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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide care in
a manner that enhanced resident dignity and ensured full recognition of individuality, for
three additional residents (Residents #151, #16 and #26). The facility census was 47.
During an interview on 2/13/19 at 6:30 P.M., the Administrator said the facility did not
have a policy regarding treating resident’s with dignity and respect.
1. Review of Resident #16’s care plan, dated 8/19/18, showed the following:
-[DIAGNOSES REDACTED].
-Alteration in self-care ability related to stroke. Staff should allow choices to promote
sense of autonomy and control. Assist with elimination needs as he/she requested;
-At risk for skin breakdown and/or urinary tract infections related to occasional urinary
incontinence. Staff should encourage the resident to report need for urinary elimination
in a timely manner to reduce potential for incontinence;
-At risk for exacerbation of depression. Goal was able to report acceptance of life status
without negative emotions/exacerbation of symptoms of depression. Staff should allow
resident to direct his/her care at all possible opportunities (what to wear and eat, rest
and comfort needs/desires, bedtimes, activities) to promote sense of control/autonomy.
Assure basic physical needs were met to reduce physical distress/discomfort as causes of
emotional distress.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 11/10/18, showed the following:
-Cognitively intact;
-Required extensive assistance of two staff members with bed mobility;
-Required total assistance of two staff members with transfers and toileting;
-Frequently incontinent of bowel and bladder.
Observations on 2/7/19, showed the following:
-From 6:58 A.M. until 7:20 A.M., the call light for the resident’s room was on and the
room door was closed;
-At 7:20 A.M., Nurse Aide (NA) G entered the resident’s room and turned off the call
light. The resident said, I need the bedpan, needed it for 15 minutes. I already went. I
don’t intend to do that, it makes it hard to wait. NA G washed his/her hands and put on
gloves;
-At 7:22 A.M., the resident said, I need the bedpan. The pad is wet. I already went. I
told you that. NA G removed his/her gloves and left the room. The resident said, I peed
the bed;
-At 7:25 A.M., NA G returned to the resident’s room with a clean washable incontinence bed
pad;
-At 7:27 A.M., NA G rolled the resident on his/her side, the resident’s incontinence bed
pad was saturated with urine.
During an interview on 2/7/19 at 7:27 A.M., the resident said if there was something
he/she needed to do, he/she asked staff two hours ahead of time. Otherwise, staff would
not assist him/her in time. He/She did not like urinating in the bed. If he/she had the
bed pan quicker, he/she would not urinate in the bed. He/She was unable to hold urine for
very long.
During a telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-He/She should assist Resident #16 with the bedpan when he/she asked. It was not dignified
when residents became incontinent, because they were waiting on staff to take them to the

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
bathroom or to provide a bed pan;
-He/She was unsure why the resident was not given the bedpan when he/she asked;
-The facility was short of staff and it was hard to get another staff member to help when
a resident required two staff members to provide assistance. There was only one Certified
Nursing Assistant (CNA) usually on each hall. It was unfair to the other residents to take
a CNA off their hall;
-The resident often had to wait because there was no one available to help.
2. Review of Resident #151’s undated Interim Plan of Care showed no staff direction
regarding the resident’s care needs.
Review of the resident’s Physician order [REDACTED].
-admitted [DATE];
-Mobility with mechanical lift and two staff assistance.
Observation on 2/7/19, showed the following:
-From 7:45 A.M. to 8:00 A.M., the resident’s call light was on. The resident sat on the
edge of the bed with a wheelchair positioned directly in front and facing the resident;
-At 8:08 A.M., CNA E entered the resident’s room. The resident said, I want to go to the
bathroom. CNA E turned the call light off and told the resident he/she needed to get help.
The resident remained seated on the edge of the bed;
-At 8:12 A.M., NA G carried the resident’s breakfast tray into the resident’s room and sat
it on the bedside table. The resident said, I need to use the bathroom. NA G left the
resident’s room. The resident’s roommate turned the call light back on;
-At 8:16 A.M., NA G pushed the resident’s wheelchair out of the way and placed the
resident’s bedside table and breakfast tray in front of the resident. NA G said he/she was
waiting to learn the resident’s transfer status before taking the resident to the
bathroom. NA G left the room;
-From 8:18 A.M. to 8:24 A.M., NA G and Certified Medication Technician (CMT) R entered the
room and assisted the resident’s roommate with toileting;
-At 8:24 A.M. the resident said, I haven’t been to the bathroom yet, I need to go. NA G
and CMT R did not respond to the resident.
During an interview on 2/7/19 at 8:25 A.M., the resident said the following:
-At 8:25 A.M., he/she still had to go the bathroom. He/She did not know why staff would
not help him/her transfer to the wheelchair and go the bathroom. He/She could get in the
wheelchair with help;
-At 9:05 A.M., staff finally took him/her to the bathroom. It was hard to hold it so long.
His/Her breakfast was cold. He/She did not know why staff would not help him/her transfer
to the wheelchair and go the bathroom.
During a telephone interview on 2/26/19 at 12:10 P.M., NA G said he/she did not know how
Resident #151 was supposed to be transferred, so he/she did not transfer the resident.
Residents should not have to wait to go the bathroom.
3. Review of Resident #26’s annual MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Always continent of bladder and bowel;
-Extensive assist of one for personal hygiene.
Review of the resident’s care plan, last revised on 12/15/18, showed staff was to provide
supervision and encouragement with activities of daily living (ADLs).
Observation on 2/7/19 at 6:35 A.M., showed the following:
-The resident lay in bed;
-CNA J and NA K entered the room to assist the resident with morning cares;
-CNA J pulled the resident’s covers back;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-The resident lay naked on a cloth incontinent pad wearing only socks;
-CNA J assisted the resident to sit on the side of the bed;
-NA K opened the door to the room, exited the room to obtain linens and closed the door
behind him/her;
-The privacy curtain was not pulled around the bed, which allowed the resident to be
visible from the hallway. The window curtains, which opened to the parking lot, were
partially open;
-CNA J removed the resident’s socks, and applied clean gloves as the resident sat
unclothed on the bed;
-NA K opened the door and re-entered, which allowed the unclothed resident to be visible
from the hallway;
-CNA J and NA K stood the resident to position him/her further back on side of the bed;
-NA K opened the door, exited the room (while the resident remained unclothed on side of
bed) to obtain perineal wash, re-opened the door and re-entered the room;
-CNA J and NA K dressed the resident, performed perineal care and assisted him/her to the
toilet.
During an interview on 2/13/19 at 4:45 P.M., NA K said the following:
-The privacy curtain should be pulled when providing personal care for the resident;
-Staff should not enter and exit the resident’s room while care is being provided causing
the resident to be visible from the hallway, as the resident could feel upset if someone
saw him/her naked.
During interview on 2/28/19 at 2:12 P. M., CNA J said the following:
-Staff should not enter and exit a resident’s room during resident cares, unless the
privacy curtain was pulled;
-It would be a dignity issue if staff entered and exited the resident’s room during cares
(without the privacy curtain pulled) and the resident was unclothed.
During an interview on 2/13/19 at 5:10 P.M., the Director of Nursing (DON) said the
following:
-Staff should answer call lights quickly and assist the residents;
-Staff should not turn off call lights and leave the room without caring for the resident;
-Staff should not enter and exit the room if the privacy curtain was not pulled during
personal cares;
-Staff should assist a resident with toileting as soon as the resident asked for
assistance, and should not leave residents waiting for an extended period of time to
toilet. A resident waiting to toilet until they became incontinent was a dignity issue;
-Staff should not leave residents unclothed on the side of the bed and visible from the
hallway. This was a dignity issue;
-Staff should assist a resident with toileting as quickly as possible and then deliver the
meal tray;
-If CNA staff were unsure of a resident’s transfer status and requirements they should ask
the charge nurse or other CNA staff for direction.

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 observation, interview and record review, the facility failed to ensure one

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
resident (Resident #12), of 13 sampled residents was free from physical abuse. The
facility census was 47.
Review of the facility policy Abuse Prohibition, dated 8/2017, showed the following:
Purpose: To ensure residents are free from abuse, corporal punishment, and involuntary
seclusion;
Policy:
-It is the policy of this facility that each resident has the right to be free from abuse,
corporal punishment, exploitation, and involuntary seclusion;
-Residents must not be subjected to abuse by anyone, including but not limited to staff,
other residents, consultants, volunteers, staff of other agencies servicing the residents,
family or legal guardians, friends, or other individuals;
-ABUSE means the willful infliction of injury, unreasonable confinement, intimidation,
punishment, or the taking or using photographs or recordings resulting in physical harm,
pain, mental anguish, demean or humiliate the resident;
-Physical abuse: includes hitting, slapping, pinching and kicking;
-If resident to resident abuse occurs staff should separate the residents then report to
the charge nurse. The charge nurse should then notify the Administrator and/or Director of
Nursing (DON).
1. Review of Resident #12’s care plan dated 5/21/18 showed the following:
-Focus: Activities of Daily Living (ADL’s) care performance deficit;
-No behaviors.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument to be completed by the facility staff, dated 11/17/18, showed the following:
-Cognitively intact;
-Made self understood and understood others;
-No mood or behavior indicators;
-Supervision only with mobility in wheelchair on and off unit.
Review of the resident’s Physician Order Sheet (POS), dated (MONTH) 2019, showed the
following:
-[DIAGNOSES REDACTED].
-Up in wheelchair to transport self.
Observation on 2/5/19 at 4:10 P.M., showed a half dollar sized, yellowish-green bruise on
the resident’s right, top forearm.
During an interview on 2/5/19 at 4:10 P.M., the resident said the following:
-He/she was returning from lunch one day and a resident, he/she did not know the
resident’s name, but could identify the resident, grabbed and pinched his/her arm;
-The aggressive resident never said anything, but grabbed his/her arm and then slapped
his/her face four times;
-The aggressive resident sat at the first table when entering the dining room and wore a
red jacket;
-If he/she saw the resident headed down the hall, he/she would wait until the resident
passed by to avoid him/her;
-He/she denied a history of conflicts with any other residents;
-The bruise on his/her right forearm was where this resident grabbed and pinched his/her
arm.
Observation and interview on 2/5/19 at 4:45 P.M., showed the resident pointed to Resident
#24 as the resident who struck him/her and caused the bruising to his/her arm.
During an interview on 2/13/19 at 11:50 A.M., the resident said Resident #24 tried to hit
him/her many times before, but he/she had always been able to grab the resident’s arm to
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
stop him/her. The day Resident #24 grabbed his/her arm, he/she had just exited the dining
room and Resident #24 was entering the dining room.
2. Review of Resident #24’s Admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;-Delusions;
-Physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing,
scratching, grabbing, abusing others sexually) one to three days;
-Verbal behaviors directed towards others (e.g. threatening others, screaming at others,
cursing at others) one to three days;
-Behaviors put resident at significant risk for physical illness or injury, interfered
with the resident’s care and with the resident’s participation in activities or social
interactions;
-Behaviors significantly disrupted care or living environment.
Review of the resident’s care plan, dated 6/6/18, showed the following:
-Focus: Impaired cognitive function/dementia. Goal: Will develop skills to cope with
cognitive decline and maintain safety, Interventions: None.
-Focus: Behavior Problem. Goal: will have fewer/no episodes of behavior by next review
date of 9/4/18, Interventions: None.
-Focus: Potential for physical behaviors. Goal: Will not harm self or others through the
review date of 9/4/18, Interventions: Analyze key times, places, circumstances, triggers
and what de-escalates behavior and document, Intervene before agitation escalates; guide
away from source of distress; engage calmly in conversation. If response is aggressive,
staff to walk calmly away and approach later.
Review of the resident’s nurses’ note, dated 11/10/18 at 12:00 P.M., showed the resident
in room xxx (staff did not document a room number, but rather xxx), claimed to have been
slapped by this resident. This resident said he/she did not slap the resident in room xxx.

Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Verbal behaviors occurred daily;
-Independent with locomotion on/off unit in wheelchair.
Review of the resident’s nurse’s note, dated 1/26/19 and untimed, showed resident
provoking another resident, hit him/her three times then laughed. Staff intervened and
separated the residents. While pushing the resident he/she said, Won’t do nothing about
it. The resident then turned his/her head towards the resident he/she hit and laughed.
Review of a faxed document from the facility to the resident’s physician, dated 1/29/19
(three days after the incident on 1/26/19), showed the following handwritten note authored
by Registered Nurse (RN) H:
-On 11/10/18 the resident slapped another resident;
-On 1/26/19 slapped another resident three times.
During an interview on 2/8/19 at 8:45 A.M. and 2/13/19 at 2:30 P.M., Certified Nurse Aide
(CNA) F said the following:
-He/she was standing at the nurse’s desk on 1/26/19 when he/she heard Resident #12 yelling
and cursing;
-As he/she arrived to the area just outside of the dining room, he/she took hold of
Resident #24’s wheelchair and began to push him/her back to his/her room;
-Registered Nurse (RN) H arrived and began to assess Resident #12;
-He/she was unsure if Resident #12 had any injuries;
-RN H attempted to speak with Resident #24 when the resident struck him/her in the
stomach.

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
During an interview on 2/6/19 at 8:10 A.M., 2/8/19 at 9:15 A.M. and 2/13/19 at 10:15 A.M.,
RN H said the following:
-He/she did not witness the altercation between Resident #12 and Resident #24. He/She was
at the desk when he/she heard Resident #12 yell, You can’t hit me like that! He/She
responded to the hall between the dining room and the nurse’s desk where CNA F had already
arrived. Resident #12 said Resident #24 had smacked him/her on the back of the head three
times. Staff separated the residents;
-After the altercation with Resident #12 and Resident #24, he/she had attempted to speak
with Resident #24 about the incident and the resident yelled at him/her and struck him/her
in the arm with his/her hand.
During an interview on 2/8/19 at 1:12 P.M. and 5:12 P.M., the Director of Nurses (DON)
said the following:
– The resident’s behaviors would be considered abuse;
-He/she was not aware of an allegation of a resident being slapped by Resident #24 prior
to this incident.
During interview on 2/13/19 at 3:15 P.M., the Administrator said the following:
-He/she had only been at the facility since (MONTH) 2, 2019;
-He/she believed Resident 24’s behaviors toward Resident #12 constituted abuse.
MO # 152

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to report to the state agency an
allegation of physical abuse involving two residents (Resident #12 and #24), in a review
of 13 sampled residents. The facility census was 47.
Review of the facility policy Abuse Prohibition, dated 8/2017, showed the following:
Purpose: To ensure residents are free from abuse, corporal punishment, and involuntary
seclusion;
Policy:
-It is the policy of this facility that each resident has the right to be free from abuse,
corporal punishment, exploitation, and involuntary seclusion;
-Residents must not be subjected to abuse by anyone, including but not limited to staff,
other residents, consultants, volunteers, staff of other agencies servicing the residents,
family or legal guardians, friends, or other individuals;
-The administrator will be the coordinator of the abuse prevention quality improvement
committee;
Defining Abuse:
ABUSE means the willful infliction of injury, unreasonable confinement, intimidation,
punishment, or the taking or using photographs or recordings resulting in physical harm,
pain, mental anguish, demean or humiliate the resident;
Types of abuse:
-Physical abuse: includes hitting, slapping, pinching and kicking;
Investigation:
-Facility will investigate all types of abuse (physical, mental, sexual, financial,
involuntary seclusion) and 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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
-The facility will ensure all alleged violations involving mistreatment, neglect, abuse,
injuries of unknown origin and misappropriation of resident property will be reported to
the charge nurse immediately;
-If resident to resident abuse occurs staff should separate the residents then report to
the charge nurse. The charge nurse should then notify the administrator and/or Director of
Nursing (DON);
Reporting:
-The facility will ensure that all alleged violations involving mistreatment, neglect, or
abuse, including injuries of unknown origin and misappropriation of resident property are
reported immediately to the supervisor, the supervisor will then report to the
administrator and/or DON;
-The results of all investigations will be reported to the administrator and/or his/her
designee and to the other officials in accordance with state law and federal regulations;
-Initial report will be filed to state certification agency immediately (within two hours)
without delay, with follow-up and findings within five working days of incident, and is
the alleged violation is verified appropriate, corrective action will be taken;
1. Review of Resident #12’s care plan dated 5/21/18, showed the following:
-Focus: Activities of Daily Living (ADL’s) care performance deficit;
-No behaviors.
Review of the resident’s nurse’s notes, dated 11/10/18, showed the resident alleged
Resident #24 slapped him/her in the face.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument to be completed by the facility staff, dated 11/17/18, showed the
following:
-Cognitively intact;
-Made self understood and understood others;
-No mood or behaviors.
Review of the resident’s Physician Order Sheet (POS), dated 2/19, showed the resident’s
[DIAGNOSES REDACTED].
During an interview on 2/13/19 at 11:50 A.M., the resident said Resident #24 had tried to
hit him/her many times before, but that he/she had always been able to grab Resident #24’s
arm to stop him/her.
2. Review of Resident #24’s Admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Delusions;
-Physical behavioral symptoms directed towards others (e.g , hitting, kicking, pushing,
scratching, grabbing, abusing others sexually) one to three days;
-Verbal behaviors directed towards others (e.g., threatening others, screaming at others,
cursing at others) one to three days;
-Behaviors put resident at significant risk for physical illness or injury, interfered
with the resident’s care and with the resident’s participation in activities or social
interactions;
-Behaviors significantly disrupted care or living environment.
Review of the resident’s care plan, dated 6/6/18, showed the following:
-Focus: Impaired cognitive function/dementia, Goal: Will develop skills to cope with
cognitive decline and maintain safety, Interventions: None.
-Focus: Behavior Problem, Goal: will have fewer/no episodes of behavior by next review
date of 9/4/18, Interventions: None.
-Focus: Potential for physical behaviors, Goal: Will not harm self or others through the
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
review date of 9/4/18, Interventions: Analyze key times, places, circumstances, triggers
and what de-escalates behavior and document, Intervene before agitation escalates; guide
away from source of distress; Engage calmly in conversation, If response is aggressive,
staff to walk calmly away and approach later.
Review of the resident’s nurses note, dated 11/10/18 at 12:00 P.M., showed the resident in
Room xxx (staff did not document a room number, but rather xxx), claimed to have been
slapped by this resident. This resident said he/she did not slap the resident in Room xxx.

Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Verbal behaviors occurred daily;
-Independent with locomotion on/off unit in wheelchair.
During an interview on 2/8/19 at 9:08 A.M., Certified Nurse Aide (CNA) E said he/she
observed Resident #24 attempt to hit other residents in the dining room and he/she had
reported it to the charge nurses.
During an interview on 2/13/19 at 2:32 P.M., CNA D said he/she had seen Resident #24 raise
his/her hand to Resident #12 many times in the dining room, but he/she was not aware of
any physical contact.
During an interview on 2/6/19 at 8:10 A.M. and 2/13/19 at 10:15 A.M., Registered Nurse
(RN) H said the following:
-He/She was new to the facility;
-He/She had not known of the allegation of abuse from 11/10/18, until he/she was asked (by
the administrator) to review nurse’s notes for past behaviors for a physician fax;
-He/She was not aware of the resident’s name which Resident #24 allegedly slapped on
11/10/18 and he/she assumed it had been investigated, but did not have knowledge if it had
or had not been reported to state.
During an interview on 2/8/19 at 1:12 P.M., the Director of Nursing (DON) said the
following:
-He/She was new to the facility as of 12/1/18;
-He/She was not aware of an allegation of a resident being slapped by Resident #24 before
now, so it was most likely not reported to the state agency;
-He/She or the administrator were responsible for reporting to the state agency;
-He/She expected to be notified of all allegations of abuse and all allegations should be
investigated.
During an interview on 2/13/19 at 3:15 P.M., the Administrator said the following:
-He/She had only been at the facility since 1/2/19;
-He/She was not aware of the allegation of abuse from 11/10/18;
-Although the incident preceded his/her employment at the facility, the facility should
have reported the allegation of abuse to the state agency;
-He/She searched and could not find an investigation into the incident or that it had been
reported to the state agency.
MO # 152

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to investigate an allegation of

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
physical abuse involving two residents (Resident #12 and Resident #24) in a review of 13
sampled residents. The facility census was 47.
Review of the facility policy Abuse Prohibition, dated 8/2017, showed the following:
Purpose: To ensure residents are free from abuse, corporal punishment, and involuntary
seclusion;
Policy:
-It is the policy of this facility that each resident has the right to be free from abuse,
corporal punishment, exploitation, and involuntary seclusion;
-Residents must not be subjected to abuse by anyone, including but not limited to staff,
other residents, consultants, volunteers, staff of other agencies servicing the residents,
family or legal guardians, friends, or other individuals;
-Physical abuse: includes hitting, slapping, pinching and kicking;
Investigation:
-Facility will investigate all types of abuse (physical, mental, sexual, financial,
involuntary seclusion) and report;
-The facility will ensure all alleged violations involving mistreatment, neglect, abuse,
injuries of unknown origin and misappropriation of resident property will be reported to
the charge nurse immediately;
-If resident to resident abuse occurs staff should separate the residents then report to
the charge nurse. The charge nurse should then notify the administrator and/or Director of
Nursing (DON).
1. Review of Resident #12’s care plan dated 5/21/18, showed the following:
-Focus: Activities of Daily Living (ADL’s) care performance deficit;
-No behaviors.
Review of the resident’s nurse’s notes, dated 11/10/18, showed the resident alleged
Resident #24 slapped him/her in the face.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument to be completed by the facility staff, dated 11/17/18, showed the
following:
-Cognitively intact;
-Made self understood and understood others;
-No mood or behaviors.
Review of the resident’s Physician Order Sheet (POS), dated (MONTH) 2019, showed the
resident’s [DIAGNOSES REDACTED].
2. Review of Resident #24’s Admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Delusions;
-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,
scratching, grabbing, abusing others sexually) one to three days;
-Verbal behaviors directed towards others (e.g., threatening others, screaming at others,
cursing at others) one to three days;
-Behaviors put resident at significant risk for physical illness or injury, interfered
with the resident’s care and with the resident’s participation in activities or social
interactions;
-Behaviors significantly disrupted care or living environment.
Review of the resident’s care plan, dated 6/6/18, showed the following:
-Focus: Impaired cognitive function/dementia, Goal: Will develop skills to cope with
cognitive decline and maintain safety, Interventions: None.
-Focus: Behavior Problem, Goal: will have fewer/no episodes of behavior by next review
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
date of 9/4/18, Interventions: None.
-Focus: Potential for physical behaviors, Goal: Will not harm self or others through the
review date of 9/4/18, Interventions: Analyze key times, places, circumstances, triggers
and what de-escalates behavior and document, Intervene before agitation escalates; guide
away from source of distress; Engage calmly in conversation, If response is aggressive,
staff to walk calmly away and approach later.
Review of the resident’s nurses note, dated 11/10/18 at 12:00 P.M., showed the resident in
Room xxx (staff did not document a room number, but rather xxx), claimed to have been
slapped by this resident. This resident said he/she did not slap the resident in Room xxx.

Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Verbal behaviors occurred daily;
-Independent with locomotion on/off unit in wheelchair.
During an interview on 2/6/19 at 8:10 A.M. and 2/13/19 at 10:15 A.M., Registered Nurse
(RN) H said the following:
-He/She was new to the facility;
-He/She had not known of the allegation of abuse from 11/10/18 until he/she was asked (by
the administrator) to review nurse’s notes for past behaviors for a physician fax;
-He/She was not aware of the resident’s name which Resident #24 allegedly slapped on
11/10/18 and he/she assumed it had been investigated, but did not have knowledge if it had
or had not been reported to state.
During an interview on 2/8/19 at 1:12 P.M., the Director of Nursing (DON) said the
following:
-He/She was new to the facility as of 12/1/18;
-He/She was not aware of an allegation of a resident being slapped by Resident #24 before
now;
-He/She expected to be notified of all allegations of abuse and all allegations should be
investigated.
During an interview on 2/13/19 at 3:15 P.M., the Administrator said the following:
-He/She had only been at the facility since 1/2/19;
-He/She was not aware of the allegation of abuse from 11/10/18;
-He/She searched and could not find an investigation into the incident.
MO # 152

F 0623

Level of harm – Potential for minimal harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to provide a copy of the
transfer notice to a representative of the Office of the State Long-Term Care Ombudsman
for three of 13 sampled residents (Resident #8, #38, and #40) and two of five residents
selected for closed record review (Resident #43 and #44). The facility census was 47.
Review of the policies and procedures provided by the facility showed there was no policy
for providing transfer/discharge notices to a representative of the Office of the State
Long-Term Care Ombudsman.
1. Review of Resident #8’s medical record showed the following:

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 10)
-He/She was admitted to the facility 5/18/18;
-He/She was transferred to the hospital on [DATE];
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
2. Review of Resident #38’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
3. Review of Resident #40’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
4. Review of Resident #43’s closed medical record showed the following:-He/She was
admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
5. Review of Resident #44’s closed medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-There was no documentation to show the facility notified the Office of the State
Long-Term Care Ombudsman of the resident’s transfer.
During an interview on 2/8/19 at 10:45 A.M., the Social Service Designee said the
following;
-He/She did not notify the ombudsman of discharges and transfers from the facility;
-He/She was not aware of this regulatory requirement.
During an interview on 2/13/19 at 5:30 P.M., the Administrator said the facility had not
been sending notifications of transfers and discharges to the State Ombudsman’s office.

F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform residents and/or legal
representatives of their bed hold protocol at the time of transfer for three sampled
residents (Resident #8, #38, #40), and for two (Resident #43 and #44) of five residents
selected for closed record review. The facility census was 47.
Review of the facility’s undated Bed Reservation Agreement showed the following:
-If a resident’s care at the facility was being paid for by Medicaid/Medicare, the
facility would reserve the resident’s bed while he/she was on therapeutic leave for any
period that was a covered service under the program for which the resident was eligible;
-If the resident’s absence from the facility exceeded the time period covered or was due
to a hospitalization , the facility would automatically reserve or continue to reserve the
bed only if the resident and/or legal representative signed and agreed to pay the amount

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 11)
indicated for each day the bed was reserved;
-If there was no signed request for a bed to be reserved automatically, the resident
and/or the legal representative still had to request that the bed be reserved, but would
have to do so within 24 hours of the resident’s departure from the facility;
-If the bed was not reserved, the resident would be readmitted to the first available bed
in a semi-private room at the facility if the resident required services and was eligible
for Medicaid nursing facility services.
1. Review of Resident #8’s medical record showed the following:
-He/She was admitted to the facility 5/18/18;
-He/She was transferred to the hospital on [DATE];
-No documentation the facility notified the resident’s legal representative in writing of
the facility’s bed hold policy at the time of transfer on 2/6/19.
3. Review of Resident #38’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-No documentation the facility notified the resident’s legal representative in writing of
the facility’s bed hold policy at the time of transfer on 1/9/19.
4. Review of Resident #40’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-No documentation the facility notified the resident’s legal representative in writing of
the facility’s bed hold policy at the time of transfer on 11/25/18.
5. Review of Resident #43’s closed medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-No documentation the facility notified the resident’s legal representative in writing of
the facility’s bed hold policy at the time of transfer on 4/18/18.
6. Review of Resident #44’s closed medical record showed the following:
-He/She was admitted to the facility on [DATE];
-He/She was transferred to an outside facility for evaluation and treatment of [REDACTED].
-No documentation the facility notified the resident’s legal representative in writing of
the facility’s bed hold policy at the time of transfer on 11/21/18.
During an interview on 2/8/19 at 10:45 A.M., the Social Service Designee said the
following:
-He/she did not give bed hold letters upon transfer/discharge to hospital for residents;
-Residents were notified of the facility’s bed hold policy information upon admission;
-Residents would only receive another notification of the policy if the facility was at
full capacity.
During an interview on 2/13/19 at 6:30 P.M., the Administrator said the following:
-She just learned last week of the need to provide residents or the residents’ legal
guardians in writing the facility bed hold policy on admission and at the time of transfer
from the facility;
-The facility was not providing a copy of the facility bed hold policy at the time of
transfer from the facility.

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
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and staff interview, the facility failed to develop a
plan of care consistent with resident’s specific conditions, needs, and risks for three of
13 sampled residents (Resident #40, #24 and #12). The facility census was 47.
1. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User’s
Manual, Version 3.0, Chapter 4, dated (MONTH) 2011, showed the following:
-The care plan is driven not only by identified resident issues and /or conditions but
also by a resident’s unique characteristics, strengths, and needs;
-A well-developed and executed assessment and care plan looks at each resident as a whole
human being with unique characteristics and strengths;
-The care plan should be revised on an ongoing basis to reflect changes in the resident
and the care that the resident is receiving;
-The effectiveness of the care plan must be evaluated from its initiation and modified as
necessary;
-Changes to the care plan should occur as needed in accordance with professional standards
of practice and documentation. The interdisciplinary team members should communicate as
needed about care plan changes;
-Federal statute and regulations require that residents are assessed promptly upon
admission (but no later than Day 14) and the results are used in planning and providing
appropriate care to attain or maintain the highest practicable well-being;
-Facilities have seven days after completing the admission RAI assessment to develop or
revise the resident’s care plan;
-Minimum Data Set (MDS), federally mandated assessment instruments, completed by facility
staff, are not required for minor or temporary variations in resident status – in these
cases, the resident’s condition is expected to return to baseline within two weeks.
However, staff must note these transient changes in the resident’s status in the
resident’s record and implement necessary assessment, care planning, and clinical
interventions, even though an MDS assessment is not required.
2. Review of the facility’s Care Plan Updates for Short Term Problems policy, dated 2/7/17
showed the following:
-Purpose of the policy was to ensure individualized care was delivered to all residents
according to their needs, to ensure all pertinent staff were aware of short term problems
and appropriate interventions that had been put in place, and to provide comprehensive
interventions to help resolve any short term problems the resident developed;
-It was the policy of the facility to provide individualized care to each resident and
continue to update care plans as short term problems arose;
-All residents who had a fall, infection, required isolation, had skin issues, behavioral
changes, suicidal ideation or any other problem that would likely resolve in a short time,
would have a short term care plan reviewed and initiated and placed with their long term
care plan;
-Once a short term problem was identified, the charge nurse was responsible for initiating
a short term care plan;
-The care plans were located in a binder at the nurses’ station;
– Charge nurses were to find the appropriate care plan, review it, and fill in the
resident’s name, date, and sign;
-Charge nurses were to add interventions that were identified but not on the short term
care plan or strike through those interventions that were not indicated, and initial;

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-Notifications that the care plan had been updated were to be sent to the MDS coordinator
and Director of Nursing (DON).
3. Review of the facility’s MDS and Care Planning policy and procedure, dated 3/28/17,
showed the following:
-It was the policy of the facility to assess and interview each resident per state and
federal guidelines to form an accurate MDS assessment;
-Based on the resident’s needs and the outcomes of the MDS assessment a care plan shall be
initiated for each individual;
-Physical and psychosocial needs would be addressed on the plan of care with interventions
specific to each individual resident;
-Assessments would be completed in compliance with Federal and State regulations for each
resident admitted to the facility;
-All residents would have a care plan in place and staff aware of where to review the plan
of care;
-A care plan meeting the resident’s basic ADLs needs would be initiated upon admission;
– Staff would be informed by the charge nurse of the resident care needs on an ongoing
basis;
-Care plans would be reviewed at least quarterly and adjustments made as needed to best
meet the needs of the resident;
-Changes should be added to the plan of care as they occur and updates added as warranted.
4. Review of Resident #40’s Admission MDS, dated [DATE], showed the following:
-He/She was admitted to the facility on [DATE];
-His/Her cognition was severely impaired;
-He/She was dependent of two staff with bed mobility, transfers, dressing, toilet use, and
bathing;
-He/She was dependent on one staff with eating, personal hygiene, and locomotion on and
off of the unit;
-He/She was always incontinent of bowel and bladder;
-He/She was non-verbal;
-He/She rarely/never understood others;
-He/She was rarely/never understood by others;
-His/Her vision was impaired;
-He/She received scheduled pain medication;
-He/She received non-medication interventions for pain;
-He/She held food in his/he mouth/cheek;
-He/She was on a mechanically altered diet;
-He/She had obvious or likely cavities or broken natural teeth;
-He/She experienced a fall two months prior to admission.
Review of the resident’s care plan, initiated on 6/11/18, showed the following:
-The care plan was incomplete;
-His/Her [DIAGNOSES REDACTED]., Dow[DIAGNOSES REDACTED], arthralgia (painful joints), and
[MEDICAL CONDITION] (low blood iron level);
-He/She had an ADL self-care performance deficit, but interventions documented were not
specific to the resident and did not give direction on how many staff were required for
bed mobility, transfers, toilet use, and bathing;
-The care plan did not specify that the resident required the use of a Hoyer lift for
transfers;
-The resident was on pain medication but there were no interventions listed to assist with
his/her pain alleviation;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-The resident had bowel and bladder incontinence, but there were no interventions
directing staff regarding the resident’s needs with incontinence care;
-He/She had oral/dental health problems, but there were no specific interventions
directing staff on when to assist/provide oral hygiene;
-He/She had impaired cognitive function/dementia or impaired thought process.
Interventions were incomplete and not specific to the resident;
-The resident had nutritional problems or potential nutritional problems. The care plan
did not specify any interventions to address;
-The resident had a communication problem. Interventions were incomplete and not specific
to the resident;
-The resident had impaired visual function. The plan provided no interventions to address
the resident’s impaired visual function;
-The resident was at risk for falls; the plan did not specify the level of risk (low,
moderate, or high) and there were no documented goals or interventions.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-He/She was admitted to the facility on [DATE];
-His/Her cognition was severely impaired;
-He/She was dependent of two staff with bed mobility, transfers, dressing, toilet use, and
bathing;
-He/She was dependent on one staff with eating, personal hygiene, and locomotion on and
off of the unit;
-He/She was always incontinent of bowel and bladder.
Review of the resident’s care plan, initiated on 6/11/18, showed there were no changes,
corrections, or revisions made to his/her plan of care. The plan remained generic and non
specific to the resident’s needs.
Review of the resident’s Significant Change MDS, dated [DATE], showed the resident was
admitted to hospice.
Review of the resident’s care plan, initiated on 6/11/18, showed there were no changes,
corrections, or revisions made to his/her plan of care after the resident was admitted to
hospice. There was no documentation on the care plan to show that the resident was
admitted to hospice.
5. Review of Resident #24’s care plan, dated 6/6/18 and last revised 1/26/19, showed the
following;
-The care plan was incomplete;
-His/Her [DIAGNOSES REDACTED]. iron);
-He/She had an Activity of Daily Living (ADL) self-care performance deficit, but
interventions documented were not specific to the resident and did not give direction on
how much assistance was required for bed mobility, personal hygiene, transfers, toilet
use, oral care, bedtime routine, morning routine and bathing;
-He/She had limited physical mobility but had no specific interventions to direct staff;
-He/She had pain identified but there were no interventions
(pharmacological/non-pharmacological) listed to address the resident’s pain;
-The resident had stress, urge bladder incontinence, but there were no interventions
directing staff regarding toileting or needs related to incontinence;
-He/She was resistive to care but there were no interventions to direct staff on how to
approach the resident;
-He/She had impaired cognitive function/dementia or impaired thought process. The plan did
not provide interventions specific to the resident;
-The resident had nutritional problems or potential nutritional problems, but did not
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
specify what is was related to and there were no interventions documented;
-The resident had a communication problem, but did not specify what it was related to,
interventions were incomplete and not specific to the resident;
-The resident was at risk for falls, but did not specify the level of risk (low, moderate,
or high) and there were no documented goals or interventions;
-The resident had a fall, but did not specify the details of the fall, if there were any
injuries sustained, and there were no documented goals or interventions.
Review of the resident’s nurse’s notes showed the resident had an unwitnessed fall in the
hallway on 7/3/18.
Review of the resident’s care plan, dated 6/6/18 and last revised 1/26/19, showed there
were no new interventions or updates following the fall on 7/3/18.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Rejection of care occurred one to three days;
-Extensive assist of two staff for bed mobility, transfer, toilet use and bathing;
-Supervision with set-up only for eating;
-Limited assist of one for personal hygiene;
-Frequently incontinent of bladder;
-Occasionally incontinent of bowel;
-PRN (as needed) pain medications used;
-Non-medicinal pain interventions;
-Weight loss which was not physician prescribed;
-Mechanically altered diet;
-Use of an anticoagulant (blood thinner).
-Wheelchair for mobility.
Review of the resident’s care plan, dated 11/29/18, showed the Interdisciplinary team
signed the care plan as reviewed. There were no changes, corrections, or revisions made
after the quarterly MDS was completed.
Review of the resident’s POS, dated (MONTH) 2019, showed the following:
-Mechanically soft/catered diet with honey thickened liquids;
-Med Pass (supplemental drink) 60 milliliters two times daily;
-Low air loss mattress;
-Xarelto (blood thinner)10 mg by mouth daily;
-Tylenol ([MEDICATION NAME]) 650 mg by mouth every six hours PRN for pain.
Review of the resident’s care plan, dated 11/29/18, showed there were no changes,
corrections, or revisions made to his/her plan of care.
6. Review of Resident #12’s care plan, dated 5/21/18, showed the following:
– The care plan was incomplete;
-The resident’s [DIAGNOSES REDACTED].
-He/She had an ADL self-care performance deficit, but interventions documented were not
specific to the resident and did not give direction on how much assistance was required
for bed mobility, personal hygiene, transfers, toilet use, oral care, bedtime routine,
morning routine and bathing;
-He/She had hypertension and goal read to maintain the following parameters but none were
listed. Interventions listed to take blood pressure with cuff, obtain blood pressures
frequently and weight frequently (time frames not specific and not parameters were
listed);
-The resident had a fall, but did not specify the details of the fall, if there were any
injuries sustained, and there were no documented goals or interventions;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-He/She had mood problem but did any not list interventions to direct care;
-He/She had care area listed for depression but had no interventions listed to direct
cares;
-He/She had care area for limited physical mobility but had no interventions listed to
direct cares;
-He/She had care area for nutritional problem or potential nutritional problem but did not
list diet or interventions;
-The resident had bladder incontinence; the plan did not list interventions for care.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Extensive assist of two staff for bed mobility;
-Total dependence of two staff for transfers, toilet use and bathing;
-Independent with set up only for locomotion on and off unit;
-Supervision with set up only for eating;
-Extensive assist of one staff for personal hygiene;
-Always incontinent of bladder and bowel;
-Weight loss not physician prescribed;
-Therapeutic diet;
-Use of anticoagulant and diuretic last seven days.
Review of the resident’s POS, dated (MONTH) 2019, showed the following;
-[MEDICATION NAME] (blood thinner) five milligrams (mg) by mouth daily (2/5/19);
-[MEDICATION NAME] (diuretic) 40 mg by mouth daily (5/4/18).
Review of the resident’s care plan showed there were no updates, revisions or corrections
made to the document.
7. During an interview on 2/13/19 at 5:07 P.M., the Director of Nursing (DON) said the
following:
-Care plans should be personalized and specific to the resident’s care he/she required;
-Care plans should be updated when there were changes in the resident’s condition;
-He/she said he/she or any nurse could update the care plans.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to follow
physician orders [REDACTED].#6 and #38) and for two additional residents (#150, #151).
Staff failed to apply ACE wraps (compression wraps to minimize swelling) to Resident #6’s
lower extremities, failed to monitor weights daily as ordered for Resident #38, failed to
provide wound care as ordered for Resident #150 and failed to ensure Resident #151 had
access to continuous supplemental oxygen while in the dining room. The facility census was
47.
Review of the facility’s policies and procedures provided by the facility showed there was
no policy for following physician orders.
Review of the facility’s undated policy for oxygen administration showed the following:
-Oxygen administration was the responsibility of the licensed nursing staff and certified
medication technicians;
-The purpose of the policy was to administer oxygen to the resident when insufficient

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
oxygen is being carried by the blood to the tissues;
-At regular intervals, check liter flow contents of the oxygen cylinder and asses the
resident’s respirations to determine further need for oxygen therapy.
1. Review of Resident #150’s Face Sheet showed an admitted d 1/25/19.
Review of the resident’s Physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Cleanse wounds with normal saline (wound cleansing liquid that contains salt), apply
primary dressing of [MEDICATION NAME] (wound dressing that promotes healing and destroys
bacteria) to wound beds, cover with gauze and a compression dressing for [MEDICAL
CONDITION] (swelling with fluid in the tissues) control. Single layer compression wrap to
affected legs. Apply from toes to knee and cover the heel;
-Change wound dressings every two to three days and as needed;
-Elevate legs as much as possible, avoid standing in one position more than ten minutes,
avoid sitting with legs down and do not cross legs when sitting;
-Change wound dressings on Mondays, resident to wound clinic appointment on Thursdays.
Review of the resident’s undated bowel and bladder assessment completed by facility staff
showed the resident’s lower legs were [MEDICAL CONDITION], had [MEDICAL CONDITION] and
weeping wounds.
Review of the resident’s record showed staff initiated no initial baseline care plan.
There was no staff direction regarding care of the resident.
Review of the resident’s Treatment Administration Record (TAR), dated (MONTH) 2019, showed
the following:
-Weekly skin check. No staff initials indicating staff completed the resident’s weekly
skin check from 1/25/19 (admitted ) to 1/31/19;
-[MEDICATION NAME] dressing to open areas, cover with gauze, wrap with Coban on Mondays;
-On 1/27/19, staff initialed completion of the physician ordered wound care treatment;
-On 1/28/19, the TAR indicated staff should provide the resident’s wound care. Staff did
not initial the TAR on this date to indicate staff completed the resident’s wound care;
-On 1/30/19, staff initialed the physician ordered wound care was provided.
Review of the resident’s Nurses’ Note showed the following:
-On 1/30/19, staff documented the resident’s lower legs were wrapped with dressings clean,
dry and intact. No documentation staff changed the resident’s lower leg dressings or
completed an assessment of the resident’s wounds wounds on 1/30/19;
-On 1/31/19, the resident had drainage from both lower legs and severe [MEDICAL
CONDITION]. Staff documented wound bandages were changed due to excessive drainage and
seeping of drainage to the ankle.
Review of the resident’s Weekly Skin Assessment, dated (MONTH) 2019, showed no
documentation staff assessed the resident’s skin from 1/25/19 (admitted ) to 1/31/19.
Review of the resident’s Weekly Skin Assessment, dated (MONTH) 2019, showed on 2/2/19
staff documented both lower legs had reddened areas after 30 minutes of pressure
reduction, open [MEDICAL CONDITION] to both lower legs treated at wound clinic, open
ulcers to both lower legs and excessive [MEDICAL CONDITION].
Review of the resident’s TAR, dated (MONTH) 2019, showed the following:
-[MEDICATION NAME] dressing to open areas, cover with gauze, wrap with Coban on Mondays;
-Staff marked 2/4/19 as the date staff should provide the resident’s wound care. The
2/4/19 box did not contain initials indicating staff provided the resident’s wound care.
During an interview on 2/6/19 at 10:30 A.M., the resident said he/she had sores on his/her
legs and the bottom of his/her foot. Staff were supposed to change the dressings every
Monday and he/she went to the wound clinic on Thursdays. Staff had not changed his/her
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
wound dressings for a week.
Observation on 2/6/19 at 4:30 P.M., showed the following:
-The resident sat in a wheelchair in the common shower/toilet room. The resident’s legs
were [MEDICAL CONDITION] and swollen with layers of dressings and wraps from knees to base
of toes. The resident’s toes were exposed and had open wounds and black areas on the tips;
-Registered Nurse (RN) H removed the layers of soiled wound dressings from both legs. The
resident’s right lower leg had six open wounds with varying amounts of drainage. An open
draining wound was noted on the resident’s right heel base. The resident’s left lower leg
contained seven open wounds with varying amounts of drainage. The tops of the resident’s
feet were [MEDICAL CONDITION];
-RN H inspected the resident’s wounds and left the shower room.
Observation on 2/6/19 at 6:10 P.M., showed the following:
-The resident sat in a wheelchair near the entrance to the dining room. A fuzzy blanket
covered the resident’s lap and lower legs. The resident’s lower extremity wounds were all
open with no wound dressings in place. His/Her toes were uncovered with open wounds and
black areas visible. The resident’s right heel wound sat on a wash cloth on the wheelchair
pedal;
-RN H administered the resident’s medications and pushed the resident in his/her
wheelchair into the dining room for supper.
Observation on 2/6/19 at 7:00 P.M., showed the resident sat in a wheelchair outside the
front door of the facility smoking. The environmental temperature was frigid. The
resident’s lower extremity wounds were all open with no wound dressings in place. His/Her
toes were uncovered with open wounds and black areas visible. The resident’s right heel
wound sat on a wash cloth on the wheelchair pedal.
Review of the resident’s TAR, dated (MONTH) 2019, showed the following:
-[MEDICATION NAME] dressing to open areas, cover with gauze, wrap with Coban on Mondays;
-On 2/6/19 staff initialed provision of the resident’s wound care.
During an interview on 2/7/19 at 6:50 A.M., the resident said the night nurse redressed
his/her lower leg wounds at approximately 11:00 P.M. last night (2/6/19). The staff did
not have time to redress his/her wounds earlier in the day following his/her shower.
During an interview on 2/7/19 at 7:45 A.M., Licensed Practical Nurse (LPN) Q said the
following:
-He/She redressed the resident’s open lower leg wounds last night sometime after 9:45
P.M.;
-It was not appropriate to leave the resident’s wounds open following the shower for an
extended period of time. Staff should have provided wound care following the shower and
covered the wounds;
-Wounds that were left uncovered increased the risk of infection. The resident was all
over the facility and outside to smoke. His/Her wounds needed to be covered and protected
from injury, further infections and the cold;
-The resident’s pain was worse especially in the right heel wound.
During an interview on 2/8/19 at 8:35 A.M., RN H said the following:
-He/She took off the resident’s lower leg wound dressings prior to the resident’s shower;
-He/She should provide the resident’s physician ordered wound care directly following the
resident’s shower. He/She should not leave the resident’s wounds open for an extended
time. The resident should not be in the dining room, halls and outside to smoke with open
wounds covered with a blanket;
-He/She did not have time to do the wound care following the resident’s shower.
2. Review of Resident #6’s quarterly Minimum Data Set (MDS), a federally mandated
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
assessment instrument completed by facility staff, dated 10/30/18, showed the resident’s
cognition was severely impaired.
Review of the resident’s care plan, last reviewed on 10/30/18, showed the resident was at
risk for respiratory distress and [MEDICAL CONDITION] related to his/her [DIAGNOSES
REDACTED]. extremities). There was no information on the resident’s care plan directing
staff to apply ACE wraps.
Review of the resident’s POS, dated 12/1/18 to 12/31/18, showed the following:
-He/she had a [DIAGNOSES REDACTED].
-On 12/4/18, an order to apply ACE wraps to the resident’s bilateral lower extremities
(BLE) in the morning and remove them at bedtime (HS).
Review of the resident’s TAR, dated 12/1/18 to 12/31/18, showed no documentation staff
applied the resident’s ACE wraps on 12/7/18.
Review of the resident’s weekly skin assessments showed the following:
-On 12/9/18, the resident had three plus (5-6 millimeter depression of the skin with a
10-30 second rebound time when the [MEDICAL CONDITION] area was pressed on; normal would
be no [MEDICAL CONDITIONS] to BLE.
Review of the resident’s TAR, dated 12/1/18 to 12/31/18, showed no documentation staff
applied the resident’s ACE wraps on 12/13/18.
Review of the resident’s weekly skin assessment, dated 12/16/18, showed the resident had
three plus [MEDICAL CONDITION] to the BLE.
Review of the resident’s TAR, dated 12/1/18 to 12/31/18, showed no documentation staff
applied the resident’s ACE wraps on 12/26/18.
Review of the resident’s weekly skin assessment, dated 12/26/18, showed the resident had
plus two (3-4 millimeter depression or a slight indentation of the skin with a 15 second
rebound time when the [MEDICAL CONDITION] area was pressed on ) [MEDICAL CONDITION] to
BLE.
Review of the resident’s TAR, dated 12/1/18 to 12/31/18, showed no documentation to show
staff applied the resident’s ACE wraps on 12/27/18 or 12/31/19.
Review of the resident’s POS, dated 1/1/19 to 1/31/18, showed the following:
-He/She had a [DIAGNOSES REDACTED].
-An order to apply ACE wraps to the resident’s BLE in the morning and remove them at HS.
Review of the resident’s TAR, dated 1/1/19 to 1/30/19, showed no documentation staff
applied the resident’s ACE wraps on 1/3/19.
Review of the resident’s weekly skin assessment, dated (MONTH) 2019, showed on 1/5/19 the
resident had [MEDICAL CONDITION] to BLE (did not specify how much).
Review of the resident’s TAR dated 1/1/19 to 1/30/19, showed no documentation staff
applied the resident’s ACE wraps on 1/10/19.
Review of the resident’s weekly skin assessment, dated (MONTH) 2019, showed on 1/10/19 the
resident had one plus (two millimeter depression or slight indention in the skin with
immediate return to normal when [MEDICAL CONDITION] area was pushed on) [MEDICAL
CONDITION] to his/her ankles.
Review of the resident’s TAR, dated 1/1/19 to 1/30/19, showed no documentation staff
applied the resident’s ACE wraps on 1/15/19.
Review of the resident’s weekly skin assessments, dated (MONTH) 2019, showed on 1/17/19
the resident had two plus [MEDICAL CONDITION] to the BLE.
Review of the resident’s TAR, dated 1/1/19 to 1/30/19, showed the following:
-There was documentation on the back of the TAR that noted the ACE wraps were not in place
on 1/20/19. There was no reason documented as to why they were not on;
-There was no documentation to show staff applied the resident’s ACE wraps on 1/23/19;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-There was documentation on the back of the TAR that noted the ACE wraps were not in place
on 1/28/19 and no reason documented as to why they were not on;
-There was no documentation to show staff applied the resident’s ACE wraps on 1/29/19.
Review of the resident’s weekly skin assessments, dated (MONTH) 2019 showed on 1/30/19,
the resident had one plus [MEDICAL CONDITION] to the BLE.
Review of the resident’s POS, dated 2/1/19 to 2/28/18, showed the following:
-He/She had a [DIAGNOSES REDACTED].
-An order to apply ACE wraps to the resident’s BLE in the morning and remove them at HS.
Review of the residents TAR, dated 2/1/19 to 2/28/19, showed the following:
-There was documentation to shows staff applied the ACE wraps on 2/6/19 and 2/7/19;
-There was a note on the back of the TAR that noted the ACE wraps were not on the
resident’s legs on 2/6/19, but there was no documentation as to why the ACE wraps were not
on.
Observation of the resident on 2/7/19 at 11:00 A.M., 1:20 P.M. and 4:18 P.M., showed the
following:
-He/She sat in his/her wheelchair without ACE wraps on his/her BLE;
-He/She had 2-3 plus [MEDICAL CONDITION] to the BLE.
Observation of the resident on 2/8/19 at 8:35 A.M., showed:
-He/She sat in his/her wheelchair without ACE wraps on his/her BLE;
-He/She had 2-3 plus [MEDICAL CONDITION] noted to his/her BLE.
-His/Her ACE wraps laid on his/her bedside table.
During an interview on 2/8/19 at 1:20 P.M., RN H said the following:
-The resident should have his/her ACE wraps applied in the morning;
-He/She did not know why the resident did not have them on;
-The charge nurse was supposed to put the ACE wraps on, but the DON was also the charge
nurse today and had been pulled in all kinds of directions today.
3. Review of Resident #38’s care plan, dated 5/29/18 showed the following:
-Focus: Hypertension (high blood pressure);
-Goal: Will remain free of complications related to hypertension;
-Interventions: Weight as ordered and record. Notify physician and family for significant
weight loss/gain.
Review of the resident’s monthly/weekly weights sheet showed a monthly weight of 224
pounds (lbs.) for (MONTH) (YEAR).
Review of the resident’s POS, dated 12/23/18, showed a hand written order for daily
weights. Notify the physician if weight increases or decreases by three pounds in one day
and/or one week (no stop date).
Review of the resident’s TAR, dated 12/1/18-12/31/18, showed staff documented obtaining
daily weights on 12/24, 12/25, 12/26, 12/27, 12/28, 12/29, 12/30 and 12/31/18, but staff
did not record the resident’s weights.
Review of the resident’s monthly record of vital signs and weight sheets showed for
(MONTH) 2019 showed an entry for the resident, undated, of 232.6 pounds.
Review of the resident’s TAR, dated 1/1/19-1/31/19, showed the following:
-216 pounds on 1/20/19;
-220 pounds on 1/28/19;
-No documentation staff obtained daily weights 29 out of 31 days.
Review of the resident’s TAR, dated 2/1/19-2/13/19, showed no documentation staff obtained
daily weights for 13 out of 13 days.
Review of the resident’s nurses’ notes, dated 12/23/18-2/13/19, showed no documentation
staff notified the physician of changes in weight when weights were obtained.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
During an interview on 2/13/19 at 9:40 A.M., Certified Nurse Aide (CNA) D said the
following:
-He/She was responsible for obtaining weekly and monthly weights;
-He/She did not weigh the resident daily or weekly, only monthly;
-He/She was not aware that the resident was a daily weight;
-CNAs assigned to the resident’s hall would be responsible for daily weights;
-He/She worked the floor a lot and never knew the resident was a daily weight.
4. Review of Resident #151’s physician’s orders [REDACTED].
-He/She was admitted to the facility on [DATE];
-He/She had a [DIAGNOSES REDACTED].
-He/She required the use of continuous Oxygen (O2) at four liters per minute via use of a
nasal cannula (tubing used to deliver oxygen in through the nostrils).
Review of the resident’s undated Interim Plan of Care showed no staff direction regarding
the resident’s care needs.
Observation on 2/7/19 at 1:20 P.M., showed the following:
-The resident sat at the dining room table yelling out for staff assistance;
-The resident leaned over the table with increased respirations as he/she attempted to
adjust the oxygen cannula that was in his/her nose;
-He/She had difficulty speaking, but was able to yell loudly out to staff that he/she was
out of oxygen;
-His/Her portable oxygen tank, located on the back of his/her wheelchair, was empty.
Observation on 2/7/19 at 1:30 P.M. (ten minutes after the resident told staff he/she was
out of oxygen), showed Certified Nurse Assistant/Restorative Aide (CNA/RA D) replaced the
resident’s empty oxygen tank on the back of his/her wheelchair with a full tank.
During an interview on 2/7/19 at 1:30 P.M., CNA/RA D said CNAs and nursing staff were
responsible for checking oxygen tanks to ensure residents had enough oxygen before they
left their rooms. He/She did not know if staff checked Resident #151’s oxygen tank.
During an interview on 2/7/19 at 1:40 P.M., the resident said the following:
-He/She wore oxygen continuously;
-He/She was unable to go very long without oxygen;
-He/She became short of breath when his/her oxygen tank was empty.
Review of the resident’s nurse’s note, dated 2/7/19 at 7:00 P.M., showed the following:
-The resident was alert and made his/her needs known;
-He/She had an episode of shortness of breath at noon;
-His/Her oxygen tank ran out and it had to be replaced;
-His/Her oxygen level was 89% (normal levels are between 94-100%) when the episode
occurred.
During an interview on 2/7/19 at 1:40 P.M., LPN C said CNAs should check residents’ oxygen
tanks prior to taking residents out of their rooms to ensure they have enough oxygen.
5. During an interview on 2/13/19 at 5:13 P.M., the Director of Nurses (DON) said the
following:
-He/She expected staff to follow all physician orders;
-If a resident had an order for [REDACTED].>-If an order was discontinued, there should
be an order along with the date to discontinue;
-If the order was listed on the POS, it should be followed at all times;
-He/She was uncertain why staff did not complete Resident #150’s wound care on Mondays as
ordered by the physician. If the wound care was not provided, staff should notify the
resident’s physician;
-Resident #6 had an order for [REDACTED].
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-He/She expected staff to check oxygen tanks prior to going to the dining room to ensure
the resident had enough in the tank;
-He/She expected staff to replace the tank if it was empty.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure facility
staff provided one resident (Resident #40) of 13 sampled residents and three additional
residents (Resident #4, #16, and #30), that were unable to perform their own activities of
daily living (ADL), the necessary care and services to maintain good personal hygiene and
prevent body odor. The facility census was 47.
Review of the facility’s undated policy for showers showed the following:
-Showers were the responsibility of licensed staff and nursing assistants;
-The purpose of showers was to cleanse and refresh the residents, and to observe the
resident’s skin;
-Staff were expected to document how well the resident tolerated the procedure and the
condition of the resident’s scalp and skin;
-The type, frequency of shower, and amount of assistance required should be listed under
the resident’s plan of care for self-care deficits.
Review of the facility’s undated policy for oral hygiene showed the following:
-Oral hygiene was the responsibility of licensed staff and nursing assistants;
-The purpose of oral hygiene was to cleanse the mouth, teeth, and dentures, to prevent
infection and irritation, and to moisten the mucous membranes;
-Residents were to be offered assistance with oral hygiene before breakfast, after each
meal, and at bedtime.
Review of the facility’s undated perineal care policy and procedure showed the following:
-Perineal care was the responsibility of the licensed nurses and nursing assistants;
-The purpose of the policy was to cleanse the perineum and prevent infection and odor;
-Equipment included peri-wipes, gloves, towels, and wash cloths;
-Procedure:
-Staff were instructed to wash their hands, gather equipment, and bring to bedside;
-Explain procedure to the resident and screen for privacy;
-Staff were to wear gloves and using disposable wipes, wipe from front to back and discard
the wipe after each
stroke;
-Towels or wash cloths may be used for perineal care;
-Assist the resident to a comfortable position with call light within reach, wash hands,
and dispose of used wipes in a
plastic bag and remove them from the room;
-The policy did not specify direction for completion of peri care for males and females.
1. Review of Resident #16’s care plan dated 8/19/18 showed the following:
-[DIAGNOSES REDACTED].
-Alteration in self-care ability related to stroke. Goal was physical needs met. Staff
should allow choices to promote sense of autonomy and control. Assist with elimination
needs as he/she requested;

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-At risk for skin breakdown and /or urinary tract infections related to occasional urinary
incontinence. Goal was to remain free of perineal irritation and /or other skin breakdown.
Staff should encourage the resident to report need for urinary elimination in a timely
manner to reduce potential for incontinence. Provide proper perineal care during routine
care and after elimination to reduce contaminants/skin irritation.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 11/10/18, showed the following:
-Cognitively intact;
-Required extensive assistance of two staff members with bed mobility;
-Required total assistance of two staff members with transfers and toileting;
-Frequently incontinent of bowel and bladder.
Observation on 2/7/19 at 7:20 A.M., showed the following:
-The resident was incontinent of urine;
-Nurse Aide (NA) G rolled the resident on his/her side, the incontinence bed pad was
saturated with urine;
-NA G rolled the urine soiled incontinence pad up and under the resident’s left hip and
placed the dry incontinence pad on the bed. NA G placed the bedpan under the resident on
top of the dry incontinence pad and rolled the resident onto the bed pan. The urine soiled
incontinence pad remained rolled up under the resident’s left hip;
-NA G left the room.
Observation on 2/7/19 at 8:18 A.M., showed the following:
-NA G and Certified Medication Technician (CMT) R entered the resident’s room;
-CMT R rolled the resident on his/her right side. Two incontinence pads were noted under
the resident. The urine soiled rolled up incontinence pad remained under the resident’s
left hip and a second dry incontinence pad lay flat under the resident;
-NA G removed the urine soiled incontinence pad, adjusted the dry incontinence pad under
the resident and left the resident’s room with bagged linens;
-NA G and CMT R did not provide incontinence care.
During an interview on 2/7/19 at 8:22 A.M., the resident said staff took him/her off the
bed pan about 45 minutes prior. Staff did not wash him/her. They usually did not provide
peri care.
During a telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-He/She should provide incontinence care every time the resident was incontinent;
-He/She did not remember if he/she gave the resident incontinence care or not. He/She
should not leave a resident soiled following an incontinent episode;
-The resident needed perineal care following an incontinent episode and after the bed pan
was removed.
2. Review of Resident #40’s face sheet showed the following:
-He/She was admitted to the facility on [DATE];
-He/She had [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/11/18, showed the following:
-He/She had oral/dental health problems;
-He/She would be free of infection, pain or bleeding in the oral cavity by next review
date;
-He/She would comply with oral care at least daily through the next review date;
-Resident required CNAs to inspect his/her mouth frequently and report changes to the
nurse;
-Staff were to monitor/document and report to the resident’s physician if signs and
symptoms of oral/dental problems that needed attention; such as pain, abscess, debris in
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
mouth lips cracked or bleeding, teeth missing, loose or broken, eroded or decayed, and if
his/her tongue was black, coated, or inflamed;
-Staff were to provide oral care as part of the resident’s ADLs.
Review of the resident’s MDS Kardex report, dated 10/6/18, showed the following:
-His/Her cognition was severely impaired for making daily decisions;
-He/She rarely made him/herself understood;
-He/She understood others;
-He/She was totally dependent on one person physical assistance with oral hygiene;
-There were no dental conditions documented.
Review of the resident’s nurse’s note, dated 11/18/18 at 7:30 A.M., showed he/she had
dried blood on his/her lips with no evidence of trauma.
Review of the resident’s nurse’s note, dated 11/24/18 at 9:00 P.M., showed the following:
-He/She had bleeding with clots of blood noted when staff provided oral care;
-His/Her teeth were at gum level and his/her bottom teeth looked like freshly removed
teeth;
-Staff were unable to provide oral care without making the resident’s gums bleed.
Review of the resident’s quarterly MDS, dated [DATE], showed the resident was dependent on
assistance of one staff with personal hygiene.
Review of the resident’s POS, dated 2/1/19 to 2/28/19, showed the following:
-He/she received hospice services;
-an order for [REDACTED].
Observation of the resident on 2/7/19 at 7:40 A.M., showed the following:
-He/She sat in the dining room in his/her high back wheelchair awaiting breakfast;
-His/Her mouth was dry and dried white exudate was noted on his/her lips and tongue.
Observation on 2/7/19 at 2:45 P.M., showed the following:
-CNA E and NA G assisted the resident to his/her bed after lunch;
-Staff did not attempt to provide any oral hygiene for the resident.
During an interview on 2/9/19 at 1:50 P.M., CNA F said the following:
-Oral care was supposed to be provided on all residents when they get up in the morning
and after meals;
-Some days he/she would forget to provide oral care;
-The resident had really bad teeth and his/her teeth sometimes bled during care;
-There was no place staff documented ADL cares.
3. Review of Resident #4’s care plan, dated 10/31/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident had impaired ability to complete ADLs. Goal was basic physical needs met by
appearing clean, properly groomed and appropriately dressed. Staff should provide
assistance when needed and allow the resident to complete tasks as able, assist with
bathing and personal care;
-The resident was at risk for impaired skin integrity. Goal was skin intact. Staff should
shower the resident two to three times weekly;
-The resident refused showers for long periods of time. Goal was to remain free of odor.
Staff should offer showers consistently, document refusals and explain the importance of
showering.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with personal hygiene;
-Required extensive assistance of one staff member while bathing;
-Continent of bowel and bladder.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
Observations on 2/6/19, showed the following:
-At 10:30 A.M., the resident walked independently in the hallway, and outside to smoke.
He/She returned to his/her room and kept the door closed;
-From 10:45 A.M. to 12:00 P.M., the resident lay in bed and watched television. A musty
body odor was noted in the resident’s room.
Observation of the resident on 2/8/19 at 10:10 A.M., showed the resident was unkempt with
greasy hair, facial hair, and dirty nails.
During an interview on 2/8/19 at 10:10 A.M., the resident said he/she did not know when
he/she had a shower last. He/She needed some staff help washing his/her lower legs and
back, otherwise he/she could wash most areas his/herself. He/She would like to take a
shower routinely.
Review of the facility shower logs, dated (MONTH) 2019 through (MONTH) 2019, showed the
following:
-From 1/13/19 through 1/19/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused;
-From 1/20/19 through 1/26/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused;
-From 2/3/19 through 2/9/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused;
-From 2/10/19 through 2/13/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused.
Observation and interview on 2/13/19 at 11:50 A.M., showed the resident remained unkempt
with greasy hair, facial hair, and dirty nails. The resident said he/she had not received
a shower.
4. Review of Resident #30’s care plan, dated 9/24/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident had bilateral (both legs) above the knee amputations (AKA);
-The resident had ADL self-care performance deficit related to AKA. Goal was demonstrate
the use of adaptive devices to increase ability. Staff should assist with ADLs as needed.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required supervision and set-up help with personal hygiene;
-Required extensive assistance of one staff member with bathing.
Observations on 2/6/19, showed the following:
-At 10:30 A.M., the resident rolled his/her wheelchair in the hallway, and outside to
smoke. He/She returned to his/her room and kept the door closed;
-From 10:45 A.M. to 12:00 P.M., the resident lay in bed and watched television. A musty
body odor was noted in the resident’s room.
Observation on 2/8/19 at 10:15 A.M., showed the resident was unkempt with long greasy hair
and facial hair.
Review of the facility shower logs, dated (MONTH) 2019 through (MONTH) 2019, showed the
following:
-From 1/13/19 through 1/19/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused;
-From 1/20/19 through 1/26/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused;
-From 2/3/19 through 2/9/19, no documentation staff provided the resident a shower, bed
bath or the resident was offered and refused;
-From 2/10/19 through 2/13/19, no documentation staff provided the resident a shower, bed
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
bath or the resident was offered and refused.
During an interview on 2/8/19 at 10:15 A.M., the resident said he/she did not know how
long it had been since he/she had a shower. He/She would like to have a shower and shave
routinely. He/She had above the knee amputations a long time ago and was able to transfer
him/herself to the wheelchair. He/She needed some staff help with showers.
Observation and interview on 2/13/19 at 11:50 A.M., showed the resident remained unkempt
with long greasy hair and facial hair. The resident said he/she had not received a shower.
5. Review of the shower assignment sheets on 2/13/19 showed staff scheduled residents for
showers two to three times per week on assigned days of the week and assigned shifts.
Review of the 100 hall shower logs dated (MONTH) 13-19, 2019 showed the following:
-List of ten residents by room number and name followed by the days of the week and space
for staff documentation a shower or bed bath was completed or the resident was offered and
refused;
-Four of the ten residents was blank. No documentation a shower or bed bath was completed
or the resident was offered and refused;
-Staff documented three of the ten residents received one shower or were offered a shower
or bed bath and refused.
Review of the 200 hall shower logs dated (MONTH) 13-19, 2019 showed the following:
-List of 14 residents by room number and name followed by the days of the week and space
for staff documentation a shower or bed bath was completed or the resident was offered and
refused;
-Seven of the 14 residents was blank. No documentation a shower or bed bath was completed
or the resident was offered and refused;
-Staff documented three of the 14 residents received one shower or were offered a shower
or bed bath and refused.
Review of the 300 hall shower logs dated (MONTH) 13-19, 2019 showed the following:
-List of 13 residents by room number and name followed by the days of the week and space
for staff documentation a shower or bed bath was completed or the resident was offered and
refused;
-Two of the 13 residents was blank. No documentation a shower or bed bath was completed or
the resident was offered and refused;
-Staff documented eight of the 13 residents received one shower or were offered a shower
or bed bath and refused.
Review of the 100 hall shower logs dated (MONTH) 20-26, 2019 showed the following:
-List of 12 residents by room number and name followed by the days of the week and space
for staff documentation a shower or bed bath was completed or the resident was offered and
refused;
-Four of the 12 residents was blank. No documentation a shower or bed bath was completed
or the resident was offered and refused;
-Staff documented seven of the 12 residents received one shower or were offered a shower
or bed bath and refused.
Review of the 200 hall shower logs dated (MONTH) 20-26, 2019 showed the following:
-List of 15 residents by room number and name followed by the days of the week and space
for staff documentation a shower or bed bath was completed or the resident was offered and
refused;
-Eight of the 15 residents was blank. No documentation a shower or bed bath was completed
or the resident was offered and refused;
-Staff documented four of the 15 residents received one shower or were offered a shower or
bed bath and refused.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
Review of the 300 hall shower logs dated (MONTH) 20-26, 2019 showed the following:
-List of 15 residents by room number and name followed by the days of the week and space
for staff documentation a shower or bed bath was completed or the resident was offered and
refused;
-Five of the 15 residents was blank. No documentation a shower or bed bath was completed
or the resident was offered and refused;
-Staff documented nine of the 15 residents received one shower or were offered a shower or
bed bath and refused.
During the group interview on 2/6/19 at 10:30 A.M., residents said the following:
-Resident #30 said he/she was supposed to get a shower three times a week. He/she had not
received a shower for over two weeks;
-Resident #150 said he/she had one shower since admission to the facility at the end of
(MONTH) 2019.
During an interview on 2/8/19 at 1:05 P.M., NA B said the following:
-On Tuesday 2/5/19, he/she had ten residents who were scheduled to have showers and he/she
was only able to get four or five of them done, because of lack of help;
-Oral care was to be provided after meals, but he/she did not think this was completed
like it should.
During an interview on 2/7/19 at 2:50 P.M., CNA E said the following:
-None of the residents had showers today;
-They were working short staffed and were unable to get tasks done;
-Staff had a difficult time getting residents’ showers done on a daily basis due to staff
shortage.
During an interview on 2/8/19 at 8:46 A.M., CNA/RA D said the following:
-Sometimes there was a shower aide;
-Usually CNAs on duty were supposed to shower the residents on their halls;
-It was overwhelming at times and hard to get them done, because of staffing;
-He/She knew they were lacking in a lot of areas, including oral care, because it was hard
to get the residents’ ADLs completed including oral hygiene.
During an interview on 2/8/19 at 8:35 A.M., Registered Nurse (RN) H said he/she was the
day shift charge nurse. He/She did not know if residents’ showers were completed or not.
Some days no showers were done, the staff did not have time to complete them. He/She had
to stay on the CNA staff to get showers completed.
During an interview on 2/8/19 at 8:50 A.M. and 2/13/19 at 5:07 P.M., the DON said the
following:
-There was no documentation to show if a resident had received ADL cares such as oral
care;.
-Staff were to assist residents with oral hygiene every morning, every evening, after
every meal, and as needed;
-Resident #40 required assistance with oral hygiene more often, because of his/her oral
condition and gingivitis (inflammation of the gums);
-Residents should not have white film or dry skin noted around their mouths.
-He/She expected residents to receive assistance with their showers on their assigned
days. CNA staff should follow the shower assignment list kept in the CNA book at the
nurses’ desk. If the showers were not completed, CNA staff should reschedule the
resident’s shower. The CNA staff was responsible for completing showers and the charge
nurse should ensure showers were done;
-Some of the ADL care was lacking. Staff did not complete the cares because of lack of
staff.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
MO # 770

F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

Provide basic life support, including CPR, prior to the arrival of emergency medical
personnel , subject to physician orders and the resident’s advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure Cardiopulmonary
Resuscitation (CPR-process of providing rescue ventilation and chest compressions to
maintain circulation of blood) certified staff were scheduled and present in the facility
24 hours a day, seven days a week and failed to develop and implement a policy addressing
CPR requirements for staff. This failure affected 25 residents who were identified as full
code status (CPR required in the event of cardiac or respiratory arrest). The facility
failed to ensure the medical record accurately and consistently indicated residents’ code
status for one resident (Resident #28) in a review of 13 sampled residents, for one
additional resident (Resident #1) and for three closed records (Resident #152, #42 and
#157) and failed to ensure staff were trained and available to provide CPR when
transporting residents who requested to be full code, in the facility van. Ten additional
residents (Resident #26, #33, #153, #25, #30, #150, #155, #154, #151 and #5) who were a
full code, were transported multiple times by the facility transporter who was not
certified to perform CPR. The facility census was 47.
1. During an interview on [DATE] at 1:00 P.M. the Director of Nursing (DON) said the
facility had no policy regarding staff CPR certification requirements, no policy regarding
scheduling CPR certified staff on every shift 24 hours per day, seven days per week and no
policy regarding CPR certified staff transporting residents who were full code.
Review of the facility undated Cardiopulmonary Resuscitation policy showed the following:
-Responsibility: Licensed nurse and any person in the facility with CPR experience;
-Purpose: To ventilate and establish circulation on a resident with absence of
respirations and pulse;
-Procedure: 3. Delegate a specific individual to check resident’s CPR status; have
individual to call paramedics, attending physician and administrative personnel when
appropriate.
Review of the facility policy Advanced Directives, dated (MONTH) (YEAR), showed the
following:
Policy:
-Residents will be informed upon admission by the Social Service Director (SSD) of the
right to have and maintain Advanced Directives, including Do Not Resuscitate (DNR) and
refusal of treatment, care and services. This will be explained in detail and written
documentation of this policy and procedure will be given to each resident and/or resident
representative upon admission;
-Residents will be involved in the initial plan of care and quarterly review of care
outlining their care wishes and informing the physician, charge nurses, Certified Nurse
Aides (CNA) and other providers of services what the specific wishes are regarding the
resident’s Advanced Directives, Do Not Resuscitate, and the right to refuse treatment,
care and services;
-The plan of care will be reviewed and revised at least quarterly and as needed to reflect
the resident’s cognitive decision making abilities as well as their refusal of treatments,
care and services by the Interdisciplinary Team and resident and/or resident

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 29)
representative;
Procedures:
The following procedures will be adhered to in maintaining the Resident’s Rights regarding
Advanced Directives:
1. It will be determined on admission whether the resident has an Advanced Directive and,
if not, determine whether the resident wishes to formulate an Advanced Directive. This
will be done by the Social Service Director and documented in the Social Service progress
notes upon admission;
-Resident’s medical record will be identified with a red dot (no CPR) or a green dot (full
code) on the binder of the medical record. The resident’s room shall have a red or green
dot, or other similar designation, beside their name on the outside of the door to their
room to designate the resident’s code status;
-Staff will be trained upon hire and at least annually regarding the Code Status
Identification and Resident Advanced Directives Policies. This will be completed by the
Social Service Director or Director of Nursing ongoing.
During an interview on [DATE] at 9:00 A.M., the Administrator said the following:
-All licensed nurses should maintain current CPR certification;
-She did not know the CPR certification status of the licensed nurses or the certified
nurse aide (CNA) staff;
-The nurses’ work schedule should reflect a CPR certified licensed nurse on every shift 24
hours per day.
Review of licensed nurses’ employee files on [DATE], showed the following:
-Licensed Practical Nurse’s (LPN) O CPR certification expired ,[DATE];
-LPN P’s CPR certification expired ,[DATE].
Review of the facility Licensed Nurse Staffing Schedule, dated (MONTH) 2019, showed the
following:
-Day shift staff worked eight hours from 6:30 A.M. to 3:00 P.M. or 12 hours from 7:00 A.M.
to 7:00 P.M.;
-Evening shift staff worked eight hours from 2:30 P.M. to 11:00 P.M.;
-Night shift staff worked 12 hours from 7:00 P.M. to 7:00 A.M.
Review of the facility Licensed Nurse Staffing Schedule, dated [DATE] through [DATE],
showed the following:
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 7:00 P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night
shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30
P.M. to 7:00 A.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 30)
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night
shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30
P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
– On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked
night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from
2:30 P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night
shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30
P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN P worked night shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff
were scheduled to work from 11:00 P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. and LPN P worked night
shift from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled to work from 2:30
P.M. to 7:00 A.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
were scheduled to work from 2:30 P.M. to 7:00 P.M.
Review of the facility Licensed Nurse Staffing Schedule, dated (MONTH) 2019, showed the
following:
-Day shift staff worked eight hours from 6:30 A.M. to 3:00 P.M. or 12 hours from 7:00 A.M.
to 7:00 P.M.;
-Evening shift staff worked eight hours from 2:30 P.M. to 11:00 P.M.;
-Night shift staff worked 12 hours from 7:00 P.M. to 7:00 A.M.
Review of the facility Licensed Nurse Staffing Schedule, dated [DATE] through [DATE],
showed the following:
-On [DATE], LPN O worked evening shift from 2:30 P.M. to 11:00 P.M. No CPR certified staff
worked from 2:30 P.M. to 7:00 P.M.;
-On [DATE], LPN O was scheduled to work evening shift from 2:30 P.M. to 11:00 P.M. and LPN
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 31)
P was scheduled to work from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled
from 2:30 P.M. through 7:00 A.M.;
-On [DATE], LPN O was scheduled to work evening shift from 2:30 P.M. to 11:00 P.M. and LPN
P was scheduled to work from 7:00 P.M. to 7:00 A.M. No CPR certified staff were scheduled
from 2:30 P.M. through 7:00 A.M.
During an interview on [DATE] at 8:50 A.M., the DON said the following:
-She was responsible for completing the nursing staff work schedule;
-She did not know which staff were CPR certified;
-She did not schedule CPR certified staff on every shift, 24 hours per day;
-She did not ensure CPR certified staff were in the facility at all times;
-She did not track staff CPR certification status. No one was currently responsible to
ensure staff was CPR certified.
2. Review of the Social Service Designee (SSD)/Transporter’s employee file on [DATE],
showed his/her CPR certification expired ,[DATE].
Review of the SSD/Transporter’s (MONTH) (YEAR) through (MONTH) 2019 schedule showed the
following:
-On [DATE], he/she transported Resident #26 (a full code resident) to a physician’s
appointment;
-On [DATE], he/she transported Resident #33 (a full code resident) to a physician’s
appointment;
-On [DATE], he/she transported Resident #153 (a full code resident) to a clinic
appointment;
-On [DATE], he/she transported Resident #25 (a full code resident) to the hospital clinic;
-On [DATE], he/she transported Resident #30 (a full code resident) to a physician’s
appointment;
-On [DATE], he/she transported Resident #153 and Resident #150 (a full code resident) to
the hospital clinic;
-On [DATE], he/she transported Resident #150 and #155 (a full code resident) to the
hospital clinic;
-On [DATE], he/she transported Resident #154 (a full code resident) and Resident #5 (a
full code resident) to a physician’s appointment;
-On [DATE], he/she transported Resident #151 (a full code resident) to the hospital
clinic.
During interview on [DATE] at 8:30 A.M., the SSD said the following:
-He/She provided transport of residents to physician visits and other appointments;
-He/She transported residents in the facility van;
-No other facility staff usually go with him/her on transports;
-He/She was not CPR certified. His/Her CPR certification expired in (MONTH) (YEAR).
During interview on [DATE] at 9:00 A.M., the Administrator said the facility transporter
should maintain current CPR certification status. The SSD was the only facility
transporter. He/She transported residents in the facility van to appointments. The
administrator was responsible for ensuring transporter staff was CPR certified.
3. Review of Resident #28’s Consent for DNR, dated [DATE], showed the following:
-He/She wished CPR to be started in the event of [MEDICAL CONDITION];
-He/She understood that emergency medical system would be automatically activated and
he/she would be transferred to the hospital;
-The consent was signed by the resident in front of two witnesses;
-The consent was not signed by a physician.
Review of the resident’s Physicians Order Sheet (POS), dated [DATE] to [DATE], showed
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 32)
there was no code status documented.
Review of the resident’s care plan, last revised on [DATE], showed the following:
-On [DATE], the resident was admitted to Hospice;
-There was no documentation to identify the resident’s code status.
Review of the resident’s Hospice comprehensive assessment and plan of care update report,
dated [DATE], showed documentation the resident wished to be a DNR on the advanced
directive portion of the assessment.
Review of the resident’s Hospice comprehensive assessment and plan of care update report,
dated [DATE], showed there was no documented code status on the assessment.
Review of the resident’s POS, dated [DATE] to [DATE], showed no code status documented.
Review of the resident’s POS, dated [DATE] to [DATE], showed no code status documented.
4. Review of the Resident #152’s closed record showed the following:
-Consent for DNR dated [DATE];
-He/She did not wish to have CPR efforts in the event of [MEDICAL CONDITION];
-The consent was signed by the resident’s legal representative in front of two witnesses;
-The consent was not signed by a physician.
Review of the resident’s POS, dated [DATE] to [DATE], showed no code status order
documented.
5. Review of Resident #42’s closed record showed the following:
-Consent for DNR dated [DATE];
-He/She did not wish CPR efforts in the event of [MEDICAL CONDITION];
-The consent was signed by the resident’s legal representative in front of two witnesses;
-The consent was not signed by a physician.
Review of the resident’s POS, dated [DATE], showed the following:
-Hospice level of care;
-Code Status was left blank. No DNR physician’s order documented.
5. Review of Resident #157’s closed record showed the following:
-Consent for Do Not Resuscitate (DNR) dated [DATE];
-He/She did not wish CPR efforts in the event of [MEDICAL CONDITION];
-The consent was signed by the resident’s legal representative in front of two witnesses;
-The consent was not signed by a physician.
Review of the resident’s POS, dated [DATE] through [DATE], showed the following:
-Hospice level of care;
-Full code status.
6. Review of Resident #1’s consent for DNR, dated [DATE], showed the following:
-He/She wished CPR to be started in the event of [MEDICAL CONDITION];
-He/She understood that emergency medical system would be automatically activated and
he/she would be transferred to the hospital;
-The consent was signed by the resident’s legal representative in front of two witnesses.
Review of the resident ‘s medical chart showed a green sticker on the binder indicating
Full Code Status.
Review of the resident’s POS, dated [DATE] through [DATE], showed a physician’s order for
DNR.
7. During an interview on [DATE] at 4:10 P.M., LPN C said the following:
-If a resident was in cardiac or respiratory arrest, he/she would check the resident’s
door or closet door for a red or green sticker to determine the resident’s code status. If
no red or green stickers were on the resident’s room door or closet door, he/she would
check the resident’s face sheet;
-He/she could also look at the resident’s Consent for DNR form in the chart. The Consent
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 33)
for DNR form should match the physician’s order for DNR. The Consent for DNR form was not
a physician’s order.
-He/she did not know why the residents’ code status did not match.
During an interview on [DATE] at 4:16 P.M., the Assistant Director of Nursing (ADON) said
the following:
-Staff should go by the DNR consent form in the resident’s chart to determine whether a
resident was a full code or DNR;
-There should be a physician’s order if the resident’s code status was DNR.
During an interview on [DATE] at 4:20 P.M., the SSD said the following:
-He/she obtained the resident’s code status consent when the resident was admitted to the
facility;
-He/she reviewed the Consent for DNR form with the resident and/or the resident’s family.
The consent form was completed indicating the resident’s wishes and signed by either the
resident or the resident’s legal representative and two witnesses. The completed Consent
for DNR was placed in the resident’s chart;
-The Consent for DNR forms were not signed by the physicians. The form did not include the
physician’s signature;
-He/she kept four binders containing all resident’s Consent for DNR forms. The four
binders were located at the nurses’ desk, the dining room, the activity room and in the
transport van. The four books were not currently up to date and did not currently reflect
the resident’s current code status;
-He/she put red or green stickers on the resident’s room door and on the binder of the
resident’s medical chart. The red sticker indicated DNR and the green sticker indicated
Full Code;
-The current POS should reflect the resident’s code status.
During an interview on [DATE] at 3:45 P.M., the DON said the following:
-On admission the SSD or the charge nurse completed the Consent for DNR form with the
resident and family. If the resident was unable to express their code status wishes, the
family was consulted;
-The consent for DNR form was placed in the chart and a red or green sticker should be
placed on the outside binder edge of the chart. The red sticker indicated DNR and the
green sticker indicated Full Code status;
-There was no facility policy that required a physician’s order for DNR status;
-If a resident requested DNR status the resident’s POS should contain a signed DNR
physician’s order;
-If the resident’s chart did not include a signed DNR physician’s order, staff should
perform CPR;
-He/she did not know why the residents’ code status did not match;
-There was nobody responsible to ensure that code status matched.
During an interview on [DATE] at 5:57 P.M., the DON said the following:
-He/she expected all resident’s Consent for DNR and Physician Orders to match indicating
the resident’s current code status. The resident’s medical chart should include a
corresponding red or green sticker on the binder;
-The resident’s POS should include either Full Code or DNR and should include the
physician’s signature;
-If a resident requested DNR status, a physician’s signed DNR order was required otherwise
the staff should perform CPR in the event of cardiac or respiratory arrest.
NOTE: At the time of the survey, the violation was determined to be at the immediate and
serious jeopardy level K. Based on observation, interview, and record review completed
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0678

Level of harm – Immediate jeopardy

Residents Affected – Some

(continued… from page 34)
during the onsite visit, it was determined the facility had implemented corrective action
to address and lower the violation at the time. During the onsite visit, the facility
implemented a new policy regarding scheduling CPR certified staff on every shift 24 hours
per day, seven days per week, began inservicing of staff to ensure CPR certified staff
were on duty at all times, began review of staffing schedules, and an audit of staff to
determine CPR certification status. The facility scheduled to ensure CPR certified staff
were on duty on all shifts. A final revisit will be conducted to determine if the facility
is in substantial compliance with participation requirements.
At the time of exit, the severity of the deficiency was lowered to the E level. This
statement does not denote that the facility has complied with State law (Section 198.026.1
RSMo.) requiring that prompt remedial action be taken to address Class I violations(s).

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
performed safe transfer techniques for two additional residents (Resident #26 and #151).
The facility census was 47.
Review of the facility’s undated policy and procedure for general safety rules showed the
following:
-General safety of the residents was the responsibility of all employees;
-Staff were to report or correct any unsafe conditions that were observed;
-Staff were to report all injuries;
-Staff were to wear gait belts and use caution when lifting or transferring residents;
-Gait belts were to be used during one person and two person transfers.
Review of the facility’s Gait Belt Policy, dated 10/17/13, showed the following:
-The gait belt was a mandatory part of the nursing department’s uniform;
-Nursing staff were expected to use gait belts at all times when ambulating or
transferring a resident for the safety of the resident;
-Gait belts were to be utilized when assisting a resident from the bed, chair, or
commode/toilet;
-An employee who was injured or caused an injury to a resident as a result of failure to
properly apply and use a gait belt was subject to disciplinary action which could include
termination;
-The policy was to be reviewed and signed by the facility’s employees;
-The policy did not instruct staff on proper placement or instruction on how to use the
gait belt.
1. Review of Resident #26’s Annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/21/18, showed the following:
-Limited assist of one for transfers;
-Extensive assist of two to walk in room and for toileting;
-Used a walker and wheelchair;
-Not steady, only able to stabilize with staff assistance.
Review of the resident’s care plan, last revised on 12/15/18 showed:
-Supervision and encouragement with Activities of Daily Living (ADL’s);
-Independent with ambulation without an assistive device, gait slow and steady.

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 35)
Review of the resident’s Physician order [REDACTED].
Observation on 2/7/19 at 6:35 A.M., showed the following:
-The resident lay on his/her back on the bed;
-Certified Nurse Aide (CNA) J and Nurse Aide (NA) K entered the room to assist the
resident with morning cares;
-CNA J swung the resident’s legs around to the side of the bed and then held the
resident’s hands and pulled the resident up to sit on the side of the bed;
-CNA J and NA K attempted to stand the resident. The resident wore socks with no grippers.
Without using a gait belt, CNA J and NA K lifted the resident under his/her arms
unsuccessfully three times in order to sit the resident further back on the bed;
-The resident’s feet slid out from under him/her and he/she was unable to stand.
During an interview on 2/13/19 at 4:45 P.M., NA K said the following:
-Gait belts should be used with one or two person assist transfers;
-Staff should not lift residents under the arms, they should lift by holding the gait belt
on the back and front.
During a telephone interview on 2/28/19 at 2:12 P.M., CNA J said the following:
-Staff should apply a gait belt to the resident before they attempted to stand them;
-Staff should ensure the resident has non-skid socks or shoes on prior to assisting them
to stand;
-Staff should not pull the resident by their hands when assisting a resident to move from
a lying position to sit on the side of the bed. They should place one hand behind the
resident’s back and the other behind the legs and in one motion assist the resident to
sit;
-Staff should place their hands on the gait belt when they assist to transfer residents;
-They should not lift the resident under the arms.
During an interview on 2/13/19 at 2:08 P.M., the Physical Therapy/program director said
the following:
-He/She expected staff to apply a gait belt around a resident’s waist anytime a transfer
required staff to physically lay their hands on the resident;
-He/She expected staff to ensure the resident either wore non-skid socks or shoes before
attempting to stand a resident;
-Staff should not pull a resident by their hands to a sitting position or assist a
resident to stand by lifting them under the arms.
2. Review of Resident #2’s care plan, dated 10/23/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident was at risk for falls related to gait/balance problems. Staff should
anticipate and meet the resident’s needs;
-The resident required assistance and encouragement to complete ADLs. Goal was work
towards increased independence. Two staff members should provide mechanical lift
transfers.
Review of the resident’s care plan, updated 1/8/19, showed the resident used a sit to
stand lift for transfers on and off the toilet.
Review of the resident’s annual MDS dated [DATE] showed the following:
-Cognitively intact;
-Required total assistance of two staff members with transfers;
-Required extensive assistance of two staff members with toileting.
Review of the resident’s POS, dated 1/22/19, showed staff could transfer the resident with
a stand up lift.
Review of the resident’s nurses note, dated 1/31/19 at 5:00 P.M., showed Registered Nurse
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
(RN) H was informed of an incident where the back of the resident’s legs might be injured.
Both legs were inspected. No bruising, no open areas and no pain was found.
Review of the facility Event/Incident Report, dated 2/1/19, completed by CNA F showed the
following:
-Event date 1/31/19 at 12:25 P.M.;
-CNA F asked CNA A to help get the resident off the toilet. CNA A followed CNA F into the
restroom;
-CNA F hooked the resident into the sit to stand lift pad and lifted the resident off the
toilet;
-The resident’s legs relaxed and it lowered the resident;
-CNA A grabbed the wheelchair and pushed it under the resident. The wheelchair slammed
into the back of the resident’s legs. The resident started crying and said it hit the back
of his/her legs.
During an interview on 2/6/19 at 5:50 P.M., the resident said a CNA shoved the wheelchair
twice into the back of his/her legs. He/She was in the lift getting off the toilet. The
CNA grabbed the wheelchair and pushed it real hard into the back of his/her legs. It
caused pain when the wheelchair hit the back of his/her legs.
During an interview on 2/8/19 at 10:20 A.M., CNA F said the following:
-He/She and another CNA took the resident to the bathroom. The resident required a sit to
stand mechanical lift transfer with two staff assistance;
-He/She asked CNA A to assist transferring the resident off the toilet. They hooked the
resident to the sit to stand lift pad and he/she raised the resident off the toilet. The
resident hung in the lift with knees bent in a sitting position;
-CNA A rammed the wheelchair under the resident hitting the back of the resident’s legs
with the seat of the wheelchair. The resident cried and said the wheelchair hurt his/her
legs. CNA A left the bathroom;
-He/She took the resident to his/her room and informed the Administrator of the incident.
During an interview on 2/10/19 at 10:35 A.M., the Director of Nursing (DON) said he/she
assessed the resident’s legs following the incident and found redness on the backs of the
resident’s legs. The resident was crying and upset.
During an interview on 2/13/19 at 4:38 P.M., CNA A said the following:
-The resident was in the common shower room on the toilet. CNA F raised the resident off
the toilet with the sit to stand mechanical lift. The resident hung in the air with knees
bent, feet on the sit to stand lift platform. The resident was unable to straighten
his/her legs;
-He/She held the locked wheelchair in place and CNA F rolled the resident with the sit to
stand lift towards the wheelchair;
-The back of the resident’s legs hit the front edge of the wheelchair seat. He/She tipped
the wheelchair backwards and pushed the wheelchair under the resident;
-He/She held the wheelchair in place and CNA F lowered the resident with the sit to stand
mechanical lift into the wheelchair;
-The transfer was not appropriate, they should have gotten help from another staff member
or sat the resident back on the toilet.
During an interview on 2/13/19 at 5:12 P.M., the DON said the following:
-Staff should not pull a resident by their hands to a sitting position;
-Staff should not lift residents under the arms when performing a gait belt transfer;
-Staff should not attempt to stand a resident when they are wearing slick socks and are
not wearing either nonskid socks or shoes;
-CNA A and CNA F should not have continued with the transfer when Resident #2’s legs bent.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
They should have regrouped, sat the resident back on the toilet and started over. They
should not have let the resident hang in the sit to stand lift with knees bent and should
not have rammed the wheelchair into the back of the resident’s legs. Staff should not tip
the wheelchair while lowering the resident into the chair.
MO # 375

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 provide
incontinence care with an indwelling urinary catheter (a sterile tube inserted through the
urethra into the bladder to drain urine) consistent with acceptable standards of practice,
failed to keep the catheter bag off the floor and failed to maintain the catheter bag
below the level of the bladder during mechanical lift transfers for two of 13 sampled
residents (Resident #2 and #38). The facility reported two residents with indwelling
catheters. The facility census was 47.
Review of the facility’s undated policy for catheter care showed the following:
-Catheter care was the responsibility of licensed nurses and nursing assistants;
-The purpose of the policy was to prevent infection, reduce irritation, and monitor and
record urine output;
-Insertion site care included to wash the perineum well with soap and warm water or
peri-wipes, taking care to wash from front to back;
-NOTE: DO NOT CONTAMINATE THE AREA WITH FECES, IF THE RESIDENT HAD AN INVOLUNTARY BOWEL
MOVEMENT, CLEAN THIS AREA FIRST, WASH HANDS, AND OBTAIN CLEAN EQUIPMENT FOR CATHETER CARE;
-Cleanse the area at the catheter insertion site well.
Review of the facility’s undated perineal care policy and procedure showed the following:
-Perineal care was the responsibility of the licensed nurses and nursing assistants;
-The purpose of the policy was to cleanse the perineum and prevent infection and odor;
-Equipment; peri-wipes, gloves, towels, and wash cloths;
-Procedure:
-Staff were instructed to wash their hands, gather equipment, and bring to bedside;
-Explain procedure to the resident and screen for privacy;
-Staff were to place on gloves and using disposable wipes, wipe from front to back and
discard the wipe after each stroke;
-Towels or wash cloths may be used for perineal care;
-Assist the resident to comfortable position with call light within reach, wash hands,
and dispose used wipes in a plastic bag and remove them from the room.
Review of the Nurse Assistant in a Long Term Care Facility, 2001 revision, showed the
following:
-The bladder is considered sterile, the catheter, drainage tubing and bag are a sterile
system;
-Drainage tubing/bags must not touch the floor;
-The drainage bag should always be below the level of the bladder;
-If moved above, urine could flow back into the bladder.
Review of the manual also showed the procedure for giving peri care with a catheter

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
included the following instructions:
-Wash the catheter tubing from the opening of the urethra outward four inches or farther
if needed;
-Using a fresh washcloth, continue washing and rinsing the peri area.
1. Review of Resident #38’s care plan, dated 11/8/18, showed the following:
-Focus: Urinary catheter related to benign prostate hypertrophy ([MEDICAL CONDITION])
(enlargement of the prostate gland) and [MEDICAL CONDITION];
-Goal: Resident will show no signs/symptoms of urinary infection through review date of
11/2/18;
-There were no interventions to direct staff to provide catheter care;
-Focus: ADL self care performance deficit related to stroke and immobility;
-Interventions: One staff assist with personal hygiene.
Review of the resident’s quarterly Minimum Data Set (MDS) a federally mandated assessment
tool, dated 12/13/18, showed the following:
-Extensive assist of two staff for transfers, ambulation in room and toilet use;
-Extensive assist of one staff for personal hygiene;
-Presence of urinary catheter;
-Occasionally incontinent of bowel.
Review of the resident’s Physicians Order Sheet (POS), dated (MONTH) 2019, showed an order
for [REDACTED].>Observation on 2/8/19 at 2:10 P.M., showed the following:
-The resident sat in his/her recliner in his/her room;
-The resident was incontinent of stool;
-Certified Nurse Aide (CNA) D entered the room and assisted the resident to the toilet;
-CNA D changed the resident’s incontinent brief and performed rectal perineal care;
-CNA D did not perform catheter care, pulled the resident’s pants up and assisted the
resident back to his/her chair.
During an interview on 2/13/19 at 9:40 A.M., CNA D said the following:
-CNAs were responsible for catheter care;
-Catheter care should be completed when residents get up every morning and periodically as
needed;
-Catheter care should be done after a resident had been incontinent of bowel.
2. Review of Resident #2’s Kardex Care Plan, dated 10/18/18, and located inside the
resident’s closet door showed the following:
-Total dependence with transfers;
-Wheelchair mobility device;
-Indwelling urinary catheter;
-Frequently incontinent of bowel.
Review of the resident’s care plan, dated 10/23/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident was at risk for falls related to gait/balance problems and urinary catheter
tubing. Goal was free of falls. Staff should anticipate and meet the resident’s needs and
ensure the urinary catheter tubing was not an obstacle;
-The resident had an indwelling urinary catheter. Goal was no complications. Staff should
change the urinary catheter drainage bag every two weeks, provide catheter care every
shift and position catheter tubing appropriately to minimize pulling and to provide
infection control measures;
-The resident required assistance and encouragement to complete Activities of Daily Living
(ADLs). Staff should encourage and promote increased independence, two staff members
should provide mechanical lift transfers and assist with bathing.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 39)
Review of the resident’s annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required total assistance of two staff members with transfers;
-Required extensive assistance of two staff members with toileting.
Observation on 2/6/19 showed the following:
-At 8:22 A.M., the resident lay in bed. His/Her urinary catheter bag contained
approximately 300 milliliters (ml) of urine and laid directly (not in a privacy bag) on
the floor beside the resident’s bed. The catheter tubing was pulled tight;
-At 8:25 A.M., Nurse Aide (NA) N sat the resident’s breakfast tray on his/her bedside
table, rolled the head of the resident’s bed up, adjusted the resident in the bed and left
the room. The resident’s urinary catheter bag remained directly on the floor with the
catheter tubing pulled tight;
-At 8:27 A.M., NA G adjusted the resident in the bed and provided the resident a wet wash
cloth;
-At 8:30 A.M., NA G picked up the resident’s urinary catheter bag and hung the bag on the
bed frame.
Observation on 2/8/19 at 9:00 A.M., showed the following:
-The resident was elevated in the mechanical lift above his/her bed. The resident’s
urinary catheter bag hung from the top lift bar of the mechanical lift approximately
twelve inches above the level of the resident’s bladder. Urine ran down the catheter
tubing toward the resident’s bladder;
-CNA D and CNA I lowered the resident onto the bed. CNA I removed the resident’s catheter
bag from the top lift bar of the mechanical lift and laid the catheter bag on the
resident’s bed. Urine remained in the catheter tubing;
-CNA D and CNA I removed the resident’s pants and provided the resident urinary catheter
care and perineal care. The catheter tubing leg strap attached to the resident’s right leg
was loose and did not secure the position of the catheter tubing;
-CNA I placed the resident’s catheter bag and tubing through the leg of a clean
incontinence brief and the resident’s pants. Urine remained in the catheter bag tubing;
-CNA I and CNA E rolled the resident back and forth, pulling up the resident’s
incontinence brief and pants. The catheter bag laid on the resident’s bed. Urine remained
in the catheter tubing;
-CNA I picked up and hung the resident’s catheter bag on the strap of the mechanical lift
pad above the level of the resident’s bladder. Urine ran down the catheter tubing toward
the resident’s bladder;
-CNA I and CNA E transferred the resident with the mechanical lift and lowered the
resident into the wheelchair;
-CNA I removed the catheter drainage bag from the strap of the mechanical lift pad and
placed the catheter drainage bag in a privacy bag located under the resident’s wheelchair.
Urine ran down the catheter tubing into the urinary drainage bag.
During an interview on 2/13/19 at 9:30 A.M., CNA I said the following:
-Catheter drainage bags should never touch the floor;
-Catheter drainage bags should never be above the level of the bladder;
-He/She should not place the catheter drainage bag during mechanical lift transfers above
the level of the bladder.
During a telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-He/She did not know where the catheter drainage bag should hang while the resident was
transferred with a mechanical lift. He/She saw CNA staff hook the catheter bag on the lift
pad straps or hold the catheter drainage bag during the transfer;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 40)
-The catheter drainage bag should not be hung on the mechanical lift bar above the level
of the resident’s bladder;
-The catheter drainage bag should not be on the floor. This caused contamination.
During an interview on 2/13/19 at 5:10 P.M., the Director of Nursing (DON) said the
following:
-Staff should provide incontinence care after every incontinent episode. Staff should not
leave a resident soiled with urine or feces and dress a resident in a clean incontinence
brief and clothing;
-Staff should keep urinary drainage bags off the floor and below the level of the bladder;
-Staff should not attach the resident’s catheter drainage bag on the mechanical lift above
the level of the bladder and let urine run back into the resident’s bladder. This could
cause a urinary tract infection;
-Catheter care should be performed after a resident had been incontinent of bowel.

F 0712

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure physician visits,
including initial comprehensive visits were conducted within the first 30 days after
admission, and then at 30 day intervals up until 90 days after the admitted for four of 13
sampled residents (Resident #3, #9, #22, and #40). The facility census was 47.
1. Review of Resident #40’s medical record on 2/13/19, showed the following:
-He/She admitted to the facility on [DATE];
-He/She was seen by his/her Family Nurse Practitioner (FNP) on 11/16/18;
-There was no documentation to show he/she had been seen by his/her physician since
admission.
2. Review of Resident #22’s medical record on 2/13/19, showed the following:
-He/She admitted to the facility on [DATE];
-He/she was seen by his/her FNP on 10/19/18;
-There was no documentation to show he/she had been seen by his/her physician since
admission.
3. Review of Resident #9’s medical record on 2/13/19, showed the following:
-admitted [DATE];
-He/She was seen by the FNP on 11/16/18;
-There was no documentation the physician or FNP saw the resident from 11/16/18 to
2/13/19;
4. Review of Resident #3’s medical record on 2/13/19, showed the following:
-admitted [DATE];
-The resident was seen by the physician in 10/2018;
-There was no documentation the physician or FNP saw the resident from 10/2018 to
2/13/2019.
During an interview on 2/13/19 at 5:07 P.M., the Director of Nurses (DON) said the
following:
-There were three physicians that came to the facility to see residents once a month;
-There was a FNP who came to the facility every Friday to see residents;
-The FNP did not see all of the residents every Friday;

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0712

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 41)
-Skilled residents were to be seen by a physician within two weeks of admission to the
facility;
-There was no documentation to show the residents were seen;
-Physicians do not provide the facility with documentation after residents are seen.
During an interview on 2/28/19 at 11:33 A.M., the Administrator said the facility did not
have a policy regarding physician’s visits. They followed federal and state regulations.

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide enough nursing staff every day to meet the needs of every resident; and have a
licensed nurse in charge on each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
sufficient nursing staff to meet residents’ needs for four residents (Residents #2, #3,
#8, and #9), in a review of 13 sampled residents and for six additional residents
(Residents #4, #16, #18, #30, #33, and #39). Staff failed to provide routine showers to
ensure good personal hygiene and prevent body odors, failed to respond timely to call
lights, and failed to provide restorative therapy when the restorative aide (RA) was
pulled to work as a Certified Nurse Aide (CNA) and was unable to complete duties for the
restorative therapy nursing program. The facility census was 47.
1. Review of the facility’s undated policy for call lights showed the following:
-Staff was to respond promptly to a resident’s call for assistance and to assure call
system is in proper working order;
-All nursing personnel were to be aware of call lights at all times;
-Staff was to answer ALL call lights promptly whether or not they were assigned to care
for that particular resident;
-For bedside call lights, a light would appear over the door of the resident’s room and on
the board at the nursing station;
-Staff was to answer all call lights in a prompt, calm, courteous manner, and turn off the
call light as soon as they entered the room;
-Staff was to never make a resident feel they were too busy to give assistance;
-Be sure all call lights were placed on the bed at all times and ensure they were never on
the floor or bedside stand.
2. During the group interview on 2/6/19 at 10:30 A.M., residents in attendance said the
following:
-Resident #30 and #156 said they usually wait 30 minutes for staff to answer call lights.
Staff was busy and there was not enough staff to answer call lights quickly;
-Resident #156, #150, and #30 said staff turn the call lights off and say they will be
back. Staff does not come back, they forget or get busy with someone else;
-Resident #30 said he/she waited on pain medications for a long time;
-Resident #156 said he/she waited on pain medication and for staff to take him/her to the
bathroom for a long time;
-Resident #30 said he/she was supposed to get a shower three times a week. He/She had not
received a shower for over two weeks;
-Resident #150 said he/she had one shower since admission to the facility at the end of
(MONTH) 2019;
-Resident #32 said he/she had waited ten to 12 days for a shower.
3. Review of Resident #4’s care plan, dated 10/31/18, showed the following:

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 42)
-The resident had impaired ability to complete activities of daily living (ADLs). Staff
should provide assistance when needed and allow the resident to complete tasks as able,
assist with bathing and personal care;
-Staff should shower the resident two to three times weekly.
Observation on 2/8/19 at 10:10 A.M., showed the resident was unkempt with greasy hair,
facial hair, and dirty nails.
During an interview on 2/8/19 at 10:10 A.M., the resident said he/she did not know when
he/she last had a shower. He/She needed some help washing his/her lower legs and back,
otherwise, he/she could wash most areas by himself/herself. He/She would like to take a
shower routinely.
Review of the facility shower logs, dated (MONTH) 2019 through (MONTH) 2019, showed the
following:
-From 1/13/19 through 1/19/19, no documentation staff provided the resident a shower or
bed bath and no documentation staff offered the resident a shower and he/she refused;
-From 1/20/19 through 1/26/19, no documentation staff provided the resident a shower or
bed bath and no documentation staff offered the resident a shower and he/she refused;
-From 2/3/19 through 2/9/19, no documentation staff provided the resident a shower or bed
bath and no documentation staff offered the resident a shower and he/she refused;
-From 2/10/19 through 2/13/19, no documentation staff provided the resident a shower or
bed bath and no documentation staff offered the resident a shower and he/she refused;
Observation and interview on 2/13/19 at 11:50 A.M., showed the resident remained with the
same appearance, unkempt with greasy hair, facial hair, and dirty nails. The resident said
he/she had not received a shower.
4. Review of Resident #30’s care plan, dated 9/24/18, showed staff should assist with ADLs
as needed.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 12/21/18, showed the resident
required extensive assistance of one staff member with bathing.
Observation on 2/8/19 at 10:15 A.M., showed the resident was unkempt with long greasy hair
and facial hair.
Review of the facility shower logs, dated (MONTH) 2019 through (MONTH) 2019, showed the
following:
-From 1/13/19 through 1/19/19, no documentation staff provided the resident a shower or
bed bath and no documentation staff offered the resident a shower and he/she refused;
-From 1/20/19 through 1/26/19, no documentation staff provided the resident a shower or
bed bath and no documentation staff offered the resident a shower and he/she refused;
-From 2/3/19 through 2/9/19, no documentation staff provided the resident a shower or bed
bath and no documentation staff offered the resident a shower and he/she refused;
-From 2/10/19 through 2/13/19, no documentation staff provided the resident a shower or
bed bath and no documentation staff offered the resident a shower and he/she refused;
During an interview on 2/8/19 at 10:15 A.M., the resident said he/she did not know how
long it had been since he/she had a shower. He/She would like to have a shower and shave
routinely. He/She needed some staff help with showers.
Observation and interview on 2/13/19 at 11:50 A.M., showed the resident remained with the
same appearance, unkempt with long greasy hair and facial hair. The resident said he/she
had not received a shower.
5. Review of the shower assignment sheets on 2/13/19 showed staff scheduled residents for
showers two to three times per week on assigned days of the week and assigned shifts.
Review of the 100 hall shower logs, dated 1/13/19 through 1/19/19, showed the following:
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 43)
-List of ten residents followed by the days of the week and space for staff documentation
a shower or bed bath was completed;
-No documentation four residents received a shower or bed bath and documentation to show
staff the residents refused;
-Staff documented three of the ten residents only received one shower.
Review of the 200 hall shower logs, dated 1/13/19 through 1/19/19, showed the following:
-List of 14 residents followed by the days of the week and space for staff documentation a
shower or bed bath was completed;
-No documentation seven residents received a shower or bed bath and no documentation to
show the residents refused;
-Staff documented three residents only received one shower.
Review of the 300 hall shower logs, dated 1/13/19 through 1/19/19, showed the following:
-List of 13 residents followed by the days of the week and space for staff documentation a
shower or bed bath was completed;
-No documentation two residents received a shower or bed bath and no documentation to show
the residents refused;
-Staff documented eight residents only received one shower.
Review of the 100 hall shower logs, dated 1/20/19 through 1/26/19, showed the following:
-List of 12 residents followed by the days of the week and space for staff documentation a
shower or bed bath was completed;
-No documentation four residents received a shower or bed bath and no documentation the
residents refused;
-Staff documented only seven residents received one shower.
Review of the 200 hall shower logs, dated 1/20/19 through 1/26/19, showed the following:
-List of 15 residents followed by the days of the week and space for staff documentation a
shower or bed bath was completed;
-No documentation eight residents received a shower or bed bath and no documentation the
residents refused;
-Staff documented four residents only received one shower.
Review of the 300 hall shower logs, dated 1/20/19 through 1/26/19, showed the following:
-List of 15 residents followed by the days of the week and space for staff documentation a
shower or bed bath was completed;
-No documentation five residents received a shower or bed bath and no documentation the
residents refused;
-Staff documented nine residents only received one shower.
6. During an interview on 2/8/19 at 1:05 P.M., Nurse Assistant (NA) B said on 2/5/19,
he/she had ten residents who were scheduled to receive a shower. He/She was only able to
give showers to four of five residents because there was not enough help.
During an interview on 2/7/19 at 2:50 P.M., Certified Nurse Assistant (CNA) E said the
following:
-No residents received a shower today (2/7/19);
-Staff was working with a lack of staff, so staff was unable to complete their assigned
tasks;
-Staff had a difficult time completing resident showers on a daily basis due to not enough
staff.
During an interview on 2/8/19 at 8:46 A.M., Restorative Aide (RA)/CNA D said the
following:
-Usually CNAs on duty were supposed to assist residents on their halls with showers;
-It was overwhelming at times and hard to get the showers completed due to not enough
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 44)
staff.
During interview on 2/8/19 at 8:35 A.M., Registered Nurse (RN) H said he/she was the day
shift charge nurse. He/She said on some days, staff do not complete the assigned showers
because they do not have enough time.
7. Review of Resident #9’s care plan, dated 8/28/18, showed the resident had limited
physical mobility related to left sided weakness and right above the knee amputation.
Staff should assist with mobility, provide supportive care and assistance as needed.
Provide total assistance with ambulation
Review of the resident’s quarterly MDS, dated [DATE], showed the resident required total
assistance from two staff with transfers.
Observation on 2/6/19 showed the following:
-At 9:17 A.M., the call lights to Resident #1, Resident #9 and Resident #33′ rooms were
turned on;
-At 9:21 A.M., NA G entered Resident #9’s room and told the resident it would be a minute,
he/she needed to get some help. NA G turned off the resident’s call light and left the
resident’s room. NA G then entered Resident #1’s room. Resident #1 said, What are we
doing? NA G gave the resident a drink and turned off the resident’s call light. NA G then
entered Resident #33’s room and turned off the call light and told the resident, I know,
can you wait? The resident sat in a chair and wanted to lay down.
-From 9:21 A.M. to 9:30 A.M., NA G assisted Resident #16 and pushed a mechanical lift down
the hallway;
-At 9:35 A.M., Resident #9 turned on his/her call light;
-At 9:38 A.M., NA G said Resident #9 wanted transferred to his/her recliner chair. NA G
walked past the resident’s room and entered another resident’s room;
-At 9:39 A.M., Resident #9’s call light was on;
-At 9:40 A.M., RN H entered Resident #9’s room, turned off the call light and told the
resident he/she would get some help. Resident #9 said, I want to get in that chair. RN H
left the room;
-At 9:42 A.M., RN H entered Resident #9’s room with the mechanical lift, positioned the
mechanical lift over the resident, and attached the mechanical lift pad positioned under
the resident to the mechanical lift bar. RN H left the room. Resident #9 remained seated
in the wheelchair with the lift pad positioned under him/her and attached to the
mechanical lift. The lift bar was directly over the resident’s head. No staff were present
in the resident’s room;
-At 9:46 A.M., NA G and CNA E entered Resident #9’s room and transferred the resident from
the wheelchair to the recliner chair with the mechanical lift.
During telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-Residents should not have to wait very long for staff to answer call lights. He/She
should answer the resident’s call light and provide the resident’s care. He/She should not
turn the resident’s call light off without providing the resident’s care before leaving
the resident’s room;
-The facility was short of staff and staffing was a major issue. If he/she needed help
with a resident, he/she had to wait on staff from other halls to help. Doing this took
staff away from those residents and that was not fair to them.
8. Review of Resident #18’s care plan, dated 6/7/18, showed no specific staff direction
regarding the resident’s ADL care needs was indicated on the care plan.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Made self understood and able to understand others;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
-Required extensive assistance of two staff members with transfers and toileting;
-Frequently incontinent of bowel and bladder.
Observations on 2/7/19 showed the following:
-At 6:58 A.M., the resident sat on the side of the bed, rocked back and forth and said
someone help me, I have to go the bathroom. The resident’s call light was on;
-At 7:01 A.M., the resident sat on the side of the bed and said repeatedly, Someone help
me to the bathroom. The resident’s call light remained on;
-At 7:03 A.M., the resident’s call light remained on;
-At 7:06 A.M., the resident laid down on the bed. His/Her call light remained on;
-At 7:10 A.M., the resident sat up on the side of the bed and said help me downstairs. The
resident’s call light remained on;
-At 7:11 A.M., the housekeeper stopped at the resident’s doorway and said there was
nothing downstairs, let me get someone. The resident’s call light remained on. The
housekeeper walked down the hall to the nurses’ desk and found CNA D;
-At 7:12 A.M., CNA D entered the resident’s room, turned off the call light, transferred
the resident to a wheelchair with a mechanical lift and took the resident to the bathroom;
During interview on 2/7/19 at 7:12 A.M., RA/CNA D said he/she was the restorative aide.
He/She would help the resident to toilet and dress for breakfast. The CNA staff assigned
to the resident’s hall was in the dining room helping with breakfast. No additional staff
was available.
9. Review of the Restorative Service Delivery Record Book, located at the nurses’ desk, on
2/13/19, showed the following:
-The restorative aide (RA) documented he/she worked the floor nine of 13 days in (MONTH)
(YEAR) as a CNA and did not provide restorative therapy as scheduled for Residents #2, #3,
#4, #8, #9, #16, #18, #33, and #39;
-The RA documented he/she worked the floor nine of 17 days in (MONTH) 2019 as a CNA and
did not provide restorative therapy as scheduled for Residents #2, #3, #4, #8, #9, #16,
#33, and #39;
-The RA documented he/she worked the floor four of eight days in (MONTH) 2019 as a CNA and
did not provide restorative therapy as scheduled for Resident #3, #8, #9, and #16.
During an interview on 2/7/19 at 7:35 A.M., RA/CNA D said the following:
-He/She was responsible for providing restorative therapy to the residents;
-He/She was pulled to work the floor to work as a CNA a lot;
-He/She could not complete the residents’ therapy on days he/she was pulled to the floor
as there was not enough time.
During interview on 2/8/19 at 11:55 A.M., the Physical Therapy Assistant/ Program Director
said the following:
-Therapy staff completed the restorative nursing program plan for the residents;
-The problem with the restorative nursing program was the RA was pulled from providing
therapy to work the floor to work as a CNA when the facility was short staffed;
-When the RA worked as a CNA, the residents did not receive therapy on those days.
10. During interview on 2/13/19 at 5:10 P.M., the Director of Nursing said the following:
-Staff should answer call lights quickly and assist the residents;
-Staff should not turn off call lights and leave the room without caring for the resident;
-The restorative nursing program was not going well. The RA was pulled to the floor to
fill in for CNA staff;
-The RA was supposed to provide restorative nursing services five days per week;
-He/She expected residents to receive assistance with their showers on their assigned
days. If the showers were not completed, CNA staff should reschedule the resident’s
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 46)
shower.
-Staff was unable to complete some ADL cares because of lack of staff.
During interview on 2/13/19 at 6:30 P.M., the Administrator said he/she was disappointed
with the staffing issue. Residents were complaining about showers not being completed and
he/she thought it was better. The facility was staffed based on the facility census.

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that nurses and nurse aides have the appropriate competencies to care for every
resident in a way that maximizes each resident’s well being.

Based on observation, interview and record review, the facility failed to ensure staff had
appropriate competencies and skills sets to provide nursing and related services to assure
resident safety and attain or maintain the highest practicable physical, mental, and
psychosocial well-being of each resident, as determined by resident assessments and
individual plans of care. The facility had six nursing assistants (NAs) who had not
completed the mandatory 16 hours of certified nurse’s aide training (CNA) prior to
providing direct care to residents. The facility census was 47.
Review of the policies and procedures provided by the facility showed there was no policy
directing NAs to have the required 16 hours of CNA training prior to providing direct care
to residents.
1. Review of a list of NAs provided by the facility showed the following NAs were
currently working at the facility:
-NA K was hired on 12/26/18;
-NA N was hired on 1/2/19;
-NA B was hired on 1/7/19;
-NA M was hired on 1/11/19;
-NA G was hired on 1/17/19;
-NA L was hired on 2/1/19.
Observation on 2/7/19 at 7:20 A.M., showed the following:
-NA G entered Resident #16’s room with a washable incontinence bed pad. He/She washed
hands and applied gloves;
-NA G rolled the resident on his/her side, the washable incontinence bed pad was saturated
with urine;
-NA G rolled up the urine soiled incontinence pad under the resident’s left hip and placed
the dry incontinence pad on the bed. NA G placed the bedpan under the resident on top of
the dry incontinence pad and rolled the resident onto the bed pan. The urine soiled
incontinence pad remained rolled up under the resident’s left hip;
-NA G removed gloves, washed hands and left the room.
Observation on 2/7/19 at 8:18 A.M., showed the following:
-NA G and Certified Medication Technician (CMT) R entered Resident #16’s room and without
washing hands or applying gloves, rolled the resident on his/her right side. Two
incontinence pads were noted under the resident. The urine soiled rolled up incontinence
pad remained under the resident’s left hip and a second dry incontinence pad lay flat
under the resident;
-NA G with ungloved hands, pulled out the urine soiled incontinence pad and through the
pad on the floor beside the bed;
-NA G with ungloved soiled hands, adjusted the dry incontinence pad under the resident,

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
touched the resident’s hip and arm and touched the resident’s bed linens;
-NA G with ungloved hands, picked up the urine soiled incontinence pad from the floor and
placed in a plastic bag;
-NA G and CMT R did not provide incontinence care;
-NA G without washing hands left the room with the bagged linens.
During an interview on 2/7/19 at 8:22 A.M., Resident #16 said staff took him/her off the
bed pan about 45 minutes prior. Staff did not wash him/her. Staff usually did not provide
peri care.
2. Observation on 2/7/19 at 7:45 A.M., showed the following:
-Resident #151’s call light was on. The resident sat on the edge of the bed with a
wheelchair positioned directly in front of and facing the resident. NA G carried the
resident’s breakfast tray into the resident’s room and sat it on the bedside table out of
the resident’s reach. The resident said, I need to use the bathroom. NA G left the
resident’s room. The resident’s roommate turned the call light back on;
-NA G entered the room and pushed the resident’s wheelchair out of the way, placed the
resident’s bedside table and breakfast tray in front of the resident. NA G said he/she was
waiting to learn the resident’s transfer status before taking the resident to the
bathroom. NA G left the room;
-NA G and CMT R entered the room and assisted the resident’s roommate with toileting. The
resident said, I haven’t been to the bathroom yet, I need to go. NA G and CMT R did not
respond to the resident;
-NA G and CMT R left the resident’s room.
During a telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-He/She started work at the facility in (MONTH) 2019;
-He/She had not worked as a CNA before;
-During orientation another CNA showed him/her where supplies were kept and he/she
followed the CNA for three days;
-No skill check offs were completed during orientation;
-He/She asked other CNA staff how to do something if he/she did not know;
-He/She did not know how Resident #151 was supposed to be transferred so he/she did not
transfer the resident. Residents should not have to wait to go the bathroom;
-He/She did not remember if he/she gave Resident #16 incontinence care or not.
During an interview on 2/7/19 at 5:45 P.M., NA G said there were no CNAs working at that
time (evening shift). There were only two NAs and the licensed nurses were helping them
provide resident care.
During an interview on 2/8/19 at 8:55 A.M. the Director of Nurses (DON) said the
following:
-The NAs who were currently working had not started classes yet, but were scheduled to
start in a couple of weeks;
-NAs were trained for three days while working with CNAs who provided resident care;
-NAs were evaluated for their readiness to go out on their own after working with the CNAs
for three days;
-This last group of NAs (NA K, NA N, NA B, NA M, NA G, and NA L) did not have the 16
required hours of training before they started on the floor, because they did not have any
one who was certified to provide the hours of required CNA training.
During an interview on 2/13/19 at 6:30 P.M. the Administrator said she was unaware if any
NA training or orientation was done on hire. The DON handled new NA employee orientation.

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview, and record review, the facility failed to provide each
resident with a palatable meal served at appetizing temperatures. The facility census was
47.
1. During an interview on 2/05/19 at 10:50 A.M., Resident #27 said the food was cold at
all meals. He/She ate in his/her room. The resident’s spouse confirmed the food was cold.
During an interview on 2/5/19 at 11:59 A.M., Resident #4 said the meals were cold, staff
did not serve food on the menu, and he/she would like more variety.
Observation on 2/6/19 at 8:22 A.M., showed Nurse Aide (NA) N delivered Resident #2’s
breakfast tray of pancakes, bacon, cereal and milk. NA N sat the resident up and in bed
and adjusted the bedside table for the resident. The resident took a bite of bacon and
pancake and said the food was cold. Staff did not reheat the resident’s breakfast.
During an interview on 2/6/19 at 9:43 A.M., the Dietary Manager said she was in the
resident council meeting on 2/5/19 and several residents said the dining room food was
cold. The Dietary Manager said a few months back resident’s had complained about cold
food.
During a group interview on 2/6/19 at 10:30 A.M., residents said the following:
-Resident #30 said staff serve the same foods over and over, there was no variety. He/She
ate in his/her room and the food was cold. He/She voiced food concerns recently to the
administrator and Dietary Supervisor, and there had been no change;
-Resident #150 said he/she ate in the dining room and the food was cold.
During an interview on 2/13/19 at 10:30 A.M., Resident #150 said over the weekend the
chicken was hard and cold. He/She was unable to chew the chicken. This morning the
pancakes were cold. His/Her family brought in food for him/her that was hot and he/she was
able to eat. The facility food was poor.
Review of the lunch menu for 2/6/19, showed residents were to receive roast pork, dressing
with gravy, broccoli, bread and butter, and pineapple cake.
Observation on 2/6/19 showed the following:
-At 12:14 P.M., the Assistant Dietary Manager took the temperatures of the food on the
steam table prior to preparing the hall trays. The temperature of the pork roast was 167
degrees Fahrenheit (F), broccoli was 168 degrees F, gravy was 168 degrees F, and the
dressing was 169 degrees F;
-At 12:24 P.M., staff prepared hall trays and placed them on the hall cart;
-At 12:31 P.M., the Dietary Manager took the cart containing the hall trays to the nurses
station and announced the hall trays were at the nurse’s station and ready for delivery.
He/She returned to the kitchen;
-No nursing staff were in the hallways when the dietary manager delivered the trays to the
nurse’s station and announced they were ready for delivery.
-At 12:37 P.M., the certified nurse assistant (CNA) on the hall passed the first hall
tray;
-At 12:39 P.M., the CNA passed the second hall tray.
-At 12:40 P.M., staff passed the third hall tray. Staff left the doors on both sides of
the hall cart open;
-At 12:45 P.M., staff passed the ninth hall tray. The CNA shut the doors on the hall cart.
The doors remained open on the cart from 12:40 P.M. to 12:45 P.M.;
-At 12:49 P.M., staff passed the last hall tray;

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 49)
-At 12:50 P.M., staff served a test tray from the hall cart. The temperature of the pork
roast was 102 degrees F, the broccoli was 113 degrees F, the dressing with gravy was 112
degrees F.
Observations on 2/7/19, showed the following:
-At 8:12 A.M., NA G carried Resident #151’s breakfast tray into the resident’s room and
sat it on the bedside table. The resident’s wheelchair was parked in between the resident
and the bedside table. The resident was unable to reach his/her breakfast tray;
-At 8:16 A.M., NA G pushed the resident’s wheelchair out of the way and placed the
resident’s bedside table. The breakfast tray consisted of scrambled eggs and a muffin. NA
G left the room;
-At 9:05 A.M. the resident said his/her breakfast was cold when served.
During an interview on 2/7/19 at 9:02 A.M., the Dietary Manager said dietary staff take
the hall trays to the nurse’s station and announce the trays are there for delivery. The
CNA assigned to hall trays was responsible for passing the hall trays out to the
residents. If dietary does not see staff in the halls when they deliver the trays to the
nurse’s station, they do not go looking for the CNA responsible for passing the trays. She
expected the temperature of the hot foods on the hall trays to be at least 165 degrees F
at the time of delivery.
During an interview on 2/7/19 at 9:09 A.M., the Director of Nursing (DON) said the CNA on
the hall was responsible for passing the hall trays.
During an interview on 2/7/19 at 9:13 A.M., CNA A said his/her duties included passing
hall trays. He/She said the CNA assigned to the 200 hall was responsible for passing the
hall trays. If he/she is busy helping a resident when the trays come to the nurse’s
station, the trays sit until he/she is finished helping the resident. Residents complain
at least once a week that the food on the hall trays is cold.
During an interview on 2/7/19 at 9:33 A.M., the Administrator said she expected hot foods
on the hall trays to be 165 degrees F at the time of delivery.

F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide or get specialized rehabilitative services as required for a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that four
of 13 sampled residents (Resident #3, #9, #10, and #22), and two additional residents
(Resident #16 and #1) with limited mobility received appropriate services and assistance
to maintain or improve mobility with the maximum practicable independence. The facility
census was 47.
Review of the facility’s undated restorative activities of daily living (ADL) program
policy showed the following:
-It was the responsibility of the licensed nurses and restorative aides (RA) to perform
these duties;
-The purpose of this policy was to assess the need of residents to attain, maintain, or
re-train ADLs;
-Equipment required was adaptive devices as assessed per therapist, restorative
documentation log, and a computer;
-RA would perform procedures listed on care plan ADL goals;
-Licensed nurses were to provide restorative therapy to each resident should the RA be
unavailable on any day residents were to receive therapy to ensure orders were being

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 50)
followed;
-Nursing and therapy would assess ADL needs of the residents;
-Therapy would assess the need for adaptive devices;
-Assessments and re-assessments would be done on admission and quarterly (Minimum Data
Set, MDS- a federally mandated assessment tool, and Care Plan).
Review of the facility’s undated restorative ambulation, mobility, range of motion (ROM),
and transfer program policy showed the following:
-It was the responsibility of the licensed nurses, RAs, speech, occupational, and physical
therapists;
-The purpose was to continue to maintain or improve the level of functioning physical
therapy has attained for the resident;
-Equipment required; gait belt, walker, cane, wheelchair, restorative documentation log;
-RA would perform and document procedures;
-Licensed staff were to provide and document restorative therapy to each resident should
the RA be unavailable on any day residents were to receive therapy to ensure orders were
being followed;
-Physical therapy and nursing would assess need of resident for restorative nursing;
-Assessment and re-assessment would be made on admission and quarterly (MDS and Care
Plan);
-Physical therapy and nursing would evaluate need for RA to continue with resident
assigned.
Review of the facility’s undated restorative feeding program policy showed the following:
-It was the responsibility of licensed nurses, RAs, speech, occupational, and physical
therapist;
-The purpose was to assess the needs of residents and to restore, maintain the ability to
eat and feed themselves, and place the resident in the program if needed;
-The RA would conduct and chart daily and weekly progress reports in the resident’s
record;
-Nurses would assess and identify needs of the residents in conjunction with therapies;
-Nursing and occupational therapy would use and identify adaptive devices;
-Speech therapists would evaluate for appropriateness of the program and monitor while
resident was in the program;
-Occupational therapist would evaluate for assistive devices;
-Dietary would be informed of assistive devices and of the resident’s prominent hand;
-Assessment would be done upon admission and quarterly in the MDS and Care Plan;
-Care plans would include dining program in progress.
1. Review of Resident #22’s care plan, last revised on 11/3/18, showed the following:
-He/She had [MEDICAL CONDITION] (paralysis on one side of the body); related to [MEDICAL
CONDITION] ([MEDICAL CONDITION] – stroke);
-He/She would maintain optimal status and quality of life within limitations imposed by
[MEDICAL CONDITION] through next review date;
-He/She had an ADL self-care performance deficit related to [DIAGNOSES
REDACTED].>-He/She would improve current level of function in transfers, toileting and
dressing through the review date (2/1/19);
-He/She would be able to use hemi cane to assist with standing and tie his/her own shoes;
-He/She required one or two staff participation with transfers, dressing, bathing, and
toilet use;
-He/She had limited physical mobility due to [DIAGNOSES REDACTED].>-He/She would
demonstrate the appropriate use of adaptive devices to increase mobility through the
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 51)
review date (2/1/19);
-His/Her devices used included leg lifter and hemi walker;
-He/She used a wheelchair for locomotion;
-There was no documentation to show that he/she was to participate in the restorative
nursing program.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-His/Her cognition for daily decision making was intact;
-His/Her range of motion (ROM) was impaired on one side of upper and lower extremities;
-There was no documentation to show the resident received restorative therapy.
Review of the resident’s Physician order [REDACTED].
Review of the resident’s restorative nursing record, dated (MONTH) of (YEAR), showed the
following:
-Goal; maintain transfers, sit and stand, BLE strengthening, and ROM;
-Exercises included; sit and stand at rail five times to resident’s tolerance, ten lateral
and supine right knee extension stretches, ten knee flexions; clam shell ten times,
bridging ten times, and ten heel slides;
-He/She received therapy seven out of 12 times;
-Documentation on the back of the restorative nursing record showed the resident did not
receive therapy as scheduled on 12/1/18, 12/2/18, 12/3/18, 12/4/18, 12/7/18, 12/13/18,
12/14/18 12/21/18, and 12/25/18, because the RA worked as an aide and not as restorative.
Review of the resident’s POS, dated 1/1/19 to 1/30/19, showed the RA was to exercise the
resident’s BLE three times a week.
Review of the resident’s restorative nursing documentation, dated (MONTH) 2019, showed the
following:
-Goal; maintain transfers, sit and stand, BLE strengthening, and ROM;
-Exercises included sit and stand at rail five times to resident’s tolerance, ten lateral
and supine right knee extension stretches, ten knee flexions; calm shell ten times,
bridging ten times, and ten heel slides;
-He/She received therapy eight out of 12 times;
-The RA documented the resident did not receive therapy on 1/3/19, 1/4/19, 1/5/19,
1/6/19,1/20/19, 1/29/19, and 1/30/19, because he/she worked as an aide on the floor;
-The RA documented he/she did not get a chance to work with the resident on 1/22/19,
1/24/19, and 1/28/19, but there was no reason documented.
Review of the resident’s POS, dated 2/1/19 to 2/28/19, showed the RA was to exercise the
resident’s BLE three times a week.
Review of the resident’s restorative nursing documentation dated 2/1/19 to 2/5/19 showed
the following:
-Physical therapy was discontinued on 10/16/18;
-Goal; maintain transfers, sit and stand, BLE strengthening, and ROM;
-Exercises included sit and stand at rail five times to resident’s tolerance, ten lateral
and supine right knee extension stretches, ten knee flexions; calm shell ten times,
bridging ten times, and ten heel slides;
-The RA was unable to work with the resident on 2/2/19 and 2/3/19 because he/she worked as
an aide on the floor;
-The RA was unable to work with the resident on 2/5/19, but no reason was documented.
Observation of the resident on 2/7/19 at 7:40 A.M., showed he/she sat in his/her
wheelchair. He/She had [MEDICAL CONDITION] of the right side of his/her body and wore a
brace on his/her right leg.
During interview on 2/7/19 at 1:47 P.M., the resident said he/she did not receive physical
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 52)
therapy anymore and worked with the RA, but was uncertain of the RA schedule.
2. Review of Resident #10’s care plan, dated 11/8/18, showed the following:
-Focus: Right sided [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Goal: Will
maintain optimal status and quality of life within limitation through review date;
-Focus: ADL self care performance deficit related to right sided [MEDICAL CONDITION] and
above the knee amputation (AKA);
-Goal: Will increase level of function in ADLs by next review date;
-Interventions: Total dependence on staff for toilet use, two staff assist with Hoyer lift
for transfers and toileting,two staff assist with repositioning, turning in bed and
dressing, one to two staff assist with bathing and personal hygiene.
Review of the resident’s Admission MDS, dated [DATE], showed severely impaired cognition.
Review of the resident’s undated Restorative Care Program showed the following:
-Resident discharged from PT on 12/3/18;
-Goals: to maintain bilateral lower extremity strength and ROM, maintain sit to stand in
parallel bars;
-Approach/recommendations for implementation of goals: Right ankle dorsiflexion stretch in
sitting and passive range of motion (PROM) stretch, sit to stand in parallel bars with
nonskid below right foot, knee flexion stretch;
-Signed and dated 12/3/18 by the physical therapist.
Review of the resident’s Restorative Service Delivery Record, dated 12/18, showed:
-Heel slides x 15, hip abduction in lying position x 15, knee flexion stretch at wall x
10, straight leg raises x 10, modified hamstring stretch x 15, ankle circles x 15, ankle
four way x 15, isometric hip abduction x 15, long arc quads x 15, seated ankle plantar
flexion x 15, seated dorsiflexion x 15, seated hamstring stretch x 15, seated knee flexion
x 15, seated marches x 15, inner arm stretch x 10, wrist stretch x 10, cane reach x 10,
straight push x 10, circle movement x 10, cane leaning x 10, punching movement x 10,
pushing movement x 10, no weights bicep curls x 15, weight bicep curls x 10, open arm
movement x 10, side arm raise x 10, sitting elbow flexion x 10, overhead press x 10,
shoulder abduction x 10, bridging lying post x 15, clam shells x 15, sit to stand at rails
x 5;
-Documentation showed the RA was unable to work with the resident on 12/4, 12/7, 12/13,
12/14, 12/21, and 12/25/18 as he/she worked on the floor as an aide.
Review of the resident’s Restorative Service Delivery Record, dated 1/19, showed:
-Heel slides x 15, hip abduction in lying position x 15, knee flexion stretch at wall x
10, straight leg raises x 10, modified hamstring stretch x 15, ankle circles x 15, ankle
four way x 15, isometric hip abduction x 15, long arc quads x 15, seated ankle plantar
flexion x 15, seated dorsiflexion x 15, seated hamstring stretch x 15, seated knee flexion
x 15, seated marches x 15, inner arm stretch x 10, wrist stretch x 10, cane reach x 10,
straight push x 10, circle movement x 10, cane leaning x 10, punching movement x 10,
pushing movement x 10, no weights bicep curls x 15, weight bicep curls x 10, open arm
movement x 10, side arm raise x 10, sitting elbow flexion x 10, overhead press x 10,
shoulder abduction x 10, bridging lying post x 15, claw shells x 15, sit to stand at rails
x 5;
-Documentation showed the RA was unable to work with the resident on 1/4, 1/5, 1/6, 1/15,
1/19, 1/20, 1/28, 1/29 and 1/30/19 as he/she worked on the floor as an aide.
During an interview on 2/6/19 at 2:53 P.M., the resident’s family member said the
following:
-The resident was on restorative therapy for two months;
-The resident had only received restorative therapy 30% of the time;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 53)
-The resident returned to skilled therapy recently. He/She felt like the resident had lost
ground due to lack of restorative therapy;
-There was only one restorative aide and the facility pulled him/her to the floor all the
time.
During a telephone interview on 2/22/19 at 2:50 P.M., the therapy program director said
the following:
-The resident’s skilled therapy end date was 12/3/18;
-Restorative therapy should start the day after the skilled therapy has ended or on the
first weekday after it ended.
3. Review of Resident #16’s annual MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Cognitively intact;
-Required extensive assistance of two staff members with bed mobility;
-Required limited assistance of one staff member with personal hygiene;
-Required total assistance of two staff members with transfers and toileting;
-No functional limitation in upper and lower extremities range of motion;
-Zero days of restorative programs performed.
Review of the resident’s care plan, dated 8/19/18, showed the following:
-[DIAGNOSES REDACTED].
-Alteration in self-care ability related to stroke, limited mobility, dexterity and
flaccid paralysis. Goal was physical needs met. Staff should allow choices to promote
sense of autonomy and control. Encourage participation in activities to promote sense of
inclusion and security.
-No staff direction was provided regarding restorative nursing care.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Functional limitation in upper and lower extremities on one side;
-Zero days of restorative programs performed.
Review of the resident’s POS, dated (MONTH) (YEAR), showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) (YEAR), showed
the following:
-Goal was to maintain strength, maintain sit to stand, maintain range of motion
-Exercises were sit to stand at the rail to resident tolerance, range of motion to all
joints, hip flexion and extension, standing to resident tolerance, ankle dorsiflexion and
plantar flexion;
-Staff documented on 12/1/18, 12/2/18, 12/3/18, 12/4/18 and 12/7/18, no therapy provided.
The RA worked the floor;
-Staff documented on 12/13/18 and 12/14/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/21/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/25/18, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services for nine of 17
days scheduled.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 2019, showed
the following:
-Goal was to maintain strength, maintain sit to stand, maintain range of motion;
-Exercises were sit to stand at the rail to resident tolerance, range of motion to all
joints, hip flexion and extension, standing to resident tolerance, ankle dorsiflexion and
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 54)
plantar flexion;
-Staff documented on 1/3/19, 1/4/19, 1/5/19 and 1/6/19, no therapy provided. The RA worked
the floor;
-Staff documented on 1/15/19, no therapy provided. The RA worked the floor part of the
day;
-Staff documented on 1/16/19, did not get a chance to work with the resident;
-Staff documented on 1/19/19 and 1/20/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/22/19, 1/24/19 and 1/28/19, did not get a chance to work with the
resident;
-Staff documented on 1/29/19 and 1/30/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/31/19, did not get a chance to work with the resident.
-Staff documented the resident did not receive restorative nursing services 14 days of 17
days scheduled.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 2019, showed
the following:
-Goal was to maintain strength, maintain sit to stand, maintain range of motion;
-Exercises were sit to stand at the rail to resident tolerance, range of motion to all
joints, hip flexion and extension, standing to resident tolerance, ankle dorsiflexion and
plantar flexion;
-Staff documented on 2/2/19 and 2/3/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/7/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/8/19, did not get a chance to work with the resident;
-Staff documented on 2/11/19, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services six of eight
days scheduled.
Observation on 2/7/19 at 8:18 A.M. showed Nurse Aide (NA) G assisted the resident with the
bedpan. The resident required assistance to roll side to the side and move up in the bed.
The resident’s left arm was flaccid (without movement). Staff moved the resident’s left
arm and repositioned the arm for the resident. The resident required a mechanical lift
transfer from bed to chair and used a motorized wheelchair for mobility.
4. Review of Resident #1’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].>-Zero days of restorative programs performed.
Review of the resident’s POS, dated (MONTH) (YEAR), showed restorative nursing as needed.
Review of the resident’s care plan, revised 10/17/18, showed the resident had alteration
in ADLs and required one to two staff assistance related to decreased mobility. Staff
should assist resident with all ADLs. No staff direction was provided regarding
restorative nursing care.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) (YEAR), showed
the following:
-Goals were to increase bilateral upper extremity range of motion and strength;
-Activities were bike for ten minutes as tolerated, shoulder and elbow flexion and
extension with one to one-a-half pound weights, bilateral lower extremity extension ankle
pumps, marching and hip, abdomen and quad sets;
-Staff documented on 12/1/18, 12/2/18, 12/3/18, 12/4/18 and 12/7/18, no therapy provided.
The RA worked the floor;
-Staff documented on 12/13/18 and 12/14/18, no therapy provided. The RA worked the floor;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 55)
-Staff documented on 12/21/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/25/18, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services for nine of 17
days scheduled.
Review of the resident’s quarterly MDS, dated [DATE], showed zero days of restorative
programs performed.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nursing as needed.
Review of the resident’s Restorative Service Delivery Record dated (MONTH) 2019 showed the
following:
-Goals were to increase bilateral upper extremity range of motion and strength;
-Activities were bike for ten minutes as tolerated to maintain endurance. Sit and stand at
grab bars five times, bilateral extension ankle pumps, marching and hip, abdomen, gluteal
and quad sets. Chest push and pulls ten times, bicep curls ten times, knee bed in seated
position ten times and long arc quads ten times;
-Staff documented on 1/3/19, 1/4/19, 1/5/19 and 1/6/19, no therapy provided. The RA worked
the floor;
-Staff documented on 1/19/19 and 1/20/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/29/19 and 1/30/19, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services for eight of
17 days scheduled.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nursing as needed.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 1-12, 2019,
showed the following:
-Goals were to increase bilateral upper extremity range of motion and strength;
-Activities were bike for ten minutes as tolerated to maintain endurance. Sit and stand at
grab bars five times, bilateral extension ankle pumps, marching and hip, abdomen, gluteal
and quad sets. Chest push and pulls ten times, bicep curls ten times, knee bed in seated
position ten times and long arc quads ten times;
-Staff documented on 2/2/19 and 2/3/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/7/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/11/19, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services for four of
seven days scheduled.
Observation of the resident during survey 2/5/19 to 2/13/19, showed the resident required
staff assistance for transfer to and from the wheelchair, chair and bed. The resident was
able to feed self with encouragement. During the day the resident sat in a reclining
chair. He/She was able to move upper extremities purposefully. He/She had limited use of
his/her lower extremities.
4. Review of Resident #3’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Independent in bed mobility, transfers, walking in room and corridor, and toileting;
-Required limited assistance of one staff member with dressing;
-Zero days of restorative programs performed.
Review of the resident’s Care Plan, dated 10/23/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident had pain related to arthritis. Goal was pain controlled. Staff should refer
to therapy services as needed;
-The resident was at risk for falls related to gait disturbance and dementia. Goal was
free from injury. Staff should refer to therapy services as needed. Provide supervision
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 56)
with ambulation in the hallway and ADLs;
-No staff direction was provided regarding restorative nursing care.
Review of the resident’s POS, dated (MONTH) (YEAR), showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) (YEAR), showed
the following:
-Goal was to maintain mobility, strength for ADLs, performance increase and facility
tasks;
-Exercises were chest press, bicep curls, chest pulls, ambulate to dining room with
wheeled walker, front raises, upright row, butterfly wings, overhead press, isometric hip
adduction, standing hip abduction, hip extension, and long arc quad;
-Staff documented on 12/1/18, 12/2/18, 12/3/18, 12/4/18 and 12/7/18, no therapy provided.
The RA worked the floor;
-Staff documented on 12/13/18 and 12/14/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/21/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/25/18, no therapy provided. The RA worked the floor;
-Staff documented the resident was not offered restorative nursing services for nine of 17
days scheduled.
Review of the resident’s annual MDS, dated [DATE], showed zero days of restorative
programs performed.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 2019, showed
the following:
-Goal was to maintain mobility, strength for ADLs, performance increase and facility
tasks;
-Exercises were chest press, bicep curls, chest pulls, ambulate to dining room with
wheeled walker, standing marches, isometric hip adduction, standing hip abduction,
bilateral upper and lower extremity strengthening, and long arc quad;
-Staff documented on 1/3/19, 1/4/19, 1/5/19 and 1/6/19, no therapy provided. The RA worked
the floor;
-Staff documented on 1/15/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/19/19 and1/20/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/22/19 and 1/28/19, did not get a chance to work with the resident;
-Staff documented on 1/29/19 and 1/30/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/31/19, did not get a chance to work with the resident.
-Staff documented the resident was not offered restorative nursing services 12 days of 17
days scheduled.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 2019, showed
the following:
-Goal was to maintain strength, maintain sit to stand, maintain range of motion
-Exercises were chest press, bicep curls, chest pulls, ambulate to dining room with
wheeled walker, standing marches, isometric hip adduction, standing hip abduction, front
raises, standing side kicks, and long arc quad;
-Staff documented on 2/2/19 and 2/3/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/7/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/11/19, no therapy provided. The RA worked the floor;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 57)
-Staff documented the resident did not receive restorative nursing services four of eight
days scheduled.
Observation of the resident during survey 2/5/19 to 2/13/19 showed the resident walked
with a walker in the hallway and to the dining room. During the day the resident sat in a
chair in his/her room. Staff redirected the resident and assisted with dressing and
grooming.
5. Review of Resident #9’s care plan, dated 8/28/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident had limited physical mobility related to left sided weakness and right above
the knee amputation. Goal was appropriate use of adaptive devices. Staff should assist
with mobility, provide supportive care and assistance as needed;
-No staff direction was provided regarding restorative nursing care.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Required extensive assistance of two staff member with bed mobility;
-Required total assistance of two staff members with transfers and toileting;
-Required total assistance of one staff member with dressing;
-Impaired functional limitation in range of motion of upper and lower extremities on one
side;
-Zero days of restorative programs performed.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) (YEAR), showed
the following:
-Goal was to maintain bilateral upper and lower extremity range of motion and strength;
-Exercises were left lower extremity active and passive range of motion, bilateral upper
extremity passive range of motion to hand, elbow and shoulder, right stump range of motion
and hip extension, bilateral strengthening exercise, and right stump rubbing along end of
incision;
-Staff documented on 12/1/18, 12/2/18, 12/3/18, 12/4/18 and 12/7/18, no therapy provided.
The RA worked the floor;
-Staff documented on 12/13/18 and 12/14/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/21/18, no therapy provided. The RA worked the floor;
-Staff documented on 12/25/18, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services for nine of 17
days scheduled.
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 2019, showed
the following:
-Goal was to maintain bilateral upper and lower extremity range of motion and strength;
-Exercises were left lower extremity active and passive range of motion, bilateral upper
extremity passive range of motion to hand, elbow and shoulder, right stump range of motion
and hip extension, bilateral strengthening exercise, and right stump rubbing along end of
incision;
-Staff documented on 1/3/19, 1/4/19, 1/5/19 and 1/6/19, no therapy provided. The RA worked
the floor;
-Staff documented on 1/19/19 and 1/20/19, no therapy provided. The RA worked the floor;
-Staff documented on 1/29/19 and 1/30/19, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services eight days of
17 days scheduled.
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 58)
Review of the resident’s POS, dated (MONTH) 2019, showed restorative nurse program three
to five times weekly.
Review of the resident’s Restorative Service Delivery Record, dated (MONTH) 2019, showed
the following:
-Goal was to maintain bilateral upper and lower extremity range of motion and strength;
-Exercises were left lower extremity active and passive range of motion, bilateral upper
extremity passive range of motion to hand, elbow and shoulder, right stump range of motion
and hip extension, bilateral strengthening exercise, and right stump rubbing along end of
incision;
-Staff documented on 2/2/19 and 2/3/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/7/19, no therapy provided. The RA worked the floor;
-Staff documented on 2/11/19, no therapy provided. The RA worked the floor;
-Staff documented the resident did not receive restorative nursing services four of eight
days scheduled.
Observation of the resident during survey 2/5/19 to 2/13/19, showed the resident had an
above the right knee amputation. He/She required a mechanical lift transfer and was mobile
about the facility in a wheelchair. The resident sat in a recliner chair in his/her room
during the day. The resident’s left arm had limited movement.
6. During an interview on 2/7/19 at 7:35 A.M., RA/CNA D said the following:
-He/She was responsible for providing restorative therapy to the residents;
-He/She was pulled to the floor a lot;
-He/She could not get therapy done on days he/she was pulled to the floor, as there was
not enough time;
-He/She charted F for the days he/she was pulled to the floor and charted the reason on
the back of the resident’s restorative form.
During interview on 2/8/19 at 11:55 A.M., the Physical Therapy Assistant/ Program Director
said the following:
-He/She would generally expect restorative therapy to be provided three times weekly;
-Therapy staff completed the restorative nursing program plan for the residents;
-The problem with the restorative nursing program was the RA was pulled from providing
therapy to the floor to work as a CNA when the facility was short staffed;
-When the RA worked as a CNA the residents did not receive therapy on those days.
During interview on 2/13/19 at 5:57 P.M. the Director of Nursing (DON) said the following:
-The restorative nursing program was not going well. The RA was pulled to the floor to
fill in for CNA staff;
-The RA was supposed to provide restorative nursing services five days per week;
-The facility had one RA to provide restorative services. No one else provided therapy if
RA/CNA D was off or pulled to the floor;
-The RA needed additional training with the therapy department.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure nursing
staff washed their hands after each direct resident contact, failed to wear gloves and
change gloves during direct resident personal care and failed to ensure proper handling of
soiled linens when indicated by professional practices during personal care for three

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 59)
residents (Resident #12, #27 and #38) of 13 sampled residents and for two additional
residents (Resident #16 and #26). The facility also failed to practice acceptable
infection control practices and prevent cross-contamination during the provision of wound
care for one resident (Resident #150) and during storage of personal medical equipment for
two residents (Resident #40 and #6). The facility failed to ensure procedures were
implemented to address prevention of [MEDICAL CONDITION] (TB) for four residents (Resident
#22, #12, #27, and #28). The facility census was 47.
Review of the undated facility policy Universal Precautions showed the following:
-Purpose was to follow the most current recommendations of the Center for Disease Control
regarding Universal Precautions;
-Gloves must be used for procedures involving contact with mucous membranes;
-Gloves were must be changed between resident contacts;
-Immediate and thorough washing of hands and other skin surfaces that came in contact with
body fluids to which universal precautions apply must be observed.
Review of the undated facility policy Infection Control showed the following:
-Purpose was to reduce transmission of organisms from resident to resident, from nursing
staff to residents, and from residents to nursing staff;
-Hands should be thoroughly washed before and after providing resident care;
Review of the undated facility policy Using Gloves showed the following:
-Purpose was to prevent the spread of infection and disease to residents and employees;
-Gloves should be used to prevent contamination of the employees’ hands while providing
treatment or services to the resident or when cleaning contaminated surfaces;
-Wash hands before donning gloves, gloves did not replace hand washing. Wash hands after
removing gloves.
Review of the facility’s undated policy for use of nebulizer (breathing) treatments showed
staff were to store nebulizer cannula and tubing in a plastic bag at bedside with the
resident’s name and date the equipment was changed.
1. Review of Resident #150’s Face Sheet showed an admission date of [DATE].
Review of the resident’s Physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Cleanse sounds with normal saline (wound cleansing liquid that contains salt), apply
primary dressing of [MEDICATION NAME] (wound dressing that promotes healing and destroys
bacteria) to wound beds, cover with gauze and a compression dressing (ace wrap or Coban
wrap securely around the legs) for [MEDICAL CONDITION] (swelling with fluid in the
tissues) control. Single layer compression wrap to affected legs. Apply from toes to knee
and cover the heel;
-Change wound dressings every two to three days and as needed;
-Elevate legs as much as possible, avoid standing in one position more than 10 minutes,
avoid sitting with legs down and do not cross legs when sitting.
Review of the resident’s record showed staff had initiated no baseline care plan. There
was no direction regarding care of the resident.
Observation on 2/6/19 at 4:30 P.M., showed the following:
-The resident sat in a wheelchair in the common shower/toilet room. Registered Nurse (RN)
H sat directly on the floor with gloves on;
-The resident’s legs were [MEDICAL CONDITION] and swollen with layers of dressings and
wrappings from knees to base of toes. The resident’s toes were exposed and had open wounds
and black areas on the tips;
-Wearing gloves, RN H removed the layers of soiled wound dressings from both legs and
placed the soiled dressings directly on the floor of the common shower/toilet room. RN H
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 60)
did not bag the soiled wound dressings;
-The resident’s right lower leg had six open wounds with varying amounts of drainage. An
open draining wound was noted on the resident’s right heel base. The resident’s left lower
leg contained seven open wounds with varying amounts of drainage. The tops of the
resident’s feet were [MEDICAL CONDITION];
-RN H inspected the resident’s wounds, laid over on his/her side directly on the common
shower/toilet room floor and inspected the back of the resident’s lower legs and feet;
-RN H bagged the pile of wound dressings on the floor, washed hands and left the room;
-The resident said he/she was getting a shower.
Observation on 2/6/19 at 6:10 P.M., showed the following:
-The resident sat in a wheelchair near the entrance to the dining room. A fuzzy blanket
covered the resident’s lap and lower legs. The resident’s lower extremity wounds were all
open with no wound dressings in place. His/Her toes were uncovered with open wounds and
black areas visible. The resident’s right foot heel wound sat on a wash cloth on the
wheelchair pedal;
-RN H administered the resident’s medications and pushed the resident in his/her
wheelchair into the dining room for supper.
Observation on 2/6/19 at 7:00 P.M., showed the resident sat in a wheelchair outside the
front door of the facility smoking. The environmental temperature was frigid. The
resident’s lower extremity wounds were all open with no wound dressings in place. His/Her
toes were uncovered with open wounds and black areas visible. The resident’s right foot
heel wound sat on a wash cloth on the wheelchair pedal.
During interview on 2/7/19 at 6:50 A.M., the resident said the night nurse redressed
his/her lower leg wounds at approximately 11:00 P.M. last night. The staff did not have
time to redress his/her wounds earlier in the day following his/her shower.
During interview on 2/7/19 at 7:45 A.M., Licensed Practical Nurse (LPN) Q said the
following:
-He/She redressed the resident’s open lower leg wounds last night sometime after 9:45 P.M.
on 2/6/19;
-It was not appropriate to leave the resident’s wounds open following the shower for an
extended period of time. Staff should have provided wound care following the shower and
covered the wounds;
-Wounds left open increased the risk of infection. The resident was all over the facility
and outside to smoke. His/Her wounds needed to be covered and protected from injury,
further infections and the cold.
During interview on 2/8/19 at 8:35 A.M., RN H said the following:
-He/She took the resident’s lower leg wound dressings off prior to the resident’s shower;
-He/She should not sit directly on the shower room floor. This was not good infection
control practice;
-He/She should not lay the soiled wound dressings directly on the shower room floor. This
was not good infection control practice. Soiled wound dressings should be contained in a
plastic bag;
-He/She should provide the resident’s physician ordered wound care directly following the
resident’s shower. He/She should not leave the resident’s wounds open for an extended
time. The resident should not be in the dining room, halls and outside to smoke with open
wounds covered with a blanket. This was not good infection control practice;
-He/She did not have time to do the wound care following the resident’s shower.
2. Review of Resident #16’s care plan, dated 8/19/18, showed the following:
-[DIAGNOSES REDACTED].
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 61)
-Alteration in self-care ability related to stroke. Goal was physical needs met. Staff
should allow choices to promote sense of autonomy and control. Assist with elimination
needs as she requested;
-At risk for skin breakdown and/or urinary tract infections related to occasional urinary
incontinence. Goal was remain free of perineal irritation and/or other skin breakdown.
Staff should encourage the resident to report need for urinary elimination in a timely
manner to reduce potential for incontinence.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 11/10/18, showed the following:
-Cognitively intact;
-Required extensive assistance of two staff members with bed mobility;
-Required total assistance of two staff members with transfers and toileting;
-Frequently incontinent of bowel and bladder.
Observation on 2/7/19 at 8:18 A.M., showed the following:
-The resident was incontinent of urine;
-Nurse Aide (NA) G and Certified Medication Technician (CMT) R entered the resident’s room
and did not wash hands or apply gloves;
-CMT R with ungloved hands, rolled the resident on his/her right side. Two incontinence
pads were noted under the resident. A urine soiled rolled up incontinence pad remained
under the resident’s left hip and a second dry incontinence pad lay flat under the
resident;
-With ungloved hands NA G pulled the urine soiled incontinence pad out from under the
resident and threw the pad on the floor beside the bed;
-With ungloved soiled hands, NA G adjusted the dry incontinence pad under the resident,
touched the resident’s hip and arm, and touched the resident’s bed linens;
-NA G with ungloved hands, picked up the urine soiled incontinence pad on the floor and
placed the soiled pad in a plastic bag;
-Without washing hands NA G left the room with the bagged linens.
During telephone interview on 2/26/19 at 12:10 P.M., NA G said the following:
-He/She should wash hands every time he/she entered and left a resident’s room, anytime
hands were soiled and every time he/she changed gloves;
-He/She should not remove urine soiled linens from the residents’ beds with bare hands;
-He/She should not place soiled linens on the floor. No linens go on the floor;
-He/She should bag soiled linens and take them to the dirty utility room;
-He/She did not remember touching urine soiled bed linens with bare hands or placing the
soiled linens on the floor.
2. Review of Resident #26’s Annual MDS, dated [DATE], showed the following:
-Extensive assist of two to walk in room and for toileting;
-Always incontinent of bladder and bowel;
-Extensive assist of one staff for personal hygiene.
Review of the resident’s care plan, last revised on 12/15/18, showed:
-Supervision and encouragement with ADLs;
-Incontinent of bowel and bladder, assist with personal hygiene and toileting.
Observation on 2/7/19 at 6:35 A.M., showed the following:
-The resident lay on his/her back in bed;
-CNA J and NA K entered the room, applied gloves, sat the resident on the side of the bed,
dressed him/her and applied a gait belt;
-CNA J and NA K assisted the resident to stand;
-CNA J performed perineal care with washcloths, obtaining stool with each wipe of the
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 62)
cloth and then asked the resident if he/she wanted to sit on the toilet;
-CNA J removed his/her gloves and without washing hands, held onto the resident’s gait
belt and the resident’s walker.
During an interview on 2/28/19 at 2:22 P.M., CNA J said hands should be washed any time
they become soiled and after perineal care. Clean items should not be touched with soiled
hands.
3. Review of Resident #12’s care plan, dated 5/21/18, showed the following:
-ADL care performance deficit;
-Bladder incontinence without interventions.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Always incontinent of bladder and bowel;
-Extensive assist of one for personal hygiene.
Observation on 2/7/19 at 7:53 A.M., showed the following:-The resident lay in bed;
-CNA D entered the room, applied gloves, and without washing his/her hands, placed the
bedpan under the resident;
-CNA D removed his/her gloves, sanitized hands, exited the room, returned and without
washing hands or sanitizing, applied gloves and performed perineal care;
-CNA I entered the room and without washing his/her hands, assisted CNA D to transfer the
resident to his/her wheelchair;
-CNA D and CNA I exited the room without washing hands.
During interview on 2/8/19 at 10:28 A.M., CNA I said hands should be washed when entering
and exiting the room.
4. Review of Resident #38’s care plan, dated 5/9/18, showed the following:
-Goal: Resident will show no signs/symptoms of urinary infection through review date of
11/2/18;
-ADL self care performance deficit related [MEDICAL CONDITION] immobility;
-One staff assist with personal hygiene.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Extensive assist of two staff for transfers, ambulation in room and toilet use;
-Extensive assist of one staff for personal hygiene;
-Occasionally incontinent of bowel.
Review of the resident’s POS, dated (MONTH) 2019, showed [DIAGNOSES REDACTED].
Observation on 2/8/19 at 2:10 P.M., showed the following:
-The resident sat in his/her recliner in his/her room;
-The resident was incontinent of stool;
-CNA D entered the room and assisted the resident to the toilet;
-CNA D changed the resident’s incontinent brief and performed rectal perineal care;
-CNA D removed his/her gloves and without washing his/her hands, pulled the resident’s
pants up and assisted the resident back to his/her chair.
5. Review of Resident #27’s quarterly MDS, dated [DATE], showed the
following:-Cognitively intact;
-Extensive assist of two for bed mobility;
-Total dependence of toilet use;
-Supervision with set up only for personal hygiene;
-Always incontinent of bladder and bowel.
Review of the resident’s care plan, dated 10/3/18, showed the following:-Focus: Bladder
incontinence;
-Goal: Remain free from skin breakdown due to incontinence and brief use;
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 63)
-No interventions listed.
Review of the resident’s POS, dated (MONTH) 2019, showed [DIAGNOSES REDACTED].
Observation on 2/7/19 at 8:27 A.M., showed the following:
-The resident lay in the bed;
-CNA I entered the room and with gloved hands, untaped the resident’s urine soiled
incontinent brief and completed perineal care to the resident’s peri area, placed a clean
incontinent brief under the resident and secured the brief;
-Without changing gloves or washing hands,
-CNA I removed his/her gloves and without washing hands covered the resident, applied
clean gloves and exited the room with soiled items.
During an interview on 2/8/19 at 10:28 P.M., CNA I said hands should be washed any time
they become soiled and with glove changes. Clean items should not be touched with soiled
hands.
6. Review of Resident #6’s quarterly MDS, dated [DATE], showed his/her cognition was
severely impaired.
Review of the resident’s POS, dated 2/1/19 to 2/28/19, showed the following:
-His/Her [DIAGNOSES REDACTED].
-On 2/25/18 he/she started on [MEDICATION NAME]/solution [MEDICATION NAME] (inhaled
respiratory medication) nebulizer treatments to be administered every six hours as needed
for congestion.
Observation of the resident’s room on 2/7/19 at 7:30 A.M., showed the resident’s nebulizer
mask laid on the bedside table uncovered.
Observation of the resident’s room on 2/8/19 at 8:35 A.M., showed the resident’s nebulizer
mask was laid on the bedside table uncovered.
7. Review of Resident #40’s quarterly MDS, dated [DATE], showed the following:
-His/Her cognition was severely impaired
-He/She was dependent on assistance of one staff with personal hygiene.
Review of the resident’s POS, dated 2/1/19 to 2/28/19, showed on 1/24/19 he/she was
started on [MEDICATION NAME]/solution [MEDICATION NAME] nebulizer treatments twice a day
for two weeks.
Observation of the resident’s room on 2/7/19 at 7:40 A.M., showed his/her nebulizer mask
laid uncovered on his bedside table next to peri wash and peri-wipes.
Observation of the resident’s room on 2/7/19 at 2:50 P.M., showed his/her nebulizer mask
laid uncovered on his bedside table next to peri wash and peri-wipes.
Observation of the resident’s room on 2/8/19 at 8:40 A.M., showed his/her nebulizer mask
laid uncovered on his bedside table next to peri wash and peri-wipes.
During an interview on 2/9/19 at 1:50 P.M., CNA F said the following:
-Staff were to place nebulizer masks in a plastic bag;
-He/She had not been told to do that by the facility, but said he/she knew that was the
practice at other facilities where he/she had previously worked.
During interview on 2/13/19 at 4:30 P.M., RN H said the following:
-Residents’ nebulizer masks should be stored in plastic bags when not in use;
-He/She had only worked at the facility for a short time and was not aware of the
facility’s policy.
During an interview on 2/13/19 at 5:07 P.M., the DON said she expected nebulizer masks to
be stored in plastic bags and away from perineal wipes.
8. Review of the TB Screening for Long Term Care Residents flowchart, revised 3/11/14
showed the following:
-When a resident is admitted to a long term care facility and has no documentation of a
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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 64)
two-step [MEDICATION NAME] skin test (TST), the facility must administer the first step
TST within one month prior to or one week after admission;
-Staff is to read the results of the first step TST within 48 to 72 hours after
administration;
-If the results were negative, staff must administer the second step TST within one to
three weeks;
-Staff is to read the results of the second step TST within 48 to 72 hours.
-Results must be read and documented in millimeters (mm);
-The facility must complete an annual evaluation of residents to rule out signs and
symptoms of TB.
Review of Resident #22’s medical record showed the following:
-He/She was admitted to the facility on [DATE];
-First TST was administered on 8/11/18 and read on 8/18/18;
-Second TST administered on 8/18/18;
-Facility staff did not document results of the resident’s second TST.
Review of Resident #12’s medical record showed the following:
-He/She was admitted on [DATE];
-Review of the resident’s immunization record showed staff administered the first TST on
5/4/18, results were documented as 0 mm (millimeters), but did not include the date it was
read.
Review of Resident #27’s medical record showed the following:
-He/She was admitted on [DATE];
-Staff administered the first TST on 8/31/18 with no documentation of results;
-There was no documentation of the second TST being administered.
Review of Resident #28’s medical record showed the following:
-He/She was admitted on [DATE];
-Staff administered the first TST on 5/29/18 with no documentation of results.
9. During interview on 2/13/19 at 5:10 P.M., the DON said the following:
-Staff should wash hands after every direct resident care, during cares and after
providing incontinence care;
-Staff should wash hands, when entering and exiting resident rooms and every time gloves
were changed;
-Staff should wear gloves while providing resident cares and change gloves when gloves
were soiled. Staff should not touch urine soiled incontinence pads with bare hands and
should not throw soiled linens on the floor. Staff should not touch clean items with
soiled hands or soiled gloves;
-Clean items touched with soiled hands were contaminated;
-Staff should not place soiled wound dressings on the floor. Staff should place soiled
wound dressings in plastic bag;
-Staff should not sit directly on the shower/toilet room floor while providing residents
wound care;
-Staff should not delay providing wound care following a shower. The resident’s wounds
should not be exposed in the dining room, hallways and while outside smoking. This could
cause further infection or spread infection to others;
-Staff should follow CDC guidelines while administering and reading resident TB skin
tests. If the procedure was not completed correctly, staff should start the process over
and complete a 2 step TB skin test.

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:

265419

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

02/14/2019

NAME OF PROVIDER OF SUPPLIER

COUNTRY VIEW NURSING FACILITY, INC

STREET ADDRESS, CITY, STATE, ZIP

2106 WEST MAIN, PO BOX 330
BOWLING GREEN, MO 63334

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an Infection
Prevention and Control Program (IPCP) that included an Antibiotic Stewardship Program with
antibiotic use protocols and a system to monitor antibiotic use. The facility census was
47.
1. Review of Resident #6’s medical record showed the following:
-His/Her [DIAGNOSES REDACTED].
-On 1/9/19, he/she started a Z-pack (oral antibiotic). Staff administered [MEDICATION
NAME] (antibiotic) 500 milligrams (mg) and [MEDICATION NAME] (steroid) 50 mg
intramuscularly (IM);
-On 1/10/19, orders were obtained to administer [MEDICATION NAME] 750 mg IM daily for four
days and to discontinue the Z-pack.
2. Review of Resident #150’s medical record showed the following:
-admitted [DATE];
-[DIAGNOSES REDACTED].
-Orders for [MEDICATION NAME] (antibiotic medication) 100 mg twice daily.
3. Review of Resident #16’s medical record showed the following:
-On 1/1/19 a new physician’s orders [REDACTED].
Review of the facility’s infection control documentation on 2/8/19 at 2:30 P.M., showed
the facility had not tracked infections since (MONTH) 31, (YEAR).
During an interview on 2/8/19 at 3:30 P.M., the Director of Nursing (DON) said the
following:
-The facility did not have a Antibiotic Stewardship Program;
-The facility did not have a Antibiotic Stewardship Program policy and procedure;
-There was nothing currently being done to track and monitor infections;
-He/She was responsible for tracking infections;
-He/She skimmed through two or three resident charts a week, but had not completed whole
chart audits.