions of scrambled eggs and a biscuit and gravy onto a plate
seated in an insulated bottom, then covered the plate with an insulated top.
– The DM then loaded the test tray into the cart.
Observation and interview on 5/9/19, starting at 8:10 A.M., showed:
– A certified nurse aide (CNA) take the cart to the south 100 hall and deliver the first
breakfast tray to room [ROOM NUMBER] at 8:12 A.M.
– He/she then proceeded down the south 100 hall serving several residents, then to the
center 300 hall.
– The CNA served each resident with a plate placed in an insulated bottom and top.
– While on the center portion of the 300 hall, a second CNA arrived to help serve the
trays.
– The DM said two CNAs normally served the hall trays, but sometimes one was needed to
help a resident so only one served until the other was free to help.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
– After serving residents hall trays on the 300 center hall, the CNAs took the cart to the
100 north hall, then to the 300 unit serving the last tray to room [ROOM NUMBER] at 8:38
A.M.
– The surveyor, with the DM present, measured the temperature of the test tray at 8:40
A.M.
– The scrambled eggs measured 110? – 111? F and the biscuit and gravy 108.7? F.
During an interview on 5/9/19, at 8:40 A.M., the DM said she was aware food should be a
minimum 120? F when served and these temperatures were low.

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
provided care in a manner to prevent infection or the possibility of infection when they
did not change gloves and wash their hands between dirty and clean tasks during perineal
care which affected three of 16 sampled residents (Resident #21, #54 and #163) and during
catheter care which affected one sampled resident (Resident #112); failed to administer
the yearly [MEDICAL CONDITION] (TB) skin test or perform an assessment for TB which
affected one sampled resident (Resident #11); and failed to place the graduate (a clear
plastic container with markings used to collect and measure fluids) on a clean barrier,
which affected one sampled resident (Resident #47). The facility census was 61.
1. Review of the facility’s indications for glove use policy, revised (MONTH) 2011,
showed, in part:
– Proper hand hygiene/hand washing technique will be accomplished at all times that
handwashing is indicated;
– Hand hygiene/handwashing is the most important component for preventing the spread of
infection. Maintaining clean hands is important for residents and visitors as well as
staff;
– Hand hygiene/hand washing is done before: resident contact and after contact with soiled
or contaminated articles, such as articles that are contaminated with body fluids, after
resident contact, after toileting or assisting others with toileting and after removal of
gloves;
– Gloves are appropriate barrier for protection from blood or body substances likely to
soil the hands;
– Gloves are to be worn when touching mucous membranes or non-intact skin of all residents
(while doing oral hygiene, bathing, catheter care or disposing of excrement), touching
urine, cleaning a resident following incontinence and anytime required by the facility
policies and procedures or regulations;
– Hands are washed immediately after gloves are removed, before contact with another
resident;
– Gloves are changed if contaminated with blood or body fluids before touching other parts
of the same resident;
– Hands are washed prior to donning gloves.
Review of the facility’s [MEDICAL CONDITION] Exposure Control Plan, dated (MONTH) 2011,
showed:
– Residents are tested when the person has not been tested (assessed) in the past year and
in accordance with applicable regulations.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 27)
2. Review of Resident #112’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/1/19, showed:
– Entered from an acute hospital;
– Extensive assist of one staff for toileting;
– Urinary catheter;
– Frequently incontinent of bowel;
– Antibiotics for three days;
– No [DIAGNOSES REDACTED].
Review of the care plan last updated on 5/6/19, showed:
– Indwelling urinary catheter;
– Catheter care managed appropriately as evidenced by not exhibiting signs of infection or
urinary opening trauma;
– Position drainage bag below level of bladder;
– Report signs and symptoms of a UTI, urgency, acute confusion, frequency, bladder spasms,
burning, pain, difficulty urinating, nocturia (night time urination), low back and kidney
area pain, malaise, nausea/vomiting, chills, fever, foul odor to urine, concentrated
urine, blood in urine).
During an observation and interview on 5/8/19, at 8:53 A.M., Certified Nurse Aide (CNA) C
and CNA D did and said:
– Provided perineal and catheter care to the resident;
– Both CNAs washed their hands and put on gloves;
– CNA D provided perineal care, cleaning fecal material from the resident’s rectum;
– Did not change gloves or wash hands;
– Provided catheter care, touching the resident’s catheter at the insertion site with
soiled gloves, touched the resident to roll him/her to the right side and again wiped
fecal material from the rectum;
– Removed his/her gloves and washed her hands;
– CNA C assisted CNA D during catheter care;
– CNA D said he/she should wash front to back all areas, should change gloves and wash
hands after cleaning fecal material and before performing clean tasks, and he/she should
not have wiped the drainage bag tubing and then the catheter without changing his/her
gloves and washing his/her hands.
3. Review of Resident #21’s quarterly MDS, dated [DATE], showed:
– Short- and long-term memory problems;
– Severe cognitive impairment;
– Extensive assist of two or more staff for bed mobility and toileting;
– Always incontinent of bowel and bladder;
– No record of diagnoses.
Review of the care plan last updated on 4/1/19, showed:
– Incontinent of bowel and bladder.
During an observation and interview on 5/8/19, at 9:09 A.M., Certified Nurse Aide (CNA) C
did and said:
– Entered room to provide perineal care to the resident;
– Washed his/her hands and applied gloves;
– Picked up floor mat from floor;
– With soiled gloves, place perineal care supplies on the resident’s bed;
– Sprayed wipes with perineal cleanser, removed wet wipes from the package, removed the
resident’s boots from his/her feet and removed socks;
– Rolled the resident side to side and removed his/her pants and brief with same soiled
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 28)
gloves;
– Removed gloves, washed hands, and applied clean gloves;
– Provided proper perineal care but cleaned the front perineal area and fecal material was
noted to the wipe;
– Removed his/her gloves and did not wash his/her hands;
– His/her gait belt fell on to the floor by the resident’s bed;
– CNA C picked up the gait belt and placed it around his/her waist;
– Without washing his/her hands, repositioned the resident’s pillow, placed the resident’s
boots on his/her feet, and covered the resident;
– Then washed his/her hands;
– CNA C said he/she should change his/her gloves between dirty and clean tasks;
– Said he/she did not change his/her gloves or wash his/her hands after cleaning fecal
material;
– The gait belt slipped off of her waist onto the floor and it should not have.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing said:
– She expected staff to clean all areas of the skin during perineal or catheter care.
– She expected staff to clean the areas from front to back.
– Staff should change gloves when going from dirty to clean tasks.
– Staff should change gloves and wash hands after cleaning fecal material.
4. Review of Resident #11’s annual MDS, dated [DATE], showed:
– A Brief Interview for Mental Status score of three which indicated he/she did not make
his/her own decisions;
– Hospice;
– Diagnoses included: Diabetes and [MEDICAL CONDITION].
Review of the Medical Record showed:
– Last TB test 5/1/18.
Review of the physician’s orders [REDACTED].
– 4/30/18: (MONTH) have Two Step TB test on admission and One Step annually thereafter.
– 4/30/18: Resident is free of communicable disease.
During an interview on 5/9/19, at 3:06 P.M., the Director of Nursing (DON) said:
– Resident #11’s TB test or assessment should have been done annually.
– The test or assessment was just not done in May, 2019.
5. Review of Resident #163’s admission MDS, dated [DATE], showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility, transfers and toilet use;
– Upper and lower extremities impaired on one side;
– Always incontinent of bowel and bladder.
Review of the resident’s care plan, revised 5/7/19, showed:
– The resident experienced bladder incontinence related history of stroke and dependent on
staff for activities of daily living (ADLs) and transfers;
– Provide incontinence care after each incontinent episode.
Observation on 5/8/19, at 9:54 A.M., showed:
– CNA A and CNA B used the mechanical lift and transferred the resident from his/her
wheelchair to the bed;
– CNA A and CNA B pulled the resident’s pants down and tucked the wet incontinent brief
between the resident’s legs;
– CNA A wiped across the abdominal folds twice with a different wipe each time;
– CNA A provided incontinent care to the front perineal folds;
– CNA A removed his/her gloves, did not wash his/her hands and applied new gloves;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 29)
– After CNA A and CNA B provided incontinent care to the buttocks and placed a clean
incontinent brief on the resident, CNA A and CNA B removed gloves, did not wash their
hands and applied new gloves;
– CNA A and CNA B used the mechanical lift and transferred the resident from his/her bed
to his/her wheelchair.
During an interview on 5/8/19, at 3:00 P.M., CNA A said:
– He/she should wash his/her hands before and after touching the resident, and between
glove changes.
7. Review of Resident #54’s admission MDS, dated , 4/2/19, showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility and transfers;
– Limited assistance of two staff for toilet use;
– Lower extremity impaired on one side;
– Occasionally incontinent of bowel and bladder;
– Diagnoses included right tibia fracture (large bone between the knee and the ankle).
Review of the resident’s care plan, revised 4/3/19, showed:
– The resident is limited in ability to transfer self related to bilateral weakness and
fracture of right tibia;
– The resident is dependent on staff for ADLs, transfers, and bed mobility;
– Provide assistance for transfers;
– Remind resident not to transfer without assistance.
Observation on 5/8/19, at 9:19 A.M., showed:
– The resident urinated and had a bowel movement on the toilet in his/her room;
– CNA B entered the resident’s bathroom, did not wash his/her hands and applied gloves;
– CNA B provided incontinent care, pulled up the resident’s shorts, and assisted the
resident into his/her wheelchair;
– CNA B removed his/her gloves, put the foot pedals on the resident’s wheelchair then
washed his/her hands and left the room.
During an interview on 5/8/19, at 3:46 P.M., CNA B said:
– He/she should wash his/her hands before and after dealing with the resident, after
cleaning fecal material, between glove changes, when you enter the room and before leaving
the room.
During an interview on 5/9/19, at 3:09 P.M., the DON said:
– Staff should change gloves when going from dirty to clean tasks;
– Staff should remove gloves and wash hands when cleaning fecal material;
– Between glove changes, staff can either wash hands or use hand sanitizer.
8. Review of Resident #47’s quarterly MDS, dated [DATE], showed:
– Cognitive skills intact;
– Required extensive assistance of two staff for bed mobility, transfers and toilet use;
– Had a Foley catheter ( sterile tube inserted into the bladder to drain urine);
– Frequently incontinent of bowel.
Review of the resident’s care plan, revised 4/15/19, showed:
– The resident required a supra pubic catheter (enters the bladder through the lower
abdomen) related to a [MEDICAL CONDITION] bladder (a dysfunction that results from
interference with the normal nerve pathways associated with urination) and [MEDICAL
CONDITION] (a progressive deteriorating nervous system disease that results in a gradual
loss of muscle function);
– The resident had a history of [REDACTED].
Observation on 5/8/19, at 3:52 P.M., showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265857

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

NAME OF PROVIDER OF SUPPLIER

LIBERTY HEALTH AND WELLNESS

STREET ADDRESS, CITY, STATE, ZIP

2201 GLENN HENDREN DR
LIBERTY, MO 64068

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 30)
– Licensed Practical Nurse (LPN) B placed the graduate (a clear plastic container with
markings used to collect and measure fluids) directly on the floor, removed the spout from
the sleeve, cleaned the port with an alcohol wipe and emptied urine in the graduate.
During an interview on 5/8/19, at 4:07 P.M., LPN B said:
– He/she should have placed the graduate on a clean barrier.
During an interview on 5/9/19, at 3:09 P.M., the DON said:
– Staff should place a barrier under the graduate.