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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
treat each resident with respect and dignity and provide care in a manner and in an
environment that promotes maintenance or enhancement of his or her quality of life by
failing to respond to residents’ requests for staff assistance or attention and by
referring to an adult incontinence brief as a diaper while providing care, for three
residents (Resident #55, #44 and #40). The census was 61.
1. Review of Resident #55’s quarterly Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 12/28/18, showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 2 out of 15 (a score of 0 to 7
indicates cognitive impairment);
-Extensive assistance required for bed mobility, dressing and personal hygiene.
Observation of the resident in his/her room on 1/27/19, showed:
-At 7:43 A.M., the resident’s room was located at the end of the 300 hall. The resident’s
door stood open and the privacy curtain not pulled. The resident lay in bed and faced the
door, without clothing. The resident’s gown off and his/her chest exposed. The resident’s
back lay against the left side rail. He/she continued to attempt to sit up. Housekeeper M
exited out of the room directly across the hall from Resident #55’s room. He/she looked
into the resident’s room and walked to his/her cart in the middle of the hall to put on
gloves. Housekeeper M walked down the hall, away from Resident #55’s room;
-At 7:52 A.M., the social worker walked into the facility from the entrance at the end of
the 300 hall, near the resident’s room. The social worker walked past the resident’s open
door and past Housekeeper M. Housekeeper M did not say anything to the social worker;
-At 7:55 A.M., Certified Medication Technician (CMT) N walked down the 300 hall. CMT N
walked to the housekeeping cart and removed gloves from the cart. Housekeeper M walked
passed CMT N in the hallway after he/she left out of another room. Housekeeper M did not
say anything to CMT N as they crossed paths. Resident #55’s door continued to be open and
the privacy curtain not pulled;
-At 8:03 A.M., the resident lay in bed and only wore a brief. Housekeeper M continued to
go from room to room on the 300 Hall;
-At 8:20 A.M., the resident lay in bed and attempted to cover him/herself with a blanket.
The resident remained without a shirt and his/her chest exposed. The door remained open
and the privacy curtain not pulled. Housekeeper M continued to work on the 300 hall;
-At 8:27 A.M., a resident propelled down to the end of the hall and looked into Resident
#55’s room. Housekeeper M continued to go from room to room on the 300 hall;
-At 8:52 A.M., the resident’s door now stood half closed, but Resident #55 visible from
the hall, in bed without clothing. The resident said, help me please several times.
Housekeeper M was at the other end of the 300 hall;
-At 8:58 A.M., two Certified Nurse Aides (CNAs) entered the resident’s room and closed the
door.
Observation on 1/28/19 at 7:32 A.M., showed the resident lay in his/her bed, without a
shirt on, bare chest exposed, and pulled on his/her brief with pajama pants pulled half
way down over his/her hips. The resident pulled on the privacy curtain that hung from the
ceiling while asking for help. The call light lay on the floor, out of the resident’s
reach. CNA Q entered the room and shut the door. After washing his/her hands and donning
gloves, the CNA rolled the resident onto his/her side. The resident coughed violently and

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
spat out thick, yellow, brown phlegm onto the mattress and floor. CNA Q stated the
resident often spat out mucous. The CNA did not clean the phlegm off of the resident’s
mattress nor off of the floor. CNA Q stripped the resident of his/her clothes and urine
soaked brief. The resident lay naked, without the privacy curtains drawn, while CNA Q
performed perineal care (peri-care, washing the front and back of the hips, genitals, anal
area and buttocks). There was a knock on the resident’s door and CNA Q called out, come in
without asking who was there. The resident lay completely bare, in open view of the
doorway and the hall. The door opened, a staff member poked his/her head into the room,
mumbled something to the CNA and shut the door. The resident was left uncovered during the
encounter.
Observation on 1/28/19 at 2:33 P.M., showed the resident in bed without clothing. His/her
chest exposed. The resident’s door stood open and the privacy curtain not pulled. The
resident began to pull on the privacy curtain and said, help. CNA O entered the room and
pulled the curtain. During an interview at this time, CNA O said the resident had a
history of [REDACTED].
During an interview on 1/30/19 at 12:06 P.M., the Director of Nursing (DON) said she would
expect all staff to respect the dignity and privacy of the residents in the facility. If a
housekeeping staff saw the resident in the room without clothing, she would expect them to
pull the privacy curtain and close the door. The DON would had preferred the housekeeper
to notify a CNA or nurse because they would be able to assist the resident with putting on
clothing. If the housekeeper heard the resident say help, she would expect the housekeeper
to notify nursing staff within a reasonable amount of time.
2. Review of Resident #44’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 5 out of 15 (indicates cognitive impairment);
-No behaviors;
-Incontinent of urine;
-Required maximum assistance from the staff for transfers, dressing, hygiene and bathing.
Observation on 1/27/19 at 7:35 A.M., showed the resident lay in bed awake. CNA G washed
hands, put on gloves and told the resident he/she was going to remove his/her wet diaper.
After unfastening the resident’s adult incontinence brief, CNA G turned the resident onto
his/her left side and said he/she was going to remove the diaper from under him/her. CNA G
provided the resident with incontinence care. After providing care, CNA G opened the door
to the resident’s room, called out to an unknown staff member in the hallway to hand
him/her a blue brief. After receiving the incontinence brief from the other staff member,
CNA G placed the brief on the resident, dressed and transferred the resident into his/her
wheelchair.
3. Review of Resident #40’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 3 out of 15 (indicates cognitive impairment);
-No behaviors;
-Incontinent of bowel and bladder;
-Required total assistance from staff for transfers, dressing, eating, hygiene and
bathing.
Observation on 1/28/19 at 7:48 A.M., showed the resident lay in bed. CNA G washed hands,
put on gloves and provided the resident with incontinence care. CNA G turned the resident
onto his/her left side and told resident going to put a clean diaper on him/her. CNA G
placed a clean adult incontinence brief under the resident, turned the resident onto
his/her back and told the resident he/she was going to fasten the diaper.
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
4. During an interview on 1/30/19 at 11:55 A.M., the DON said it would never be
appropriate for staff to refer to the adult incontinence brief as a diaper, they should
refer to it as a brief due to dignity issues.
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written Emergency
Transfer notices to residents and/or representative as soon as practicable when a resident
is temporarily transferred on an emergency basis to an acute care facility and their
return to the facility was expected. Of the 15 sampled residents, seven had been recently
transferred to a hospital for various medical reasons, all seven were expected to return
and had not been issued a written transfer notice upon leaving the facility (Residents
#29, #28, #40, #63, #44, #21 and #52). The census was 61.
1. Review of Resident #29’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfers.
2. Review of Resident #28’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
3. Review of Resident #40’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfer.
4. Review of Resident #63’s medical record, showed:
-Transferred to the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
5. Review of Resident #44’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 3)
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfers.
6. Review of Resident #21’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfers.
7. Review of Resident #52’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfers.
8. During an interview on 1/30/19 at 9:00 A.M., the Social Service Designee (SSD) said the
emergency transfer notice would be issued by either the Business Office (BO) managers or
the SSD, he/she had not issued any emergency transfer notices since starting at the
facility in April, (YEAR).
9. During an interview on 1/30/19 at 9:10 A.M., both BO Managers A and B said they were
not aware of who would be responsible for issuing an emergency transfer notice and neither
of them had issued any written emergency transfer notice to any resident and/or their
representative.
10. During an interview on 1/30/19 at 9:15 A.M., the Director of Nurses (DON), Assistant
Director of Nurses (ADON) and Nurse C said when a resident is sent out to the hospital,
they send a copy of the resident’s face sheet, physician order [REDACTED]. They had not
been issuing any emergency transfer notices upon emergency transfer to the hospital with a
return anticipated.
F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide written notice to the
resident or their legal representative of the facility bed hold policy at the time of
transfer to the hospital, for seven of seven sampled residents who were recently
transferred to the hospital for various medical reasons (Residents #29, #28, #40, #63,
#44, #21 and #52). The sample was 15. The census was 61.
1. Review of Resident #29’s medical record, showed:
-Discharge to the hospital on [DATE];

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 4)
-Returned to the facility from the hospital on [DATE];
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfers.
2. Review of Resident #28’s medical record, showed:
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfer.
3. Review of Resident #40’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfer.
4. Review of Resident #63’s medical record, showed:
-discharged to the hospital on [DATE];
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfer.
5. Review of Resident #44’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfers.
6. Review of Resident #21’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfers.
7. Review of Resident #52’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 5)
-No documentation the resident and/or the representative received written notice of the
facility’s bed hold policy at the time of transfers.
8. During an interview on 1/30/19 at 9:00 A.M., the Social Service Designee (SSD) said
he/she had not issued any written bed hold policy to the resident or their representative
when discharged to the hospital with a return anticipated.
9. During an interview on 1/30/19 at 9:10 A.M., both Business Office Managers A and B said
they were not aware of who would be responsible for issuing a written bed hold policy to a
resident and or their representative when a resident is discharged to the hospital with a
return anticipated, neither of them had issued any written bed hold policy to any resident
and/or their representative.
10. During an interview on 1/30/19 at 9:15 A.M., the Director of Nurses (DON), Assistant
Director of Nurses (ADON) and Nurse C said when a resident is sent out to the hospital,
they send a copy of the resident’s face sheet, physician order [REDACTED]. They had not
been issuing any written bed hold policy to the resident and or their representative upon
emergency discharge to the hospital with a return anticipated.
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete and electronically
transmit a discharge Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, for one of one sampled residents who expired at the facility
(Resident #1). The census was 61.
Review of Resident #1’s admission MDS, dated [DATE], showed:
-Originally admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s nurses notes, showed he/she expired at the facility on [DATE].
Further review of the resident’s MDS records, reviewed on [DATE], showed:
-Significant change MDS done on [DATE];
-No discharge MDS found as late as [DATE] at 2:36 P.M.
During an interview on [DATE] at 9:15 A.M., the Director of Nurses (DON) said she is
responsible for completing the discharge MDS, looked in computer, verified no discharge
MDS had been completed or transmitted for Resident #1 and said it should have been done
and was missed.

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

Based on interview and record review, the facility staff failed to complete a
comprehensive discharge summary for one of three closed record sampled residents (Resident
#62). The census was 61.
Review of Resident #62’s closed medical record, showed the resident discharged to the
community on 11/2/18. Staff did not complete a discharge summary, which would include a

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
final summary of the resident’s status, a reconciliation of all pre and post discharge
medications and a post-discharge plan of care.
During an interview on 1/30/19 at 9:05 A.M., the Social Service Designee (SSD) said she
had worked at the facility since (MONTH) (YEAR), was not aware of who would be responsible
for completing a discharge summary for residents who were discharged to the community and
thought it would be nursing.
During an interview on 1/30/19 at 9:15 A.M., the Director of Nurses (DON), Assistant
Director of Nurses (ADON) and Nurse C all said they had not been doing any discharge
summary on any resident who had been discharged to the community and were unaware of the
requirement.
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure
residents, who were unable to carry out activities of daily living (ADLs), received the
necessary services to maintain good grooming and personal hygiene, for three of three
observations of incontinence care (Residents #112, #18 and #44). The total sample was 15.
The census was 61.
Review of the facility’s Perineal Care (peri care, cleansing of the surface area between
the thighs, extending from the pubic bone to the tail bone) policy, dated 7/17/12, showed:
-Gather necessary equipment: No rinse peri wash, wash cloths, towels for drying, bed pad,
plastic bags and gloves;
-Wash hands and put on gloves;
-Expose the perineal area: Gently wash all areas of the genitals. Wipe front to back. Get
a clean cloth and continue cleaning down legs as needed;
-Dry peri area;
-Roll resident onto one side to continue washing soiled/wet area from back down to rectal
area;
-Roll soiled pad up to resident, place clean pad up to soiled pad. Roll resident over onto
clean pad, continue to wash soiled/wet area. If resident is only wet, you may wash from
back to buttocks to legs. If resident has stool, wash from back to buttocks, get clean
cloth and wash rectal area. After cleaning stool, change gloves, get cloth and continue
cleaning legs. Dry area;
-Roll clean pad under resident;
-Remove gloves, position resident so they are comfortable;
-Place soiled linen in proper container;
-Wash hands.
1. Review of Resident #112’s face sheet, showed [DIAGNOSES REDACTED].
Observation on 1/27/19 at 5:15 A.M., showed the resident lay in bed awake. Certified Nurse
Aide (CNA) E and CNA F washed hands, put on gloves and provided the resident with care.
CNA E removed the resident’s urine soiled adult incontinence brief, washed the resident’s
right side of the outer genitals with a wet wash cloth and no-rinse peri wash, turned the
resident onto his/her right side, washed the resident’s rectal area, changed wash cloths,
lifted the resident’s left leg and cleaned the central area of the genitals, from front to
back with one swipe. CNA E changed his/her gloves, applied barrier cream to the resident’s

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
buttocks, removed the soiled pad from under him/her, removed gloves, covered the resident,
washed hands and left the resident’s room. CNA F removed his/her gloves, washed hands and
left the resident’s room. Neither CNAs E nor F cleaned the resident’s left outer genitals
or buttocks to ensure all urine had been removed from the resident’s skin, nor did they
dry the resident’s skin prior to leaving the room.
2. Review of Resident #18’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/7/18, showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15 (0 to 7
indicates severe cognitive impairment);
-No behaviors;
-Incontinent of bowel and bladder;
-Required maximum assistance from staff for transfers, dressing, personal hygiene and
bathing.
Observation on 1/27/19 at 5:25 A.M., showed the resident lay on the bed awake. CNA F
washed hands, put on gloves and provided the resident with care. CNA F removed a urine
soiled adult incontinence brief, washed and dried the resident’s peri area and outer
genitals, turned the resident onto his/her left side, washed the back of the resident’s
thighs and then washed the rectal area. After changing his/her soiled gloves, CNA F had
the resident turn onto his/her back, applied barrier cream to the peri area, covered the
resident, removed his/her gloves, washed hands and left the resident’s room. CNA F did not
wash the resident’s entire genital area or buttocks to ensure all urine had been removed
from the resident’s skin prior to leaving the room.
3. Review of Resident #44’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 5 out of 15 (indicates cognitive impairment);
-No behaviors;
-Incontinent of urine;
-Required maximum assistance from the staff for transfers, dressing, personal hygiene and
bathing.
Observation on 1/27/19 at 7:35 A.M., showed the resident lay in bed awake. CNA G washed
hands, put on gloves, washed the resident’s peri area and genitals in a back to front
motion, at least six times and then dried in the same manner. CNA G turned the resident
onto his/her left side, washed and dried the back of the resident’s thighs and rectal
area, applied a clean adult incontinence brief on the resident, dressed and transferred
him/her into his/her wheelchair. CNA G did not wash the resident’s buttocks or hips to
ensure all of the urine had been removed from the resident’s skin prior to dressing and
transferring him/her into the wheelchair.
4. During an interview on 1/30/19 at 11:55 A.M., the Director of Nurses (DON) said would
expect staff to wash the entire genital area and all areas of skin that may have come into
contact with urine or stool, in a front to back motion, to ensure all urine and stool had
been removed from the skin and to prevent skin breakdown and urinary tract infections.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement of indwelling urinary catheters (a tube inserted into the bladder for the
purpose of continual urine drainage). The facility identified two residents as having
indwelling urinary catheters and of those two, problems were found with both residents
(Residents #54 and #29). The census was 61.
1. Review of Resident #54’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 12/26/18, showed:
-[DIAGNOSES REDACTED].
-Severe cognitive impairment with short and long term memory problems;
-Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach through the
abdomen for the purpose of providing liquid nutrition, hydration and medications);
-Indwelling urinary catheter;
-Incontinent of bowel;
-Required total assistance from staff for transfers, dressing, eating, personal hygiene
and bathing.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 9/28/18, for the use of an indwelling urinary catheter;
-An order dated 9/28/18, for a #20 French (size) Foley (type of indwelling urinary
catheter) catheter with a 30 cubic centimeter (cc) balloon (size of balloon on end of
catheter which holds the catheter in the bladder), change as needed;
-An order dated 1/3/19, to obtain an urinalysis with culture and sensitivity (UA with
C&S, a urine test to identify any urinary infection and type of medication needed to
clear the infection);
-An order dated 1/8/19, to administer [MEDICATION NAME] (a broad spectrum antibiotic)
500-125 milligrams (mg) one tablet by [DEVICE] four times a day for 10 days for urinary
tract infection.
Review of the resident’s care plan, in use during the survey, showed:
-Problem: Indwelling urinary catheter to promote wound healing;
-Goal: Identify factors and minimize risk of urinary tract infection while promoting wound
healing;
-Interventions included: Catheter care every shift. Monitor catheter for proper drainage.
Keep drainage bag below level of bladder. Keep bag and tubing off floor. Monitor for any
signs/symptoms of a urinary tract infection. (MONTH) use dignity bag for catheter bag to
keep off floor and cover bag.
Review of the resident’s UA with C&S, obtained on 1/3/19 and reported on 1/8/19,
showed:
-Turbid yellow urine (normal is clear yellow);
-White blood cells – 16 to 25 (normal is 0 to 4);
-Bacteria – few (normal is none);
-Culture – 50,000 to 100,000 colony forming unit (CFU) per milliliter (ml) of
Extended-spectrum beta-lactamases (ESBL, a type of enzyme or chemical produced by some
bacteria that cause some antibiotics not to work) producing [DIAGNOSES REDACTED] pneumonia
(a bacteria normally found in the intestines).
Observation on 1/28/19 at 7:13 A.M., showed the resident lay in bed with side rails up on
both sides of the bed. The indwelling urinary catheter tubing draped over the top of the
left side rail, down into the collection bag. Approximately 3 inches of the bottom of the
collection bag lay directly on the floor without any type of privacy bag or protective
covering. The collection bag contained a clear amber colored urine.
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
Observation on 1/29/19 at 6:57 A.M., showed the resident lay in bed. Approximately 24
inches of the indwelling urinary catheter tubing hung down over the side of the bed,
looped back upward approximately 12 inches into the collection bag. The tubing contained a
cloudy yellow urine without any urine in the last approximate 8 inches of the tubing where
it enters the collection bag. The collection bag, without any type of protective covering
or privacy bag, hung on the left side of the bed frame. Approximately 3 inches of the
bottom of the collection bag lay directly on the floor.
2. Review of Resident #29’s quarterly MDS, dated [DATE], showed:
-Brief interview of mental status (BIMS) score of 4 out of 15, showed the resident had
severe cognitive impairment;
-Extensive assistance of one person physical assist required for transfers, locomotion off
unit, dressing and toilet use;
-Use of an indwelling urinary catheter;
-[DIAGNOSES REDACTED].
-Hospice.
Review of the resident’s electronic POS, showed:
-An order dated 9/28/18, for indwelling catheter care;
-An order dated 11/21/18, for indwelling catheter, 20 French gauge, 30 ml balloon;
-An order dated 12/26/18, for [MEDICATION NAME] (an antibiotic used to treat bacterial
infections) 100 mg, 1 tab by mouth every 12 hours for ten days for urinary tract
infection.
Review of the resident’s care plan, in use at the time of survey, showed:
-Problem (onset 3/22/18): At risk for complications due to indwelling catheter for[MEDICAL CONDITION], history of urinary tract infections;
-Interventions included: Keep bag and tubing off floor. (MONTH) use leg bag as needed.
Education for infection control attempted due to resident moves catheter bag around and
takes out of dignity bag and sets on floor. Education effective only short periods of time
due to dementia. Staff to monitor and assist as needed to prevent bag or tubing from
contacting floor or being placed above level of bladder by resident.
Review of the resident’s nurse’s notes from 3/13/18 through 1/29/19, showed no
documentation of patient education regarding infection control or behaviors regarding
his/her catheter.
Observations of the resident, showed:
-On 1/28/19 at 11:36 A.M., approximately 10 inches of catheter tubing filled with urine,
lay on the floor under the resident’s Broda chair (medical reclining chair), not in a
privacy bag. The resident attempted to push the tubing back under his/her pant leg, but it
fell back onto the floor;
-On 1/29/19 at 1:01 P.M., approximately 4-6 inches of catheter tubing filled with urine,
lay on the floor under the resident’s Broda chair, not in a privacy bag;
-On 1/29/19 at 3:49 P.M., approximately 4-6 inches of catheter tubing filled with urine,
lay on the floor under the resident’s Broda chair, not in a privacy bag;
-On 1/30/19 at 12:06 P.M., approximately 5 inches of catheter tubing filled with urine,
lay on the floor under the resident’s Broda chair while he/she sat in the dining room
awaiting lunch, not in a privacy bag. Several staff came in and out of the dining room.
3. During an interview on 1/30/19 at 11:56 A.M., the Director of Nursing (DON) said it is
expected for catheter bags to be placed in privacy bags. If a catheter bag is hung on a
resident’s bedside, it should be covered. Catheter tubing should never touch or drag on
the floor due to infection control. Residents who move their catheter bags and/or tubing
should be educated on this and the tubing should be cleansed or replaced. It is expected
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
that staff monitor the residents who reposition their catheter bags and tubing.
F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
humidified oxygen therapy consistent with professional standards of practice, for one of
two sampled resident who received oxygen (Resident #14). The sample size was 15. The
census was 61.
Review of the facility’s Oxygen Administration Policy and Procedure, dated (MONTH) 2010,
showed the following:
-Check the tubing connected to the oxygen cylinder to assure that it is free of kinks;
-Turn on the oxygen;
-Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal
catheter);
-Check the mask, tank, humidifying jar, etc., to be sure they are in good working order
and are securely fastened. Be sure there is water in the humidifying jar and that the
water level is high enough that the water bubbles as oxygen flows through;
-Periodically re-check water level in humidifying jar.
Review of Resident #14’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/2/18, showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 3 out of 15 (indicates cognitively
impaired);
-No behaviors;
-Oxygen usage not marked;
-Required maximum assistance from staff for dressing, personal hygiene and bathing.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 11/14/18 to administer oxygen at 2 liters by nasal prongs as needed for
shortness of breath;
-No orders found to change the oxygen tubing or the humidifying bottle or how often.
Review of the resident’s care plan, dated 5/14/18, and in use during the survey, showed:
-Problem: At risk for shortness of breath due to refusing or removing oxygen;
-Goal: Will not have respiratory distress and comfort will be maintained;
-Interventions included: Education will be given on need to keep oxygen tubing off the
floor, but due to dementia education ineffective. Staff to assist with oxygen placement or
maneuvering of tubing as needed and monitor for resident’s tubing for infection control
issues as needed.
Observation on 1/27/19 at 5:45 A.M., showed the resident lay in bed sleeping. The oxygen
concentrator turned on at 2 liters (L) a minute. The oxygen tubing hung over the side rail
with the nasal prongs directly touching the side rail. The humidifying bottle did not have
any water in it and appeared dry. Neither the tubing nor the humidifying bottle were
dated. At 7:05 A.M., the resident was out of his/her room. The oxygen concentrator had
been turned off. The oxygen tubing lay coiled on top of the oxygen concentrator without
any type of protective covering. The prongs directly touched the concentrator and the
humidifying bottle remained empty.
Observation on 1/28/19 at 6:58 A.M., showed the resident out of his/her room. The oxygen

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 11)
concentrator off. The oxygen tubing lay coiled on top of the concentrator without any type
of bag or protective covering. The nasal prongs directly touched the concentrator. The
humidifying bottle remained empty of any water. Neither the oxygen tubing nor the
humidifying bottle were dated.
Observation on 1/29/19 at 6:55 A.M., showed the resident lay in bed with the oxygen tubing
in his/her nose and oxygen administered at 2 L a minute by nasal prongs. The humidifying
bottle remained empty of any water. At 9:09 A.M., the resident had been taken out of
his/her room. The oxygen concentrator had been turned off. The oxygen tubing lay coiled on
top of the oxygen concentrator without any type of bag or protective covering. The
humidifying bottle remained empty of water. Neither the oxygen tubing nor the humidifying
bottle were dated.
During an interview on 1/29/19 at 9:18 A.M., the Director of Nurses (DON) looked at the
oxygen concentrator, said she would expect staff to date the tubing and humidifying
bottle, keep fluid in the humidifying bottle for resident comfort and for the tubing to be
placed in a plastic bag when not in use for infection control issues. The resident is on
hospice and hospice takes care of orders for oxygen.
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, orders, monitoring and ongoing communication with the [MEDICAL TREATMENT] (the process of filtering toxins from the blood for individuals with kidney failure)
center. In addition, the facility failed to monitor and assess complaints of headaches
following [MEDICAL TREATMENT] treatment. The facility identified one resident who received[MEDICAL TREATMENT] (Resident #43). The sample size 15. The census was 61.
Review of the facility’s [MEDICAL TREATMENT], Care of a Resident Receiving policy, dated
March, (YEAR), showed the following:
-Keep the [MEDICAL TREATMENT] access area clean and dry;
-Feel for the thrill (pulse) sensation daily;
-Inspect the access for redness, swelling, or warmth;
-Watch for bleeding after [MEDICAL TREATMENT];
-Monitor for signs of infection;
-Nurse will check the thrill daily and document daily. This will be documented on the
resident’s treatment record;
-The policy failed to identify staff should obtain physician orders [REDACTED].
-The policy failed to identify staff should obtain physician orders [REDACTED].
-The policy failed to identify staff should document ongoing communication with the[MEDICAL TREATMENT] center;
-The policy failed to require checking the bruit (placing a stethoscope over the fistula
and hear the blood rush through the connection of the artery and vein) daily.
Review of Resident #43’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/3/18, showed the following:
-Brief interview for mental status (BIMS) score of 14 out of 15, showed the resident was
cognitively intact;
-[DIAGNOSES REDACTED].
-Received [MEDICAL TREATMENT].

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
Review of the resident’s care plan, dated (MONTH) (YEAR) and in use at the time of the
survey, showed:
-Problem: At risk for complications related to [MEDICAL TREATMENT] treatment;
-Approach: [MEDICAL TREATMENT] on Monday, Wednesday and Friday;
-Receives a diet with renal considerations. Sack lunch on [MEDICAL TREATMENT] days to
maintain intake;
-Pre/post treatment vital signs and weights via [MEDICAL TREATMENT] clinic staff with
concerns phoned to facility’s nurse;
-Keep [MEDICAL TREATMENT] clinic informed of medical changes. Review for any
administration changes recommended on [MEDICAL TREATMENT] days;
-Monitor bruit/thrill to left arm shunt, monitor for any signs of hemorrhage (bleed) or
site infections symptoms and report to physician and [MEDICAL TREATMENT] staff, for
uncontrolled bleeding, apply pressure and call initiate emergency services;
-If resident is unable to reach [MEDICAL TREATMENT] appointment due to transportation
issue or inclement weather, contact [MEDICAL TREATMENT] clinic for further instructions;
-Avoid blood draws and blood pressures to shunt arm (left arm).
Review of the resident’s January, 2019 physician order [REDACTED].
-An order, dated 11/28/18, for [MEDICAL TREATMENT] on Monday, Wednesday and Friday;
-An order, dated 12/3/18, to check [MEDICAL TREATMENT] access shunt at left arm for bruit
and thrill every shift.
Review of the resident’s January, 2019 treatment administration record (TAR), showed the
following:
-Check [MEDICAL TREATMENT] access shunt at left arm for bruit and thrill every shift;
-First shift showed no documentation on 1/7, 1/11, 1/26 and 1/28/19;
-Second shift showed no documentation on 1/2, 1/7, 1/10, 1/11, 1/22, 1/24, 1/26 and
1/28/19;
-Third shift showed no documentation on 1/2/19 through 1/28/19.
Review of the resident’s January, 2019 nurse’s notes, showed the following:
-On 1/17/19, resident complained of dizziness and headache. States feels [MEDICAL
TREATMENT] treatment taking too much off. Contacted [MEDICAL TREATMENT] clinic to review
most recent labs with no critical findings noted. vital signs 96.5 (normal 97.8 through
99.1) degrees Fahrenheit (F), heart rate 75 (normal 60 through 100), respirations 18
(normal 12 through 20), blood pressure 220/96 (normal 90/60 through 120/80). Resident
reminded to change position slowly due to dizziness. As needed (PRN) given for head ache.
Physician exchange phoned regarding elevated blood pressure. Awaiting call back;
-New orders received for [MEDICATION NAME] (medication used to treat high blood pressure)
10 milligram (mg) now and 10 mg daily on non-[MEDICAL TREATMENT] days. Orders noted.[MEDICATION NAME] given as directed. Will continue to monitor;
-On 1/25/18, received call from [MEDICAL TREATMENT] clinic with new orders to discontinue
double portions, order given to dietary;
-No documentation regarding the resident’s [MEDICAL TREATMENT] treatments or assessments
and monitoring of the shunt site.
Review of the resident’s (MONTH) 2019, vitals, showed:
-On 1/17/19, temperature 97.7 degrees F;
-Pulse 71;
-Respirations 18;
-Blood pressure 121/81;
-On 1/18/19, blood pressure 136/76;
-On 1/25/19, temperature 98.8 degrees F;
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-Pulse 80;
-Respirations 16;
-Blood pressure 150/60.
During an interview on 1/28/19 at 11:24 A.M. and 1/29/19 at 10:49 A.M., the resident
confirmed he/she goes to [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. He/she
began to get bad headaches and felt faint after he/she returned from [MEDICAL TREATMENT] in the past month. He/she reported it to staff, but he/she could not remember who. The
resident said he/she refused to go back to [MEDICAL TREATMENT] until he/she saw a doctor.
The facility staff does not complete an assessment before or after he/she returned from[MEDICAL TREATMENT]. Staff do not check the bruit and thrill using a stethoscope. The
resident said he/she was going to [MEDICAL TREATMENT] today and tomorrow. He/she wanted to
talk to the physician at the [MEDICAL TREATMENT] center to find out why he/she started to
get headaches. He/she fell after he/she returned from [MEDICAL TREATMENT] about a month
ago. He/she was found by staff in his/her room. He/she spoke to the social worker at the
facility, but had not spoken to the physician from the facility. He/she really wanted to
know why he/she was heaving headaches after [MEDICAL TREATMENT]. He/she was fine right
after [MEDICAL TREATMENT] and on the way back to the facility, but once he/she returned,
the headaches started.
During an interview on 1/30/19 at 9:26 A.M., the resident confirmed he/she went to[MEDICAL TREATMENT] yesterday. He/she had a headache when he/she returned to the facility.
He/she did not talk to the physician at the [MEDICAL TREATMENT] center. He/she was tired
of the headaches. He/she refused to go to [MEDICAL TREATMENT] one day in the past month
because no one did anything. The only way he/she could get the staff attention was to not
go to [MEDICAL TREATMENT].
During an interview on 1/30/19 at 10:11 A.M., the social worker said the resident came
from another facility which had a [MEDICAL TREATMENT] center. He/she did not like to wait
to receive his/her treatment. He/she also complained of headaches and wanted to talk to
the physician at the [MEDICAL TREATMENT] center. The social worker spoke to the [MEDICAL
TREATMENT] center and confirmed that the physician will be available to speak to the
resident today when he/she received the treatment.
During an interview on 1/30/19 at 12:06 P.M., the Director of Nursing (DON) said she would
expect staff to follow physician’s orders [REDACTED]. She would not expect staff to check
the resident’s blood pressure, assess the site and assess for pain after every visit. The
resident is asked how he/she was doing, staff chart by exception, so there was no routine.
If he/she complained of something, then an assessment is completed, but it is not
routinely checked. The [MEDICAL TREATMENT] center would communicate if there was a problem
that needed on going monitoring. The communication between the facility and the [MEDICAL
TREATMENT] center is done by phone, so there is no documentation. The DON was informed of
the resident’s headaches after he/she returned from [MEDICAL TREATMENT]. The social worker
had been in contact with the center. The resident believed they took too much fluid off.
The DON would have to review if or how staff documented the headaches. The resident
complained to the DON and she followed up and called the [MEDICAL TREATMENT] center. She
was not sure when she spoke to the [MEDICAL TREATMENT] center. The DON did not believe the
headaches were necessarily a reason to check vitals after [MEDICAL TREATMENT] unless the[MEDICAL TREATMENT] center wanted the facility to do something.
During an interview on 1/31/19 at 4:00 P.M., the [MEDICAL TREATMENT] clinical nurse
manager said he/she would expect for the facility to check the resident’s vitals, thrill
and bruit, and signs of infection or change of condition. Even though the [MEDICAL
TREATMENT] center checked the resident’s vitals every 30 minutes, he/she could have a
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
change of condition on the way back to the facility. It is important to ensure that the
resident’s vital signs are checked when he/she returned to the facility. He/she spoke to
the social worker this week regarding the resident’s concerns with having headaches and
speaking to the physician. He/she would have expected the facility staff to monitor and
assess the resident after his/her [MEDICAL TREATMENT] treatment. Typically, the [MEDICAL
TREATMENT] center would have written documentation between the center and the facility;
however, it had not been implemented.
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

Based on interview and record review, the facility failed to establish a system of records
of receipt and disposition of all controlled drugs in sufficient detail to enable an
accurate reconciliation. The facility had one narcotic count book located at the nurses
station for the current month of (MONTH) 2019, broken down into six sections. All six
sections were reviewed and issues were identified with all six. The facility was only able
to provide two narcotic count sheets for the month of (MONTH) (YEAR) and issues were
identified with both. The facility census was 61.
Review of the facility’s Controlled Substance policy, dated 10/2007, showed:
-At each shift change, a physical inventory of controlled medications, as defined by state
regulation, is conducted by two licensed clinicians and is documented on an audit record;
-Current controlled medication accountability records and audit records are kept by the
nursing care center. When completed, audit and accountability records are kept on file;
-Any discrepancy in a controlled substance medication count is reported to the Director of
Nursing (DON) immediately. The director or designee investigates and makes every
reasonable effort to reconcile all reported discrepancies.
1. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 100, 300 and 600 hall pills,
showed:
-41 out of 82 shifts without a count of narcotics;
-Of the 41 shifts with a count of narcotics, only one nurse documented as witness to the
count for 27 of the 41 shifts;
-One nurse pre signed as off going on the 1/28/19 3:00 P.M., shift count that had not yet
occurred.
2. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 100, 300 and 600 hall liquids,
showed:
-72 out of 82 shifts without count of narcotics;
-Of the 10 shifts with count of narcotics, only one nurse documented as witness to the
count for all 10 shifts.
3. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 400, and 500 hall pills, showed:
-51 out of 82 shifts without a count of narcotics;
-Of the 31 shifts with a count of narcotics, only one nurse documented as witness to the
count for 22 of the 31 shifts.
4. Review of the facility’s controlled substance shift change count check sheet, dated

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 15)
(MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 400, and 500 hall liquids, showed:
-64 out of 82 shifts without a count of narcotics;
-Of the 18 shifts with a count of narcotics, only one nurse documented as witness to the
count for 14 of the 18 shifts.
5. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the 400, and 500 hall patches, showed:
-65 out of 82 shifts without a count of narcotics;
-Of the 17 shifts with a count of narcotics, only one nurse documented as witness to the
count for 16 of the 17 shifts.
6. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) 2019, reviewed on 1/28/19 at 9:20 A.M., for the refrigerator, showed:
-57 out of 82 shifts without a count of narcotics;
-Of the 25 shifts with a count of narcotics, only one nurse documented as witness to the
count for 20 of the 25 shifts.
7. On 1/29/19 the DON provided the narcotic count sheets for the month of (MONTH) and said
the following is all she was able to locate:
-The facility’s controlled substance shift change count check sheet, dated (MONTH) (YEAR),
reviewed on 1/29/19 at 1:00 P.M., for unspecified nurse’s station, showed 5 out of 93
shifts with the same nursing staff documenting for both the on and off shift narcotic
count, 36 out of 93 shifts with one nurse documenting, and 24 out of 93 shifts with a
narcotic count without any nursing staff documenting for on or off shift narcotic count;
-The facility’s controlled substance shift change count check sheet, dated (MONTH) (YEAR),
reviewed on 1/29/19 at 1:50 P.M., for unspecified nurse’s station, showed 11 out of 93
shifts with the same nursing staff documenting for both the on and off shift narcotic
count, 45 out of 93 shifts with one nurse documenting, and 9 out of 93 shifts with a
narcotic count without any nursing staff documenting for on or off shift narcotic count
8. During an interview on 1/29/19 at 1:40 P.M., the DON and Assistant Director of Nursing
(ADON) stated:
-The expectation is for nursing staff to verify the narcotic counts by counting the
narcotics, recording the corresponding number and initialing for both the oncoming or off
going shift on the narcotic count sheet;
-The DON or ADON reviews the narcotic logs monthly;
-The shift to shift narcotic count sheet is the only documentation that shows the nurses
are verifying correct narcotic counts daily;
-Though there are six separate narcotic shift change reports, each designated for a type
of narcotic and location, the DON verified she was only able to find two narcotic shift
change reports for (MONTH) (YEAR). The DON was not able to verify which location or type
of narcotic the shift change reports represented.
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure drugs and
biologicals were labeled in accordance with currently accepted professional principles and
failed to discard expired medications for three of three medication carts reviewed. 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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 – Some

(continued… from page 16)
facility census was 61.
Review of the Medication Storage in the Facility Policy, dated November, (YEAR), showed:
-Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked,
soiled or without secure closures will be immediately withdrawn from stock by the
facility. They will be disposed of according to drug disposal procedures, and reordered
from the pharmacy if a current order exists;
-Medication and treatment carts are a property of the pharmacy, the facility is required
to keep the carts clean and damage free.
Review of the facility’s Labeling of Medication Containers policy, dated April, 2007,
showed:
-Medication labels must be legible at all times;
-Any medication packaging or containers that are inadequately or improperly labeled shall
be returned to the issuing pharmacy;
-Labels for individual drug containers shall include all necessary information, such as:
-The resident’s name;
-The prescribing physician’s name;
-The name, address, and telephone number of the issuing pharmacy;
-The name, strength, and quantity of the drug;
-The date the medication was dispensed;
-Directions for use.
1. Observation on 1/28/19 at 7:00 A.M., of the nurse’s treatment cart, showed:
-An opened tube of [MEDICATION NAME] gel (an antibiotic gel used for vaginal infections),
unlabeled with a resident’s name;
-An opened tube of Ascend (silver [MEDICATION NAME] cream, an antibiotic, works by
stopping the growth of bacteria that may infect an open wound) unlabeled with a resident’s
name;
-Two tubes of Santyl (sterile enzymatic [MEDICATION NAME] ointment) unlabeled with a
resident’s name, opened, and one tube without a cap on top;
-One bottle of liquid Levetiracetam (used to treat [MEDICAL CONDITION]), expired on
1/6/19;
-One bottle of [MEDICATION NAME] syrup (used to soften stools), expired on 12/2018;
-One bottle of Acetic Acid (a chemical sometimes used to treat topical fungal infections),
unlabeled with a resident’s name, open;
-The bottom drawer had visible debris and covered in a sticky substance;
-Bottles of [MEDICATION NAME], Levetiracetam and Geri [MEDICATION NAME] (used to treat
coughs and congestion) had sticky substances on the sides and on the bottoms of the
bottles.
2. Observation on 1/28/19 at 9:05 A.M., of the certified medical technician (CMT)
medication cart for the 400-500 halls, showed:
-A bottle of Vitamin B12 pills with the manufacturer expiration date rubbed off;
-A bottle of [MEDICATION NAME] propionate spray (an inhaled steroid), expired 11/19/18;
-A bottle of [MEDICATION NAME] Syrup (used to relive constipation), expired on 12/2018;
-The bottom drawer had visible debris, was covered in a sticky substance and the bottles
of oral medications were sticky with run off on the sides.
3. Observation on 1/28/19 at 11:15 A.M., of the CMT medication cart for the 100, 300 and
600 halls, showed:
-A bottle of [MEDICATION NAME] syrup expired 10/2018;
-A bottle of [MEDICATION NAME] syrup expired 12/2018;
-A bottle of GeriCare Geri Mucil expired 8/2018;
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 – Some

(continued… from page 17)
-A bottle of [MEDICATION NAME] propionate spray, lying loose in the top drawer, without a
lid;
-The bottom drawer had visible debris, was covered in a sticky substance, and the bottles
of oral medications were sticky with run off on the sides.
4. During an interview on 1/29/19 at 1:50 P.M., the Director of Nursing (DON) and
Assistant Director of Nursing (ADON) stated:
-Topical ointments, creams and powders should be in a bag labeled with the resident’s
name or in the box that has the pharmacy label attached;
-Tubes of Santyl can be used on multiple residents if nursing staff are not applying it
directly on the resident’s wound or skin. Nursing staff are directed to apply Santyl onto
the bandage and not directly to the wound base;
-A resident’s bottle of prescription [MEDICATION NAME] propionate should be stored with
its cap on, in its box or baggy in which it was delivered from the pharmacy;
-If medications are expired or no longer in use by the resident, the medication should
either get returned to the pharmacy or disposed of in the appropriate manner;
-Nursing staff should keep the medication cart drawers free of debris and sticky
substances;
-Nursing staff is expected to clean medication bottles of any spills, keeping them clean
and protecting the label;
-CMTs are expected to clean the medication carts every Friday.
5. Review of the manufacturer’s directions for use of Santyl Ointment, showed:
-Apply Santyl ointment only to the area of the wound, from edge to edge;
-Avoid application to the surrounding skin;
-Apply a nickel thick layer of Santyl to the wound base;
-The directions do not indicate application of the Santyl directly to the dressing.
F 0770

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely, quality laboratory services/tests to meet the needs of residents.

Based on observation, interview and record review, the facility failed to provide
laboratory services to meet the needs of its residents with regards to the quality of the
laboratory services by failing to obtain blood glucose testing (BGT) using acceptable
technique by not preventing exposure of test strips to light and moisture, on one of one
nurses medication/treatment cart. The census was 61.
Review of the True Metrix Blood glucose test strip information insert, found in the box
with the test strips, showed:
-Test strips must be kept in original vial with cap tightly sealed;
-Do not expose to extreme heat or cold, light or humidity for any length of time. (MONTH)
cause inaccurate results;
-WARNING: Use test strip quickly after removing from vial. Recap vial right away. Test
strips left outside of vial too long give an error message.
1. Observation on 1/27/19 at 6:10 A.M., showed Nurse D opened the cap of the BGT strip
bottle, removed a blood glucose test strip from the bottle and obtained a BGT on Resident
#39. Nurse D did not close the cap of the bottle after removing the strip. The open bottle
of test strips sat on top of the medication cart.
2. Observation on 1/27/19 at 6:13 A.M., showed Nurse D removed a test strip from the
opened BGT strip bottle and obtained a BGT on Resident #60. Nurse D did not close the cap

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0770

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
after removing the strip. The open bottle of test strips sat on top of the medication
cart.
3. Observation on 1/27/19 at 6:30 A.M., showed Nurse D removed a test strip from the
opened BGT strip bottle and obtained a BGT on Resident #40. Nurse D did not close the cap
after removing the strip. The opened bottle of test strips sat on top of the medication
cart.
4. During an interview on 1/27/19 at 6:35 A.M., Nurse D said he/she had 15 residents to
obtain a BGT every morning. Observation at this time, showed the opened bottle of test
strips remained on top of the medication cart.
5. Observation on 1/27/19 at 6:46 A.M., at 7:00 A.M. and at 7:15 A.M., showed the opened
bottle of test strips remained on top of the medication cart.
6. During an interview on 1/29/19 at 2:27 P.M., the Director of Nurses (DON) said staff
should close the lid of the test strip bottle immediately after removing a test strip
because leaving it open can damage the test strips and cause an inaccurate test result.
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review, the facility failed to meet the
nutritional needs of residents by failing to ensure recipes and menus were followed when
preparing the pureed meals, for two of two observed meals. The facility identified four
residents as receiving pureed diets at the facility. The census was 61.
1. Observation on 1/29/19 at 3:07 P.M., showed Cook H prepared the pureed Cuban pork
sandwiches. Cook H said the facility had four residents on a pureed diet, so he/she would
make four servings. He/she added a pre-measured amount of cooked shredded pork,
approximately 18 ounces (oz.), to the blender. He/she added two slices of bread and pureed
the mixture for one minute. He/she added approximately 1/2 cup of water to the blender and
then added two scoops of thickening powder. He/she stirred the mixture, added two more
heaping scoops of thickening powder and continued to puree the mixture. Cook H sprayed a
metal pan with multi-purpose cooking spray and used a spatula to scrape the pureed pork
into the pan. The mixture appeared very thick, like mashed potatoes. Cook H did not taste
the puree before covering the entrée and placing it in the warming tray.
Review of the pureed recipes for entrees and sandwiches for four servings, showed staff
should use 12 oz. of cooked meat and two slices of bread. Broth should be used to obtain
the correct consistency.
2. Observation on 1/30/19 at 7:00 A.M. showed Cook I prepared the pureed breakfast meal.
He/she used a 1/2 cup scoop to add a total of three cups of cooked eggs to a measuring
cup. He/she added 1 1/2 strips of bacon and one sausage patty to the measuring cup and
poured an unmeasured amount of milk into the cup; he/she said it was 1/4 cup of milk.
He/she dumped the mixture into the blender and pureed the contents for approximately two
minutes. He/she used a spatula to scoop the mixture into a pan. The texture was smooth and
creamy. Cook I did not taste the puree before placing it in the warming tray and covering
it. The puree tasted like creamed eggs with a hint of bacon.
During an interview on 1/30/19 at 7:20 A.M., Cook I said he/she combined the egg and
sausage purees because that was how he/she had been taught to prepare the breakfast
purees. He/she said sausage purees did not turn out right.

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
Review of the pureed recipes, hung above the blender in the kitchen, showed no recipe for
the egg, bacon and sausage puree.
3. During an interview on 1/30/19 at 11:30 A.M., the Dietary Manager (DM) said menus
should be followed for pureed recipes in order to preserve the nutritional content. Pureed
food should be pudding thick so residents on pureed diets do not choke. The DM said she is
the one who tastes every pureed meal served at the facility, every day of the week, for
taste and texture.
4. During an interview on 1/31/19 at 12:20 P.M., Dietician K said dietary staff is
expected to follow the puree recipes as approved by the dietician. If a recipe has not
been provided by the dietician, then it should not be provided to the residents. It would
not be acceptable to create a recipe and serve it without consulting the dietician.
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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to store, prepare, distribute and
serve food in accordance with professional standards for food service safety by failing to
ensure staff wore hair restraints properly when in food preparation areas, trash
receptacles were covered while not in use and proper handling of bulk food storage. In
addition, the facility failed to have a system in place for ensuring the dish machine
sanitizes properly. These deficient practices had the potential to affect all residents
who ate at the facility. The census was 61.
1. Observations of the dietary staff in the kitchen, showed the following:
-On [DATE] at 5:55 A.M., Cook H wore a hair restraint on top of his/her head with his/her
ponytail uncovered while preparing the breakfast meals;
-On [DATE] at 8:09 A.M., the Dietary Manager (DM) stood in the kitchen at the service
counter for the dining room. She wore a hair restraint on top of her head with
approximately 4 inches of braided hair uncovered;
-On [DATE] at 2:57 P.M., Cook H wore a hair restraint with approximately ,[DATE] inches of
bangs that stuck out the front. The DM wore a hairnet on top of her head with
approximately 4 inches of braided hair uncovered.
During an interview on [DATE] at 11:30 A.M., the DM said all hair should be fully covered
by hair restraints while dietary staff is in the kitchen. Hair restraints are used to
prevent contamination of food and beverages.
2. Observations of the kitchen, showed the following:
-On [DATE] at 5:55 A.M., a scoop lay directly inside the bulk flour bin and the handle
touched the flour. The trash receptacle at the end of the dish line was uncovered and
contained food;
-On [DATE] at 6:06 A.M., a scoop lay inside the bulk sugar bin and the handle touched the
sugar. The trash receptacle next to the stove was uncovered and not in use.
During an interview on [DATE] at 11:30 A.M., the DM said scoops should not be kept inside
the bulk storage bins to prevent contamination. Trash cans should have the lids on them
when they are not in use to deter pests.
3. Observation on [DATE] at 6:58 A.M., showed the kitchen’s low-temperature chemical
dishwasher did not have legible specifications or manufacturer information on the label,
as it had worn off. The dishwasher had an external thermometer and ran to a tub of dish

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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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

(continued… from page 20)
soap and a tub of chlorine-based sanitizer solution. The DM took a test strip that is used
to measure concentrations of quaternary ammonium compound (QAC), and dipped it into the
dishwasher’s external water reservoir. She compared the strip to the guide on the
packaging, which indicated a concentration level of 400 parts per million (ppm). The DM
said the result was too high and the results she had been getting up until this test had
been reading 100 ppm, which was what it should be. She ran the dishwasher again and used
two or three more QAC test strips; all yielded the same result of 400 ppm.
During an interview on [DATE] at 6:58 A.M., the DM said she was the only member of the
kitchen staff who knew how to test the dishwasher’s sanitizer concentration levels. She
tests the dishwasher every three days and works at the facility seven days a week. She did
not have a copy of the manufacturer’s book for the dishwasher. The dishwasher does not get
routine maintenance and is only serviced when needed. She could not recall the last time
the dishwasher was serviced.
Review of the dishwasher sanitizer logs from (MONTH) (YEAR) through (MONTH) 2019, showed
levels of 100 ppm until [DATE]. From [DATE] through (MONTH) 2019, the logs showed levels
of 400 ppm. The logs did not track the temperature of the dishwasher.
During an interview on [DATE] at 11:30 A.M., the DM said the chlorine test strips she had
been using on the dishwasher expired in (MONTH) (YEAR). She began using the QAC test
strips at that time. Using the wrong test strips provided inaccurate readings of the
dishwasher’s sanitizer concentration levels. It is important to have accurate readings to
ensure the dishwasher is sanitizing dishes properly and the chlorine levels are not too
high.
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
used acceptable infection control procedures during blood glucose testing (BGT) and during
incontinence care. Four BGTs were observed and problems were identified during all four.
In addition, three residents receiving incontinence care were observed and problems were
found with one. (Residents #54, #39, #60, #40 and #44). The census was 61.
Review of the facility’s Blood Sampling Finger Stick policy, revised (MONTH) 2009, showed:
-Purpose: To guide the safe handling of capillary-blood sampling devices to prevent
transmission of blood borne disease to residents and employees;
-Procedure: Wash hands, place gloves on, place the blood sugar monitoring device on a
clean field and obtain the blood sample. Following the manufacturer’s instruction, clean
and disinfect reusable equipment after each use.
1. Review of Resident #54’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 1/27/19 at 6:00 A.M., showed Nurse D applied gloves, did not clean the
glucometer (machine used to test blood sugar levels) prior to use with any type of
disinfecting agent and placed the glucometer on a barrier, directly on top of the
resident’s soiled bed linen. Nurse D obtained the resident’s BGT, removed the used test
strip from the glucometer, removed his/her gloves and washed his/her hands. Nurse D did
not clean the glucometer machine after use with any disinfecting agent before moving on to
the next resident and did not throw the soiled barrier away, taking the barrier with
him/her to the next resident.
2. Review of Resident #39’s medical record, showed a [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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 – Few

(continued… from page 21)
Observation on 1/27/19 at 6:10 A.M., showed Nurse D applied gloves, did not clean the
glucometer prior to use with any type of disinfecting agent and placed the glucometer on
the used barrier from Resident #54. Nurse D placed the soiled barrier directly on top of
Resident #39’s soiled bed linen. Nurse D obtained the resident’s BGT, removed the used
test strip from the glucometer, removed his/her gloves and washed his/her hands. Nurse D
placed the soiled barrier directly on top of the medication cart. Nurse D did not clean
the glucometer machine after use with any type of disinfecting agent before moving on to
the next resident.
3. Review of Resident#60’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 1/27/19 at 6:13 A.M., showed Nurse D applied gloves, opened a drawer in the
medication cart, got out a clean barrier and threw the soiled barrier away. He/she failed
to clean the top of the medication cart, where the soiled barrier had been removed.
Without cleaning the glucometer prior to use with any type of disinfecting agent, Nurse D
placed the glucometer on the clean barrier. Nurse D obtained the resident’s BGT, removed
his/her gloves and washed his/her hands. Nurse D did not clean the glucometer after use
with any type of disinfecting agent before moving on to the next resident.
4. Review of Resident#40’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 1/27/19 at 6:30 A.M., showed Nurse D applied gloves and without cleaning
the glucometer prior to use with any type of disinfecting agent, Nurse D placed the
glucometer on a clean barrier. Nurse D obtained the resident’s BGT, removed his/her gloves
and washed his/her hands. Nurse D did not clean the glucometer machine after use with any
type of disinfecting agent after use. Nurse D said he/she had approximately 15 BGTs to
obtain in the morning.
5. During an interview on 1/27/19 at 7:30 A.M., Nurse D said he/she did not know the
facility policy for cleaning the glucometer machine. He/she usually cleans it with a water
dampened towel, but forgot to clean the machine while obtaining the BGTs.
6. During an interview on 1/29/19 at 2:27 P.M., the Director of Nursing (DON) and the
Assistant Director of Nurses (ADON) both said the glucometer machine should be cleaned
with a sani-wipe (germicidal disposable wipes) after each resident use. It would never be
appropriate to use the same barrier on multiple residents and staff should obtain a clean
barrier for each resident due to infection control.
7. Review of Resident #44’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/5/18, showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 5 out of 15 (indicates cognitive
impairment);
-No behaviors;
-Incontinent of urine;
-Required maximum assistance from the staff for transfers, dressing, personal hygiene and
bathing.
Observation on 1/27/19 at 7:35 A.M., showed the resident lay in bed awake. Certified Nurse
Assistant (CNA) G washed his/her hands, put on gloves and provided the resident with
incontinence care. CNA G removed the resident’s wet with urine adult incontinence brief,
washed and dried the resident’s perineal area (the surface area between the thighs,
extending from the pubic bone to the tail bone) and genitals, turned the resident onto
his/her left side and washed the resident’s buttocks and rectal area. Without removing
his/her soiled gloves, he/she opened the resident’s door, called out for an unknown staff
member to bring more supplies, took the clean supplies from the staff person, closed the
door and while wearing the same soiled gloves, continued to clean the resident. Without
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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 – Few

(continued… from page 22)
changing his/her soiled gloves, CNA G applied a clean adult incontinence brief and dressed
the resident.
During an interview on 1/30/19 at 11:55 A.M., the DON said it would never be appropriate
for staff to open a closed door with soiled gloves and then without changing the gloves,
continue to provide care with the same soiled gloves, due to infection control. The
facility policy is to change gloves when going from dirty to clean areas.
Review of the facility’s Perineal Care policy, revised (MONTH) 17, 2012, showed the policy
failed to direct staff to change their gloves and sanitize their hands when going from the
perineal area to the rectal area and/or before or after touching other surfaces.
F 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Make sure there is a pest control program to prevent/deal with mice, insects, or other
pests.

Based on observation, interview and record review, the facility failed to maintain an
effective pest control system when an abundance of gnats were noted in the kitchen, where
all facility meals are prepared. This had the potential to affect all residents who eat
from the facility kitchen. The facility census was 61.
Observation of the kitchen on 1/27/19 at 5:55 A.M., showed:
-Several gnats flew throughout the dishwashing area, where large pots, pans, colanders and
some large utensils were stored;
-The trash receptacle at the end of the dish line was uncovered and contained food;
-Gnats crawled on the folded table linens and cloth napkins;
-Gnats flew throughout the dry food storage area.
Further observations of the kitchen on 1/28/19 at 4:40 P.M. and 1/29/19 at 2:57 P.M.,
showed:
-Gnats flew throughout the dishwashing area;
-Gnats crawled on the folded table linens and cloth napkins;
-Gnats flew throughout the dry food storage area.
During an interview on 1/29/19 at 3:07 P.M., Maintenance Supervisor P said the pest
control company came out to the facility on ce a month for routine maintenance. The
exterminator would be out to the facility again on 2/4/19 for a routine treatment.
Observation and interview on 1/30/19 at 6:06 A.M, showed:
-Several gnats flew throughout the dishwashing area;
-Gnats crawled on clean, folded table linens and cloth napkins;
-The trash receptacle next to the stove, uncovered;
-Gnats crawled on the clean utensils that hung above the three-vat sink, including a pair
of tongs;
-Dietary Aide J shook his/her head and said, these gnats are out of control;
-Cook I used the tongs, observed to have gnats that crawled on them, to transfer bacon
from a cookie sheet to a metal pan.
During an interview on 1/30/19 at 6:36 A.M., the Dietary Manager (DM) said she had noticed
an increase in gnats in the kitchen and the pest control treatment should be stronger. It
is important to maintain effective pest control because some insects can transfer germs.
Review of the facility’s pest control logs from (MONTH) through (MONTH) (YEAR), showed
standard maintenance completed on a monthly basis.
During an interview on 1/30/19 at 11:09 A.M., Exterminator L said he/she noticed 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:

265732

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

01/30/2019

NAME OF PROVIDER OF SUPPLIER

BENTLEYS EXTENDED CARE

STREET ADDRESS, CITY, STATE, ZIP

3060 ASHBY ROAD
OVERLAND, MO 63114

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 0925

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 23)
facility had an issue with gnats or drain flies during his/her last routine treatment in
(MONTH) (YEAR). He/she provided encouragement to the facility’s dietary staff to keep the
drains clear of buildup and food debris. Keeping trash cans covered with lids when not in
use will assist with pest control.
During an interview on 1/30/19 at 11:30 A.M., the DM said ensuring the drains are clean
and clear is not part of her dietary staff’s cleaning schedule. Dietary staff should be
putting lids back on trash cans when they are not in use.
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