SWEET SPRINGS VILLA

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	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 three of 12 sampled residents (Resident #3, #8 and #22), that were unable to do their own activities of daily living, the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 37. 1. Review of the facility’s policy, Perineal Care, dated (MONTH) (YEAR), showed the following: -Purpose: to cleanse the perineum and to prevent infection and odor; -Female perineal care: put on disposable gloves, wet washcloth and make a mitt with it. Apply soap lightly, use one gloved hand to stabilize and separate the labia, with the other hand, wash from front to back, rinse and pat dry; -Male perineal care: put on disposable gloves, wet washcloth and make a mitt with it. Apply soap lightly, wash pubis and penis: if uncircumcised, pull back foreskin of penis and wash; carefully dry and return foreskin to normal position. Make sure shaft of penis is dry; -Turn resident away from you. Use a new washcloth and wash around the anus. Rinse and dry. 2. Review of the facility’s policy, Oral Hygiene, dated (MONTH) (YEAR), showed the following: -Purpose: to cleanse the mouth, teeth and dentures; -Offer oral hygiene before breakfast, after each meal and at bedtime. 3. Review of the facility’s policy, Shaving the Resident, dated (MONTH) (YEAR), showed the following: -Purpose: to remove facial hair and improve the resident’s appearance and morale; -The facility’s policy does not instruct staff on when to shave residents. 4. Review of Resident #3’s Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/17/19, showed the following: -Cognitively intact; -Required total assistance of two staff for toileting; -Required total assistance of one staff for personal hygiene; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan dated 4/4/19 and last reviewed 6/19/19 showed the following: -At risk for skin breakdown and falls due to incontinence/limited mobility; -Barrier cream after each incontinence episode; -Check for incontinence upon rising, before and after meals, at bedtime and as needed. Observation of the resident on 7/17/19 6:18 A.M., showed the following: -The resident lay on his/her back in bed; -Certified Nurse Assistant (CNA) A picked up a disposable wipe, cleansed the groin areas and front genitalia and folded the wipe after each swipe; -CNA A assisted the resident to roll to his/her right side; -The resident was incontinent of black tarry feces; -Using the same cloth surface, CNA C cleansed the buttocks with a back and forth motion; -CNA C placed a clean incontinence brief behind the resident; -CNA A assisted the resident to roll to his/her back; -CNA A cleansed the groin areas again to remove feces and secured the incontinence brief;

(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

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 three of 12 sampled residents (Resident #3, #8 and #22), that were unable
to do their own activities of daily living, the necessary care and services to maintain
good personal hygiene and prevent body odor. The facility census was 37.
1. Review of the facility’s policy, Perineal Care, dated (MONTH) (YEAR), showed the
following:
-Purpose: to cleanse the perineum and to prevent infection and odor;
-Female perineal care: put on disposable gloves, wet washcloth and make a mitt with it.
Apply soap lightly, use one gloved hand to stabilize and separate the labia, with the
other hand, wash from front to back, rinse and pat dry;
-Male perineal care: put on disposable gloves, wet washcloth and make a mitt with it.
Apply soap lightly, wash pubis and penis: if uncircumcised, pull back foreskin of penis
and wash; carefully dry and return foreskin to normal position. Make sure shaft of penis
is dry;
-Turn resident away from you. Use a new washcloth and wash around the anus. Rinse and dry.
2. Review of the facility’s policy, Oral Hygiene, dated (MONTH) (YEAR), showed the
following:
-Purpose: to cleanse the mouth, teeth and dentures;
-Offer oral hygiene before breakfast, after each meal and at bedtime.
3. Review of the facility’s policy, Shaving the Resident, dated (MONTH) (YEAR), showed the
following:
-Purpose: to remove facial hair and improve the resident’s appearance and morale;
-The facility’s policy does not instruct staff on when to shave residents.
4. Review of Resident #3’s Admission Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 4/17/19, showed
the following:
-Cognitively intact;
-Required total assistance of two staff for toileting;
-Required total assistance of one staff for personal hygiene;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan dated 4/4/19 and last reviewed 6/19/19 showed the
following:
-At risk for skin breakdown and falls due to incontinence/limited mobility;
-Barrier cream after each incontinence episode;
-Check for incontinence upon rising, before and after meals, at bedtime and as needed.
Observation of the resident on 7/17/19 6:18 A.M., showed the following:
-The resident lay on his/her back in bed;
-Certified Nurse Assistant (CNA) A picked up a disposable wipe, cleansed the groin areas
and front genitalia and folded the wipe after each swipe;
-CNA A assisted the resident to roll to his/her right side;
-The resident was incontinent of black tarry feces;
-Using the same cloth surface, CNA C cleansed the buttocks with a back and forth motion;
-CNA C placed a clean incontinence brief behind the resident;
-CNA A assisted the resident to roll to his/her back;
-CNA A cleansed the groin areas again to remove feces and secured the incontinence brief;

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

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

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265606

If continuation sheet
Page 1 of 10

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 1) -CNA A and CNA C dressed the lower half of the resident and transferred the resident with a mechanical lift to his/her wheelchair; -CNA A and CNA C dressed the top portion of the resident’s body, applied deodorant and perfume to the resident, and brushed the resident’s hair; -Staff wheeled the resident to the dining room for breakfast; -Staff provided neither offered or provided oral care. Observation on 7/17/19 at 7:49 A.M., showed CNA A brought the resident back to his/her room from breakfast. CNA A neither offered or provided oral care. During interview on 7/17/19 at 7:50 A.M., the resident mouthed no when asked if staff provided oral care before or after breakfast. Resident mouthed yes when asked if he/she would like staff to provide oral care. During interview on 7/18/19 at 9:31 A.M., CNA A said the following: -Staff should cleanse the groin areas, the frontal genitalia, buttocks and gluteal crease when providing peri-care; -Staff should fold the cloth after each wipe or get a new cloth for each wipe; -Staff should not repeatedly cleanse an area using the same cloth surface due to contamination; -Staff should be providing oral care when getting the residents up in the morning; -If a resident does not have teeth then staff should use mouth swabs to clean the resident’s gums; -He/she should have offered oral care to Resident #3 but forgot. During interview on 7/18/19 at 9:40 A.M., CNA C said the following: -Staff should cleanse the groin areas, the front genitalia wiping front to back, the buttocks and gluteal crease; -Staff should brush a resident’s teeth or use mouth swabs in the morning. 5. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/23/19 showed the following: -Severely impaired cognition; -Required extensive assistance of two staff members with personal hygiene, bed mobility and toileting; -Always incontinent of bowel and bladder. Review of the resident’s care plan last reviewed/revised 7/17/19 showed the following: -The resident was limited in his/her ability to perform activities of daily living (ADLs) related to history [MEDICAL CONDITION] weakness; -Needs one assist with bed mobility, locomotion on unit, dressing and hygiene; -Provide full assistance with toileting every two hours and as needed; -At risk for for pressure ulcers, keep clean and dry as possible, minimize exposure to moisture. Observation of the resident on 7/16/19 showed the following: -At 10:30 A.M. the resident was unshaven with unkempt facial and chin hair growth; -At 5:03 P.M. the resident remained unshaven. Observation on 7/17/19 at 6:53 A.M. showed the resident was unshaven with unkempt facial and chin hair growth, and more prominent than the day before. Observation on 7/17/19 at approximately 7:00 A.M. showed the following: -CNA A and CNA C entered the resident’s room and prepared to get the resident up for the day; -CNA A and CNA C unfastened the resident’s dry incontinence brief, CNA A provided front pericare; -CNA A and CNA C assisted the resident to his/her left side, the resident was incontinent

(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 1)
-CNA A and CNA C dressed the lower half of the resident and transferred the resident with
a mechanical lift to his/her wheelchair;
-CNA A and CNA C dressed the top portion of the resident’s body, applied deodorant and
perfume to the resident, and brushed the resident’s hair;
-Staff wheeled the resident to the dining room for breakfast;
-Staff provided neither offered or provided oral care.
Observation on 7/17/19 at 7:49 A.M., showed CNA A brought the resident back to his/her
room from breakfast. CNA A neither offered or provided oral care.
During interview on 7/17/19 at 7:50 A.M., the resident mouthed no when asked if staff
provided oral care before or after breakfast. Resident mouthed yes when asked if he/she
would like staff to provide oral care.
During interview on 7/18/19 at 9:31 A.M., CNA A said the following:
-Staff should cleanse the groin areas, the frontal genitalia, buttocks and gluteal crease
when providing peri-care;
-Staff should fold the cloth after each wipe or get a new cloth for each wipe;
-Staff should not repeatedly cleanse an area using the same cloth surface due to
contamination;
-Staff should be providing oral care when getting the residents up in the morning;
-If a resident does not have teeth then staff should use mouth swabs to clean the
resident’s gums;
-He/she should have offered oral care to Resident #3 but forgot.
During interview on 7/18/19 at 9:40 A.M., CNA C said the following:
-Staff should cleanse the groin areas, the front genitalia wiping front to back, the
buttocks and gluteal crease;
-Staff should brush a resident’s teeth or use mouth swabs in the morning.
5. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/23/19 showed the following:
-Severely impaired cognition;
-Required extensive assistance of two staff members with personal hygiene, bed mobility
and toileting;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan last reviewed/revised 7/17/19 showed the following:
-The resident was limited in his/her ability to perform activities of daily living (ADLs)
related to history [MEDICAL CONDITION] weakness;
-Needs one assist with bed mobility, locomotion on unit, dressing and hygiene;
-Provide full assistance with toileting every two hours and as needed;
-At risk for for pressure ulcers, keep clean and dry as possible, minimize exposure to
moisture.
Observation of the resident on 7/16/19 showed the following:
-At 10:30 A.M. the resident was unshaven with unkempt facial and chin hair growth;
-At 5:03 P.M. the resident remained unshaven.
Observation on 7/17/19 at 6:53 A.M. showed the resident was unshaven with unkempt facial
and chin hair growth, and more prominent than the day before.
Observation on 7/17/19 at approximately 7:00 A.M. showed the following:
-CNA A and CNA C entered the resident’s room and prepared to get the resident up for the
day;
-CNA A and CNA C unfastened the resident’s dry incontinence brief, CNA A provided front
pericare;
-CNA A and CNA C assisted the resident to his/her left side, the resident was incontinent

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 2) of a large amount of urine, urine ran between the resident’s buttocks and down between the resident’s legs; – CNA A cleansed the resident’s thigh and inner buttocks area with disposable wipes, CNA A tucked a clean incontinence brief into place under the resident; -CNA A and CNA C assisted the resident to his/her back and pulled the resident’s incontinence brief up into place and fastened without providing front pericare; -CNA A and CNA C dressed the resident and transferred the resident to his/her wheelchair by mechanical lift; -CNA A combed the resident’s hair and pushed the resident in his/her wheelchair to the dining room, CNA A did not offer to assist the resident with oral care. During interview on 7/17/19 at 8:00 A.M., the resident said if he/she had his/her mouth cleaned it would make his/her mouth feel fresh. Observation on 7/17/19 at 2:00 P.M. showed the resident remained unshaven. Observation on 7/18/19 at 8:00 A.M. showed the resident was unshaven with unkempt facial and chin hair growth, and more prominent than the day before. During interview on 7/18/19 at 9:00 A.M. the resident said when he/she was at home he/she shaved his/her facial hair with a razor, he/she could not see to shave now, (the resident touched his/her facial area) he/she did not like it when it was long like it was. During interview on 7/18/19 at 10:26 A.M., CNA A said the following: -He/She should always offer resident’s oral care but he/she did not; -The resident was always incontinent of urine when he/she was turned on his/her side, he/she forgot to provide front pericare after the resident was incontinent; -Staff normally shaved the resident on shower day, the resident refused his/her shower yesterday but staff should still offer to shave the resident. 6. Review of Resident #22’s quarterly MDS dated [DATE] showed the following: -Intact cognition; -Independent with personal hygiene; -Rejection of care not exhibited. Review of the resident’s care plan last revised 7/17/19 showed the following: -[DIAGNOSES REDACTED]. -The resident resists cares at times and refuses showers, explain importance of showers for hygiene; -Follow familiar routines, maintain a calm environment and approach to the resident. Observation on 7/16/19 at 11:10 A.M., showed the resident sat in his/her room unkempt, unshaven with significant hair growth to his/her chin and facial area. Observation on 7/17/19 at 8:00 A.M., showed the resident was unshaven with unkempt facial and chin hair growth, and more prominent than the day before. Observation on 7/18/19 at 9:13 A.M., showed the resident sat in his/her room unshaven, with unkempt facial and chin hair growth, and more prominent than the day before. During interview on 7/19/19 at 10:26 A.M., CNA A said the resident often refused to allow him/her to shave him/her. The resident had a connection with one of the CNAs and that specific aide could assist the resident with shaving and ADLs without any difficulties. The facility should make it a point to assure that aide shaved the resident routinely so it would be done. 7. During interview on 7/18/19 at 12:15 P.M., the Director of Nurses said the following: -Staff should cleanse the frontal genitalia from front to back and the groin areas; -Staff should cleanse any skin area that had been soiled; -Staff should fold the wipe after each swipe. If the wipe becomes soiled with feces then staff should get a new wipe after each swipe;

(X4) ID PREFIX TAG

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

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
of a large amount of urine, urine ran between the resident’s buttocks and down between the
resident’s legs;
– CNA A cleansed the resident’s thigh and inner buttocks area with disposable wipes, CNA A
tucked a clean incontinence brief into place under the resident;
-CNA A and CNA C assisted the resident to his/her back and pulled the resident’s
incontinence brief up into place and fastened without providing front pericare;
-CNA A and CNA C dressed the resident and transferred the resident to his/her wheelchair
by mechanical lift;
-CNA A combed the resident’s hair and pushed the resident in his/her wheelchair to the
dining room, CNA A did not offer to assist the resident with oral care.
During interview on 7/17/19 at 8:00 A.M., the resident said if he/she had his/her mouth
cleaned it would make his/her mouth feel fresh.
Observation on 7/17/19 at 2:00 P.M. showed the resident remained unshaven.
Observation on 7/18/19 at 8:00 A.M. showed the resident was unshaven with unkempt facial
and chin hair growth, and more prominent than the day before.
During interview on 7/18/19 at 9:00 A.M. the resident said when he/she was at home he/she
shaved his/her facial hair with a razor, he/she could not see to shave now, (the resident
touched his/her facial area) he/she did not like it when it was long like it was.
During interview on 7/18/19 at 10:26 A.M., CNA A said the following:
-He/She should always offer resident’s oral care but he/she did not;
-The resident was always incontinent of urine when he/she was turned on his/her side,
he/she forgot to provide front pericare after the resident was incontinent;
-Staff normally shaved the resident on shower day, the resident refused his/her shower
yesterday but staff should still offer to shave the resident.
6. Review of Resident #22’s quarterly MDS dated [DATE] showed the following:
-Intact cognition;
-Independent with personal hygiene;
-Rejection of care not exhibited.
Review of the resident’s care plan last revised 7/17/19 showed the following:
-[DIAGNOSES REDACTED].
-The resident resists cares at times and refuses showers, explain importance of showers
for hygiene;
-Follow familiar routines, maintain a calm environment and approach to the resident.
Observation on 7/16/19 at 11:10 A.M., showed the resident sat in his/her room unkempt,
unshaven with significant hair growth to his/her chin and facial area.
Observation on 7/17/19 at 8:00 A.M., showed the resident was unshaven with unkempt facial
and chin hair growth, and more prominent than the day before.
Observation on 7/18/19 at 9:13 A.M., showed the resident sat in his/her room unshaven,
with unkempt facial and chin hair growth, and more prominent than the day before.
During interview on 7/19/19 at 10:26 A.M., CNA A said the resident often refused to allow
him/her to shave him/her. The resident had a connection with one of the CNAs and that
specific aide could assist the resident with shaving and ADLs without any difficulties.
The facility should make it a point to assure that aide shaved the resident routinely so
it would be done.
7. During interview on 7/18/19 at 12:15 P.M., the Director of Nurses said the following:
-Staff should cleanse the frontal genitalia from front to back and the groin areas;
-Staff should cleanse any skin area that had been soiled;
-Staff should fold the wipe after each swipe. If the wipe becomes soiled with feces then
staff should get a new wipe after each swipe;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 3) -If a resident voids during personal cares then she would expect staff to cleanse the soiled area again; -Morning cares would consist of providing pericare, washing the resident’s face and hands, providing oral care, dressing the resident and brushing the resident’s hair; -If a resident does not have teeth, then staff should clean the resident’s mouth with swabs; -If a resident refuses oral care, staff should at least offer to do the oral care for the resident or offer to set them up to perform the task themselves; -Staff are encouraged to shave any resident who needs shaved after breakfast and especially during showers.
	F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff provided incontinence care according to accepted standards of practice to prevent urinary tract infections (UTIs) for one resident (Resident #2) and the facility failed to keep the catheter (sterile tube inserted in to the bladder to drain urine) bag off the floor for one resident (Resident #33) in a sample of 12 residents. The facility reported one resident with a catheter. The facility census was 37. 1. Review of the facility’s policy, Catheter Care, dated (MONTH) (YEAR), showed it failed to direct staff to keep the catheter bag, tubing and dignity bag off the floor. 2. 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. 3. Review of Resident #33’s urinalysis (UA), dated 5/20/19, showed the following: -Urine color: red (normal is yellow); -Urine appearance: cloudy (normal is clear); -Urine blood: large amount (normal is negative); -Urine leukocyte esterase: large amount (normal is negative); -Urine red blood cells: greater than 50 (normal is 0-5/high power field (hpf)); -Urine white blood cells: greater than 100 (normal is 0-5/hpf); -Urine bacteria: many (normal is negative). Review of the resident’s hospital note, dated 6/3/19, showed a [DIAGNOSES REDACTED]. Review of the resident’s Physician order [REDACTED].>Review of the resident’s Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 6/12/19, showed the following: -Moderately impaired cognition; -Required total assistance of two staff for toileting; -Required extensive assistance of two staff for personal hygiene;

(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 3)
-If a resident voids during personal cares then she would expect staff to cleanse the
soiled area again;
-Morning cares would consist of providing pericare, washing the resident’s face and hands,
providing oral care, dressing the resident and brushing the resident’s hair;
-If a resident does not have teeth, then staff should clean the resident’s mouth with
swabs;
-If a resident refuses oral care, staff should at least offer to do the oral care for the
resident or offer to set them up to perform the task themselves;
-Staff are encouraged to shave any resident who needs shaved after breakfast and
especially during showers.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview, the facility failed to ensure staff
provided incontinence care according to accepted standards of practice to prevent urinary
tract infections (UTIs) for one resident (Resident #2) and the facility failed to keep the
catheter (sterile tube inserted in to the bladder to drain urine) bag off the floor for
one resident (Resident #33) in a sample of 12 residents. The facility reported one
resident with a catheter. The facility census was 37.
1. Review of the facility’s policy, Catheter Care, dated (MONTH) (YEAR), showed it failed
to direct staff to keep the catheter bag, tubing and dignity bag off the floor.
2. 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.
3. Review of Resident #33’s urinalysis (UA), dated 5/20/19, showed the following:
-Urine color: red (normal is yellow);
-Urine appearance: cloudy (normal is clear);
-Urine blood: large amount (normal is negative);
-Urine leukocyte esterase: large amount (normal is negative);
-Urine red blood cells: greater than 50 (normal is 0-5/high power field (hpf));
-Urine white blood cells: greater than 100 (normal is 0-5/hpf);
-Urine bacteria: many (normal is negative).
Review of the resident’s hospital note, dated 6/3/19, showed a [DIAGNOSES REDACTED].
Review of the resident’s Physician order [REDACTED].>Review of the resident’s Admission
Minimum Data Set (MDS), a federally mandated assessment instrument required to be
completed by facility staff, dated 6/12/19, showed the following:
-Moderately impaired cognition;
-Required total assistance of two staff for toileting;
-Required extensive assistance of two staff for personal hygiene;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 4) -Indwelling catheter; -Received an antibiotic in the last seven days. Review of the resident’s care plan, dated 6/5/19 and last reviewed on 7/16/19, showed the following: -Potential for UTI related to use of catheter; -Assess for UTI signs and symptoms; -Use principals of infection control and universal/standard precautions when doing any treatments or catheter care. Observations on 7/17/19 showed the following: -At 05:05 A.M., the resident lay on his/her back in a low bed with the catheter hooked to bed frame and laying on the floor. The catheter bag was not covered with a dignity bag; -At 05:21 A.M., the resident lay on his/her back in a low bed with the catheter hooked to bed frame and laying on the floor. The catheter bag was not covered with a dignity bag; -At 05:51 A.M., the resident lay on his/her back in a low bed with the catheter hooked to bed frame and laying on the floor. The catheter bag was not covered with a dignity bag; -At 06:10 A.M., the resident lay on his/her back in a low bed with the catheter hooked to bed frame and laying on the floor. The catheter bag was not covered with a dignity bag; -At 06:46 A.M., the resident lay on his/her back in a low bed with the catheter covered with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the floor; -At 07:10 A.M., the resident lay on his/her back in a low bed with the catheter covered with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the floor; -At 07:23 A.M., the resident lay on his/her back in a low bed with the catheter covered with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the floor; -At 08:12 A.M., the resident lay on his/her back in a low bed with the catheter covered with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the floor; -At 11:12 A.M., the resident lay on his/her back in a low bed with the catheter covered with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the floor. Observation on 07/18/19 at 07:50 A.M., the resident lay on his/her back in a low bed with the catheter covered with a dignity bag, the catheter bag was hooked on bed frame and the dignity bag touched the floor. During interview on 7/18/19 at 9:31 A.M., (Certified Nurse Assistant) CNA A said no part of the catheter bag, dignity bag or tubing should be touching the floor due to contamination. 4. Review of Resident #2’s Significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/12/19, showed the following: -Severely impaired cognition; -Required extensive assistance of one staff for toileting and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s urinalysis UA, dated 6/24/19, showed the following: -Cloudy color (normal is clear); -Protein 30mg/dl (normal is negative); -[MEDICATION NAME] positive (normal is negative), positive indicates presence of bacteria;

(X4) ID PREFIX TAG

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

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-Indwelling catheter;
-Received an antibiotic in the last seven days.
Review of the resident’s care plan, dated 6/5/19 and last reviewed on 7/16/19, showed the
following:
-Potential for UTI related to use of catheter;
-Assess for UTI signs and symptoms;
-Use principals of infection control and universal/standard precautions when doing any
treatments or catheter care.
Observations on 7/17/19 showed the following:
-At 05:05 A.M., the resident lay on his/her back in a low bed with the catheter hooked to
bed frame and laying on the floor. The catheter bag was not covered with a dignity bag;
-At 05:21 A.M., the resident lay on his/her back in a low bed with the catheter hooked to
bed frame and laying on the floor. The catheter bag was not covered with a dignity bag;
-At 05:51 A.M., the resident lay on his/her back in a low bed with the catheter hooked to
bed frame and laying on the floor. The catheter bag was not covered with a dignity bag;
-At 06:10 A.M., the resident lay on his/her back in a low bed with the catheter hooked to
bed frame and laying on the floor. The catheter bag was not covered with a dignity bag;
-At 06:46 A.M., the resident lay on his/her back in a low bed with the catheter covered
with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the
floor;
-At 07:10 A.M., the resident lay on his/her back in a low bed with the catheter covered
with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the
floor;
-At 07:23 A.M., the resident lay on his/her back in a low bed with the catheter covered
with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the
floor;
-At 08:12 A.M., the resident lay on his/her back in a low bed with the catheter covered
with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the
floor;
-At 11:12 A.M., the resident lay on his/her back in a low bed with the catheter covered
with a dignity bag, the catheter bag hooked on bed frame and the dignity bag touched the
floor.
Observation on 07/18/19 at 07:50 A.M., the resident lay on his/her back in a low bed with
the catheter covered with a dignity bag, the catheter bag was hooked on bed frame and the
dignity bag touched the floor.
During interview on 7/18/19 at 9:31 A.M., (Certified Nurse Assistant) CNA A said no part
of the catheter bag, dignity bag or tubing should be touching the floor due to
contamination.
4. Review of Resident #2’s Significant change Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 4/12/19, showed
the following:
-Severely impaired cognition;
-Required extensive assistance of one staff for toileting and personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s urinalysis UA, dated 6/24/19, showed the following:
-Cloudy color (normal is clear);
-Protein 30mg/dl (normal is negative);
-[MEDICATION NAME] positive (normal is negative), positive indicates presence of bacteria;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0690 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 5) -Large amount leukocyte esterase, (normal is negative), increase indicates infection; -White blood cell too numerous to count (TNTC), (normal is 0-4); -5-15 Red blood cells, (normal is 0-4); -Rare amount of bacteria, (normal is none). Review of UA culture and sensitivity, dated 6/27/19, showed greater than 100,000 colony forming unit/milliliter (CFU/ml) of Escherichia coli (bacteria commonly found in the intestine). Review of the resident’s Physician order [REDACTED]. -[DIAGNOSES REDACTED]. -On 6/28/19 an order for [REDACTED]. Review of the resident’s care plan, dated 1/13/18 and last reviewed on 7/17/19, showed the following: -At risk for skin breakdown due to occasional bladder and bowel incontinence; -Check for incontinence upon arising, before and after meals, at bedtime and as needed; -Provide peri-care after each incontinence episode -On 6/18/19 an order for [REDACTED]. Observation on 07/18/19 at 07:59 A.M., showed the following: -The resident lay on his/her back in bed; -CNA A entered the resident’s room, washed his/her hands and put on gloves; -CNA A pulled down the front of the incontinence brief; -The resident was incontinent of urine; -CNA A provided peri-care to the front genitalia; -CNA A assisted the resident to roll to his/her left side in bed; -Using a back and forth motion, CNA A cleansed the resident’s buttock three times with the same cloth surface of the wash cloth; -CNA A tucked the soiled brief under the resident, assisted the resident to roll to his/her right side and removed the brief. During interview on 7/18/19 at 9:31 A.M., CNA A said the following: -Staff should cleanse the groin areas, the frontal genitalia, buttocks and gluteal crease when providing pericare; -Staff should fold the cloth after each swipe or get a new cloth for each swipe; -Staff should not repeatedly cleanse an area using the same cloth surface. During interview on 7/18/19 at 9:40 A.M., CNA C said the following: -Staff should cleanse the groin areas, the front genitalia wiping front to back, the buttocks and gluteal crease; -Staff should change the cloth surfaces with each swipe or get a new wipe for each swipe. 5. During interview on 7/18/19 at 12:15 P.M., the Director of Nurses said the following: -Staff should keep the catheter bag in the lowest position; -It is hard to keep the catheter bag and dignity bag off the floor when the resident is in a low bed; -No part of the catheter tubing, bag or dignity bag should touch the floor due to contamination.
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	Provide and implement an infection prevention and control program. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY

(X4) ID PREFIX TAG

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

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
-Large amount leukocyte esterase, (normal is negative), increase indicates infection;
-White blood cell too numerous to count (TNTC), (normal is 0-4);
-5-15 Red blood cells, (normal is 0-4);
-Rare amount of bacteria, (normal is none).
Review of UA culture and sensitivity, dated 6/27/19, showed greater than 100,000 colony
forming unit/milliliter (CFU/ml) of Escherichia coli (bacteria commonly found in the
intestine).
Review of the resident’s Physician order [REDACTED].
-[DIAGNOSES REDACTED].
-On 6/28/19 an order for [REDACTED].
Review of the resident’s care plan, dated 1/13/18 and last reviewed on 7/17/19, showed the
following:
-At risk for skin breakdown due to occasional bladder and bowel incontinence;
-Check for incontinence upon arising, before and after meals, at bedtime and as needed;
-Provide peri-care after each incontinence episode
-On 6/18/19 an order for [REDACTED].
Observation on 07/18/19 at 07:59 A.M., showed the following:
-The resident lay on his/her back in bed;
-CNA A entered the resident’s room, washed his/her hands and put on gloves;
-CNA A pulled down the front of the incontinence brief;
-The resident was incontinent of urine;
-CNA A provided peri-care to the front genitalia;
-CNA A assisted the resident to roll to his/her left side in bed;
-Using a back and forth motion, CNA A cleansed the resident’s buttock three times with the
same cloth surface of the wash cloth;
-CNA A tucked the soiled brief under the resident, assisted the resident to roll to
his/her right side and removed the brief.
During interview on 7/18/19 at 9:31 A.M., CNA A said the following:
-Staff should cleanse the groin areas, the frontal genitalia, buttocks and gluteal crease
when providing pericare;
-Staff should fold the cloth after each swipe or get a new cloth for each swipe;
-Staff should not repeatedly cleanse an area using the same cloth surface.
During interview on 7/18/19 at 9:40 A.M., CNA C said the following:
-Staff should cleanse the groin areas, the front genitalia wiping front to back, the
buttocks and gluteal crease;
-Staff should change the cloth surfaces with each swipe or get a new wipe for each swipe.
5. During interview on 7/18/19 at 12:15 P.M., the Director of Nurses said the following:
-Staff should keep the catheter bag in the lowest position;
-It is hard to keep the catheter bag and dignity bag off the floor when the resident is in
a low bed;
-No part of the catheter tubing, bag or dignity bag should touch the floor due to
contamination.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 6) Based on observation, record review, and staff interview, the facility staff failed to practice acceptable infection control practices and prevent cross-contamination during the provision of care for three residents (Resident #2, #3 and #8) in a review of 12 sampled residents. The facility failed to have a plan on how to test for Legionella and what to do if Legionella was found. The facility census was 37. 1. Review of the facility’s policy, Handwashing, dated (MONTH) (YEAR), showed the purpose is to reduce transmission of organisms from resident to resident, from nursing staff to resident; and from resident to nursing staff. Review of the facility’s policy, Gloves, dated (MONTH) (YEAR), showed the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact wit mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash. Gloves must be changed between residents and between contacts with different body sites of the same residents. If the glove is torn or a needle stick or other injury occurs, the glove should be removed, discarded in the trash and a new glove used promptly as resident safety permits; -REMEMBER: Gloves are not a cure-all. They should reduce the likelihood of contaminating the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects. Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. Handling medical equipment and devices with contaminated gloves is not acceptable. 2. Review of the undated facility policy, Water Management Program to Reduce Legionella Growth showed the following: -Policy: Our facility will develop and implement a Water Management Program to inhibit microbial growth in building systems that reduce the risk of growth and spread Legionella and opportunistic pathogens in water Purpose: To establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -The facility will create a water management committee which will consist of the administrator, Director of Nursing, and Maintenance Director; -The water management committee will implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures, such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -The water management committee will specify testing protocols and acceptable ranges for control measures, and document the results of testing and correction actions taken when control limits are not maintained. During interview on 7/18/19 at 8:08 A.M., the Maintenance Supervisor said the facility did not have a CDC toolkit as the facility policy indicated. The facility removed a fish pond and a fountain a couple years ago. He did not feel the facility was the type of facility that was at risk for Legionella. The facility did not complete any type of annual cleaning or disinfecting as indicated per the facility policy or testing for environmental pathogens. He had only heard about Legionella but had not received any training on it. He did not know what specific areas in the facility would be considered at risk for Legionella or what would need to be tested . The facility did complete a monthly water inspection checklist, which included visual inspection and water temperature testing. During interview on 7/18/19 at 10:45 A.M. the Administrator said the facility had a policy that addressed Legionella. The policy was put in place a couple years ago. The facility

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 6)
Based on observation, record review, and staff interview, the facility staff failed to
practice acceptable infection control practices and prevent cross-contamination during the
provision of care for three residents (Resident #2, #3 and #8) in a review of 12 sampled
residents. The facility failed to have a plan on how to test for Legionella and what to do
if Legionella was found. The facility census was 37.
1. Review of the facility’s policy, Handwashing, dated (MONTH) (YEAR), showed the purpose
is to reduce transmission of organisms from resident to resident, from nursing staff to
resident; and from resident to nursing staff.
Review of the facility’s policy, Gloves, dated (MONTH) (YEAR), showed the following:
-Wear gloves when it can be reasonably anticipated that hands will be in contact wit
mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound
drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these
substances) and/or persons with a rash. Gloves must be changed between residents and
between contacts with different body sites of the same residents. If the glove is torn or
a needle stick or other injury occurs, the glove should be removed, discarded in the trash
and a new glove used promptly as resident safety permits;
-REMEMBER: Gloves are not a cure-all. They should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects.
Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a
glove easier than to the skin on your hands. Handling medical equipment and devices with
contaminated gloves is not acceptable.
2. Review of the undated facility policy, Water Management Program to Reduce Legionella
Growth showed the following:
-Policy: Our facility will develop and implement a Water Management Program to inhibit
microbial growth in building systems that reduce the risk of growth and spread Legionella
and opportunistic pathogens in water Purpose: To establish and maintain an infection
prevention and control program designed to provide safe, sanitary, and comfortable
environment and to help prevent the development and transmission of communicable diseases
and infections;
-The facility will create a water management committee which will consist of the
administrator, Director of Nursing, and Maintenance Director;
-The water management committee will implement a water management program that considers
the ASHRAE industry standard and the CDC toolkit, and includes control measures, such as
physical controls, temperature management, disinfectant level control, visual inspections,
and environmental testing for pathogens;
-The water management committee will specify testing protocols and acceptable ranges for
control measures, and document the results of testing and correction actions taken when
control limits are not maintained.
During interview on 7/18/19 at 8:08 A.M., the Maintenance Supervisor said the facility did
not have a CDC toolkit as the facility policy indicated. The facility removed a fish pond
and a fountain a couple years ago. He did not feel the facility was the type of facility
that was at risk for Legionella. The facility did not complete any type of annual cleaning
or disinfecting as indicated per the facility policy or testing for environmental
pathogens. He had only heard about Legionella but had not received any training on it. He
did not know what specific areas in the facility would be considered at risk for
Legionella or what would need to be tested . The facility did complete a monthly water
inspection checklist, which included visual inspection and water temperature testing.
During interview on 7/18/19 at 10:45 A.M. the Administrator said the facility had a policy
that addressed Legionella. The policy was put in place a couple years ago. The facility

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 7) assessment identified a fountain and a water feature that were at risk to harbor pathogens at that time, and those items were removed from the facility. She was not sure what would be tested or what areas in the facility were identified at risk now. The facility did not complete annual testing for Legionella. She felt the facility needed training on Legionella. 3. Review of Resident #3’s Admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/17/19, showed the following: -Cognitively intact; -Required total assistance of two staff for toileting; -Required total assistance of one staff for personal hygiene; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan dated 4/4/19 and last reviewed 6/19/19 showed the following: -At risk for skin breakdown and falls due to incontinence/limited mobility; -Check for incontinence upon rising, before and after meals, at bedtime and as needed. Observation on 7/17/18 at 6:18 A.M., showed the following: -The resident lay on his/her back in bed; -Certified Nurse Assistant (CNA) A entered the resident’s room, washed hands and put on gloves; -CNA C washed his/her hands and put on gloves; -CNA A pulled disposable wipes out of the container repeatedly with his/her soiled gloved hand and provided peri-care to the resident’s front genitalia; -Wearing the same soiled gloves, CNA A assisted the resident to roll to his/her right side; -The resident was incontinent of black tarry stool; -CNA C cleaned the buttocks and gluteal crease; -Wearing the same soiled gloves, CNA C opened the bedside table drawer, picked up a tube of barrier cream, squeezed the barrier cream onto his/her dirty gloved hand, applied the cream to the resident’s right buttock, placed the tube of barrier cream back in the bedside table drawer and closed the drawer; -Wearing the same soiled gloves, CNA C picked up the clean incontinence brief and positioned the brief behind the resident; -Wearing the same soiled gloves, CNA A assisted the resident to roll to his/her back, cleansed the resident’s groin areas again and secured the resident’s incontinence brief. During interview on 7/18/19 at 9:31 A.M., CNA A said the following: -Staff should wash their hands upon entering a room, between glove changes, after providing peri-care and before leaving a room; -Staff should wash their hands or use hand sanitizer in between glove changes; -Staff should remove their gloves and wash hands before touching anything considered clean due to contamination. During 7/18/19 at 9:40 A.M., CNA C said the following: -Staff should wash their hands upon entering a room, between glove changes, after providing pericare and before leaving a room; -Staff should change their gloves and wash hands before touching clean items due to contamination. 4. Review of Resident #2’s Significant change MDS, dated [DATE], showed the following: -Severely impaired cognition;

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 7)
assessment identified a fountain and a water feature that were at risk to harbor pathogens
at that time, and those items were removed from the facility. She was not sure what would
be tested or what areas in the facility were identified at risk now. The facility did not
complete annual testing for Legionella. She felt the facility needed training on
Legionella.
3. Review of Resident #3’s Admission Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 4/17/19, showed
the following:
-Cognitively intact;
-Required total assistance of two staff for toileting;
-Required total assistance of one staff for personal hygiene;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan dated 4/4/19 and last reviewed 6/19/19 showed the
following:
-At risk for skin breakdown and falls due to incontinence/limited mobility;
-Check for incontinence upon rising, before and after meals, at bedtime and as needed.
Observation on 7/17/18 at 6:18 A.M., showed the following:
-The resident lay on his/her back in bed;
-Certified Nurse Assistant (CNA) A entered the resident’s room, washed hands and put on
gloves;
-CNA C washed his/her hands and put on gloves;
-CNA A pulled disposable wipes out of the container repeatedly with his/her soiled gloved
hand and provided peri-care to the resident’s front genitalia;
-Wearing the same soiled gloves, CNA A assisted the resident to roll to his/her right
side;
-The resident was incontinent of black tarry stool;
-CNA C cleaned the buttocks and gluteal crease;
-Wearing the same soiled gloves, CNA C opened the bedside table drawer, picked up a tube
of barrier cream, squeezed the barrier cream onto his/her dirty gloved hand, applied the
cream to the resident’s right buttock, placed the tube of barrier cream back in the
bedside table drawer and closed the drawer;
-Wearing the same soiled gloves, CNA C picked up the clean incontinence brief and
positioned the brief behind the resident;
-Wearing the same soiled gloves, CNA A assisted the resident to roll to his/her back,
cleansed the resident’s groin areas again and secured the resident’s incontinence brief.
During interview on 7/18/19 at 9:31 A.M., CNA A said the following:
-Staff should wash their hands upon entering a room, between glove changes, after
providing peri-care and before leaving a room;
-Staff should wash their hands or use hand sanitizer in between glove changes;
-Staff should remove their gloves and wash hands before touching anything considered clean
due to contamination.
During 7/18/19 at 9:40 A.M., CNA C said the following:
-Staff should wash their hands upon entering a room, between glove changes, after
providing pericare and before leaving a room;
-Staff should change their gloves and wash hands before touching clean items due to
contamination.
4. Review of Resident #2’s Significant change MDS, dated [DATE], showed the following:
-Severely impaired cognition;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 8) -Required extensive assistance of one staff for toileting and personal hygiene; -Always incontinent of bowel and bladder; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 1/13/18 and last reviewed on 7/17/19, showed the following: -At risk for skin breakdown due to occasional bladder and bowel incontinence; -Check for incontinence upon arising, before and after meals, at bedtime and as needed; -Provide peri-care after each incontinence episode. Observation on 07/18/19 at 07:59 A.M., showed the following: -The resident lay on his/her back in bed; -CNA A entered the resident’s room, washed his/her hands and put on gloves; -CNA A pulled down the front of the incontinence brief; -The resident was incontinent of urine; -CNA A provided peri-care to the front genitalia; -Wearing the same soiled gloves, CNA A assisted the resident to roll to his/her left side in bed; -Wearing the same soiled gloves, CNA A cleansed the resident’s buttocks, tucked the soiled brief under the resident, assisted the resident to roll to his/her right side and removed the soiled brief; -CNA A removed his/her gloves and without washing his/her hands covered the resident with a sheet and blanket and clipped the resident’s call light to his/her blanket. During interview on 7/18/19 at 9:31 A.M., CNA A said the following: -Staff should wash their hands upon entering a room, between glove changes, after providing peri-care and before leaving a room; -Staff should wash their hands or use hand sanitizer in between glove changes; -Staff should remove their gloves and wash hands before touching anything considered clean due to contamination. During interview on 7/18/19 at 9:40 A.M., CNA C said the following: -Staff should wash their hands upon entering a room, between glove changes, after providing pericare and before leaving a room; -Staff should change their gloves and wash hands before touching clean items due to contamination. 5. Review of Resident #8’s quarterly MDS dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of two staff members with personal hygiene, bed mobility and toileting; -Always incontinent of bowel and bladder. Review of the resident’s care plan last reviewed/revised 7/17/19 showed the following: -The resident was limited his/her ability to perform activities of daily living (ADLs) related to history [MEDICAL CONDITION] weakness; -Needs one assist with bed mobility, locomotion on unit, dressing and hygiene; -Encourage to participate in ADLs as he/she was able, praise for efforts; -Transfers with two assist and mechanical lift. Observation on 7/17/19 at 7:05 A.M. showed the following: -CNA A and CNA C washed hands and applied gloves; -CNA A pulled the blankets down and provided front pericare; -CNA A and CNA C turned the resident to his/her left side, CNA A wiped the inner buttocks, the resident was incontinent of a large amount of urine at that time, urine ran between the resident’s buttocks and inner thighs;

(X4) ID PREFIX TAG

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

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 8)
-Required extensive assistance of one staff for toileting and personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 1/13/18 and last reviewed on 7/17/19, showed the
following:
-At risk for skin breakdown due to occasional bladder and bowel incontinence;
-Check for incontinence upon arising, before and after meals, at bedtime and as needed;
-Provide peri-care after each incontinence episode.
Observation on 07/18/19 at 07:59 A.M., showed the following:
-The resident lay on his/her back in bed;
-CNA A entered the resident’s room, washed his/her hands and put on gloves;
-CNA A pulled down the front of the incontinence brief;
-The resident was incontinent of urine;
-CNA A provided peri-care to the front genitalia;
-Wearing the same soiled gloves, CNA A assisted the resident to roll to his/her left side
in bed;
-Wearing the same soiled gloves, CNA A cleansed the resident’s buttocks, tucked the soiled
brief under the resident, assisted the resident to roll to his/her right side and removed
the soiled brief;
-CNA A removed his/her gloves and without washing his/her hands covered the resident with
a sheet and blanket and clipped the resident’s call light to his/her blanket.
During interview on 7/18/19 at 9:31 A.M., CNA A said the following:
-Staff should wash their hands upon entering a room, between glove changes, after
providing peri-care and before leaving a room;
-Staff should wash their hands or use hand sanitizer in between glove changes;
-Staff should remove their gloves and wash hands before touching anything considered clean
due to contamination.
During interview on 7/18/19 at 9:40 A.M., CNA C said the following:
-Staff should wash their hands upon entering a room, between glove changes, after
providing pericare and before leaving a room;
-Staff should change their gloves and wash hands before touching clean items due to
contamination.
5. Review of Resident #8’s quarterly MDS dated [DATE], showed the following:
-Severely impaired cognition;
-Required extensive assistance of two staff members with personal hygiene, bed mobility
and toileting;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan last reviewed/revised 7/17/19 showed the following:
-The resident was limited his/her ability to perform activities of daily living (ADLs)
related to history [MEDICAL CONDITION] weakness;
-Needs one assist with bed mobility, locomotion on unit, dressing and hygiene;
-Encourage to participate in ADLs as he/she was able, praise for efforts;
-Transfers with two assist and mechanical lift.
Observation on 7/17/19 at 7:05 A.M. showed the following:
-CNA A and CNA C washed hands and applied gloves;
-CNA A pulled the blankets down and provided front pericare;
-CNA A and CNA C turned the resident to his/her left side, CNA A wiped the inner buttocks,
the resident was incontinent of a large amount of urine at that time, urine ran between
the resident’s buttocks and inner thighs;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265606

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

SWEET SPRINGS VILLA

STREET ADDRESS, CITY, STATE, ZIP

518 E MARSHALL
SWEET SPRINGS, MO 65351

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.

	(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 9) -CNA A cleansed urine from the resident’s buttocks and inner thighs using several disposable clothes, tucked a clean incontinence brief in place under the resident; -With the same soiled gloves, CNA A grasped the resident’s right arm/side and assisted the resident to his/her back, pulled the clean incontinence brief up into place and fastened it; -With the same soiled and gloved hands, CNA A pulled the resident’s clean pants up into place, put the resident’s shoes on the resident, and tucked the mechanical lift pad into place under the resident; -With the same soiled gloves, CNA A attached the sling to the mechanical lift, grasped the mechanical lift control, raising the resident off of the bed and lowering the resident into his/her wheelchair, CNA A assisted with putting a clean shirt on the resident; -CNA A removed his/her soiled gloves and washed his/her hands. During interview on 07/18/19 10:26 AM CNA A said he/she should have removed his/her dirty gloves and washed his/hands after providing pericare and before touching the resident or anything else that was clean. During interview on 7/18/19 at 12:15 P.M., the Director of Nurses said the following: -Staff should wash their hands upon entering a room, in between glove changes, when going from a dirty to clean task, and before leaving a resident’s room; -Staff should not be touching clean items before removing their gloves and washing their hands due to cross-contamination.

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SWEET SPRINGS VILLA

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