Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review, the facility failed to check for Federal Indicators
using the State Nurse Aide (NA) Registry for five out of nine employee files reviewed. The
facility hired 98 employees since the last survey. The census was 122.
Review of selected employee files, showed the following:
-Assistant Director of Nursing I’s file, showed a hire date of 12/13/17, and no
documentation of NA registry (checks for a Federal Indicator of abuse, neglect or
misappropriation of property) check as completed;
-Activity Aide A’s file, showed a hire date of 5/22/18, and no documentation of the NA
registry check as completed;
-Licensed Practical Nurse (LPN) J’s file, showed a hire date of 3/20/18, and no
documentation of the NA registry check as completed;
-Certified Nursing Assistant (CNA) D’s file, showed a hire date of 11/7/17, and no
documentation of the NA registry check as completed;
-LPN F’s file, showed a hire date of 3/27/18, and no documentation of the NA registry
check as completed.
During an interview on 8/9/18 at 2:08 P.M., the Director of Nursing said human resources
is responsible for completing the NA registry checks before the employee starts work in
the facility. The NA registry checks should be done before the employee is offered
employment. The background checks and NA registry checks are completed by an outside
vendor. He/she did not know why some of the reviewed files did not have the NA registry
check completed.
During an interview on 8/15/18 at 8:25 A.M., the Administrator said the backgrounds checks
and NA registry are completed by a separate vendor for the company. He/she did not know
several of the staff had not had a NA registry inquiry completed. The human resource
department is responsible to verify all of the required checks are completed before the
employee is offered any position of employment.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
l dBased on observation, interview and record review, the facility failed to ensure care
plans were reviewed, updated and/or followed to include behaviors, fall interventions,
provision of restorative therapy and elopement interventions for seven of 24 sampled
residents (Residents #64, #12, #63, #10, #42, #76 and #31). The census was 122.
1. Review of Resident #64’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/20/18, showed the following:
-Severely impaired cognition;
-Ambulated independently;
-Extensive assistance needed for personal care;
-Diagnoses included

[MEDICAL CONDITION], mechanical heart valve and depression.
Review of the resident’s care plan, dated 4/4/18, showed the following:
-Problem: At risk for complications from blood thinning medication;
-Goal: Resident would not develop complications from blood thinning medication and not
require outside medical attention;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-Approaches included:
-Vital signs per routine and as needed (PRN);
-Monitor for presence of bone, abdominal, joint or other pain;
-Monitor for presence or absence of signs of hemorrhage under the skin, inside of the
mouth and/or conjunctiva (white of the eye) at least daily;
-Monitor for presence or absence of active bleeding such as hematuria (blood in the
urine), petechiae
(very small red or purple spot on the skin), bruising, bloody nose or bloody stools;
-Prevent falls which could cause bleeding;
-Administer medications and monitor labs per orders and inform physician of lab results
and concerns;
-Staff did not include approaches for when the resident is resistant to having his/her
blood drawn.
Review of the resident’s current physician’s orders [REDACTED].
-An order, dated 7/31/18, to obtain a [MEDICATION NAME] time (PT, a blood test used to
help detect and diagnose a bleeding disorder or excessive clotting disorder)
/international normalized ratio (INR, calculated from a PT result and used to monitor how
well blood thinning medication is working to prevent blood clots) on 8/14/18;
-An order, dated 7/31/18, to administer [MEDICATION NAME] (blood thinner) 13 milligrams
(mg) every evening.
Review of a nurse’s note, dated 7/27/18 at 3:44 A.M., showed resident scheduled for blood
draw, second time in the same week. Resident fights to the point it took three certified
nurse aide’s (CNAs) to hold him/her down while the technician drew blood. Resident tore
off the bandage and flailed his/her arms, causing blood to run down his/her arm and on to
his/her clothes. The nurse applied a second bandage and resident ripped the bandage off a
second time.
Review of the nurse’s note, dated 7/31/18 at 3:01 A.M., showed lab in to draw the
resident’s blood. The procedure required three staff members to hold him/her down due to
combative behavior. Staff educated if resident swung arm, to allow movement and leave
him/her alone. On coming shift to contact the physician regarding possible medication
change to avoid blood draws.
During an interview on 8/14/18 at 6:58 AM, Licensed Practical Nurse (LPN) K said the
family is aware of the struggle to obtain the resident’s blood work and they approve
because he/she needs the medication. Other medications had been attempted, however they
were not effective. He/she added it is all about the approach and even more helpful when
the resident is asleep because it can be done without him/her knowing it.
During an interview on 8/14/18 at 10:00 A.M., the Director of Nursing (DON) said she
believed the family is aware the resident takes [MEDICATION NAME]. She was unaware if they
knew he/she is so resistant to the blood draws. She was aware it took three staff members
to hold/him her down. She said the adverse reaction the resident displays when his/her
blood is drawn should be on the care plan. Also, the care plan should show if the family
is aware of the resident’s resistance. She said the resident’s rights need to be
respected.
During an interview on 8/14/18 at 12:30 P.M., the attending physician said [MEDICATION
NAME] is the only anti-coagulant approved for the resident’s condition and the blood tests
must be done. He said he has told the staff that if the resident starts to resist the
blood draw, they are to stop and try another day. He added without this particular
medication, the resident is at a higher risk of death. He had not had an in depth
conversation with the family regarding any possible alternatives or the stress the blood
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
draw creates for the resident. He agreed there is the possibility of other options and the
Power of Attorney (POA) for health care should be given the knowledge of those options.
During an interview on 8/16/18 at 1:15 P.M., the resident’s POA said he/she has not had a
conversation with the physician, but has spoken with the nursing staff. He/she is aware of
staff holding the resident down, but did not know of any other available options. He/she
believed the resident had to have the medication and he/she felt terrible about it. The
nursing staff or physician have not presented any alternatives. He/she said the matter of
the resident’s resistance is discussed at every care plan meeting.
2. Review of Resident #12’s significant change MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Two or more falls since last assessment;
-Received hospice care;
-Received zero days of restorative therapy;
-Diagnoses included high blood pressure and dementia.
Review of the resident’s nurse’s notes, showed the following:
-On 7/1/18 at 7:29 A.M., Resident observed on the floor by CNA. Resident assessed with[REDACTED].
-On 7/2/18 at 2:30 A.M., Resident noted to be sitting upright on the floor by CNA,
screaming in pain. Bruise to right hip and skin tear to right elbow. Resident said he/she
was trying to use the bathroom. Resident was sent to the hospital;
-On 7/2/18 at 10:22 P.M., Resident returned from the hospital with skin tear to right
elbow and bruise to right hip. Resident cried in pain. Pain medication and anti-anxiety
medication given to ease pain;
-On 7/29/18 at 7:39 A.M., Resident observed on the floor next to the bed. assessed with[REDACTED].
-On 7/29/18 at 2:19 P.M., Hospice nurse visited and requested resident be toileted
throughout the night to prevent falls;
-On 7/30/18 at 10:17 A.M., Resident observed and monitored due to fall on 7/29/18. Safety
measures in place include low bed and wedge cushion. Fall interventions in place include
low bed, high visibility area and wedge cushion.
Review of the resident’s care plan, last updated on 7/30/18, and in use during the survey,
showed the following:
-Problem: Resident has a history of falls related to impaired cognition and poor safety
awareness. Resident also receives routine antidepressant;
-Goal: Resident will have fall risk evaluation completed and safety interventions
implemented;
-Approaches included:
-Fall risk to be completed quarterly (9/10/17);
-Keep room free of clutter and provide adequate lighting (9/10/17);
-Keep call light within reach (9/10/17);
-Keep bed in low position when resident is in it (9/10/17);
-Keep frequently used items within reach (9/10/17);
-Keep resident close to the nurse’s station when possible (9/10/17);
-Resident is to ask for assistance with transfers (9/10/17);
-Staff education provided to provide toileting care at routine times (12/15/17);
-Lock wheelchair prior to transfers (12/15/17);
-Assess for needs when awake at night, such as hunger, thirst, etc. (1/25/18);
-Resident prefers sleeping toward edge of bed, staff to monitor for placement in bed when
rounding (2/8/18);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Mat at bedside (2/8/18);
-Anti-rollback (prevents the wheelchair from rolling backwards) to wheelchair (4/30/18);
-Check oxygen saturation three times a day (6/12/18);
-Educate staff about following safety interventions, keeping bed in low position when
resident is in bed (6/23/18);
-Ask hospice for a defined perimeter (scoop) mattress (7/30/18).
Observations of the resident, showed the following:
-On 8/09/18 at 1:38 P.M., the resident lay in a low bed in his/her room with no fall mat,
wedge or scoop mattress in place. No other fall precautions observed;
-On 8/10/18 6:56 A.M., the resident lay in a low bed with one foot on floor. No fall mat,
wedge or scoop mattress observed in the room;
-On 8/13/18 at 7:00 A.M., the resident lay in a low bed with his/her eyes closed. No fall
mat, wedge or scoop mattress observed in the room;
-On 8/14/18 at 7:00 A.M., the resident lay in a low bed with his/her eyes closed. No fall
mat, wedge or scoop mattress observed in the room.
During an interview on 8/14/18 at 10:30 A.M., the DON said if a fall intervention is
listed on the resident’s care plan, it should be in place. At the time of the fall, the
nurse can document if a new intervention will be implemented. Falls and correlating
interventions are discussed at the weekly interdisciplinary team meeting. If the
intervention is no longer applicable, it should be removed from the care plan. The MDS
nurse and charge nurses are responsible for updating the care plan.
Further review of the resident’s care plan, showed the following:
-Problem: Restorative nursing program: Active range of motion (AROM, the performance of an
exercise to move a joint without any assistance or effort of another person to the muscles
surrounding the joint). Staff did not individualize the care plan to show where the AROM
should be performed;
-Goal: Maintain joint flexion;
-Approach: Instruct resident on AROM technique and rational (3/15/18).
Review of the resident’s medical record, showed no documentation staff had provided
restorative therapy.
During an interview on 8/14/18 at 10:30 A.M., the DON said since the resident is on
hospice, restorative therapy is not provided. The care plan should have been updated to
reflect this.
3. Review of Resident #63’s most recent elopement assessment, dated 7/4/17, showed the
following:
-Resident at risk for wandering/elopement;
-Interventions included visual checks and placement of wanderguard.
Review of the resident’s care plan, last updated 4/3/18 and in use during the survey,
showed the following:
-Problem: At risk for elopement related to dementia, evidenced by risk assessment;
-Goal: Resident will remain happy with facility placement and not display exit seeking
behaviors;
-Approaches included: Wanderguard placement, wanderguard placement checks every shift and
ensure wanderguard is working properly.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Wandering behavior occurred daily;
-Required limited assistance with wheeling around facility in wheelchair;
-[DIAGNOSES REDACTED].>-Wander/elopement alarm used daily.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
Review of the resident’s (MONTH) (YEAR) POS, showed an order, dated 4/10/18, to use
wanderguard and check placement every other shift.
Observations of the resident on 8/8/18 at 1:29 P.M., 8/9/18 at 1:35 P.M., 8/10/18 at 6:52
A.M., 8/13/18 at 1:11 P.M. and 8/14/18 at 6:56 A.M., showed the resident without a
wanderguard on his/her ankles, wrists or wheelchair.
During an interview on 8/13/18 at 1:11 P.M., CNA N said the resident does not wear a
wander guard.
During an interview on 8/14/18 at 10:30 A.M., the quality assurance nurse said the
resident was recently assessed for elopement and is no longer a risk. The resident no
longer uses a wander guard. The care plan should have been updated to reflect this.
Elopement assessments are completed quarterly. A request was made for the resident’s most
recent elopement assessment, but as late as 3:00 P.M. on 8/14/18, no further information
was provided.
4. Review of Resident #10’s annual MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for transfers and toileting;
-Diagnoses included [MEDICAL CONDITION] (poor blood circulation causing severe pain) and
diabetes.
Review of the resident’s care plan, dated 10/13/17 and in use during the survey, showed
the following:
-Problem: Resident has terminal prognosis related to (no diagnosis listed);
-Goal: Resident will be free of pain and suffering and die a peaceful, dignified death;
-Approaches included:
-Hospice referral and services through (no date);
-Hospice nurse visits (no number) times per week with PRN visits;
-Hospice social worker and chaplain visit (no frequency) and PRN;
-Hospice volunteer visits as indicated;
-Monitor for pain or symptoms of distress or anxiety and notify hospice nurse or
physician;
-Administer medications for comfort as indicated and as ordered. Monitor for
effectiveness and observe for side effects and notify physician PRN;
-Hospice CNA will visit (no frequency) and provide bathing and personal care;
-Problem: Restorative nursing program for maintenance of joint strength and flexibility;
-Goal: Maintain joint flexion;
-Approaches: Perform AROM 2-3 times a week and may participate in exercise class or tai
chi with activities.
Review of the (MONTH) (YEAR) POS, showed no orders for hospice services or restorative
therapy.
Further review of the medical record, showed no documentation the resident received any
hospice visits or restorative therapy.
During an interview on 8/14/18 at 10:00 A.M., the DON and administrator said the resident
was presently not receiving hospice services but uncertain if she had been on hospice in
the past. Either way, hospice should not presently be on his/her care plan.
5. Review of Resident #42’s quarterly MDS, dated [DATE], showed the following:
-Cognition not assessed;
-Required total assistance from staff for all activities of daily living;
-Diagnoses included stroke, [MEDICAL CONDITION] (a disorder of the central nervous system
that affects movement, often including tremors) and anxiety;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-Received zero days of restorative therapy for seven of seven days assessed.
Review of the resident’s care plan, last updated on 10/3/17 and in use during the survey,
showed the following:
-Problem: Restorative nursing program: AROM for arms/legs to maintain flexibility;
-Goal: Maintain join flexion;
-Approach: Perform AROM as resident tolerates of arms and legs in all directions per
scheduled time and tolerance 2-3 days a week.
Further review of the resident’s medical record, showed no documentation staff had
provided restorative therapy.
During an interview on 8/14/18 at 10:30 A.M., the DON said she would provide documentation
of the resident’s restorative therapy. Staff did not provide documentation to show staff
had provided restorative therapy to the resident as late as 3:00 P.M. on 8/14/18.
6. Review of Resident #76’s annual MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Dependent on staff for all mobility and personal care;
-Unable to ambulate;
-Diagnoses included [MEDICAL CONDITION] and [MEDICAL CONDITION] (paralysis of all four
limbs).
Review of the care plan, dated 2/23/17, and in use during the survey, showed the
following:
-Problem: Restorative nursing;
-Goal: To maintain range of motion and prevent decline;
-Approaches: Conduct passive range of motion (PROM, the performance of an exercise to move
a joint with assistance or effort of another person to the muscles surrounding the joint)
as tolerated five times a week.
Review of the (MONTH) (YEAR) POS in use during the survey, showed no orders for
restorative therapy.
Further review of the chart, showed no documentation the resident received any restorative
therapy.
7. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Not steady when moving from sitting to standing, on and off the toilet and surface to
surface transfers;
-Incontinent of bowel and bladder;
-One fall without injury;
-Diagnoses included high blood pressure, stroke, dementia and [MEDICAL CONDITION].
Review of the resident’s care plan, updated 7/26/18 and in use during the survey, showed
the following:
-Problem: Restorative nursing program, AROM for improved positioning and flexibility;
-Goal: Maintain joint flexion;
-Approach: Perform AROM of arms and legs in all directions as tolerated per scheduled time
and tolerance.
Review of the resident’s medical record, showed no documentation he/she received
restorative therapy.
8. During an interview on 8/14/18 at 10:00 A.M., the DON said they used to have a CNA
designated to provide restorative therapy. They were aware of issues with this format and
the system was in the process of being changed. Now, each CNA would provide restorative
therapy to their assigned residents. The CNAs who had been trained, documented in the
point of care system under the restorative tab or under activities of daily living. Not
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
all CNAs had yet been trained to provide restorative therapy.
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure all
physician’s orders were obtained or followed by not administering oxygen at the proper
rate, not applying a wanderguard as ordered and not following a physical therapy
recommendation for restorative therapy for three of 24 sampled residents. (Residents #68,
#63 and #75). The census was 122.
1. Review of Resident #68’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/27/18, showed the following:
-Moderate cognitive impairment;
-Poor appetite and tired with little energy, half or more days;
-Extensive assistance required for dressing, toilet use and personal hygiene;
-Total dependence on staff for transfers and bathing;
-Lower extremity impairment on both sides;
-Received oxygen therapy;
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s order sheet (POS), dated 8/2018, showed:
-Additional [DIAGNOSES REDACTED].
-An order, dated 12/7/16, for oxygen at 3 liters (L)/minute per nasal cannula (NC) to keep
saturations above 93%.
-An order, dated 7/31/18, to send to emergency room for low oxygen.
Review of the resident’s care plan, updated 8/1/18, showed the following:
-Required extensive staff assistance with activities of daily living (ADL’s) due to[MEDICAL CONDITION] with lower extremity weakness and inability to stand;
-Needs will be met, should have continuous positive airway pressure therapy ([MEDICAL
CONDITION]-machine that makes breathing easier) on at all times while in bed, uses
continuous oxygen;
-Potential for shortness of breath and/or respiratory complications related to OSA and
will have no respiratory complications or signs and symptoms of shortness of breath;
-Monitor oxygen saturation and administer oxygen per physician’s orders.
Observation of the resident, showed the following:
-On 8/9/18 at 1:06 P.M., the resident lay in bed on his/her back and wore oxygen via NC at
4L per minute;
-On 8/10/18 at 1:00 P.M., the resident lay in bed and said he/she did not feel good. The
resident wore oxygen via NC at 2L per minute;
-On 8/13/18 at 7:39 A.M., the resident lay in bed on his/her back and wore oxygen via NC
at 3.5L per minute;
-On 8/13/18 at 10:51 A.M., the resident sat in an electric wheelchair in the hallway and
wore oxygen via NC at 3L per minute;
-On 8/14/18 at 7:19 A.M., the resident lay in bed with eyes closed and wore oxygen via NC
at 2.5L.
During an interview on 8/14/18 at 10:00 A.M., the Directory of Nursing (DON) said oxygen
should be administered at the rate ordered by the physician. The resident was not able to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
change the setting on the oxygen concentrator, but could ask staff to change the setting.
During an interview on 8/14/18 at 1:39 P.M., the quality assurance nurse said staff told
her the resident asked them to change the settings on the oxygen concentrator. They needed
a physician’s order to allow the oxygen to be set at a range of 2L to 4L.
2. Review of Resident #63’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Wandering behavior occurred daily;
-Required limited assistance with wheeling around facility in wheelchair;
-[DIAGNOSES REDACTED].
-Wander/elopement alarm used daily.
Review of the resident’s 8/2018 POS, showed an order, dated 4/10/18 to use wanderguard and
check placement every other shift.
Review of the 8/2018 treatment administration record (TAR), showed the following:
-An order, dated 4/10/18, to use wanderguard and check placement every other shift;
-Staff documented checking the placement of the wanderguard 26 out of 26 opportunities.
Observations of the resident on 8/8/18 at 1:29 P.M., 8/9/18 at 1:35 P.M., 8/10/18 at 6:52
A.M., 8/13/18 at 1:11 P.M. and 8/14/18 at 6:56 A.M., showed the resident without a
wanderguard on his/her ankles, wrists or wheelchair.
During an interview on 8/13/18 at 1:11 P.M., certified nurse assistant (CNA) N said the
resident does not wear a wanderguard.
During an interview on 8/14/18 at 10:30 A.M., the quality assurance nurse said the
elopement book was updated and the resident’s wanderguard was removed. The order for the
wanderguard should have been discontinued. If the wanderguard is not in place, staff
should not document it is in place.
3. Review of Resident #75’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Tired with little energy half or more days;
-Extensive assistance required for all activities of daily living (ADL’s);
-Not steady when moving from sitting to standing, on and off the toilet and surface to
surface transfers;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 1/22/18, showed the following:
-Needs assistance with daily ADL care related to cognition and decreased mobility and will
have daily needs met;
-Needed assistance with transfers using two staff and a gait belt; physical therapy will
provide education on proper transfer techniques.
Review of the resident’s physical therapy records, showed services received 5/15/18
through 6/12/18, and a discharge recommendation that the resident would benefit from
restorative therapy.
Review of the resident’s medical record, showed no documentation or orders that he/she
received restorative therapy.
During an interview on 8/14/18 at 10:00 A.M., the Director of Nursing said all physician’s
order should be followed. They used to have a certified nurse aide (CNA) designated to
provide restorative therapy. That system was being changed so that CNA’s provided
restorative therapy to the residents they were assigned to care for. The CNA’s who had
been trained documented in the point of care system under the restorative tab or under
activities of daily living.
During an interview on 8/17/18 at 10:55 A.M., the DON said the system of communicating
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
therapy discharge recommendations changed recently due to a couple of residents being
discharged with recommendations that were not communicated to staff. They are changing
therapy companies and intend to work collaboratively with the entire therapy department,
not just the director. Recommendations are now being communicated via e-mail.
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, interview and record review, the facility failed to maintain proper
placement of indwelling urinary catheters to prevent potential contamination. The facility
identified five residents as having indwelling urinary catheters and of those five, three
were found touching the floor (Residents #60, #21 and #30). The sample size was 24. The
census was 122.
Review of the facility’s Urinary Catheter Care Policy, dated 12/2016 and last revised on
12/2017, showed the following:
-Purpose: The purpose of the procedure is to prevent catheter-associated urinary tract
infections;
-Infection Control:
-Be sure the catheter tubing and drainage bag are kept off the floor;
-Drainage bag should be kept below the level of the bladder.
1. Review of Resident #60’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 6/16/18, showed the
following:
-Severely impaired cognition;
-Extensive assistance required for all mobility and personal care;
-Indwelling urinary catheter (a tube inserted into the bladder for purpose of continual
urine drainage).
Review of the current physician’s orders [REDACTED].
Observation on 8/8/18 at 11:41 A.M., 8/9/18 at 6:26 A.M., 8:37 A.M., 10:41 A.M. and 1:11
P.M. and 8/10/18 at 6:55 A.M., showed the urinary drainage bag lay directly on the floor.
Staff did not provide an additional bag to cover the drainage bag.
2. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Dependent on staff for mobility and personal hygiene;
-[DIAGNOSES REDACTED].
-Always incontinent of urine.
Review of the POS [REDACTED].
Observation on 8/13/18 at 6:47 A.M., 11:00 A.M. and 1:30 P.M., showed the urinary catheter
bag hung on the bed frame in full view from the hallway and the tip of the bag rested on
the floor.
3. Review of Resident #21’s admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance required for all personal hygiene and mobility;
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-Frequently incontinent of bladder.
Review of the physician’s orders [REDACTED].
Observations on 8/8/18 at 2:30 P.M. and 4:45 P.M., 8/9/18 at 7:15 A.M., and 10:50 A.M.,
8/10/18 at 6:55 A.M. and 1:02 P.M., showed the urinary catheter drainage bag hung on the
bed frame in full view from the hallway and the tip of the bag rested on the floor.
During an interview on 8/14/18 at 10:00 A.M., the Director of Nursing said the catheter
drainage bag should hang on the bed frame. The drainage bag should always be covered with
a dignity bag for privacy and should never touch the floor because that increases the risk
of contamination thus infection.
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure as needed
(PRN) psychiatric medications were re-evaluated after 14 days of use for two of two
sampled residents (Residents #76 and #64). The census was 122.
Review of the facility’s [MEDICAL CONDITION] Medication policy, dated 12/16 and last
reviewed/revised on 2/18, showed the following:
-Residents will not receive PRN doses of [MEDICAL CONDITION] medications unless that
medication is necessary to treat a specific condition that is documented in the clinical
record;
-The need to continue PRN orders for [MEDICAL CONDITION] medications beyond 14 days
requires that the practitioner document the rationale for the extended order. The specific
duration of the PRN order will be indicated in the order;
-PRN orders for [MEDICAL CONDITION] medications will not be renewed beyond 14 days unless
the health care practitioner has evaluated the resident for the appropriateness of that
medication.
1. Review of Resident #76’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/23/18, showed the following:
-Severely impaired cognition;
-Dependent on staff for all mobility and personal care;
-Unable to ambulate;
-[DIAGNOSES REDACTED].
Review of the current physician’s orders [REDACTED]. The order showed no stop date and no
reason for the continued PRN use.
Review of the psychiatric consultation notes, dated 3/24/18 and 6/24/18, showed to
continue the [MEDICATION NAME] as prescribed.
Review of the pharmacy controlled substance proof of use, showed the following:
-27 doses of [MEDICATION NAME] administered from 7/1/18 through 7/31/18;
-12 doses of [MEDICATION NAME] administered from 8/1/18 through 8/13/18.
During an interview on 8/14/18 at 10:30 A.M., the Director of Nursing (DON) said she is
aware that PRN [MEDICAL CONDITION] must be renewed every 14 days, however the nurse
practitioner said he/she could not be at the facility every 14 days so the medication
would be renewed every 30 days or whenever when he/she visits. She added that the nurse

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
practitioner did not want to change the PRN medication to routine.
2. Review of Resident #64’s annual MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Ambulates independently;
-Extensive assistance needed for personal care;
-[DIAGNOSES REDACTED].
Review of the current POS in use during the survey, showed an order, dated 1/2/18, to
administer [MEDICATION NAME] 0.5 mg every six hours PRN for anxiety.
Review of the monthly pharmacy review, dated (MONTH) (YEAR), showed a recommendation for
the physician to either discontinue the medication or provide a rationale for the extended
time period beyond 14 days and the physician responded, do not stop.
Further review of the medical record, showed no documentation by the nurses or physician
regarding the continued use of PRN [MEDICATION NAME].
Review of the pharmacy controlled substance proof of use, showed no administration of[MEDICATION NAME] for the months of 7/18 or 8/18.
Review of the medication administration records (MAR)’s, dated 7/1/18 through 7/31/18 and
8/1/18 through 8/14/18, showed no documentation of [MEDICATION NAME] administration.
During an interview on 8/14/18 at 10:00 A.M., the DON said she was unaware of why the
medication has not been discontinued and aware there should be documentation.
F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Safeguard resident-identifiable information and/or maintain medical records on each
resident that are in accordance with accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff documented the
administration of one as needed (PRN) medication on the medication administration record
(MAR) for one of 24 sampled residents (Resident #76). The census was 122.
Review of Resident #76’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/23/18, showed the following:
-Severely impaired cognition;
-Dependent on staff for all mobility and personal care;
-Unable to ambulate;
-[DIAGNOSES REDACTED].
-Incontinent of bowel and bladder.
Review of the resident’s current physician order [REDACTED].
Review of the pharmacy controlled substance proof of use form, showed the following dates
and times of [MEDICATION NAME] administration:
-7/1/18 at 3:00 P.M.;
-7/2/18 at 1:00 P.M.;
-7/3/18 at 1:00 P.M.;
-7/4/18 at 6:00 A.M.;
-7/6/18 at 1:00 P.M. and 10:00 P.M.;
-7/7/18 at 1:00 P.M.;
-7/8/18 at 5:00 P.M.;
-7/9/18 at 4:00 A.M. and 1:00 P.M.;
-7/11/18 at 6:00 A.M. and 1:00 P.M.;
-7/12/18 at 1:00 P.M. and 8:00 P.M.;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
-7/13/18 at 8:00 A.M.;
-7/16/18 at 1:00 P.M. and 10:00 P.M.;
-7/17/18 at 1:00 P.M.;
-7/18/18 at 6:00 A.M.;
-7/19/18 at 6:00 A.M.;
-7/20/18 at 11:00 A.M.;
-7/22/18 at 8:00 P.M.;
-7/23/18 at 6:00 A.M.;
-7/26/18 at 6:00 A.M.;
-7/27/18 at 1:00 P.M.;
-7/30/18 at 1:00 P.M. and 6:00 P.M.;
-8/1/18 at 3:00 A.M.;
-8/4/18 at 1:00 P.M.;
-8/5/18 at 9:00 P.M.;
-8/6/18 at 8:00 A.M.;
-8/7/18 at 2:00 P.M.;
-8/8/18 at 1:00 P.M.;
-8/9/18 at 6:00 A.M. and 1:00 P.M.;
-8/12/18 at 6:00 A.M. and 1:00 P.M.;
-8/13/18 at 6:00 A.M.
Review of the resident’s MAR, dated 7/1/18 through 7/31/18, showed the administration of[MEDICATION NAME] recorded on 7/9/18 at 4:24 A.M., with no other administrations of[MEDICATION NAME] recorded.
Review of the MAR, dated 8/1/18 through 8/13/18, showed the administration of [MEDICATION
NAME] recorded on 8/9/18 at 12:00 P.M. with no other administrations of [MEDICATION NAME] recorded.
During an interview on 8/14/18 at 10:00 A.M., the Director of Nursing said all medications
administered must be recorded on the MAR, otherwise it is impossible to know what has and
what has not been administered. She believes the nurses record the administration of[MEDICATION NAME] in the medical record under the section for behaviors, which is
important, but it is just as important to record the administrations on the MAR and she
expected the nurses to do so.
F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Arrange for the provision of hospice services or assist the resident in transferring to
a facility that will arrange for the provision of hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to collaborate with hospice in
the development of a coordinated plan of care for residents receiving hospice care. The
facility also failed to maintain the medication listing, physician’s orders [REDACTED].
The facility identified eight residents who received hospice care. Of those eight, four
were chosen for the sample of 24 and issues were found with three of them (Residents #102,
#54, and #60). The census was 122.
1. Review of Resident #102’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 7/16/18, showed the
following:
-A condition or chronic disease that may result in a life expectancy of less than 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
months;
-admitted to hospice care on 7/6/18;
-Severe cognitive impairment;
-Tired with little energy half or more days;
-Extensive assistance required for bed mobility, dressing, eating, toileting and personal
hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of hospice provider H’s nursing facility services agreement (basic, respite and
general inpatient care for hospice patients), signed and dated 7/11/18. showed the
following:
-Hospice shall promote open and frequent communication with Facility and shall provide
Facility with sufficient information to ensure that the provision of services by Facility
under this Agreement is in accordance with the Hospice Patient’s Plan of Care,
assessments, treatment planning and care coordination. At a minimum, Hospice shall provide
the following information to Facility for each Hospice Patient residing at Facility:
-The most recent Plan of Care, medication information and physician’s orders [REDACTED].
Review of the medical record and hospice provider H’s binder, kept at the nurse’s station,
showed a sign in sheet, and dates of visits to the resident, beginning 7/6/18, by the
hospice registered nurse (RN), certified nurse aide (CNA), social worker and chaplain.
Further review of the binder, showed no hospice plan of care, medication listing,
physician’s orders [REDACTED].
2. Review of Resident #54’s significant change MDS, dated [DATE], showed the following:
-A condition or chronic disease that may result in a life expectancy of less than 6
months;
-admitted to hospice care on 6/3/18;
-Severe cognitive impairment;
-Extensive assistance required for bed mobility, dressing, eating, toilet use and personal
hygiene;
-Total assistance of staff needed for transfers and bathing;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 7/11/18, showed the following:
-Hospice: has terminal prognosis related to [MEDICAL CONDITION] and will be free of pain
and suffering and die a peaceful, dignified death;
-Hospice referral and services through hospice provider P;
-Hospice nurse visits three times per with as needed visits;
-Hospice social worker and chaplain visits 0 and as needed;
-No mention of visits by a hospice CNA;
-The facility’s care plan failed to reflect collaboration between the facility and hospice
provider in the coordination of the resident’s care.
3. Review of Resident #60’s significant change MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Extensive assistance required for all mobility and personal care;
-Indwelling urinary catheter;
-Life expectancy of less than six months.
Review of the resident’s care plan, dated 8/8/18, showed the following:
-Problem: Resident has terminal prognosis related to [MEDICAL CONDITION], dementia and
diabetes;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-Goal: Resident will be free of pain and suffering and die a peaceful dignified death;
-Approaches included:
-Hospice nurse visits per hospice schedule with as needed visits;
-Hospice social worker and chaplain visits monthly and as needed;
-Hospice volunteer visits as indicated;
-Monitor for pain or symptoms of distress or anxiety and notify hospice nurse or
physician;
-Administer medications for comfort as indicated and as ordered;
-Hospice CNA will visit twice a week to provide bathing and personal care;
-Hospice will provide oxygen, specialty mattress, wheelchair and incontinence supplies.
Review of the current POS, in use during the survey, showed no order for hospice services.
Review of the medical record, showed no documentation that a hospice nurse had visited the
resident.
Review of the hospice notebook, showed no documentation that a hospice nurse had visited
the resident.
During an interview on 8/14/18 at 12:00 P.M., Licensed Practical Nurse (LPN) K said he/she
did not know where the notes would be and that many hospice companies now use a computer
and do not leave any notes regarding the visits.
4. During an interview on 8/14/18 at 10:00 A.M., the DON said some hospice providers make
notes in a binder kept in the facility to document their visit and others send their notes
to the facility and they are placed in the binders by the nurses. There should be
documentation of hospice nurses, CNAs, social worker and chaplain visits in the binders or
in the resident chart, to show what care was provided, document any new issues discovered
or changes in care. It is the nursing team’s responsibility to ensure the facility has the
documentation. The hospice plan of care, medication list and physician’s orders[REDACTED].
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 proper
hand hygiene during times of resident care. This effected four of 24 sampled residents
(Residents #60, #76, #69 and #14). The census was 122.
Review of the facility’s Hand Hygiene Policy, dated May, (YEAR), showed the following:
-Use an alcohol based hand rub and alternate with soap and water for the following
situations:
-Before and after coming on duty;
-Before and after direct contact with residents;
-Before and after handling an invasive device such as a urinary catheter or intravenous
site;
-Before moving from a contaminated body site to a clean body site during resident care;
-After contact with a resident’s intact skin;
-After contact with blood or bodily fluids;
-After removing gloves;
-The use of gloves does not replace hand washing/hand hygiene. Integration of glove use
along with routine hand hygiene is recognized as the best practice for preventing

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 14)
healthcare-associated infections.
1. Review of Resident #60’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 6/16/18, showed the
following:
-Severely impaired cognition;
-Extensive assistance required for all mobility and personal care;
-Indwelling urinary catheter (hollow tube placed in the bladder used to drain urine).
Observation on 8/10/18 at 7:34 A.M., showed Licensed Practical Nurse (LPN) K entered the
resident’s room and donned gloves without washing his/her hands. Certified Nurse Aide
(CNA) Q and CNA P assisted the resident onto his/her side and removed the covers. LPN K
removed the resident’s urinary catheter. LPN K removed his/her gloves, wrapped the gloves
over the tip of the catheter, placed the catheter and urinary drainage bag that contained
urine into the resident’s bedroom trash can and tied the trash bag closed. LPN K did not
wash his/her hands and assisted the CNAs to reposition the resident in bed and covered the
resident with the blankets. The staff then left the room without washing their hands.
During an interview on 8/10/18 at 7:45 A.M., LPN K said staff should always wash their
hands before donning gloves and after removing gloves to prevent any contamination. He/she
made a mistake and did not wash his/her hands.
2. Review of Resident #76’s annual MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Dependent on staff for all mobility and personal care;
-Unable to ambulate;
-[DIAGNOSES REDACTED].
-Incontinent of bowel and bladder.
Observation on 8/10/18 at 10:53 A.M., showed CNA L entered the resident’s room and donned
gloves without washing his/her hands. He/she removed the resident’s urine and stool
saturated brief and provided personal care. He/she changed his/her gloves after each wipe
of stool and did not wash his/her hands between the glove changes. He/she completed the
care, used the same gloved hands to assist the resident to lay on his/her back and
provided personal care to the groin area. He/she used the same gloved hands and secured a
clean brief into place.
During an interview on 8/10/18 at 11:00 A.M., CNA L said staff should always wash hands
when finished with a task. When cleaning stool, it is important to change gloves after
each wipe in case any stool gets on the glove but it is not necessary to change gloves
when cleaning urine.
3. Review of Resident #69’s quarterly MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Extensive assistance required for all mobility and personal care;
-Incontinent of bowel and bladder.
Observation on 8/10/18 at 7:15 A.M., showed CNA G entered the resident’s room, donned
gloves without washing his/her hands, removed the resident’s dry brief, turned resident
side to side, re-applied the same brief, positioned him/her on his/her right side, removed
gloves and left the room without washing his/her hands.
During an interview on 8/10/18 at 7:25 A.M., CNA G said hands should be always washed
before and after providing care and before leaving the resident’s room.
During an interview on 8/14/18 at 10:00 A.M., the Director of Nursing (DON) said staff
should always wash their hands and don gloves before providing any resident care, whenever
going from a dirty area to a clean area and again when the task is complete.
4. Review of Resident #14’s significant change MDS, dated [DATE], showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/5/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265351

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

08/14/2018

NAME OF PROVIDER OF SUPPLIER

ALEXIAN BROTHERS LANSDOWNE VILLAGE

STREET ADDRESS, CITY, STATE, ZIP

4624 LANSDOWNE AVENUE
SAINT LOUIS, MO 63116

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 15)
-Moderate cognitive impairment;
-Extensive staff assistance needed with toileting and hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation and interview on 8/09/18 at 6:20 A.M., showed CNA B entered the room, washed
his/her hands and applied gloves. He/she removed the blanket from the resident. CNA B
placed a soapy water filled bath basin on the over the bed table and placed several wash
cloths in the basin. CNA B obtained a wash cloth and cleaned the resident’s left inner
thigh and discarded the wash cloth. He/she used the same gloved hands and obtained a
second soapy wash cloth from the basin and cleaned the resident’s groin area. He/she
discarded the wash cloth. He/she used the same gloved hands and obtained a dry wash cloth
and patted the thigh and the groin area dry. He/she used the same gloved hands and
assisted the resident to turn on to his/her side. He/she used the same gloved hands and
obtained a soapy wash cloth from the basin and cleaned between the resident’s legs and
buttocks. He/she disposed of the used wash cloth and used the same gloved hands to obtain
a dry wash cloth and dried the areas. He/she removed his/her gloves, washed his/her hands,
applied clean gloves and applied a clean brief under the resident. CNA B said he/she
should not have placed all the wash cloths into the bath basin together. He/she should
have moistened one wash cloth at a time and change gloves in between wash cloths. He/she
forgot to remove his/her gloves in between cleaning areas.
During an interview on 8/9/18 at 2:15 P.M., the DON said staff should not place multiple
wash cloths in a bath basin to be used. Wash cloths should be wet one at a time, and
soiled gloves should not come in contact with the bath basin water. Gloves should be
changed and hands washed when moving from a dirty task to a clean task or moving to
different areas of the body.
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