Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Potential for minimal harm

Residents Affected – Many

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to inform one of 13 sampled
residents (Resident #23) and two additional residents (Residents #10 and #229) when
changes were made in his/her Medicare coverage prior to the end of service date. The
facility census was 34.
CMS Standard: Notice of Medicare Non-Coverage (NOMNC) must be delivered at least two
calendar days before Medicare covered services end.
1. Review of the facility’s dated 2/31/11 showed:
– The notice showed the date current services ended.
– The resident and/or responsible party had the right to appeal the decision.
– The form provided the phone number for appeal.
– The signature page stated the resident and/or responsible party had been notified of the
effective date of end of Medicare coverage and the resident and/or responsible party could
appeal the decision.
Review of Resident #229’s NOMNC showed:
– Staff noted the resident’s services would end on 12/6/17.
– The resident’s responsible party signed the form 12/7/17.
Review of Resident #10’s NOMNC showed:
– Staff noted the resident’s services would end on 1/16/18.
– The resident signed the notice on 1/15/18.
Review of Resident #23’s NOMNC showed:
– Staff noted the resident’s services would end on 5/7/18.
– The resident signed the notice on 5/7/18.
During an interview on 5/25/18 at 11:50 A.M. the Social Services Designee (SSD) said:
– He/she gave the notices to the resident and/or their responsible party as soon as
therapy told him/her the resident was going off Medicare services.
– Physical therapy did not usually notify him/her until a resident went off services.
– He/she should give the resident the NOMNC 48 hours prior to discontinuation of services.
During an interview of 5/25/18 at 11:55 A.M. the Administrator said the SSD must give all
residents and/or their responsible party the NOMNC at least 48 hours prior to
discontinuation of services.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to assure staff
maintained all areas in the facility in a clean, comfortable, and home like manner when
staff failed to maintain the floors in resident rooms; provide covers on corner guard
posts; repair a light fixture; repair the chipped paint in walls and doors; clean rooms
timely that smelled of urine; repair floors around toilets; paint the wood around air
conditioner units; repair broken tiles around the shower faucet; repair the drinking
fountain; clean the vent by the drinking fountain; repair a broken hand rail; repair
broken trim, and failed to repair the floor by the nurse’s station. The facility census
was 34.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 1 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
1. Observations in the facility on 5/22/18 at 4:01 P.M. of occupied room [ROOM NUMBER] showed:
– A black substance on the floor close to the walls;
– Multiple nail holes on the wall with nothing attached to the nails;
– The trim pulling away from the walls and a dark substance directly above the trim.
2. Observations in the facility on 5/23/18 starting at 8:21 A.M. showed:
– A black substance on the floor around the doors into 50% of the resident rooms;
– The corner post guard (extended about half way up the post) missing on two posts in both
dining rooms;
– An uncovered light fixture, in the locked unit nurse’s station, visible to residents,
with no light bulb and exposed wires;
– On the locked unit the windows 50% of the windows appeared streaked with dirt;
– The door molding on rooms [ROOM NUMBERS] with chipped paint around the entire molding;
– Unoccupied room [ROOM NUMBER] with a very strong odor of urine that could be smelled in
the hall;
– room [ROOM NUMBER] with paint chipped on the wall ;
– room [ROOM NUMBER] with a black substance on the floor around the perimeter of the room;
– room [ROOM NUMBER] very strong odor of urine in the room and in the bathroom, and rust
around the toilet;
– A dark substance three feet by six inches on the floor by the door between nursing units
;
– room [ROOM NUMBER] rust around the base of the toilet;
– Paint chipped around the unsecured unit’s nurse’s station;
– room [ROOM NUMBER] dark substance two inches wide and the length of the wall on the
floor by the walls and in the bathroom, and bathroom floor not repaired with tiles missing
by the toilet;
– room [ROOM NUMBER] bathroom wall chipped by sink;
– room [ROOM NUMBER] dark substance on the floor by the wall approximately one inch by 20
inches’s and on the bathroom floor all around the wall
– room [ROOM NUMBER] most of the bathroom floor discolored;
– room [ROOM NUMBER] most of the bathroom floor discolored.
– room [ROOM NUMBER] strong odor of urine in the bathroom that could be smelled in the
room;
– room [ROOM NUMBER] strong odor of urine that could be smelled in the hall;
– room [ROOM NUMBER] most of the bathroom floor stained;
– room [ROOM NUMBER] strong odor of urine that was smelled in the bathroom and rust all
around the toilet;
– room [ROOM NUMBER] unpainted wood trim around the air conditioner;
– room [ROOM NUMBER] most of the bathroom floor stained and floor scuffed by the
resident’s bed;
– room [ROOM NUMBER] strong odor of urine that could be smelled in the resident’s room and
bathroom and most of the bathroom floor scuffed;
– room [ROOM NUMBER] wood around the air conditioner not panted and most of the bathroom
floor stained;
– room [ROOM NUMBER] bathroom wall scuffed on the wall close to the door;
– room [ROOM NUMBER] wood around air conditioner not painted;
– Hand rail by room [ROOM NUMBER] loose with a hole where one of the screws inserted;
-The drinking fountain by the nurses station did not work;
– Dead bugs in the tub in the shower room on the locked unit;
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 2 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
– Broken tiles around the tub faucet in the shower room on the locked unit;
– Paint chipped across the door, with paint chipped down through three layers of paint, on
the door from the main dining room to the kitchen.
3. Observation on 5/24/18 at 12:58 P.M. showed the clocks did not work in rooms [ROOM
NUMBERS].
4. Observation on 5/24/18 at 1:41 P.M. of the shower room on the locked unit showed:
– Behind the door a four inch triangle of a black substance;
– Approximately a two inch drop off between the shower floor and the shower room floor;
– Many dead bugs in the bathtub.
5. Observation on 5/25/18 at 6:35 A.M. showed:
– A dusty vent above the drinking fountain by the nurses station;
– A c-shaped area, by the nurses station chair, with the linoleum worn down to the
subfloor visible to the residents.
6. During an interview on 5/23/18 at 9:00 A.M. Housekeeper (HK) A said:
– The Maintenance Supervisor (MS) waxes the floor when he/she had time.
– He/she thought MS waxed the floors in the hall about a month age.
– MS usually waxed floors after a room was empty.
During an interview on 5/23/18 at 10:00 A.M., after touring the facility and viewing the
issues, the Administrator said:
– The MS had to transport residents most of the time.
– The facility needed to do some repairs
– The MS should finish the floors on regular basis.
– During an interview on 5/24/18 at 9:02 A.M. the MS said:
– He/she only waxed a room when it was empty.
– The floors needed to be waxed but he/she did not have time to wax floors or provide
routine maintenance because he was pulled to transport residents 90% of the time.
– Staff kept a log at the nurses station for documentation of needed repairs.
– He/she checked the repair log on a weekly basis.
During an interview on 5/25/18 at 6:353 A.M. Housekeeper B said he/she could not clean the
floor well where the linoleum was worn away.
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed follow their policy to
investigate and document a resident to resident altercation and provide monitoring to
assure there was no reoccurrence. The facility census was 34.
1. Review of the facility’s abuse prohibition policy, dated, November, (YEAR), showed, in
part:
– It is the purpose of the facility to prohibit mistreatment, neglect, and abuse to any
resident;
– Abuse is the willful infliction of injury, pain or metal anguish;
– Physical abuse is defined as hitting, slapping, pinching, kicking etc.
– To assure everything possible is being done to prevent abuse, the facility has
implemented the following seven component processes:
5. Protection of residents during an investigation;

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 3 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
6. Investigation of all alleged violations;
2. Review of Resident #185’s quarterly Minimum Data Set, (MD), a federally mandated
assessment instrument completed by facility staff, dated, 5/24/18, showed:
– Cognition severely impaired;
– No behaviors;
– Had mood issues;
– Limited assistance of one staff with bed mobility;
– Required extensive assistance of one staff for transfers;
– Frequently incontinent of urine;
– Occasionally had pain and rated a 4 on a scale of 0 – 10 scale;
– Medications used in the last seven days included antianxiety, antidepressants and
opiods;
– [DIAGNOSES REDACTED].
Review of the resident’s current care plan, showed it did not address any behaviors.
Review of the resident’s electronic chart, dated, 5/16/18, at 11:22 A.M., showed:
– In report this A.M., night nurse stated the resident had slapped another resident the
previous evening;
– He/she faxed the physician notifying of increased behaviors and foul dark urine, asking
for a urinalysis (a test to analyze urine contents) with culture and sensitivity (C &
S, a test that identifies the amount and type of bacteria and medications to treat the
infection), if indicated. The resident was on 15 minute checks as a safety precaution;
– Staff did not document the incident in the resident’s chart when it occurred.
Review of the resident’s 15 minute check sheets showed:
– Staff documented the 15 minute checks on 5/16/18 at 6:00 P.M. through 5/17/18, at 5:45
A.M.;
– Staff did not document any 15 minute checks until 5/17/18, at 11:00 P.M. through
5/18/18, at 9:45 A.M.
3. Review of Resident #1’s care plan, revised 12/18/17, showed:
– The resident was on [MEDICAL CONDITION] medications for [MEDICAL CONDITION] (a chronic
and severe mental disorder that affects how a person thinks, feels and behaves).
Review of the resident’s quarterly MDS, dated , 2/26/18, showed:
– Short and long term memory problems;
– Had mood issues;
– Wandering occurred daily;
– Medications included antianxiety and antidepressants;
– [DIAGNOSES REDACTED].
Review of the resident’s ECHART on 5/23/18, at 10:30 A.M., showed:
– Staff did not document the incident in the resident’s chart.
4. During an interview on 5/23/18, at 11:19 A.M., the Social Service Designee (SSD) said:
– He/she was not aware the resident had slapped another resident.
During an interview on 5/23/18, at 11:23 A.M., the Corporate Quality Assurance Nurse (QA
nurse) said:
– He/she was not the Director of Nursing (DON) at the time of the incident;
– He/she was training the new DON and was not aware of the incident;
– The night nurse should have documented the incident.
During an interview on 5/23/18, at 11:28 A.M., the DON said:
– He/she started (MONTH) 1, (YEAR);
– He/she was told about it the next morning when he/she came to work;
– He/she was still in training and did not do any kind of investigation about the
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 4 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
incident;
– The night nurse should have documented the incident.
During an interview on 5/23/18, at 11:39 A.M., the QA Nurse said:
– He/she had talked to Licensed Practical Nurse (LPN) A and an investigation had not been
done;
During an interview on 5/23/18, at 11:47 A.M., LPN A said:
– He/she did not remember who the night nurse was but he/she had said the resident had
slapped Resident #1 the evening before;
– He/she told the new DON and the QA Nurse and was instructed to start 15 minute checks.
During an interview on 5/24/18, at 7:42 A.M., LPN D said:
– He/she worked the 3 – 11 P.M., shift and did not know what happened between Resident
#185 and Resident #1.
During an interview on 5/25/18, at 3:36 P.M., LPN B said:
– Resident #185 and Resident #1 were in the day room on the locked 200 hall unit;
– Resident #1 was in his/her wheelchair and propelled him/herself toward Resident #185 who
was watching TV and it was aggravating Resident #185 and he/she kept swatting and hitting
at Resident #1;
– He/she removed Resident #1 and took him/her out in the hallway so he/she could roam, but
he/she headed back to the day room toward Resident #185;
– Resident #185 kept swatting and hitting at Resident #1 and was aggravated at him/her;
– He/she removed the resident and took him/her into the dining room and gave him/her
blocks to play with;
– He/she did not document the incident in the nurse’s notes or in the report book but told
LPN D.
During an interview on 5/25/18, at 4:59 P.M., the QA Nurse said:
– Staff should separate the residents and make sure they are safe;
– 15 minute checks for 24 hours;
– The family, DON, and Administrator should be notified so they can begin an
investigation;
– An investigation should have occurred;
– The incident should have been documented in both of the resident’s charts.
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to develop and
implement a base line care plan consistent with the resident’s specific conditions, needs
and risks to provide effective person centered care within 48 hours of admission for two
residents (Resident #179 and Resident #23). The facility census was 34.
1. Review of Resident #179’s medical record showed the facility admitted the resident on[DATE]. The resident is a Full Code (required CPR).
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed:
– Able to make daily decisions;
– Needed limited assistance of staff for bed mobility, transfers, walking, moving about
the facility, toilet use and personal hygiene;

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 5 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– Needed extensive assistance for dressing and bathing;
– Had frequent pain that the resident rated an eight on a scale of ,[DATE].
– A Stage II pressure ulcer (full thickness of top layer of skin missing that presents
like a crater or blister) with the wound bed covered in slough (yellow or white tissue
that adhered to the wound).
– [DIAGNOSES REDACTED].
Review of the medical record showed no initial admission care plan.
Observation on [DATE] at 10:20 A.M., showed the resident propelled him/herself in a wheel
chair up and down the hallway. The resident’s hair had not been combed and the resident
had facial hair that was at least an eighth of an inch long that covered his/her face. The
resident wore a large neck brace.
During an interview on [DATE] at 4:59 P.M., the Quality Assurance Nurse (QA), said:
– If the care plans were incomplete or if a resident did not have a care plan, it was
because facility staff had not completed the care plans for the resident.
2. Review of Resident #23’s face sheet showed:
– admitted on [DATE];
– [DIAGNOSES REDACTED].
Review of the resident’s admission MDS dated , [DATE], showed:
– Cognitive skills severely impaired;
– Had mood issues;
– Limited assistance of one staff for bed mobility, dressing, toilet use and personal
hygiene;
– Occasionally incontinent of bladder;
– [DIAGNOSES REDACTED].
Review of the medical record showed no initial admission care plan.
Observation during the survey from [DATE] through [DATE], at various times, showed:
– The resident ambulated in his/her room and halls with a rolling walker;
– Staff verbally cued the resident at times during the meals.
During an interview on [DATE], at 12:45 P.M., the QA nurse, said:
– We do not have any care plans for the resident;
– The MDS Coordinator gets pulled to the floor to work.
During an interview on [DATE], at 1:41 P.M., Licensed Practical Nurse (LPN) A said:
– He/she had been the MDS Coordinator for a little over a year;
– He/she has told Administration for the last month, he/she has not been able to get the
MDS’s or care plans done;
– He/she has been scheduled to work in his/her office to work on the MDS’s and care plans,
but then gets pulled to work on the floor;
– He she is supposed to do the admission or baseline care plans;
– The residents who do not have a care plan should have one;
– No one monitors to see if the care plans have been updated.
During an interview on [DATE], at 4:59 P.M., the Director of Nursing said;
– The baseline care plan should be filled out by the admitting nurse or the MDS
Coordinator;
– The MDS Coordinator or nurse should be updating the care plan as it happens;
– She is responsible to make sure the residents have a care plan.
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 6 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to develop and
implement a care plan consistent with the resident’s specific conditions, needs and risks
to provide effective person centered care for two residents (Resident #18 and Resident
#19). The facility census was 34.
1. Review of Resident #18’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 3/1/18, showed:
– The faciity admitted the resident on 2/28/18;
– Able to make daily decisions;
– Needed extensive assist for activities of daily living;
– Had a catheter and incontinent of bowel;
– Had a pressure ulcer;
– Frequently had pain;
– A fall without injury;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record showed no care plan for the resident.
2. Review of Resident #19’s MDS, dated [DATE], showed:
– admitted to the facility 3/6/18;
– Moderately impaired decision making skills;
– Extensive assistance required of staff for bed mobility;
– Dependent on staff for transfers, dressing, eating, toilet use, personal hygiene and
bathing;
– Always incontinent of bowel and bladder;
– Antipsychotic medications;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record showed no care plan for the resident.
During a joint interview on 5/25/18 at 4:59 P.M., the Director of Nurses and the Corporate
QA Nurse said:
– The MDS Cooordinator got pulled to work the floor often They had hired a new MDS
Coordinator but she quit before her first day;
– If the care plans were incomplete or if a resident did not have a care plan, it was
because facility staff had not completed the care plans for the resident.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record reviews the facility failed to ensure staff followed
professional standards of care when staff failed to obtain medications and create a
Medication Administration Record [REDACTED]. The facility census was 34.
1. Review of the facility policy, dated (MONTH) (YEAR), on resident admissions showed:
– The purpose of the policy was to ensure staff properly documented information when
admitting a resident.
– Staff must document the date and time he/she notified the resident’s physician of the
resident’s admission and verification of the resident’s admission orders [REDACTED]

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 7 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– Staff must note the date and time he/she ordered the resident’s medications.
Review of Resident #179’s discharge orders from the hospital, dated 5/24/18 showed the
following medication orders [REDACTED] – Lorezepam (to treat anxiety) 0.5 milligrams (mg) to be taken orally (po) three times a
day;
– [MEDICATION NAME] (a diuretic) 2.5 mg po daily;
– Milk of Magnesia (a laxative) 30 milliliters (ml) to be taken po daily;
– Multi vitamin one po daily;
– [MEDICATION NAME] (to treat yeast infections) 1 gram applied to skin daily;
– Omega 3-6-9 (a supplement) one po daily;
– Potassium 10 millequivalents (meq) po daily;
– Allopurnol 100 mg po daily;
– [MEDICATION NAME] coated aspirin (a blood thinner) 81 mg po daily;
– Carboplatin (to [MEDICAL CONDITION]) 300 mg intravenous daily;
– Carvedilol (to treat high blood pressure) 12.5 mg po two times daily;
– [MEDICATION NAME] (antidepressant) 10 mg po daily;
– [MEDICATION NAME] (a laxative) 100 mg po daily;
– Folic acid (a vitamin) 1 mg po daily;
– [MEDICATION NAME] (a diuretic) 40 mg po two times a day;
– [MEDICATION NAME] (used to treat nerve pain and [MEDICAL CONDITION])300 mg po two times
a day;
– [MEDICATION NAME] 5 mg/325 mg (a narcotic pain medication) take as needed for pain;
– [MEDICATION NAME] (to treat gastric issues) 40 mg po daily;
– Omperazole (to treat gastric issues) 20 mg po daily;
– [MEDICATION NAME] sulfate (an iron supplement) 325 mg po two times a day.
Review of the resident’s nurses notes for 5/24/18 showed:
– Staff did not document notifying the resident’s physician of the hospital orders.
– Staff did not document creating a MAR.
During an interview on 5/25/18 at 9:00 A.M. and 11:10 A.M., Registered Nurse (RN) A said:
– The resident was readmitted to the facility yesterday at change of shift.
– Since the resident was admitted at change of shift he/she did not fill out a MAR for the
resident.
– The resident did not get his morning medications because no one filled out a MAR
indicated [REDACTED].
During an interview on 5/25/18 at 9:25 A.M. Graduate Nurse (GN) A said:
– He/she had always worked nights.
– He/she did not realize that he/she needed to make a MAR for the resident.
– He/she did not receive any orientation to work as a GN.
During an interview on 5/25/18 at 11:13 A.M. the Director of Nursing said:
– Since RN A admitted the resident he/she should have made a MAR for the resident or asked
GN A to make a MAR for the resident.
– GN A had not received any orientation as a GN.
– GN A had always worked the night shift and the facility did not admit residents on the
night shift.
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 8 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record review, the facility failed to assure staff
used proper techniques to reduce the possibility of accidents and injuries during the use
of a gait belt transfer (a safety device and mobility aid used to provide assistance
during transfers, ambulation or repositioning) for two of 13 sampled residents, (Resident
#26 and #185). Staff also failed to follow the manufacturer’s guidelines for mechanical
lifts when they locked the back casters (brakes) while lifting and lowering the residents.
This affected Resident #19 and #28. The facility census was 34.
Review of the Manufacturer’s guideline for the Mechanical Lift showed:
– Does not recommend locking the rear casters of the lift when lifting the resident.
Review of the facility’s policy dated 3/15 for Gait Belt Use, showed:
– To provide better control and balance while assisting the resident with ambulation and
transfers;
– Apply belt to the resident’s waist, tighten to fit snugly.
1. Review of the Resident #19’s care plan with a start date of 3/7/17, only addressed the
resident’s difficulty making self understood.
Review of the resident’s Minimum Data Set, (MDS) a federally mandated assessment
instrument completed by facility staff, dated 3/6/18, showed:
– Moderately impaired decision making skills;
– Totally dependent on staff for transfers;
– [DIAGNOSES REDACTED].
Observation on 5/24/18 at 2:53 P.M., showed the resident sat in his/her wheelchair.
Certified Nurse Aid (CNA) B and E transferred the resident to his/her bed with a
mechanical lift. CNA E placed the lift legs around the resident’s wheel chair and locked
the rear caster’s before he/she raised the resident. He/she unlocked the brakes and rolled
the resident in the lift over to the resident’s bed. He/she placed the legs of the lift
under the bed and then locked the rear casters before he/she lowered the resident to the
bed.
2. Review of Resident #28’s MDS, dated [DATE], showed:
– Moderately impaired decision making skills, but knew he/she was in a nursing home;
– Totally dependent on staff for transfers;
– Impaired mobility on one side;
– [DIAGNOSES REDACTED].
Review of the resident’s current care plan, with a review target date of 7/25/18, did not
direct staff how to transfer the resident.
Observation and interview on 5/24/18 at 8:04 A.M., showed the resident lay in bed. CNA B
and CNA F attached the mechanical lift sling to the mechanical lift. CNA B placed the
mechanical lift legs under the bed and locked the rear casters before he/she lifted the
resident. CNA B moved the lift with the resident in the lift sling over to the resident’s
wheel chair, locked the rear castors and lowered the resident into the wheelchair. CNA B
said the facility taught the CNAs to lock the rear casters before they raised or lowered
the resident.
During a joint interview on 5/25/18 at 4:59 P.M., the Director of Nurses and the Corporate
QA Nurse said:
– They were unsure whether or not the rear castors of the mechanical lift should or should
not be locked when lifting a resident and then agreed they needed to read the
manufacturer’s guidelines to know which was correct.
3. Review of Resident #26’s care plan, revised on 10/19/17, showed:
– It did not address how the resident transferred or if he/she required assistance from
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 9 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
the staff.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– The resident had short and long term memory problems;
– Limited assistance of one staff for bed mobility, transfers, and ambulation in his/her
room and the hallways;
– [DIAGNOSES REDACTED].
Observation on 5/22/18, at 8:45 A.M., showed:
– The resident had used the toilet and stood up;
– CNA A provided incontinent care and assisted the resident to pull up his/her pants;
– As the resident turned to sit down in his/her wheelchair, CNA A grabbed the back of
his/her pants and assisted him/her to sit down in the wheelchair.
4. Review of Resident #185’s care plan, revised care plan, dated, 9/5/17, showed:
– The resident was at risk for falls due to a history of falls;
– The resident required assistance of one staff for transfers and ambulation using a
walker and gait belt.
Review of the resident’s quarterly MDS, dated , 5/24/18, showed:
– Cognitive skills severely impaired;
– Required limited assistance of one staff for bed mobility;
– Required extensive assistance of one staff for transfers and toilet use;
– [DIAGNOSES REDACTED].
Observation on 5/24/18, at 9:26 A.M., showed:
– CNA A and CNA C sat the resident on the side of the bed;
– CNA A placed the gait belt around the resident’s upper abdomen;
– CNA A and CNA C reached under the resident’s arm and grabbed the side of the gait belt
with one hand and stood the resident up;
– The gait belt slid up between the resident’s shoulder blades;
– CNA A and CNA C removed the resident’s wet incontinent brief and sat the resident back
down on the wet incontinent pad and tightened the gait belt;
– CNA A and CNA C reached under the resident’s arm and grabbed the side of the gait belt
and stood the resident up and the gait belt slid up between the resident’s shoulder
blades;
– CNA C reached around and wiped front to back twice with a different wash cloth each
time;
– The resident stated, He/she needed to sit back down, because you are killing me;
– CNA A and CNA C sat the resident back down on the wet incontinent pad and wet fitted
sheet;
– CNA A adjusted the gait belt;
– CNA C reached under the resident’s arm and grabbed the side of the gait belt with one
hand and CNA A reached under the resident’s arm and grabbed the side of the gait belt with
one hand and placed her other hand under the resident’s upper arm, and stood the resident
up;
– The gait belt slid up between the resident’s shoulder blades;
– CNA C provided incontinent care and CNA A and CNA C pulled the resident’s clean
incontinent brief up and sat the resident back down on the wet incontinent pad and wet
fitted sheet;
– CNA A adjusted the gait belt;
– CNA C reached under the resident’s arm and grabbed the side of the gait belt and CNA A
grabbed the back of the gait belt with one hand and stood the resident up;
– CNA A and CNA C pulled the resident’s pants up and CNA A and CNA C grabbed the back of
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 10 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
the resident’s pants and transferred him/her into his/her wheelchair;
– CNA A removed the gait belt.
During an interview on 5/24/18, at 10:53 A.M., CNA A said:
– He/she should have placed his/her hands on the side of the gait belt and on the back of
the gait belt;
– He/she held onto the resident’s arm sometimes because some of the residents liked to
hold onto his/her arm;
– He/she should not have grabbed the back of the resident’s pants during the transfer.
During an interview on 5/24/18, at 1:14 P.M., CNA C said:
– He/she always lifted on his/her left side;
– He/she should not lift under the resident’s arm or arm pit;
– He/she should not have grabbed the back of the resident’s pants during the transfer.
During an interview on 5/25/18, at 4:59 P.M., the DON said:
– Staff should place one hand on the side of the gait belt and one hand on the back of the
gait belt;
– The gait belt should not be loose;
– Staff should tighten the gait belt if it slides up;
– Staff should not grab the back of the resident’s pants during a transfer;
– Staff should not hold onto the resident’s arm during transfers.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure staff
provided catheter (a sterile tube inserted into the urinary bladder to drain urine) care
in a manner to prevent a urinary tract infection [MEDICAL CONDITION] or the possibility of
a UTI which affected one of 13 sampled residents who had a history of [REDACTED]. Staff
placed a urinary drainage bag on the resident’s lap above the level of the bladder during
a mechanical lift transfer and failed to provide complete and proper perineal care for
three residents (Resident #185 and #26). The facility census was 34.
Review of the facility’s Catheter Care policy dated 3/15, showed:
– To prevent infection and reduce irritation;
– Secure the catheter using a leg band strap.
Review of the facility’s Perineal Care policy, dated 3/15, showed:
– To cleanse the perinium and prevent infection and odor;
– Manipulate and thoroughly cleanse all perineal folds.
1. Review of Resident # 184’s Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/23/18, showed:
– Impaired decision making skills;
– Extensive help of staff for toilet use and personal hygiene;
– Had an indwelling catheter;
– Urinary tract infection in the last 30 days;
– [DIAGNOSES REDACTED].
Review of the resident’s current 5/18 physician’s orders [REDACTED].
Review of the resident’s care plan, target review dated 6/10/18, directed staff:

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 11 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
– To assist with brief and pericare as needed for incontinent bowel movements;
– To clean around his/her catheter two times daily.
Observation and interview on 5/23/18 at 9:16 A.M., showed the resident’s catheter tubing
and the dignity bag that contained the urinary drainage bag drug the floor as staff
wheeled the resident in to the hallway and back into his/her room to make room for the
mechanical lift. Certified Nurse Aide (CNA) F and G placed the resident’s catheter
drainage bag in the resident’s lap when they used a mechanical lift to transfer the
resident from wheelchair to bed. Staff had not attached a leg strap to anchor (keep from
pulling) the catheter tubing. When staff grasped the tubing and wiped it down, the
resident moaned. The tubing had a large amount of thick, creamy colored sediment in the
tubing. Staff placed the drainage bag into the bedside dignity bag that hung on the side
of the bed. CNA F lowered the bed to a low position. The rail of the bed rested on the
dignity bag that contained the urinary drainage bag. CNA F said the tubing and the
drainage bag should never touch the floor. He/she did not realize the bed lowered on top
of the drainage bag.
2. Review of Resident #26’s care plan, revised 10/19/17, showed:
– The resident’s urinary incontinence had deteriorated related to cognitive impairment;
– Provide incontinence care after each incontinent episode;
– The resident wore incontinent briefs during he day required assistance of one staff to
change before and after meals, at bedtime and as needed.
Review of the resident’s quarterly MDS, dated , 5/8/18, showed:
– Short and long term memory problems;
– Required limited assistance of one staff for bed mobility, transfers and toilet use;
– Upper and lower extremity impaired on one side;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 5/22/18, at 8:45 A.M., showed:
– Certified Nurse Aide (CNA) A entered the resident’s room and assisted the resident to
transfer onto the toilet;
– The resident urinated and had a bowel movement in the toilet;
– CNA A left the room to get extra linens;
– CNA A did not wash his/her hands and applied gloves;
– CNA A placed a towel on the floor;
– CNA A assisted the resident to stand up;
– CNA A wiped the rectal area with a wash cloth and threw it on a towel on the floor;
– CNA A wiped from front to back with a new wash cloth and threw it on a towel on the
floor;
– With the same gloved hands, CNA A assisted the resident to pull up his/her incontinent
brief, pants, assisted the resident to his/her wheelchair and backed the resident’s
wheelchair out of the bathroom;
– CNA A did not provide peri care to the front perineal sides.
During an interview on 5/23/18, at 11:53 A.M., CNA A said:
– He/she should have cleaned the front perineal folds;
– He/she should have cleaned all areas of the skin where urine or feces had touched.
3. Review of Resident #185’s care plan, revised 1/3/17, showed:
– The resident is at risk for pressure ulcer due to moisture;
– The resident wore pads in his/her underwear for dignity due to incontinence;
– Assist with peri care and change pads before and after meals, at bedtime and as needed.
Review of the resident’s quarterly MDS, dated , 5/24/18, showed:
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 12 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
– Cognitive skills severely impaired;
– Required extensive assistance of one staff for toilet use;
– Frequently incontinent of urine;
– [DIAGNOSES REDACTED].
Observation on 5/24/18, at 9:26 A.M., showed:
– CNA A and CNA C sat the resident on the side of the bed;
– The fitted sheet and incontinent pad were wet with urine;
– CNA A and CNA A used the gait belt and stood the resident up;
– CNA A and CNA C removed the resident’s wet incontinent brief and sat the resident back
down on the wet incontinent pad;
– CNA A and CNA C used the gait belt and stood the resident up;
– CNA C reached around and wiped front to back twice with a different wash cloth each
time;
– CNA A and CNA C sat the resident back down on the wet incontinent pad and wet fitted
sheet;
– CNA A and CNA C used the gait belt and stood the resident up;
– CNA C used a wash cloth and wiped from front to back;
– CNA A and CNA C pulled up the clean incontinent brief and sat the resident back down on
the wet incontinent pad and fitted sheet;
– CNA A and CNA C used the gait belt and stood the resident up;
– CNA A and CNA C pulled the resident’s pants up and transferred him/her into his/her
wheelchair;
– CNA C did not clean the front perineal folds and did not clean all areas where urine had
touched the skin.
During an interview on 5/24/18, at 1:14 P.M., CNA C said:
– He/she should have cleaned all areas where urine had touched the skin;
– They should not have sat the resident back down on the wet incontinent pad and fitted
sheet;
– He/she should have cleaned the resident again after he/she sat on the wet incontinent
pad and fitted sheet.
During an interview on 5/25/18, at 4:59 P.M., the Corporate Quality Assurance Nurse (QA
Nurse) said:
– Staff should clean all areas of the skin where urine had touched;
– If the resident was incontinent, staff should provide complete peri care;
– Staff should not sit a resident on wet incontinent pads or fitted sheets.
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record reviews the facility failed to assure one of 13 sampled
residents (Residents #12) who used psychoactive medications received gradual dose
reductions (GRDs) in an effort to discontinue these medications. The facility census was
34.
1. Review of the facility’s, undated, policy on pharmacy consultant and unnecessary

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 13 of 24
Back To Top
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
medications, showed:
– Purpose was to ensue each resident did not receive unnecessary medications.
– Defined unnecessary medications as any medication used in excessive dose, excessive
duration, without adequate monitoring, without adequate indications for use of the
medication, or in the presence of adverse consequences.
– The Director of Nursing (DON) must review each resident’s drug regimen monthly and as
needed.
2. Review of Resident #12’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff ,dated 5/15/18, showed:
– Cognitively impaired;
– Had mood issues;
– [DIAGNOSES REDACTED].
– Medications included antianxiety and antidepressant medications.
Review of the resident’s care plan, dated 2/14/17 showed:
– The resident received [MEDICAL CONDITION] medications.
– The facility identified goal was for the resident to receive the least possible dose of
medication to control his/her anxiety and depression.
– Staff must review the resident’s medications at least twice a month to ensure the
resident received the lowest dosage possible to treat the resident’s symptoms.
– [DIAGNOSES REDACTED].
Review of the resident’s Medication Administration Record [REDACTED].
Review of the resident’s consultant pharmacist (CP) monthly medication review showed the
resident’s [MEDICATION NAME] had not been addressed over the past year.
3. During an interview on 5/24/18 the Corporate Quality Assurance Nurse said:
– He/she had acted as the Director of Nursing (DON).
– He/she was orienting the DON.
– He/she had not monitored residents [MEDICAL CONDITION] medications.
– The facility did not have a process for monitoring a resident’s [MEDICAL CONDITION] medications.
– The facility did not have a process for monitoring a resident’s physician’s response to
the CP request for a possible GDR.
– The CP should monitor each resident’s [MEDICAL CONDITION] medications on a monthly basis
and make recommendations for a possible GDR twice on the first year and yearly thereafter.
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to ensure staff
administered medications with a less than 5% medication error rate. Facility staff made
three medication errors out of 29 opportunities for error resulting in a medication error
rate of 10.34 %. This affected one of 13 sampled residents (Resident #23) and one
additional resident (Resident #4). The facility census was 34.
1. Review of the package insert for omperazole (used to treat gastric issues) showed a
resident should take the mediation one hour before eating.
Review of Resident #4’s Medication Administration Record [REDACTED] – Omperazole 10 milligrams (mg) orally (po) daily;

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 14 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
– Calcitonin (a hormone replacement that helps regulate calcium and phosphorus) one spray
to alternate nares daily.
Observation on 5/25/18 at 7:30 A.M. showed the resident in the dining room eating
breakfast.
Observation on 5/25/18 at 8:18 A.M. of Registered Nurse (RN) A administering medications
to the resident showed :
– Gave the resident omperazole 10 mg po;
– Gave the resident one spray of [MEDICATION NAME] (used to treat allergies [REDACTED].
During an interview on 5/25/18 at 8:20 A.M. RN A said:
– He/she did not have time to give any resident medications ordered before breakfast.
– He/she should have given the resident calcitonin nasal spray.
2. Review of Resident #23’s MAR, dated 4/25/18 through 5/24/18 showed orders for:
– [MEDICATION NAME] (an antibiotic)100 mg po stated staff should not administer with
antacids, minerals,, or vitamins;
– Iron (a mineral supplement) 325 mg po;
– Vitamin C one tablet po.
Observation on 5/25/18 at 8:45 A.M. of Licensed Practical Nurse (LPN) A administering
medications to the resident showed he/she gave the resident:
– [MEDICATION NAME] (an antibiotic)100 mg po;
– Iron (a mineral supplement) 325 mg po;
– Vitamin C one tablet po.
During an interview on 5/25/18 at 8:45 A.M. LPN A said he/she should not administer[MEDICATION NAME] with vitamins or minerals.
4. During an interview on 5/25/18 at 9:00 A.M. the Director of Nursing (DON) said:
– Staff should always administer omperazole one hour before meals.
– Staff must not substitute [MEDICATION NAME] for calcitonin.
– Staff should not administer [MEDICATION NAME] within two hours of a resident receiving
vitamins, minerals, or antacids.
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to ensure staff
properly stored medications and discarded expired medications. This affected one
additional resident (Resident #11) . The facility census was 34.
1. Review of the package insert for [MEDICATION NAME] (used to treat anxiety) oral liquid,
dated (MONTH) 2012, showed staff should discard the medication 90 days after opening the
medication.
Review of the package insert for [MEDICAL CONDITION] (TB) testing medication, dated
(MONTH) 2013, showed staff should discard the medication 30 days after opening the
medication
Review of the facility policy, dated (MONTH) (YEAR), on labeling medications showed:
– Staff should destroy any improperly secured medication.
– Labels for multiuse medications should have an expiration date.
2. Observation on 5/22/18 at 2:53 P.M. of Licensed Practical Nurse (LPN) B and LPN C

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 15 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
checking medications on the main nurse’s station medication refrigerator showed:
– Two undated, opened vials of TB testing medication;
– One opened stock bottle of [MEDICATION NAME] oral liquid dated opened 2/11/17.
During an interview on 5/22/18 at 2:53 P.M. LPN B and LPN C said:
– Staff should date when opened TB testing medication.
– They were not sure when staff should discard TB testing medication.
– The opened bottle of [MEDICATION NAME] oral liquid was floor stock.
– They thought the medication was good until the unopened expiration date.
3. Observation on 5/22/18 at 3:00 P.M. of LPN A and LPN B checking medications on the
locked until showed Resident #11’s bubble pack of [MEDICATION NAME] 0.5 mg with bubble #22
torn with a pill behind the bubble and tape covering the torn bubble.
During a interview on 5/22/18 at 3:00 P.M. LPN A and LPN B said:
– They should discard any medication behind a torn bubble.
– They should not tape any torn bubbles.
4. Observation on 5/23/18 at 3:30 P.M. of Certified Medication Technician (CMT) A checking
stored medications showed:
– One bottle of doccusate (a laxative) liquid with an expiration date of (MONTH) (YEAR);
– One box of hemorrhoid suppositories with an expiration ideate of (MONTH) (YEAR);
– One box of hemorrhoid suppositories with an expiration date of (MONTH) (YEAR);
– One bottle of B6 (a vitamin supplement) tablets with an expiration date of (MONTH) 18,
(YEAR);
– One bottle of Sodium [MEDICATION NAME] ( a supplement) with an expiration date of
(MONTH) 1, (YEAR).
During an interview on 5/23/18 at 3:30 P.M. CMT A said staff did not routinely check for
medication outdates.
5. During an interview on 5/23/18 at 8:17 A.M. LPN A said:
– He/she was responsible for ordering stock medications.
– He/she last checked for medication outdates (MONTH) (YEAR).
During an interview on 5/24/18 at 10:53 A.M. the Director of Nursing said:
– Staff should open and date any multiuse medications.
– Staff should not tape torn bubbles.
– Staff should discard any medications behind torn bubbles.
– The facility did not have any process for staff checking for medications outdates.
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary needs.

Based on observations, interviews, and record reviews the facility failed to provide any
menu substitutes and follow the posted menu. This had the potential to affect all facility
residents. The facility census was 34.
1. Review of the facility policy on food preparation, dated (MONTH) 2011, showed:
– Staff must provide substitutions at each meal.
– Staff should prepare enough food to allow for resident seconds if desired.
2. Review of the facility posted menu for lunch 5/22/18 showed:
– Barbecued chicken;
– Red bliss potatoes;

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 16 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
– Creamed corn;
– Bread of choice;
– Fresh banana;
– Did not list any alternatives.
Observation on 5/22/18 at 12:00 P.M. showed staff served residents:
– Barbecued chicken;
– Mashed potatoes;
– Creamed corn;
– Sliced bread;
– Fresh banana;
– Staff did not offer residents any bread choices;
– Staff did not offer residents any alternatives.
3. Review of the registered dietician’s (RD) facility menu for 5/23/18 lunch showed:
– Barbecued chicken;
– Red Bliss potatoes;
– Creamed corn;
– Bread of choice;
– Fresh banana.
Review of the facility posted menu for lunch 5/23/18 showed:
– Stuffed pepper casserole;
– Capri blend vegetables;
– Bread;
– Apricot halves
– No alternatives listed
4. Review of the RD’s facility menu for breakfast on 5/25/18 showed:
– Juice of choice;
– Cereal of choice;
– Egg of choice;
– Sausage or bacon;
– Fresh banana;
– Toast.
Review of the facility posted menu for breakfast on 5/25/18 showed:
– Cereal of choice;
– Egg of choice;
– Sausage or bacon;
– Toast;
– Fresh banana;
– Did not list any alternatives.
Observation on 5/25/18 at 8:00 of staff serving breakfast showed:
– Staff gave residents cereal but did not ask residents their preference;
— Did not serve fresh bananas.
5. During an interview on 5/22/18 at 3:30 P.M. Resident #181 said:
– He/she had been at the facility for around three weeks for rehab.
– Last weekend, staff did not offer any meat for breakfast.
– One meal staff served cold grilled cheese.
– The posted menu was unreliable.
– One morning, ,the dietary staff ran out of meat and only served ground meat with no
substitute offered.
– One morning staff served hamburger for breakfast.
FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 17 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
During an interview on 5/23/18 at 9:30 A.M. the dietary manager said they did not offer
any menu alternatives.
During a group interview on 5/23/18 at 10:00 A.M. the group said:
– The facility did not follow the posted menu.
– The facility did not offer any menu alternatives.
– Staff did not address dietary issues at resident council.
During an interview on 5/23/18 at 10:00 A.M. the Administrator said the facility did not
offer menu alternatives.
During an interview on 5/23/18 at 10:30 A.M. Cook A said he/did not have any menu
alternatives to offer to residents.
During an interview on 5/24/18 at 3:38 P.M. Resident #9 said:
– Dietary staff never offers any meal choices.
– He/she would like some choices.
F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Employ sufficient staff with the appropriate competencies and skills sets to carry out
the functions of the food and nutrition service, including a qualified dietician.

Based on observations, interviews, and record reviews, the facility failed to ensure the
Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the
functions of the food and nutrition service. The facility census was 34.
1. Review of the facility job description for DM, dated (MONTH) 2006, showed:
– The DM was to direct and supervise dietary personnel.
– The DM was responsible for planning, preparing, and serving resident meals.
– The DM monitored quality and quantity of food.
– The DM monitored staff adherence to all sanitary regulations governing food handling and
serving.
– The DM maintained a written cleaning schedule and monitored to ensure staff cleaned the
kitchen.
– The DM visited residents as needed to assess meal service.
– The DM must supervise food care and storage.
– The DM must have competed the Certified Dietary Managers Course.
– The DM should have some supervisory experience in a hospital, cafeteria, or a
restaurant.
Observation of the kitchen on 5/22/18 at 8:30 A.M. showed:
– Multiple undated, uncovered open items in both refrigerators.
– The floor sticky in the walk-in refrigerator and walk-in freezer.
– No posted monitoring of refrigerator and freezer temperatures.
– No posted monitoring of dishwashing and three compartment sink chemicals.
– Dead bugs behind the door in the pantry.
During an interview on 5/22/18 at 9:25 A.M. the DM said:
– He/she set-up a cleaning schedule but the staff did not follow the schedule.
– He/she told the staff to monitor refrigerator and freezer temperatures but the staff did
not monitor the temperatures.
– He/she told the staff to monitor dishwasher and three compartment sink chemicals and
staff did not monitor the temperatures.
– Prior to working at the facility as a cook, he/she worked in a fast food restaurant but

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 18 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0801

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
did not have any food management experience.
– He had not discussed his/her issues with dietary staff not monitoring
refrigerator/freezer temps and chemicals for the dishwasher and three compartment sink.
– The facility had not provided him/her with any dietary management training.
– The facility had not sent him/her to a Certified Dietary Manager’s course.
– He/she did not attend resident council meetings to discuss dietary issues with
residents.
During an interview on 5/22/18 at 10:00 A.M. the Administrator said:
– The facility had only provided the DM with minimal training for the position.
– The facility had not sent the DM to any Certified Dietary Manager’s courses.
F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 observations, interviews, and record reviews the facility failed to ensure meals
were served to meet the needs of the residents when staff failed to prepare food according
to registered dietician approved recipes. The facility census was 34.
1. Review of the facility’s policy, date (MONTH) 2011, on food preparation and
distribution showed:
– Staff must follow the recipe for each item prepared.
Review of the facility’s undated recipe for stuffed pepper casserole for 50 servings
showed staff should combine:
– 12 1/2 pounds of ground beef;
– 30 green peppers;
– One gallon tomato sauce;
– Spices, chopped onions, and cooked rice that were available and used in proper portions.
Observation on 5/23/18 at 10:00 A.M. of Cook A preparing stuffed pepper casserole showed:
– Browned a 10 pound log of ground beef;
– Added a gallon of tomato sauce;
– Added 11 frozen peppers;
– Cooked the required amount of rice;
– Added the cooked rice, spices, hamburger, peppers, and tomato sauce and baked.
During an interview on 5/23/18 at 10:30 A.M. Cook A said:
– He/she made enough for 50 because some staff also ate.
– He/she did not realize that he/she should have used the amount of hamburger the recipe
called for.
– He/she did not realize he/she should have used the amount of peppers in the recipe.
– He/she used the recipe book to prepare the casserole but did not have enough peppers and
only used 10, instead of 12 and one-half of hamburger.
During an interview on 5/24/18 thee Dietary Manager( DM) said staff should use the correct
amount of ingredients in a recipe.
During an interview on 5/24/18 at 3:04 P.M. the Administrator said dietary staff should
always follow the recipes.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 19 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observations, interviews, and record reviews, the facility failed to ensure
dietary staff maintained a clean and sanitary conditions when staff failed to store food
in a sanitary manner; ensure the ice machine was cleaned on a regular basis, and failed to
monitor the chemicals in the dish washer and the three compartment sink. This had the
potential to affect all facility residents. The facility census was 34.
1. Review of the facility policy, dated (MONTH) 2011, on dish washer temperature showed:
– The purpose of the policy was to ensure that staff properly monitor and control wash and
rinse temperatures and chemicals.
– Staff must monitor dish washer temperatures and chemicals each meal.
Observation of the kitchen on 5/22/18 at 8:30 A.M. showed:
– Clean dishes on a tray with dried food on the tray;
– Clean dishes sitting on a cart with rusted shelves;
– No chemical monitoring logs on the dishwasher or three compartment sink;
– No temperature monitoring logs on any of the two refrigerators and two freezers.
– Dried on food on the tilt skillet.
– Dried grease on the wall by the stove and on the oven doors
– An opened jelly pack with dust in the pack on the floor by the ice machine.
– Dust on top of the ice machine.
– A shelf above the coffee warmer with a brown dry powder on the shelf;
– Dirt underneath the rack holding clean dishes;
– Trash but no trash bag in the trash can by the hand washing sink;
Observation of the kitchen refrigerator on 5/22/18 at 8:30 A.M. showed:
– An undated opened container of pimento cheese;
– An undated opened container of cucumber and onion salad;
– An undated opened facility filled squeeze bottle of ranch salad dressing;
– A tray, with a dried dark substance, holding tea and milk;
– An undated opened facility filled squeeze bottle of thousand island dressing;
– Two undated opened containers of parmesan cheese;
– An undated opened jug of salsa;
– An undated open bottle of Boost, a dietary supplement;
– An undated covered bowl of watermelon;
– 50% of the fronts of both refrigerators sticky;
– 80% of the floor of the walk-in refrigerator sticky;
– A strong odor of sour milk in the walk in refrigerator;
– A container of cooked lasagna dated opened 5/6/18.
Observation on 5/22/18 at 8:45 A.M. of the pantry showed:
– Five cases of bottled water on the floor;
– The 70% pantry floor sticky;
– Dead bugs on the floor behind the pantry door;
– A box of cheese puffs on the floor;
– An undated, opened, sticky bag of coconut.
During an interview on 5/22/18 at 9:00 A.M. Cook A said:
– The last time anyone used the tilt skillet was about a week ago.
– They did not have a cleaning schedule.
– They did not monitor refrigerator and freezer temps.
– They did not monitor chemicals in the dish washer and three compartment sink.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 20 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
– They did not ever deep clean the kitchen.
– They did not have a schedule for checking for outdates.
During an interview on 5/22/18 at 9:15 A.M. Dietary Aide (DA) A said:
– No one taught him/her how to use the three compartment sink.
– He/she usually washed dishes.
– No one had taught him/her to monitor the chemicals in the dish washer and three
compartment sink.
During an interview on 5/22/18 at 9:25 A.M. the Dietary Manager (DM) said:
– Staff should not place any supplies on the floor.
– Staff did not monitor refrigerator and freezer temps.
– Staff should monitor refrigerator and freezer temps on a daily basis.
– Staff did not monitor the chemicals for the dish washer and three compartment sink.
– Staff should monitor dishwasher and three compartment sink temps on a daily basis.
– Dietary staff were solely responsible for cleaning the kitchen.
– He/she did not have enough staff to deep clean the kitchen on a regular basis.
– Staff had not deep cleaned the kitchen in a long time.
– Staff did not have a schedule for checking the refrigerators for outdates.
– Staff should discard all open items three days after opening.
During an interview on 5/22/18 at 10:00 A.M. the Administrator said:
– Staff must monitor refrigerator and freezer temps.
– Staff must monitor chemicals for the dish washer and three compartment sink.
– Staff need to keep the kitchen clean.
– Staff must not store items on the floor.
– Staff should on a routine basis deep clean the kitchen.
F 0814

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Dispose of garbage and refuse properly.

Based on observations and interviews the facility did not properly dispose of empty boxes
in the kitchen. The facility census was 34.
1. Observation on 5/22/18 at 8:30 A.M. of the kitchen pantry showed a 12 inch stack of
empty boxes on the pantry floor.
During an interview on 5/22/18 at 9:30 A.M. the Dietary Manager said:
– The boxes had been sitting in the pantry for around a week.
– He/she told staff to place the boxes in the dumpster but staff did not.

F 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Have the Quality Assessment and Assurance group have the required members and meet at
least quarterly

Based on interview the facility failed maintain a Quality Assurance(QA)/ Quality Assurance
and Performance Improvement (QAPI) committee. This had the potential to affect all
facility residents. The facility census was 34.
1. The facility did not provide a policy on QA/QAPI.
During an interview on 5/24/18 at 3:00 P.M. the Administrator said:

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 21)
– The facility did not have a formal QA/QAPI committee.
– The facility QA/QAPI committee had not met since he/she started working in the facility
in November.
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to ensure staff
used acceptable infection control procedures when staff did not wash their hands and apply
gloves prior to administering an injection and when a staff member removed a needle cover
with his/her teeth prior to administering an injection. This affected one additional
resident (Resident #182), staff failed to wash their hands between soiled and clean tasks,
which affected Resident #1 and #26, and placed soiled linens on the floor which affected
Resident #26. The facility census was 34.
1. Observation on 5/25/18 at 9:00 A.M. of Registered Nurse (RN) A administering insulin to
Resident #182 showed:
– Without washing hands and applying gloves, RN A drew up the resident’s dose of insulin.
– RN A used his/her teeth to remove the needle cap on the syringe.
– Without washing hands and applying gloves, RN A gave the resident his/her insulin
injection.
During an interview on 5/25/18 at 9:00 A.M. RN A said:
– He/she should have washed his/her hands and applied gloves prior to administering the
resident’s insulin.
– He/she should not have removed the needle cap with his/her teeth.
During an interview on 5/25/18 at 1:45 P.M. the Director of Nursing (DON) said:
– Staff should always wash hands before drawing up injections.
– Staff should always wear gloves when giving any injections.
– Staff should never remove a needle cap with their teeth.
2. Review of Resident #26’s care plan, revised, 10/19/17, showed:
– The resident had urinary incontinence;
– Provide incontinence care after each incontinent care episode.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated, 5/8/18, showed:
– Long and short term memory problems;
– Limited assistance of one staff for bed mobility, transfers, and toilet use;
– Upper and lower extremities impaired on one side;
– Occasionally incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 5/22/18, at 8:45 A.M., showed:
– The resident had two different piles of dirty clothes on the floor;
– Certified Nurse Aide (CNA) A entered the resident’s room and assisted the resident to
transfer onto the toilet;
– The resident urinated and had a bowel movement in the toilet;
– CNA A left the room to get extra linens;
– CNA A did not wash his/her hands and applied gloves;
– CNA A placed a towel on the floor;
– CNA A provided incontinent care to the resident and threw the soiled wash cloths onto

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 22 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
the towel;
– With the same gloved hands, CNA A assisted the resident to pull up his/her incontinent
brief, pants, assisted the resident to his/her wheelchair and backed the resident’s
wheelchair out of the bathroom. CNA A removed the dirty clothes from the resident’s floor
and the bathroom floor and placed them in the hamper in the hallway;
– CNA A removed his/her gloves, did not wash his/her hands and made the resident’s bed and
his/her room mate’s bed and left the room.
3. Review of Resident #1’s care plan, revised on 12/18/17, showed:
– He/she needed assistance with his/her activities of daily living (ADL’s) due to his/her
dementia;
– He/she required assistance of two staff for toilet use;
– He/she required assistance of one staff for hygiene.
Review of Resident #1’s quarterly MDS, dated , 2/26/18, showed:
– Cognitive skills moderately impaired;
– Required extensive assistance of two staff for personal hygiene, transfers and toilet
use;
– Always incontinent of bowel and bladder;
– [DIAGNOSES REDACTED].
Observation on 5/24/18, at 10:13 A.M., showed:
– CNA A and CNA B transferred the resident into bed;
– CNA A washed his/her hands and applied gloves;
– CNA A provided incontinent care to the resident who had urine and fecal material in
his/her incontinent brief;
– CNA A held the resident on his/her side with the same gloved hands he/she had used to
provide incontinent care, while CNA B dried the resident’s hip area;
– After CNA A provided incontinent care to the resident, he/she removed the soiled linen
and placed in a trash bag and removed the resident’s pants.
During an interview on 5/23/18, at 11:53 A.M., CNA A said:
– He/she should wash his/her hands between glove changes, when he /she entered the room,
between residents and after peri care;
– If cleaning fecal material, should remove his/her gloves and wash hands;
– The dirty clothes and linens should not be placed on the floor.
4. During an interview on 5/25/18, at 4:59 P.M., the DON said:
– Staff should wash their hands when they enter the resident’s room, during peri care
between dirty and clean tasks and before they leave the room;
– Staff should placed soiled wash cloths in a trash bag, not on a towel on the floor;
– There should not be any piles of clothes on the resident’s floor.
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record reviews, the facility failed to assure all residents were
offered the influenza and pneumonia vaccinations in a timely manner. This affected three
of 13 sampled residents (Residents #18, #23, and #179) and one additional resident
(Resident #10). The facility census was 34.
1. Review of Resident #10’s medical records showed:
– He/she was admitted to the facility on [DATE].

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 23 of 24
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES		PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING___________
B. WING___________
(X3) DATE SURVEY COMPLETED

05/25/2018

NAME OF PROVIDER OF SUPPLIER

BETHANY CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1305 SOUTH 7TH STREET
BETHANY, MO 64424

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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
– No one offered him/her influenza and pneumonia vaccines.
Review of Resident #18’s medical records showed:
– He/she was admitted to the facility on [DATE].
– No documentation that the resident was already immunized or that staff
offered him/her influenza and pneumonia vaccines.
Review of Resident #23’s medical records showed;
– He/she was admitted to the facility on [DATE].
– No one offered him/her influenza vaccination.
Review of Resident #179’s medical record showed:
– He/she was admitted to the facility on [DATE].
– No documentation that the vaccine had been given in the past or that staff
offered the pneumonia vaccine.
During an interview on 5/25/18 at 1:45 P.M. the Director of Nursing (DON) said:
– He/she had only been the DON for three weeks.
– The DON was responsible for all resident immunizations.
– All residents should be offered pneumonia vaccination on admission.
– All residents should be offered influenza immunization upon admission if the resident
was admitted during influenza season.
– He/she had not had time to check residents for immunizations.
F 0908

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Keep all essential equipment working safely.

Based on observations, interviews, and record review the facility failed to repair the
kitchen exhaust fan. This had the potential to affect dietary staff. The facility census
was 34.
1. Observation on 5/22/18 at 8:30 A.M. of the facility kitchen showed:
– A switch plate by the stove with a sign that said Keep on for 12 hours.
– The exhaust fan did not work.
During an interview on 5/22/18 at 8:30 A.M. Cook A said:
– The exhaust fan had not worked for about two years.
– He/she reported that the exhaust fan did not work to several Administrators (ADM)
including the present ADM.
– He/she felt very hot when cooking.
– He/she felt in the winter the steam was a hazard.
During an interview on 5/22/18 at 9:30 A.M. the Dietary Manager (DM) said:
– He/she had worked at the facility for about six months.
– The exhaust fan had not worked since he/she started working at the facility.
– He/she reported the non-working exhaust fan to the ADM.
During an interview on 5/22/18 at 10:00 A.M. the ADM said he/she needed to get the exhaust
fan repaired.

FORM CMS-2567(02-99)
Previous Versions Obsolete		Event ID: YL1O11Facility ID: 265443If continuation sheet
Page 24 of 24
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