Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, and interview the facility failed to provide a clean, safe, and
comfortable homelike environment when staff failed to properly maintain the conditions of
two resident wheelchairs (Resident #33 and #58) and failed to ensure resident seating in a
common area was free of rips and tears (Resident #5). The facility census was 57.
1. Review of Resident #5’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 12/27/2018, showed the facility
assessed the resident as follows:
-Cognitively intact;
-And independent with transfers, and mobility.
Observation on 1/7/19 at 11:57 A.M., showed the resident in a leather recliner in the
foyer. Further observation showed the leather recliner with multiple rips and tears along
the foot rests where the resident’s legs rested.
Observation on 1/8/19 at 1:19 P.M., showed the resident in a leather recliner in the
foyer. Further observation showed the leather recliner with multiple rips and tears along
the foot rests where the resident’s legs rested.
During an interview on 1/08/19 at 1:20 P.M., the resident said the torn pieces of leather
on the chair scratch his/her legs sometimes, and that is why he/she tries to keep them off
to the side of the foot rests.
2. Review of Resident #33’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively impaired;
-And utilizes a wheelchair for mobility.
Observation on 1/7/19 at 2:14 P.M., showed the resident in his/her wheelchair. Further
observation showed the right wheelchair arm rest with multiple rips and tears, and the
left wheelchair arm rest to be missing.
Observation on 1/9/19 at 2:59 P.M., showed the resident in his/her wheelchair. Further
observation showed the right wheelchair arm rest with multiple rips and tears, and the
left wheelchair arm rest to be missing.
3. Review of Resident #58’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-And utilizes a wheelchair for mobility.
Observation on 1/8/19 at 11:22 A.M., showed the resident in his/her wheelchair. Further
observation showed both wheelchair arm rests with multiple rips and tears.
Observation on 1/10/19 at 8:45 A.M., showed the resident in his/her wheelchair. Further
observation showed both wheelchair arm rests with multiple rips and tears.
During an interview on 1/10/19 at 10:00 A.M., the resident said he/she would like his/her
arm rests to be fixed.
4. During an interview on 1/10/19 at 11:25 A.M., Certified Nurse Aid (CNA) C said staff
are expected to fill out a maintenance request for any equipment that is found damaged
and/or in need of repair.
During an interview on 1/10/19 at 3:10 P.M., Licensed Practical Nurse (LPN) C said if
there is equipment that needs repair the CNAs fill out a request for repair and turn it
into the administrator. He/She said they sometimes let the charge nurse know but not
always.
During an interview on 1/10/19 at 3:31 P.M., the Maintenance Director said the floor staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
fill out a repair request form and turn it in to the administrator, who then classifies
the job by priority 1, 2, or 3 and then gives it back to him/her. After looking through
his/her forms, he/she did not have a request to repair Resident #33’s wheelchair.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview the facility failed to ensure staff
provided five residents (Resident #2, #11, #26, #33 and #37), that were unable to complete
their own activities of daily living, the necessary care and services to maintain adequate
grooming. The facility census was 57.
1. Review of the facility’s Shaving the Resident Policy, dated (MONTH) 2010, shows it did
not contain direction for staff in regards to timeliness of shaving for residents.
2. Review of Resident # 2’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 12/27/18, showed the facility assessed
the resident with mild cognitive impairment, and requires supervision and set up
assistance of one person for personal hygiene.
Observation on 1/8/19 at 11:24 A.M., showed the resident in a chair in the dining room.
Further observation showed the resident with unkempt facial hair.
During an interview on 1/8/19 at 11:25 A.M., the resident said he/she likes to have a
smooth face but he/she couldn’t even remember when he/she had last been assisted to shave.

3. Review of Resident # 11’s quarterly MDS, dated [DATE], showed the facility assessed the
resident as cognitively impaired, and requires extensive assistance of one person for
personal hygiene.
Observation on 1/8/19 at 11:45 A.M., showed the resident in a chair in the dining room.
Further observation showed the resident with unkempt hair.
4. Review of Resident # 26’s 14 day MDS, dated [DATE], showed staff assessed the resident
as cognitively impaired, dependent on assistance of one person for personal hygiene and
required extensive assistance of one person for eating.
Observation on 1/8/19 at 11:35 A.M., showed the resident in a chair in the dining room.
Further observation showed the resident with unkempt facial hair.
5. Review of Resident # 33’s quarterly MDS, dated [DATE], showed staff assessed the
resident as cognitively impaired, dependent on assistance of one person for personal
hygiene and required extensive assistance of one person for eating.
Observation on 1/7/19 at 2:14 P.M., showed the resident in a wheelchair in the hallway.
Further observation showed the resident with unkempt facial hair.
Observation on 1/9/19 at 2:59 P.M., showed the resident in a wheelchair in the hallway.
Further observation showed the resident with unkempt facial hair. Additional observation
showed the resident wheeled over to a mirror in the hallway, stood up to look at
himself/herself as he/she rubbed the unkempt hair with his/her hand, then sat back down in
the wheelchair as he/she tucked his/her head down.
6. During an interview on 1/10/19 at 2:50 P.M., Licensed Practical Nurse (LPN) C said all
staff is responsible to make sure residents are clean and groomed. LPN C said the shower
aides shave residents based on need or if a resident asks.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
During an interview on 1/10/19 at 3:30 P.M., the DON said he/she expects staff to check
all residents for cleanliness every couple hours. Staff should comb residents’ hair and
wash their faces upon getting them up in the morning and anytime during the day as needed.
The DON said residents should have clean clothes on at all times, if staff notice a
resident needs changed they are expected to do it.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review and interview, facility staff failed to ensure
residents with limited range of motion (ROM) received appropriate treatments and services
to increase ROM and/or prevent further decreased in range of motion. Facility staff failed
to provide restorative therapy for two residents (Residents #38 and #58.) The facility
census was 57.
1. Review of the facility’s Rehabilitative Nursing Care Policy, dated (MONTH) 2013, showed
staff are directed as follows:
-The facility’s rehabilitative nursing care program is designed to assist each resident to
achieve and maintain an optimal level of self-care and independence;
-Rehabilitative nursing care is performed daily for those residents who require such
service. Such program includes but is not limited to: Maintaining good body alignment and
proper positioning, assisting residents to carry our prescribed therapy exercises between
visits of the therapist, and assisting residents with their routine range of motion
exercises.
2. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool completed by facility staff, dated 11/23/18, showed staff assessed the
resident as follows:
-Cognitively impaired;
-Utilizes a wheelchair for mobility;
-Received no minutes of Physical Therapy (PT) seven of the seven days in the look back
period (period of time utilized to assess the resident, prior to completing the
assessment);
-Received no minutes of Occupation Therapy (OT) seven of the seven days in the look back
period;
-And Received no minutes of Restorative Nursing Program (RNP) seven of the seven days in
the look back period.
Review of the resident’s Physician order [REDACTED].>Review of the resident’s plan of
care, dated 4/19/18, showed staff are directed to ask for therapy orders to address
discomfort through exercise and non-medication interventions.
3. Review of Resident #38’s quarterly MDS, a federally mandated assessment tool completed
by facility staff, dated 11/29/18, showed staff assessed the resident as follows:
-Cognitively intact;
-Utilizes a wheelchair for mobility;
-Received no minutes of PT seven of the seven days in the look back period;
-Received no minutes of OT seven of the seven days in the look back period;
-And Received no minutes of RNP seven of the seven days in the look back period.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
Review of the resident’s POSs dated 1/1/19-1/31/19, did not show an order for
[REDACTED].>Review of the resident’s plan of care, dated 11/29/18, showed staff are
directed to ask for therapy orders to address discomfort through exercise and
non-medication interventions.
During an interview on 1/08/19 at 4:11 P.M., the resident said restorative aides used to
come in but they quit.
3. Review of Resident #58’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Cognitively intact;
-Utilizes a wheelchair for mobility;
-Received no minutes of PT seven of the seven days in the look back period;
-Received no minutes of OT seven of the seven days in the look back period;
-And Received no minutes of RNP seven of the seven days in the look back period.
Review of the resident’s POSs dated 11/1/18-11/30/18, showed the following Order wrote on
11/21/18: PT Clarification: Patient is discharged from Skilled PT. Set up RNP for three
times per week for twelve weeks.
Review of the resident’s plan of care, dated 12/20/18, showed staff are directed to ask
for therapy and Restorative Nursing Program orders as needed and encourage my
participation.
Observation on 1/8/19 at 11:22 A.M. showed the resident in his/her wheelchair. Further
observation showed the resident to have contractures to both lower extremities. Additional
observation showed the resident did not have any assistive devices in place.
Observation on 1/10/19 at 8:45 A.M., showed the resident in his/her wheelchair. Further
observation showed the resident to have contractures to both lower extremities. Additional
observation showed the resident did not have any assistive devices in place.
During an interview on 1/10/19 at 10:00 A.M., the resident said he/she does not receive
therapy at this time, and he/she does not have any devices for his/her legs.
4. During an interview on 1/10/19 at 11:24 A.M., Certified Nurse Aid (CNA) C said he/she
thought that Resident #26 was working with therapy. He/She said there is no one assigned
right now to do range of motion and /or restorative care with the residents. He/She said
that if they get time they do some, but they don’t have it documented anywhere.
During an interview on 1/10/19 at 3:15 P.M., Licensed Practical Nurse (LPN) T said the
facility does not have a Restorative Nursing Aid (RNA) at this time. He/she said there is
no place available for the staff to document when they provide ROM or restorative
services, or which residents received the services.
During an interview on 1/10/19 at 3:27 P.M., the Director of Nursing (DON) said the
facility does not currently have an RNA to perform the RNP program at the facility.

F 0732

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation, interview, and record review, facility staff failed to complete or
post required nurse staffing information in an area readily accessible to residents and
visitors. The facility census was 57.
1. Observation on 1/07/19 2:54 P.M., showed facility staff did not display the nurse staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

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 – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 4)
posting sheet in an area readily accessible to residents and visitors.
2. Observation on 1/08/19 1:54 P.M., showed facility staff did not display the nurse staff
posting sheet in an area readily accessible to residents and visitors.
3. Observation on 1/09/19 3:05 A.M., showed facility staff did not display the nurse staff
posting sheet in an area readily accessible to residents and visitors.
4. Observation on 1/10/19 1:01 P.M., showed facility staff did not display the nurse staff
posting sheet in an area readily accessible to residents and visitors.
5. During an interview on 1/10/19 at 1:38 P.M., the Director of Nursing (DON) said other
than the schedule they do not post nurse staffing hours. He/She did not know they were
expected to complete and post a nurse staffing sheet.
During an interview on 1/10/19 at 1:54 P.M., the Administrator said he/she expects staff
to post the nurse staffing sheet at the 100 hall nurses station. He/She said it is usually
posted and he/she does not know where it is.
During an interview on 1/10/19 at 3:10 P.M., Licensed Practical Nurse (LPN) C said he/she
doesn’t know of a nurse staffing sheet that is posted, but the facility does have a form
titled daily assignment report.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to avoid use of unnecessary
medications or medication without an appropriate [DIAGNOSES REDACTED].#33, #42, and #51)
out of 18 sampled residents. The facility census was 57.
1. Review of the facility’s Depression Clinical Protocol, dated (MONTH) 2012, showed staff
are directed as follows:
-The nurse shall assess all current medications, especially those known to be associated
with depression, all diagnoses, recent or current medical, psychological or social
episodes related to the condition and any previous psychiatric consults or treatments,
-And the physician shall respond appropriately by changing or stopping problematic doses
or medications, or clearly documenting why the benefits of the medication outweigh the
risks or suspected or confirmed adverse consequences.
2. Review of Resident #33’s Medication Evaluation, dated 12/20/17, showed the pharmacist
documented a recommendation to discontinue the resident’s Trazadone (antidepressant) order
through gradual dose reduction or clarify the need, due to no supporting diagnosis. The
review did not contain a supporting diagnosis, a stop date, or a clarification for
continued use of the medication.
Review of the resident’s care plan, dated 5/11/18, showed it directed staff:
-Monitor for adverse reactions;
-[DIAGNOSES REDACTED].>-A history of behaviors.
Review of the resident’s Medication Evaluation, dated 09/26/18, showed the pharmacist
documented a recommendation to discontinue the Trazadone order through gradual dose
reduction or clarify the need, due to no supporting diagnosis. The review did not contain
a supporting diagnosis, a stop date, or a clarification for continued use of the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
medication.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment, dated 11/15/18, showed staff assessed the resident as follows:
-Physical behavior coded as 1 (occurred 1-3 days);
-Verbal behavior coded as 2 (occurred 4-6 days);
-Mood Severity score of 2 (minimal depression); and
-[DIAGNOSES REDACTED].>Review of the resident’s Physician order [REDACTED].
Review of the resident’s Medication Administration Record [REDACTED]. Further review of
the MAR indicated [REDACTED].
3. Review of Resident #42’s care plan, dated 5/11/18, showed it directed staff:
-Monitor for adverse reactions;
-[DIAGNOSES REDACTED].>-No behaviors.
Review of the resident’s quarterly MDS, dated [DATE], showed staff documented the
resident’s diagnoses as follows:
-Dementia;
-Diabetes;
-Recurrent [MEDICAL CONDITION];
-[MEDICAL CONDITION]; and
-No irregularities in mood or behavior.
Review of Resident #42’s medical record showed it did not contain a Medical Evaluation of
the medication [MEDICATION NAME] (antipsychotic).
Review of the resident’s POS, dated 1/1/19 through 1/31/19, showed an order for
[REDACTED].
Review of the resident’s MAR indicated [REDACTED]. Further review of the MAR indicated
[REDACTED].
4. Review of Resident #51’s MDS, dated [DATE], showed staff documented the resident’s
diagnoses as follows:
-Alzheimer’s;
-Depression;
-No [DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s POS showed an order for [REDACTED].
5. During an interview on 1/10/19 at 3:10 P.M., Licensed Practical Nurse (LPN) C said
he/she believes the Minimum Data Set (MDS) coordinator is responsible to track the gradual
dosage reductions and unnecessary medications.
During an interview on 1/10/19 at 3:17 P.M., the MDS coordinator said he/she expects that
gradual dosage reductions and unnecessary medication tracking would be part of his/her
job, but he/she has not yet been told that. He/She said it had been discussed with the
Director of Nursing (DON) but neither of them were doing it yet.
During an interview on 1/10/19 at 3:22 P.M., the DON said he/she expects unnecessary
medications and gradual dosage reductions to be reviewed, tracked, and attempted as
recommended according to regulations.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Based on observation, interview and record review, facility staff failed to allow
sanitized kitchenware to air dry prior to stacking in storage to prevent the growth of
food-borne pathogens. The facility census was 57.
1. Review of the facility’s General Dishroom Sanitation policy, dated (MONTH) 2006, showed
All items are to be air dried. No moisture can be found on any stacked item.
2. Observation on 01/09/19 at 9:40 A.M., showed Dietary Aide (DA) A removed five plastic
insulated dome lids from dishwasher, stacked the lids while wet and placed the stack on
the shelf above the steamtable.
3. Observation on 01/09/19 at 9:46 A.M., showed 12 plastic insulated plate holders, four
divided plates and six plastic insulated dome lids stacked wet on the shelf above the
steamtable.
4. Observation on 01/09/19 at 9:55 A.M., showed 12 metal food preparation and service pans
stacked wet on the storage shelf in the baker’s area.
5. Observation on 01/09/19 at 9:58 A.M., showed 13 plastic food service trays stacked wet
on the countertop ion front of the service window.
6. Observation on 01/09/19 at 3:32 P.M., showed 12 metal food preparation and service pans
stacked wet on the storage shelf in the baker’s area.
7. During an interview on 01/09/19 at 9:48 A.M., the Dietary Manager said dishes should be
air dried before they are put away and all staff are trained on this requirement.
8. During an interview on 01/10/19 at 12:45 P.M., the administrator said all dishes should
be air dried before they are put away and all staff are trained on this requirement.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to develop and implement
policies and procedures for the inspection, testing and maintenance of the facility water
systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak
of Legionnaire’s Disease (LD). Additionally, facility staff failed to provide clean, dated
oxygen tubing for three residents (Resident #1, #, and #39.) to prevent the spread of
bacteria and the other infection causing contaminants. Furthermore, staff failed to use
appropriate hand hygiene during medication administration to prevent the spread of
infection. The facility census was 57.
1. Review of the facility’s building maintenance, inspection and testing records, showed
the records did not contain documentation of a water management program to monitor the
facility’s water systems for the growth of waterborne pathogens and prevent LD.
During an interview on 01/09/19 at 3:40 P.M., the Maintenance Director said the facility
did not have a complete water management program. The Maintenance Director said, to date,
he/she only had a diagram of the facility’s water flow.
During an interview on 01/10/19 at 12:30 P.M., the administrator said the facility did not
have a complete water management program. The administrator said the facility had been
working to obtain information about the facility’s water flow through the building and
felt until that was completed he/she could not develop appropriate policies and procedures
to monitor the water systems.
Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification
(S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

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 – Many

(continued… from page 7)
-The bacterium Legionella can cause a serious type of pneumonia called LD in persons at
risk. Those at risk include persons who are at least [AGE] years old, smokers, or those
with underlying medical conditions such as [MEDICAL CONDITION] or immunosuppression.
Outbreaks have been linked to poorly maintained water systems in buildings with large or
complex water systems including hospitals and long-term care facilities. Transmission can
occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and
decorative fountains;
-Facilities must develop and adhere to policies and procedures that inhibit microbial
growth in building water systems that reduce the risk of growth and spread of Legionella
and other opportunistic pathogens in water;
-CMS expects Medicare certified healthcare facilities to have water management policies
and procedures to reduce the risk of growth and spread of Legionella and other
opportunistic pathogens in building water systems. An industry standard calling for the
development and implementation of water management programs in large or complex building
water systems to reduce the risk of [DIAGNOSES REDACTED] was published in (YEAR) by
American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In
(YEAR), the CDC and its partners developed a toolkit to facilitate implementation of this
ASHRAE Standard(https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html).
Environmental, clinical, and epidemiological considerations for healthcare facilities are
described in this toolkit;
-Surveyors will review policies, procedures, and reports documenting water management
implementation results to verify that facilities:
-Conduct a facility risk assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,
nontuberculous mycobacteria, and fungi) could grow and spread in the facility water
system;
-Implement a water management program that considers the ASHRAE industry standard and the
CDC toolkit, and includes control measures such as physical controls, temperature
management, disinfectant level control, visual inspections, and environmental testing for
pathogens;
-Specify testing protocols and acceptable ranges for control measures, and document the
results of testing and corrective actions taken when control limits are not maintained.
2. Review of the facility’s Oxygen Administration Policy, dated (MONTH) 2010, showed it
did not give direction to staff in regards to oxygen tubing cleanliness.
Review of the facility’s Oxygen Tubing In-Service form, dated 3/29/18, showed facility
staff are directed to change oxygen tubing every Saturday on the evening shift.
Additionally, staff are directed to date the oxygen tubing and bag to hold the tubing when
it is changed.
3. Review of Resident #1’s significant change Minimum Data Set (MDS), dated [DATE], showed
the resident receives oxygen therapy.
Review of the physician’s orders [REDACTED].
Review of the resident’s care plan, dated 5/07/18, showed it did not contain direction to
the staff on how to care for the resident related to the oxygen and its use.
Observation on 01/07/19 at 2:43 P.M., showed the resident’s nasal cannula tubing was
undated and was not in the storage bag. Further observation showed the nasal cannula
draped across the floor while in use.
Observation on 01/08/19 at 11:03 A.M., showed the resident’s nasal cannula tubing was
undated and was not in the storage bag. Further observation showed the nasal cannula
draped across the floor while in use.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265854

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

NAME OF PROVIDER OF SUPPLIER

REST HAVEN CONVALESCENT AND RETIREMENT HOME

STREET ADDRESS, CITY, STATE, ZIP

1800 SOUTH INGRAM
SEDALIA, MO 65301

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 – Many

(continued… from page 8)
4. Review of Resident #18’s Significant Change MDS, dated [DATE], showed the facility
assessed the resident as not receiving oxygen therapy.
Review of the resident’s POS’s dated 1/01/19 to 1/31/19 showed the following orders:
-Oxygen at two liters per minutes per nasal cannula (N/C) at bedtime (HS);
-And Change oxygen tubing and humidifier every Saturday.
Observation on 1/8/19 at 2:20 P.M., showed an oxygen concentrator in the resident’s room.
Further observation showed the oxygen tubing on the concentrator was undated.
Observation on 1/9/19 at 1:46 P.M., showed an oxygen concentrator in the resident’s room.
Further observation showed the oxygen tubing on the concentrator undated.
5. Review of Resident #39’s quarterly MDS, dated [DATE], showed staff assessed the
resident receives oxygen therapy. Review of the resident’s POS, dated 1/1/19 to 1/31/19,
showed the resident has an order for [REDACTED].
Review of the resident’s care plan, dated 5/07/18, showed it did not contain direction to
the staff on how to care for the resident related to the oxygen and its use.
Observation on 01/08/19 at 12:01 P.M., showed the resident with portable oxygen in use.
Further observation showed the nasal cannula tubing was undated and was not in the storage
bag.
Observation on 01/09/19 at 11:51 A.M., showed the resident with portable oxygen in use.
Further observation showed the nasal cannula tubing was undated and was not in the storage
bag.
6. During an interview on 1/10/19 at 11:25 A.M., CNA C said the staff are expected to
change oxygen tubing every week on Saturdays and that it should have a dated piece of tape
to show it has been changed.
During an interview on 1/10/19 at 2:50 P.M., Licensed Practical Nurse (LPN) C said the
nurse in charge for night shift is responsible for either changing oxygen tubing or making
sure it is changed weekly per treatment sheet.
During an interview on 1/10/19 at 3:10 P.M., CNA E said the CNA’s are in charge of
changing the resident’s oxygen tubing, however he/she is unaware how often it is done. CNA
E said staff is to date the tubing when it is changed.
7. Review of the facility’s Administering Medications Policy, dated (MONTH) 2012, showed
facility staff are directed to follow the established infection control procedures for
administration of medications, as applicable.
Observation on 01/08/19 at 12:00 P.M., showed Licensed Practical Nurse (LPN) F did not
wash his/her hands in between residents during medication administration. LPN F did not
wash/sanitize hands at appropriate times during medication administration, and between
each resident to prevent the spread of infection.
During an interview on 1/10/19 at 3:40 P.M., the DON said he/she would expect the staff
passing out medication to sanitize hands between each pass and wash his/her hands after
every five passes.
During an interview on 1/10/19 at 3:00 P.M., LPN D said the staff who pass medications are
to wash before starting, then sanitize between each pass but wash his/her hands if they
touch anything. After you sanitize about 8 times, staff are expected to wash hands with
soap and water.