Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to be treated with respect and dignity and to retain and use
personal possessions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations and interviews the facility failed to respect the dignity of one
resident (Resident #104) when staff did not keep the resident’s room odor free and when
staff did not assure resident’s thighs, hips and buttocks remained covered when in public
areas for two of 28 sampled residents (Resident #16 and #65). The facility census was 104.

1. Review of Resident #104’s care plan, dated 2/20/18. showed:
– He/she preferred to stay in his/her room.
– The resident had activity of daily living (ADL) deficits.
– The resident required extensive assistance of staff for bathing, dressing, grooming, and
mobility.
-[DIAGNOSES REDACTED].
– The resident was incontinent.
– Staff should provide good hygiene and incontinent care after each episode of
incontinence.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/10/18, showed:
– Cognitively intact;
– Total dependence upon staff for transfers and toileting;
– Required extensive staff assistance for dressing and hygiene;
– Always incontinent of bladder;
– Always continent of bowel;
– [DIAGNOSES REDACTED].
Observations of the resident and his/her room on 9/4/18 at 11:00 A.M., 9/5/18 at 11:20
A.M., 9/6/18 at 2:28 P.M., and 9/7/18 at 9:23 A.M. showed a very strong odor of urine.
During an interview on 9/6/18 at 2:28 P.M. Certified Nurse Aide (CNA) E and CNA F said:
– The resident’s room always had a very strong odor of urine.
– They did not know why the room had an odor of urine.
During an interview on 9/7/18 at 1:32 P.M. the Director of Nursing (DON) said:
– Resident rooms should not have odors.
– Staff must investigate and find the source of lingering odors.
2. Review of Resident # 16’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Required extensive assist of staff for dressing.
Review of the resident’s care plan, revised 8/22/18, showed:
– Facility staff to provide ADL (Activity of Daily Living) care as needed and not provided
by hospice staff;
– Encourage resident to perform tasks they are able to do and make choices in clothes;
– Explain procedures prior to starting;
– Positive feedback for efforts and accomplishments.
Observation on 9/6/18 from 7:45 A.M., to 8:48 A.M., showed the resident sat in the dining
room in his/her wheel chair. The resident’s long sleeved green shirt did not reach down to
the waist band of the resident’s pants. at least six inches of the resident’s abdomen and
an area of his/her side at least three inches wide and eight inches long of the resident’s
right side was exposed and visible to other resident’s and family members in the dining
room.
3. Review of Resident #65’s MDS, dated [DATE], showed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
– Able to make daily decisions;
– Required extensive assistance of staff for dressing and bathing.
Review of the resident’s care plan, last updated 8/22/18, showed:
– The resident has and ADL self care deficit;
– Provide the resident with full assistance to bath as needed;
– Explain procedures prior to assisting with bathing;
– Two showers a week;
– The resident will receive appropriate staff support with dressing;
– Encourage to make choices in clothes;
Observation on 9/4/18 at 2:45 P.M., showed the resident sat in a shower chair with a bath
blanket wrapped around the front of the shower chair. CNA G pushed the shower chair and
resident from the shower room up the hall to the resident’s room. The shower sheet did not
cover the resident’s skin on both upper, outer thighs and across the back side of the
resident. The material back of the wheelchair lacked at least two inches from coming down
to the seat of the shower chair. The resident’s thighs, hips, both buttocks and the upper
crevice of the buttocks were visible to anyone walking in the hall. CNA K assisted CNA G
dress and transfer the resident to bed.
During an interview on 9/6/18 at 4:19 P.M., CNA K said staff should:
– Shower, dry and dress the resident in the shower room;
– Residents should be transferred to their wheelchair before staff moved them from the
shower room.
During an interview on 9/7/18 at 1:56 P.M., the DON said:
– Staff should dress the resident and not just cover them with a bath blanket;
– Staff should not transport resident’s in the shower chair;
– Staff should make sure resident’s skin was covered so that visitors and other residents
could not see their skin.
F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

Based on observations and interviews, the facility failed to appropriately account for the
resident’s money when the staff stored resident’s money in the nurse’s medication cart and
in the medication room, which affected nine of 28 sampled residents (Resident #2, #3, #28,
#46, #55, #62, #76, #79, and #80). The facility census was 104.
1. Observation and interview on 9/6/18, at 7:37 A.M., of the nurse’s medication cart in
the locked narcotic drawer showed:
– Some of the white envelopes had a piece of tape to secure them and several did not;
– A white envelope with Resident #76’s name on it and a hand written amount of $24.02;
– A white envelope with Resident #46’s name on it and $2.50;
– A white envelope with Resident #28’s name on it and $5.00;
– A white envelope with Resident #80’s name on it and $3.80;
– A white envelope with Resident #3’s name on it and $5.00;
– A white envelope with Resident #2’s name on it and $4.00;
– A white envelope with Resident #55’s name on it and $3.00;
– Resident #62 had a white envelope with his/her name on it but did not have an amount
written on the envelope and was not sealed. Licensed Practical Nurse (LPN) A counted the
money and said there was $48.00 in it;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
– Resident #78 had a black lock box in the medication room and it had two billfolds with
the resident’s driver’s license, medicare card, insurance card, and a prepaid calling
card. The resident had a purple coin purse and LPN A counted $5.18 in change and $52.00 in
one dollar bills. The key to the lock box was kept on the nurse’s key ring and was passed
from one charge nurse to the next;
– LPN A said the facility was a no cash facility, so when the residents took money out of
their resident funds account for shopping days, any money left over would be brought back
to the charge nurse (CN) and the activity director and they would count it, and place it
in an envelope with the resident’s name on it and the amount. The CN would lock it in the
narcotic lock box in the nurse’s medication cart. The only way for the resident to put the
money back in their personal account was to get a money order or a check and give to the
facility.
During an interview on 9/7/18, at 11:22 A.M., LPN A said:
– We have kept the money in the medication carts for at least the last two years;
– The residents go shopping every Thursday so we either have more or less money to put in
the white envelopes;
– We have the resident’s money all the time, not just on the weekends;
– We had problems with petty theft and that is why the previous administrator set this up
and it has helped.
During an interview on 9/7/18, at 2:03 P.M., the Administrator said:
– Money should not be stored in the medication carts or the medication room.
During an interview on 9/7/18 at 10:20 A.M., Business Office Manager said she was not
aware that they had money in the medication cart. They do not keep money in there and she
thinks they did it because residents got money out over the weekend.
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations and interviews the facility failed to ensure staff maintained a
clean and home like environment and had the potential to affect all facility residents.
The facility census was 104.
1. Observations of resident room [ROOM NUMBER]-A on 9/5/18 at 9:34 A.M. and 9/6/18 at
10:30 A.M. showed:
– Two stained pillows on the resident’s bed and one without a pillow case;
– Pieces of food around the resident’s bed;
– A large number of ants in the floor around the resident’s bed.
During an interview on 9/6/18 at 10:30 A.M. Certified Nurse Aide (CNA) E and CNA F said:
– They should put pillow cases on the resident’s pillow.
– The resident often had ants in his/her room.
– They did not report the ants to anyone.
During an interview on 9/6/18 at 10:30 A.M. the Unit Manager (UM) said:
– The resident was messy.
– His/her floor was always dirty.
– He/she had ants in the floor because of the food on the floor.
– No staff had reported the ants.
– Staff should clean or replace the stained pillows.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
– Staff should always keep pillow cases on pillows.
During an interview on 9/7/18 at 1:32 P.M. the Director of Nursing (DON) said:
– Staff must keep resident floors clean.
– Staff must report ants to maintenance.
– Staff must replace stained pillows.
– Staff must cover all pillows with pillow cases.
2. Observation on 9/5/18 at 10:50 A.M., showed the following:
– Air vent covered in dust across from room A-16;
-Air vent covered in dust on village by room E-24;
-Air vent covered in dust across from room E-13;
-Light fixtures on the Village all filled with dead bugs;
-Air vent covered in dust by room D-25;
-Light fixture inside filled with bugs by room D-26;
-Air vent covered in dust by room B-9;
-Bottom of bathroom door covered in black scuff marks room B-2;
-Trash and various liquid stains throughout floor from door to smoking area all through to
the sitting area and TV area;
-Exit door at the end of timber hall, covered with cobwebs, dust, and dead bugs all
throughout the inside and outside of the door and around the door frame;
-Clean linen room on maple hall, had socks on floor and paper towels, and baseboard
missing in spots with cracks in wall above;
-Exit door on village by room e-9 top covered with cobwebs, dead bugs, and dirt;
-Black scuff marks and stains about the baseboards all along the long middle hall;
-Willow hall nurses station floor is completely covered with black stains and marks;
-Wallpaper peeling off walls in various spots throughout the facility;
-Exit door on Village by room E-9 entire top covered with cobwebs, dead bugs, and dust;
-Resident room [ROOM NUMBER]-B ants and food on the floor.
During an interview on 9/7/18 at 10:35 A.M., Housekeeping Supervisor said they clean all
rooms on a daily basis. They deep clean one room every day, so all rooms once a month.
There is a floor tech who buffers the floors daily. Everyone is assigned a common area to
clean. They check exit doors as they pass them during daily cleaning. They deep clean
common areas once a month. Air vents are maintenances responsibility to clean.
During an interview on 9/7/18 at 1:15 P.M., Maintenance Director said they clean the air
vents on the ceiling every three months.
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
followed professional standards of care when staff failed to obtain an order for[REDACTED].#39); failed to obtain a specific order for how many liters of oxygen to
administer, which affected three of 28 sampled residents, (Resident #16, #65 and #358).
The facility census was 104.
1. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 6/18/18, showed:
– Cognitively intact;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 4)
– Seven insulin injections in the last seven days;
– [DIAGNOSES REDACTED].
Review of the resident’s medication administration record (MAR), dated, August, (YEAR),
showed:
– [MEDICATION NAME]sliding scale after meals;
– If blood sugar is too low, treat the low sugar and decrease dose as directed;
– [MEDICATION NAME] pen, inject 38 units SQ at bedtime;
– [MEDICATION NAME], inject 14 units SQ after lunch and dinner;
– [DIAGNOSES REDACTED].
– The resident did not have an order to check blood sugars.
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].
– If blood sugar is too low, treat the low sugar and decrease dose as directed;
– an order for [REDACTED].
– an order for [REDACTED].
– [MEDICATION NAME] 16 units SQ after breakfast;
– [MEDICATION NAME] 14 units SQ after lunch and dinner;
– [DIAGNOSES REDACTED].
– The resident did not have an order to check blood sugars.
Observation and interview on 9/5/18, at 8:16 A.M., showed:
– Licensed Practical Nurse (LPN) A obtained the resident’s blood sugar;
– LPN A reviewed the resident’s MAR and said the resident should have an order to check
blood sugars.
During an interview on 9/7/18, at 2:03 P.M., the Assistant Director of Nursing (ADON),
said:
– Residents should have an order to check blood sugars.
2. Review of resident #358’s POS, dated, September, (YEAR), showed:
– 8/31/18: admitted ;
– an order for [REDACTED].
– The resident did not have an order for [REDACTED].
3. Review of resident #16’s POS, dated, September, (YEAR), showed:
– 5/15/18: admitted ;
– an order for [REDACTED].
– The resident did not have an order for [REDACTED].
4. Review of resident #65’s POS, dated, September, (YEAR), showed:
– 7/16/18: admitted ;
– an order for [REDACTED].
– The resident did not have an order for [REDACTED].
5. During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– There is not an order for [REDACTED].
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
who were unable to carry out their own activities of daily living (ADLs) received the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 5)
necessary services to maintain good personal hygiene when staff did not provide complete
AM (morning) care for one of 28 sampled residents (Resident #16) unit and when they failed
to provide adequate perineal cleansing for Resident #11, #16 and Resident #85. The
facility census was 104.
Review of the facility policy and procedure for Perineal Care, revised on 9/5/17, showed:
– Explain procedure and provide privacy;
– Remove necessary clothing;
– Wash, rinse and dry the skin, being certain to expose all skin surfaces which are
soiled;
– Wash front to back to avoid urethral or vaginal contamination and dry resident;
– Replace the resident’s gown or other clothing as needed.
1. Review of Resident #16’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/22/18, showed:
– Not capable of making daily decisions;
– Required assistance from staff to complete activities of daily living (ADLs);
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated 8/22/18, showed:
– The resident has ADL self care deficit;
– The resident requires extensive assistance of staff with bathing, dressing, grooming and
personal hygiene;
– Encourage residents to perform tasks they are able to do and keep needed items in easy
reach;
– Explain procedures prior to starting;
– Monitor and report decline in abilities;
– Assist resident with toilet use in the morning.
Observation on 9/5/18 at 7:30 A.M., showed the resident lay in bed with cracked, dried,
bloody lips. Certified Nurse Aides (CNAs) G and H got the resident up and ready for
breakfast. CNA H removed the resident wet brief and then provided peri care. CNA H wiped
one time down each groin, once down the center of the perineal fold, one swipe on each
buttock and one swipe from the rectum to the coccyx. CNA G wiped once on the left buttock.
Staff did not thoroughly manipulate and cleanse all perineal folds nor wash the resident’s
inner legs. Staff dressed the resident. Staff assisted the resident to brush his/her teeth
but did not offer a washcloth so the resident could wash his/her face and hands and did
not offer the resident a drink.
During an interview 9/6/18 at 1:12 P.M., CNA H said:
– He/she provided resident peri care and wiped one time down each groin;
– He/she should manipulate and thoroughly cleanse the center perineal fold;
– He/she should wipe one time from the rectum to the coccyx and once on each buttock
– He/she should have given the resident a wash cloth for his/her face and hands.
2. Review of Resident #85’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Required assistance of staff with toilet use.
Review of the care plan, last updated 8/13/18, showed:
– The resident has and ADL self care deficit due to limited mobility;
– The resident uses a urinal and a bed pan, assist the resident to clean him/herself.
Observation and interview on 9/6/18 at 9:24 A.M., showed the resident lay in bed. The
resident said he/she had back surgery and staff did everything for him except he/she could
eat alone. CNA H and CNA K provided peri care for the resident. CNA K cleaned the perineal
folds and assisted the resident to roll to his/her side. CNA K cleaned the buttocks, wiped
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 6)
from the top of the buttocks down to the gluteal fold, from the rectum to the coccyx both
directions, up and down.
During an interview on 9/6/18 at 4:19 P.M., CNA K said:
– He/she wiped up and down the buttocks, back around and up and down the buttocks again.
– He/he should clean the resident’s backside by wiping front to back, not back to front
and not back and forth.
During an interview on 9/7/18 at 1:56 P.M., the Director of Nursing (DON) said:
– Staff should use one wipe, one swipe method;
– Staff should open all perineal folds and clean;
– Staff should wipe front to back;
– Staff should assist the resident brush their hair and teeth, wash their face and hands,
offer a resident a drink before the resident left their room to be in public places.
3. Review of Resident #11’s significant change in status MDS, dated , 5/17/18, showed:
Cognitive skills severely impaired;
– Required extensive assistance of one staff for bed mobility;
– Required extensive assistance of two staff for transfers and toilet use;
– Frequently incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated, 6/4/18, showed:
– The resident was at risk for altered bladder elimination;
– Provide peri care as needed.
Observation on 9/5/18, at 7:23 A.M., showed;- CNA D unfastened the resident’s wet
incontinent brief;
– CNA D wiped across the pubic area once;
– CNA D wiped down each side of the groin with a different wipe each time;
– CNA D did not separate and thoroughly cleanse all the perineal folds;
– CNA D turned the resident onto his/her side;
– CNA B used the same area of the wipe and cleaned different areas of the buttocks;
– CNA B placed a clean incontinent brief on the resident.
During an interview on 9/7/18, at 11:15 A.M., CNA D said:
– He/she should have provided peri care to the front perineal folds;
– He/she should have cleaned all the areas where urine had touched the skin.
4. Review of Resident #80’s significant change in status MDS, dated , 7/25/18, showed:
– Cognitive skills severely impaired;
– Dependent on the assistance of one staff for bed mobility and personal hygiene;
– Required extensive assistance of two staff for toilet use;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/6/18, showed:
– The resident is at risk for altered bladder elimination;
– Peri care as needed.
Observation on 9/5/18, at 8:36 A.M., showed:
– CNA B unfastened the resident’s wet incontinent brief;
– CNA B wiped down one side of the resident’s groin, folded the wipe and wiped down the
other groin;
– CNA B used a new wipe and wiped down the middle perineal folds, folded the wipe and
wiped down the middle perineal folds;
– CNA C and CNA B turned the resident onto his/her side;
– CNA B wiped from front to back, folded the wipe and wiped up one side of the buttocks;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 7)
– CNA B used a new wipe and used the same area of the wipe to clean different areas of the
skin;
– CNA B and CNA C placed a clean incontinent brief on the resident.
During an interview on 9/6/18, at 4:27 P.M., CNA B said:
– He/she should not have used the same area of the wipe to clean different areas of the
skin;
– He/she should have cleaned all areas of the skin where urine had touched;
– Should not fold the wipe when providing peri cares.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– Staff should not fold the wipe during peri care, staff should use one wipe and one
swipe;
– Staff should clean all areas of the skin where urine had touched;
– Staff should separate and clean all the perineal folds.
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to use proper
techniques when using a mechanical lift to transfer three of 28 sampled residents
(Resident # 16, # 59 and #84). Staff failed to use proper techniques to reduce the
possibility of accidents and injuries during the use of a gait belt transfer for Resident
#11 and failed to ensure Resident #358 turned the portable oxygen off prior to going
outside to smoke. The facility census was 104.
1. Review of the manufacture’s instruction for the facility mechanical lift showed the
legs of the lift must be in the maximum open position for optimal stability and safety. If
it is necessary to close the legs of the lift to maneuver the lift under a bed, close the
legs of the lift only as it takes to position the lift over the resident and lift the
resident off the surface of the bed. When the legs of the lift are no longer under the
bed, return the legs of the lift to the maximum open position immediately.
2. Review of Resident #59 care plan, dated 4/16/18 showed he/she required the assist of
two using a mechanical lift for transfers.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/10/18, showed:
– Cognitively intact;
– Total dependence upon staff for transfers.
Observation on 9/4/18 at 9:53 A.M. of Certified Nurse Aide (CNA) D and CNA I transferring
the resident showed:- Without spreading the lift legs, both CNAs lifted the resident.
– Without spreading the lift legs, both CNAs moved the resident from his/her bed to over
his/her wheelchair.
– Spread the legs to lower the resident.
During an interview on 9/4/18 at 9:53 A.M. CNA D and CNA I said:
– They should have spread the lift legs when lifting the resident.
– They should have spread the lift legs when moving the resident in the room.
3. Review of Resident # 16’s MDS, dated [DATE], showed:
– Unable to make daily decisions;
– Dependent on staff for transfers.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 8)
Review of the resident’s care plan, revised 8/22/18, showed:
– Facility staff to provide ADL (Activity of Daily Living) care as needed and not provided
by hospice staff;
Transfer assist with adaptive device gait belt.
Observation on 9/5/18 at 7:00 A.M., showed the resident lay in bed. Underneath the bed was
clear of any cords, the bed was not in the low position. CNA H and CNA G transferred the
resident with a mechanical lift. CNA H placed the mechanical lift under the resident’s bed
and did not open the legs of the mechanical lift. Staff attached the lift sling to the
mechanical lift and CNA G pushed the control button and lifted the resident. The legs of
the lift remained in the closed position. The legs of the lift remained in the closed
position as CNA G started backing the resident out from under the bed. CNA H told CNA G,
he/she should open the legs of the lift.
During an interview on 9/7/18 at 1:12 P.M., CNA H said:
– The legs of the mechanical lift should be open when lifting, lowering and moving the
resident;
– Sometimes, he/she left the legs of the lift closed under the bed.
During an interview on 9/7/18 at 1:20 P.M., LPN E said:
– The legs of the mechanical lift should be open when raising and lowering the resident.
During an interview on 9/7/18 at 1:56 P.M., The Director of Nursing (DON) said:
– If there is enough room under the resident’s bed, the legs of the lift should be open,
the guideline says if there is not enough room, staff can close the legs of the lift while
under the bed.
– Staff should spread the legs of the lift when moving a resident.
4. Review of the manufacturer’s guidelines for the the stand up lift, revised, 1/2010,
showed, in part:
– The legs of the stand up lift MUST be in the maximum open position for optimum stability
and safety;
– If it is necessary to close the legs to maneuver the stand up lift under a bed, close
the legs only as long as it takes to position the stand up lift over the patient and lift
the patient off the surface of the bed;
– When the legs of the stand up lift are no longer under the bed, return the legs tot he
maximum open position.
5. Review of Resident #84’s annual MDS, dated , 8/6/18, showed:
– Cognition severely impaired;
– Required extensive assistance of two staff for bed mobility;
– Dependent on the assistance of two staff for transfers and toilet use;
– Lower extremities impaired on both sides.
Review of the resident’s care plan, dated, 8/14/18, showed:
– The resident required one to two staff assistance for bed mobility;
– The resident required sit to stand lift with the two staff.
Observation on 9/5/18, at 11:01 A.M., showed:
– CNA A and CNA O sat the resident on the side of the bed;
– CNA O removed the resident’s gown and put a shirt on the resident;
– CNA O put the lift pad around the resident and fastened it;
– CNA O placed the sit to stand lift under the resident’s bed with the legs of the lift
open;
– CNA O placed the resident’s feet on the footrest;
– CNA O hooked the lift pad up to the lift;
– The resident held onto the handgrips;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 9)
– CNA O raised the resident up and the resident’s shirt came up and the lift pad was on
bare skin;
– CNA O lowered the resident and adjusted the lift pad;
– CNA O raised the resident up again and lift pad and the resident’s shirt came up and the
lift pad was on bare skin;
– CNA A put the resident’s incontinent brief on and pulled the resident’s pants up;
– CNA A grabbed the back of the resident’s pants to assist the resident back into the
wheelchair and unhooked the resident;
– CNA A hooked the resident back up to the lift and raised the resident up to adjust the
body alarm under the resident;
– When CNA A raised the resident up, the resident’s shirt and the lift pad came up and was
on bare skin with the resident’s right breast was fully exposed and part of the resident’s
left breast was exposed;
– CNA A and CNA O adjusted the body alarm and lowered the resident back into his/her
wheelchair;
– CNA A and CNA O unhooked the resident from the lift pad.
During an interview on 9/6/18, at 4:27 P.M., CNA A said:
– The lift pad should not slide up, if it does, should lower the resident down and
readjust the lift pad;
– The lift pad should not be on bare skin, it should be over the resident’s clothes;
– The resident’s breasts should not be exposed.
During a telephone interview on 9/6/18, at 11:13 P.M., CNA O said:
– The lift pad should not slide up, it should be tightened;
– The lift pad should not be on bare skin;
– The resident’s breast should not have been exposed.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– The lift pad should not slide up;
– The resident’s breasts should not be exposed and it should not be on bare skin.
6. Review of Resident #11’s significant change in status MDS, dated , 5/17/18, showed:
– Cognition severely impaired;
– Required extensive assistance of one staff for bed mobility;
– Required extensive assistance of two staff for transfers and toilet use;
– Had two falls with no injuries;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated, 6/4/18, showed, in part:
– The resident required extensive assistance of one to two staff for bed mobility and
transfers;
– Transfer assist with adaptive device: gait belt.
Observation on 9/5/18, at 7:23 A.M., showed:
– After CNA B provided incontinent care, CNA D put the resident’s pants on and pulled them
up to his/her knees;
– CNA B and CNA C sat the resident on the side of the bed;
– CNA C placed the gait belt around the resident’s waist and fastened it;
– CNA C grabbed a hold of the resident’s upper arm with one hand;
– CNA D reached under the resident’s arm and grabbed the side of the gait belt;
– When CNA C and CNA D stood the resident up, the gait belt slid up in the back and CNA C
and CNA D pulled the resident’s pants up with their other hand and used the pants to
transfer him/her into his/her wheelchair;
– CNA D removed the gait belt.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 10)
During an interview on 9/6/18, at 4:37 A.M., CNA C said:
– For a two person transfer, he/she placed one hand on the back of the gait belt and held
onto the resident’s arm with his/her other hand;
– The gait belt should slide up and if it does, should set the resident down and tighten
the gait belt;
– He/she thought you could hold onto the resident’s during a transfer;
– Sometimes during a transfer, the staff would hold onto the resident’s pants to help turn
the resident or reposition the resident.
During an interview on 9/7/18, at 11:15 A.M., CNA D said:
– We should not have grabbed the resident’s pants during the transfer;
– The gait belt should not slide up, it should be readjusted;
– Should place one hand under the resident’s arm and grab the gait belt and place his/her
other hand on the back of the gait belt or whatever is comfortable for him/her.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– The gait belt should be placed around the resident’s abdomen;
– The gait belt should not slide up and if it does, staff should have the resident sit
down and readjust the gait belt;
– Staff should place one hand on the front of the gait belt and the other hand on the back
of the gait belt;
– Staff should not hold onto a resident’s arm during a transfer and should not grab a hold
of the resident’s pants during the transfer.
7. Review of the resident’s supervised smoking policy, revised, 8/25/17, showed, in part:
– The center will provide a safe, designated smoking area for residents;
– Residents will be supervised during smoking;
– Smoking is only allowed in designated areas and oxygen is not permitted;
– Staff will be assigned to supervise residents during designated smoking times
8. Review of Resident #358’s baseline care plan, dated, 8/31/18, showed, in part:
– Activity: safety with smoking;
– Remove oxygen before smoking.
Review of the resident’s safe smoking evaluation, dated, 8/31/18, showed:
– The resident was determined to be a safe smoker.
Review of the resident’s POS, dated, September, (YEAR), showed:
– an order for [REDACTED].>Observation and interview on 9/6/18, at 1:22 P.M., showed:
– A contracted staff member approached the nurse’s station on B hall and informed LPN A
Resident #358 was outside in the smoking area with his/her portable oxygen turned on and
was smoking a cigarette;
– LPN A and LPN B went outside where the resident sat in his/her wheelchair with a lit
cigarette and was accompanied by a family member;
– The resident did not have the nasal cannula in his/her nose;
– The resident said he/she forgot to turn the portable oxygen off;
– LPN A removed the portable oxygen canister and took it inside the facility;
– LPN A said the resident should not have the oxygen turned on while he/she was outside
smoking.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– Residents should not go outside and smoke with the oxygen turned on;
– All staff should monitor the residents when they go out and smoke.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record reviews, the facility failed to provide
proper catheter (a sterile tube inserted into the bladder to drain urine) care for three
residents (Residents #15, #59 and #81). The facility census was 104.
1. Review of the facility policy and procedure for Urinary Catheter Care, revised 9/5/17,
showed:
– Remove catheter securement device while maintaining connection with drainage tube;
– Wash perineal area with soap and water from front to back;
Clean catheter tubing with soap and water starting close to the urinary meatus, cleaning
in a circular motion along its length about four inches, moving away from the body;
– (MONTH) use incontinent wipes in place of soap and water;
– Reattach catheter securement device.
2. Review of Resident #15’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/22/18, showed:
– Required extensive staff assistance for transfers, toileting , and hygiene;
– Had a catheter;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/5/18, showed:
– Required two staff for bed mobility;
– The resident had a suprapupbic catheter (a sterile tube surgically inserted into the
bladder through the abdomen to drain urine);
– Staff must provide catheter care.
Observation on 9/5/18 at 3:03 P.M. of Certified Nurse Assistant (CNA) L and CNA M
providing catheter care for the resident showed:
– CNA L cleaned the front of the resident;
– Without performing hand hygiene, CNA L changed his/her gloves;
– Then CNA L cleaned the resident’s rectal area;
– Without washing hands and changing gloves, CNA L took a fresh wipe and cleaned up and
down on the catheter several times using the same part of the wipe.
During an interview on 9/5/18 at 3:03 P.M. CNA L said:- He/she should have washed hands
and changed gloves before cleaning the resident’s catheter;
– He/she should have use one wipe for each swipe on the resident’s catheter.
3. Review of Resident #59s care plan, dated 6/14/18, showed staff should provide the
resident with catheter care every shift and as needed.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– The resident had full dependence upon staff for toileting and hygiene.
– The resident had a catheter.
– The resident was always incontinent of bowel.
Observation on 9/4/18 at 9:53 A.M. of CNA D and CNA J providing catheter care for the
resident showed:
– CNA D cleaned the resident’s perineal folds.
– Without washing hands and changing gloves, CNA D cleaned the resident’s catheter.
– Both CNAs transferred the resident using a mechanical lift and did not keep the
resident’s drainage bag below the resident’s bladder.
During an interview on 9/4/18 at 9:53 A.M. CNA D and CNA J said:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 12)
– They should have washed hands and changed gloves before cleaning the resident’s
catheter.
– They should keep the resident’s catheter bag below the bladder.
During an interview on 9/7/18 at 1:32 P.M. the DON said:
– Staff should always wash their hands and change their gloves before cleaning a
resident’s catheter.
– Staff must always keep a resident catheter bag below the bladder.
– When cleaning a resident’s catheter, staff must use a fresh wipe for each swipe.
4. Review of Resident #158’s MDS, dated [DATE], showed:
– Difficulty making daily decisions;
– Dependent of staff for toilet use;
– Required extensive assist with personal hygiene;
– Always incontinent of urine;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/30/18, showed:
– Foley catheter care every shift;
– Provide incontinent care as needed.
Observation on 9/6/18 at 10:04 A.M., showed the resident lay in bed incontinent of fecal
material and with a urinary catheter drainage bag hooked to the side of the bed. CNA H and
CNA K provided perineal and catheter care for the resident. The resident did not have a
leg strap (device to secure the catheter tubing so the catheter would not be dislodged or
pulled during care). CNA H provided peri care, but did not manipulate and thoroughly clean
all perineal folds around the insertion site of the catheter. He/she did not anchor the
catheter tubing with one hand when he/she wiped the catheter tubing.
5. Review of Resident #65’s MDS, dated [DATE], showed:
– Able to make daily decisions;
– Dependent on staff for toilet use;
– Required extensive assistance of staff with personal hygiene;
– Had an indwelling Foley catheter;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated 7/24/18, showed:
– The resident has an activity of daily living (ADL) performance deficit.
The resident’s care plan does not address the resident’s catheter or [MEDICAL CONDITION].
Observation on 9/6/18 at 11:27 A.M., showed the resident lay in bed. The resident did not
have a leg strap to secure the catheter tubing.
– CNA K did not open and thoroughly cleanse all the perineal folds before he she wiped
down the catheter tubing;
– Cleaned the buttocks and wiped back to front from the top of the hip to the gluteal
fold, continued with the same wipe over to the rectal area and up to the coccyx.
During an interview on 9/6/18 at 4:19 P.M., CNA K said:
– Clean the center and all sides of the perineal fold before you wipe the catheter tube;
– Hold the catheter tube at the insertion site when you wipe down the tube;
– Wipe down the buttock then around and back up the buttocks;
– Residents should have a leg strap with their catheter.
6. Review of Resident #81’s quarterly MDS, dated , 7/30/18, showed:
– Cognitively intact;
– Had a supra pubic catheter;.;
– [DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 – Some

(continued… from page 13)
Review of the resident’s care plan, dated, 8/14/18, showed:
– The resident had altered bladder elimination;
– Catheter care as ordered and as needed;
– Change catheter as ordered.
Observation on 9/6/18, at 11:16 A.M., showed CNA N provided catheter care in the following
manner:
– Anchored the tubing and wiped down it twice with a different wipe each time;
– Wiped down each side of the groin with a different wipe each time;
– Cleaned the front perineal folds;
– Placed the graduate (clear plastic container with markings used to collect and measure
fluids), directly on the floor;
– Removed the drainage spout from the sleeve, unclamped it and emptied the urine into the
graduate;
– Used a wipe and cleaned the spout and replaced it in the sleeve;
– CNA N did not clean the buttocks.
During an interview on 9/6/18, at 11:26 A.M., CNA N said:
– He/she probably should have cleaned the buttocks.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– Staff should clean the perineal folds before they clean the catheter tubing;
– Staff should clean the buttocks even if the resident had a supra pubic catheter.
During an interview on 9/7/18 at 1:56 P.M., the Director of Nursing (DON) said:
– Staff should use one wipe, one swipe method;
– Staff should open all perineal folds and clean;
– Staff should wipe front to back;
– Staff should perform good peri care prior to performing catheter care;
– The residents with indwelling catheters should wear a leg strap.
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 observations, interviews, and record reviews the facility failed to assure staff
provided proper respiratory care for two resident (Resident #16 and #59), failed to
properly clean oxygen concentrator filters which affected one of 28 sampled residents,
(Resident #28) and failed to date the oxygen tubing and humidifier bottle, which affected
Resident #16 and #28. The facility census was 104.
1. Review of the Best Practice for Oxygen Therapy, dated 3/21/18, provided by the
facility, showed:
– Oxygen therapy is the administration by various means of devices;
– Obtain physician order, follow infection control procedures as appropriate;
– Ensure flow rate is per physician order;
– Monitor resident’s respiratory rate;
– Label and date tubing and the humidifier bottle if applicable.
2. Review of Resident #59s care plan, dated 6/14/18, showed did not discuss the resident
using oxygen.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by staff, dated 7/10/18, showed:
– The resident had full dependence upon staff for toileting and hygiene.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 14)
– The resident had a catheter.
– The resident was always incontinent of bowel.
– Did not discuss the resident’s use of oxygen.
Review of the resident’s physician order [REDACTED].
– [DIAGNOSES REDACTED].
– Should have oxygen at 4 liters (L) per minute per resident request.
Observation on 9/4/18 at 9:41 A.M. showed:
– The resident’s oxygen tubing was attached to an empty portable tank on his/her
wheelchair.
– His/her oxygen tubing and oxygen humidifier were not dated when the items were opened
for use.
– His/her oxygen concentrator filter was entirely caked with dust.
Multiple observations on 9/4/18 from 10:00 A.M. to 12:15 P.M. showed the resident’s using
his/her oxygen which was hooked up to an empty oxygen tank.
Observation on 9/4/18 at 12:19 P.M. showed staff replaced the resident’s empty oxygen tank
with a full tank.
During an interview on 9/4/18 at 12:00 P.M., Certified Nurse Aide (CNA) D said:
– He/she should have checked the resident’s oxygen tank to see if it was empty.
– Yesterday was holiday.
– Yesterday the facility was out of portable oxygen tanks.
– He/she should have hooked the resident to his/her oxygen concentrator when his/her
oxygen tank was empty.
Observation on 9/7/18 at 9:00 A.M. showed:
– The resident’s oxygen tubing and humidifier were not dated when opened for use.
– The resident’s oxygen concentrator was caked with dust.
During an interview on 9/7/18 at 9:11 A.M. Registered Nurse (RN) A said:
– He/she was the resident’s charge nurse.
– The weekend night shift charge nurse was supposed to change and date resident’s oxygen
tubing and humidifiers on a weekly basis.
– The weekend night shift charge nurse was supposed to clean the oxygen concentrator
filters on a weekly basis.
3. Review of Resident #16’s current physician order [REDACTED]. Take oxygen saturation
every shift.
Observation on 9/5/18 the undated humidifier bottle attached to the resident’s
concentrator was empty and remained empty until 11:15 A.M., on 9/6/18. The resident’s
oxygen tubing was undated.
Observation on 9/6/18 at 7:45 A.M., showed the resident sat in the dining room with a
nasal cannula affixed in the resident’s nose. The oxygen tubing was attached to a portable
oxygen tank. The flow rate meter on the oxygen tubing was in the off position. The flow
rate meter remained in the off position until at least 9:50 A.M.
During an interview on 9/6/18 at 11:12 A.M., Family Member A said the hospice nurse got to
the facility around 10:00 A.M., and performed a oxygen level on the resident, his/her
oxygen saturation was low. The hospice nurse turned the oxygen canister on and set the
flow rate on 4 until the oxygen saturation got up to the 90’s, then the hospice nurse
turned the flow rate back down.
Observation on 9/6/18 at 11:24 A.M., Licensed Practical Nurse (LPN) E and CNA K
transferred the resident from his/her wheelchair to bed. LPN E transferred his/her undated
oxygen tubing from the portable tank back to the resident’s concentrator. The undated
humidifier bottle attached to the concentrator remained empty.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 15)
During an interview on 9/6/18 at 1:20 P.M., LPN E said:
– Staff should date the oxygen tubing and the humidifier bottle when opened and put in use
for the resident;
– Staff should change out the humidifier bottle when it is empty;
– The staff should have the correct flow rate turned on when staff hooked the resident up
to the portable tank for oxygen.
4. Review of Resident #81’s quarterly MDS, dated , 7/30/18, showed:
– Cognitively intact;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/14/18, showed:
– The resident had an ineffective breathing pattern related to [MEDICAL CONDITION];
– Oxygen as ordered, see physician order [REDACTED].
Review of the resident’s POS, dated, September, (YEAR), showed:
– an order for [REDACTED].>- [DIAGNOSES REDACTED].
Observation on 09/04/18 at 11:17 A.M., showed:
– The resident had his oxygen on at 3L/NC;
– The oxygen tubing was not dated;
– The oxygen concentrator filter was covered in light gray lint.
5. During an interview on 9/7/13 at 2:03 P.M., the DON said:
– The oxygen tubing should be dated when opened, oxygen tubing should be changed weekly;
– The filters should be rinsed off in the sink, night shift is supposed to do it weekly;
– The humidifier bottle should be dated when opened, every shift should check the water in
the humidifier bottle and change when empty;
– If the cannula was in the resident’s nose the concentrator or portable tank should be
turned on.
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to ensure staff
administered medications with a less than 5% medication error rate. Staff made two
medication errors out of 25 opportunities for error, resulting in a medication error rate
of 8%. This affected one resident (Resident #59). The facility census was 104.
1. Review of the package insert for [MEDICATION NAME], dated (MONTH) 2004 showed:
– The medication was used to treat gastric issues.
– The medication should be administered on an empty stomach.
Review of the package insert for omperazole, dated (MONTH) 2012, showed:
– The medication was used to treat gastric issues.
– The medication should be given one hour before a meal.
Review of the facility policy, dated 11/30/14, on medication administration showed staff
should accurately administer medications.
Review of Resident #59’s physician’s order sheet (POS), dated (MONTH) (YEAR), showed:
– an order for [REDACTED].
– an order for [REDACTED].
Observation on 9/6/18 at 8:46 A.M. showed:
– The resident in his/her room eating breakfast.
– Certified Medication Technician (CMT) A administered to the resident one gm [MEDICATION

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
NAME] and 40 mg omperazole po.
During an interview on 9/6/18 CMT A said he/she should have given [MEDICATION NAME] and
omperazole before breakfast.
During an interview on 9/7/18 at 1:32 P.M. the Director of Nursing (DON) said staff should
always administer [MEDICATION NAME] and omperazole one hour before breakfast.
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, interviews, and record reviews the facility failed to ensure staff
properly discarded resident medications (Resident #87). Staff stored food in the
medication refrigerator, and had loose pills in the medication carts. The facility census
was 104.
1. Review of the facility’s undated delivery, receipt, storage, and inventory of
medication and products, showed, in part:
– The community should ensure that medications and biologicals: have not been retained
longer than recommended by manufacturer or supplier guidelines; once any drug or
biological package is opened, the community should follow manufacturer/supplier guidelines
with respect to expiration dates for opened medications;
– The community should ensure that food is not to be stored in the refrigerator, freezer,
or general storage areas where medications and biologicals are stored;
– The community should ensure that all controlled substances are stored in a manner that
maintains their integrity and security;
– The community should ensure that the medications and biologicals for the resident are
stored in their originally received containers.
2. Observation on 9/6/18 at 9:34 A.M. of the Unit Manager (UM) and Certified Medication
Technician (CMT) A counting controlled substances showed Resident #87’s bubble pack of
clonizapem (used to treat anxiety) with blister #11 torn with a pill inside the blister.
During an interview on 9/6/18 at 9:34 A.M. the UM said staff should always discard any
medication behind a torn blister.
During an interview on 9/7/18 at 1:32 P.M. the Director of Nursing (DON) said staff should
always discard any pills behind torn blisters.
3. Observation on 9/6/18, at 7:37 A.M., of the nurse’s medication cart showed:
– One large loose white tablet in the bottom drawer of the medication cart;
– One small green tablet in the bottom drawer of the medication cart.
Observation on 9/6/18, at 8:36 A.M., of the medication refrigerator showed:
– An opened box of thickened lemon flavored water high in vitamin C, expired 2/12/18;
– An unopened bottle of water;
– An unopened can of Coke;
– An unopened container of french onion dip;
– A bottle of [MEDICATION NAME] and claulanate potassium (antibiotic used to treat
infections) for oral suspension, discard after 9/2/18.
During an interview on 9/6/18, at 10:44 A.M., LPN A said:
– There should not be any food or drink in the medication refrigerator;
– There should not be any loose pills in the drawers of the medication cart;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 17)
– Expired medications should be removed and destroyed and not used.
Observation and interview on 9/6/18, at 9:20 A.M., of the Certified Medication Technician
(CMT) medication cart showed:
– Had on oblong loose pill in the bottom drawer of the medication cart;
– Had a round loose pill in the bottom drawer of the medication cart;
– Had a fourth of a white pill in the bottom drawer of the medication cart;
– There should not be any loose pills in the bottom drawer of the medication cart, they
should be destroyed.
During an interview on 9/7/18, at 2:03 P.M., the Assistant Director of Nursing (ADON)
said:
– There should not be any loose pills in the medication cart;
– Staff should clan it out and discard them;
– There should not be any food or drink in the medication refrigerator;
– The nurses are the primary and the unit managers are secondary to check the medication
cart and medication room for expired medications;
– The pharmacy consultant checks the medication carts at least twice monthly and not for
sure if they check the medication rooms.
F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident receives and the facility provides food that accommodates resident
allergies, intolerances, and preferences, as well as appealing options.

Based on observations, interviews, and record reviews, the facility failed to accommodate
resident’s choices for breakfast when the facility did not serve meat for breakfast daily.
This had the potential to affect all facility residents. The facility census was 104.
1. Record review of facility’s weekly menu for breakfast the week of 9/3 through 9/9/18
showed:
-Monday-Scrambled eggs and cinnamon roll;
-Tuesday-Biscuit with sausage gravy and hash browns;
-Wednesday-Baked cheese omelet and toast;
-Thursday-Scrambled eggs and English muffin;
-Friday-Western Scrambled eggs and toast;
-Saturday-Pancakes and sausage patty;
-Sunday- French Toast and bacon.
– Always available scrambled eggs and cereal.
During a group interview, on 9/5/18 at 2:00 P.M. the group said:
– The menu for Tuesday said biscuits, gravy, and hash browns but staff served scrambled
eggs.
– The facility only serves breakfast meat on the weekends.
– The facility did not serve any breakfast meat during the week.
– The group said they would like the facility to offer bacon and sausage every day for
breakfast.
– The group said they had talked to the Dietary Manager (DM) who told them the registered
dietician (RD) made the menus and he/she had to follow them.
– Several residents said they did not like eggs or were allergic to them.
– The facility did not offer any substitutes for eggs.
– The facility did not list yogurt as an alternate for eggs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
– The facility said they had yogurt to substitute for eggs but usually did not have any
yogurt.
– The DM attended council meetings but did not accommodate resident requests.
During an interview on 9/7/18 at 10:40 A.M. the DM said:
– The corporate dietician provides the menu for the fallibility.
– Breakfast is usually eggs with breakfast meat only twice a week.
– He/she had staff provide yogurt for a substitute for eggs.
During an interview on 9/7/18 at 1:27 P.M. the corporate dietary manager (CDM) said:
– Dietary staff should not substitute eggs for eggs.
– Staff should accommodate the resident’s request and serve breakfast meats daily.
F 0809

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interviews and record reviews the facility failed to ensure staff followed their
policy requiring staff to offer each resident a bedtime (HS) snack. The facility census
was 104.
1. Review of the facility policy, dated (MONTH) 2014 on snacks showed:
– Staff should provide snacks as ordered.
– Staff must offer HS snacks to all residents.
– The dietary department provided HS snacks for each resident.
– Nursing services was responsible for delivering ordered snacks to each resident and
offering snacks to each resident.
Review of the snack tray sign off sheet showed dietary staff delivered HS snacks to all
facility units.
During an group interview on 9/5/18 at 2:00 P.M. the residents said:
– Staff did not bring snacks to the room.
– Dietary did not deliver enough snacks for all residents.
– If a resident wanted an HS snack, he/she better get to the desk quickly because the
snacks went fast.
During an interview on 9/7/18 at 1:08 P.M. the Dietary Manager (DM) said dietary did not
send enough snacks for an entire wing.
During an interview on 9/7/18 at 1:27 P.M. the Corporate Dietary Manager (CDM) said the
dietary staff should send out enough HS snacks for all residents.
During an interview on 9/7/18 at 1:32 P.M. the Director of Nursing (DON) said staff must
offer all residents an HS snack,

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview the facility failed to ensure they stored and prepared

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
food under sanitary conditions and failed to keep food sealed, labeled, dated. The
facility census was 104.
1. Observation on 9/4/18 at 9:05 A.M. showed in the kitchen:
-Bag of breadsticks with freezer burn not sealed or dated;
-Air vent covered in thick dust above tray cart;
-Seven bowls of dessert not covered or dated in refrigerator;
-Exhaust fan by dishwasher covered in dust and ceiling around it covered with dust.
During an interview on 9/7/18 at 10:40 A.M., Dietary Manager said when food comes in they
have a receive date on it, and when they open it they put an open date on it as well. All
food is sealed by wrapping it up in saran wrap. Maintenance cleans the air vents on the
ceiling.
During an interview on 9/7/18 at 1:15 P.M., Maintenance Director said they clean the air
vents every three months.
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 observations, interviews, and record review the facility failed to assure staff
used proper infection control technique during cares reduce the possibility of cross
contamination. This affected two of 28 sampled residents (Resident #84 and #158) and
Residents #39, #81, #51, #88, #15, and #59. The facility census was 104.
1. Review of the facility’s insulin administration policy, revised, 9/5/17, showed, in
part:
– Cleanse the rubber cap of the insulin vial with alcohol wipe.
2. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated, 6/18/18, showed:
– Cognitive skills intact;
– Seven insulin injections in the last seven days;
– [DIAGNOSES REDACTED].
Review of the resident’s physician order sheet (POS), dated, September, (YEAR), showed:
– an order for [REDACTED].
Observation on 9/5/18, at 8:16 A.M., showed:
– Licensed Practical Nurse (LPN) A cleaned the resident’s finger with an alcohol wipe and
after obtaining the blood sample, used the same alcohol wipe to clean the area;
– LPN A picked up the resident’s insulin pen, did not clean the rubber port and placed a
new needle on it;
– LPN A used the same alcohol pad and cleaned the resident’s left upper arm and
administered the insulin.
During an interview on 9/6/18, at 10:44 A.M., LPN A said:
– He/she should not have used the same alcohol wipe to clean the resident’s finger before
and after the blood sample and then to clean the resident’s arm before he/she gave the
resident the insulin injection;
– He/she should have cleaned the port on the insulin pen before putting on the new needle.
During an interview on 9/7/18, at 2:03 P.M., the assistant director of nursing (ADON)
said:
– Staff should have cleaned the port on the insulin pen before putting the needle on;
– Staff should not have used the same alcohol pad to clean the finger before and after the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 20)
blood sugar and then using the same alcohol wipe to clean the resident’s skin before
administering the insulin.
3. Review of Resident #81’s quarterly MDS, dated , 7/30/18, showed:
– Cognitive skills intact;
– Had a supra pubic catheter (catheter which enters the bladder through the lower
abdomen);
– [DIAGNOSES REDACTED].
Observation on 9/6/18, at 11:16 A.M., showed:
– Certified Nurse Aide (CNA) N placed the graduate directly on the floor;
– CNA N removed the drainage spout from the sleeve, unclamped it and emptied the urine in
the graduate;
– CNA N clamped the drainage spout, and used a wipe to clean the drainage spout and
replaced it in the sleeve.
During an interview on 9/6/18, at 11:26 A.M., CNA N said:
– He/she did not normally work the floor;
– To his/her knowledge, staff just used a wipe to clean the drainage spout;
– He/she just normally placed the graduate directly on the floor.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– Staff should clean the drainage spout with an alcohol wipe;
– Staff should place the graduate on a clean surface.
4. Review of Resident #84’s annual MDS, dated , 8/6/18, showed:
– Cognitive skills moderately impaired;
– Required extensive assistance of two staff for bed mobility;
– Dependent of the assistance of two staff for transfers and toilet use;
– Lower extremities impaired on both sides;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 9/5/18, at 11:01 A.M., showed:
– CNA A and CNA O provided incontinent care, dressed the resident and transferred him/her
into his/her wheelchair;
– The resident’s incontinent cloth pad and the fitted sheet were wet with urine;
– CNA O removed the wet linens from the bed and did not disinfect the mattress;
– CNA A entered the room with clean bed linens and did not disinfect the mattress and made
the bed.
During an interview on 9/6/18, at 4:27 P.M., CNA A said:
– The mattress should have been cleaned before the bed was made.
During an interview on 9/6/18, at 11:13 P.M., CNA O said:
– The mattress should have been disinfected before it was made.
During an interview on 9/7/18, at 2:03 P.M., the ADON said:
– If the mattress was wet with urine or the fitted sheet was wet, staff should clean the
mattress and let it air dry before making the bed.
5. Review of the facility policy, dated 11/30/14, on glucometer cleaning showed did not
discuss where to put the used meter.
Review of Resident #51’s annual MDS, dated [DATE] showed:
– [DIAGNOSES REDACTED].>- Received insulin injections.
Review of the resident’s care plan, dated 7/9/18, showed staff should monitor the
resident’s blood glucose levels as ordered.
Review of the resident’s physician order sheet (POS) dated (MONTH) (YEAR) showed staff
must check the resident’s blood glucose before meals.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 21)
Observation on 9/5/18 at 11:20 A.M. of Registered Nurse (RN) B performing a blood glucose
check on the resident showed:
– He/she performed the blood glucose check.
– He/she then placed the used glucometer on the medication cart without using a clean
field.
– He/she then placed the used glucometer in a bag with the resident’s name on it.
During an interview on 9/5/18 RN B said he/she should have not placed the used meter
directly on the medication cart.
During an interview on 9/7/18 at 1:32 P.M. the Director of Nursing (DON) said staff should
never put a used meter on the medication cart.
6. Review of Resident #88’s care plan, dated 5/22/18,, showed the resident was unable to
transfer or toilet.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Cognitively intact;
– Total dependence upon staff for transfers, toileting, and hygiene;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 9/6/18 at 9:55 A.M. of CNA E and CNA F showed:
– The CNAs provided perineal care for the resident.
– The CNAs removed the resident’s bed pad that was soiled with fecal material.
– The CNAs placed the resident’s soiled linens on the floor.
During an interview on 9/6/18 at 9:55 A.M. CNA E and CNA F said they should have not
placed soiled linens on the floor.
During an interview on 9/7/18 at 1:23 P.M. the DON said staff should never put soiled
linens on the floor.
7. Review of the facility policy, dated 9/6/16,, on hand hygiene showed:
– Staff should wash perform hand hygiene after contact with any body fluids.
– Staff should perform hand hygiene before initiating a clean procedure.
– Staff should perform hand hygiene when hands are moved from a dirty to a clean body
site.
– Staff must perform hand hygiene after glove removal.
Review of Resident #59’s care plan, dated 6/14/18, showed staff should provide perineal
care after each episode of incontinence.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– Required extensive staff assistance for toileting;
– Had a catheter (a sterile tube inserted into the bladder to drain urine);
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Observation on 9/4/18 at 9:41 A.M. of CNA D and CNA J providing perineal care to the
resident showed:
– CNA J cleaned the resident’s rectal area which was soiled with fecal material.
– Without washing his/her hands and changing gloves, CNA J touched the resident’s bedside
stand and applied a powder to the resident’s skin folds.
During an interview on 9/4/18 at 9:41 A.M. CNA J said:
– He/she should wash his/her hands and change gloves when going from soiled to clean
tasks.
– He/she should wash his hands and change gloves after applying powder to a resident’s
skin folds.
– Should not touch a package of wipes with soiled hands.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265437

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

09/07/2018

NAME OF PROVIDER OF SUPPLIER

ASHTON COURT CARE AND REHABILITATION CENTRE

STREET ADDRESS, CITY, STATE, ZIP

1200 WEST COLLEGE STREET
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 22)
8. Review of Resident #15’s quarterly MDS, dated [DATE], showed:
– Dependence upon staff for transfers and toileting;
– Had a catheter;
– Always incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/15/18, showed the resident required staff
assistance for toileting.
Observation on 9/5/18 at 3:03 P.M. of CNA L and CNA M providing perineal care for the
resident showed:
– CNA L removed a wipe from the package and started to provide perineal care.
– CNA L removed a wipe from the package from the package every time he/she needed a wipe.
During an interview on 9/5/18 at 3:03 P.M. CNA L said he/she should not touch a package of
wipes with soiled hands.
During an interview on 9/7/18 at 1:32 P.M. the DON said:
– Staff should always wash their hands when going from soiled to clean tasks.
– Staff should always wash their hands after applying powder.
– Staff should never touch a package of wipes with soiled hands.
9. Review of Resident #158’s MDS, dated [DATE], showed:
– Difficulty making daily decisions;
– Dependent of staff for toilet use;
– Required extensive assist with personal hygiene;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/30/18, showed:
– Provide incontinent care as needed.
Observation and interview on 9/6/18 at 10:04 A.M., showed the resident lay in bed on a low
air loss mattress, incontinent of fecal material. CNA K and CNA H provided peri care. When
staff removed the two incontinent pads and the flat turn sheet, there were dried brown
stains on the right side of the mattress. Staff finished peri care and laid the resident
on top of clean incontinent pads that lay on top of the brown stains. CNA K said he/she
had not seen the dried brown stains, the dried brown stains looked like fecal material to
him/her. Staff should wiped fecal material off the mattress, transferred the resident and
got housekeeping to come in, clean and sanitize the mattress.
During an interview on 9/7/18 at 2:03 P.M., the Director of Nurses (DON) said:
– Staff should use only paper chux under the resident on the low air loss mattress;
– If the mattress were wet or had fecal material on it, that should come clean when staff
cleaned the mattress;
– Staff should let the mattress air dry before using it again.
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