Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0569

Level of harm – Potential for minimal harm

Residents Affected – Some

Notify each resident of certain balances and convey resident funds upon discharge,
eviction, or death.

Based on interview and record review, the facility failed to provide spend down letters
when the balance of the Medicaid residents’ trust fund accounts exceeded $1799.99, for
four of 20 sampled residents (Residents #5, #48, #55 and #54). This deficient practice had
the potential to affect all residents that received Medicaid services. The census was 60.
1. Review of Resident #5’s monthly balance reports, showed the following:
-8/31/17, balance of $2,447.58;
-9/30/17, balance of 2,897.91;
-10/31/17, balance of $2,948.33;
-11/30/17, balance of $2,998.93;
-12/31/17, balance of $3,048.93;
-1/31/18, balance of $3,099.30;
-2/28/18, balance of $3,149.56.
2. Review of Resident #48’s monthly balance reports, showed the following:
-9/30/17, balance of $2,658.75;
-10/31/17, balance of $3,283.98;
-12/31/17, balance of $3,474.51;
-2/28/18, balance of $1,965.57.
3. Review of Resident #55’s monthly balance reports, showed the following:
-12/31/17, balance of $3,224.09;
-2/28/18, balance of $2,541.41.
4. Review of Resident #54’s monthly balance report, showed the following:
-2/28/18, balance of $3,081.69.
5. During an interview on 3/8/18, the business office manager said she had only been doing
the job for a few months, but was familiar with the Medicaid spend down letters and would
look in the residents’ files for them.
As late as 3/9/18 at 2:45 P.M., the facility could provide no documentation of spend down
letters for Medicaid Residents #5, #48, #55 and #54.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to perform a yearly
review of code status (full code-if the heart stops beating or breathing ceases, all life
saving methods are performed) or no code (do not resuscitate, no life prolonging methods
are performed) and failed to verify code status by having conflicting information in the
medical record for four of 20 sampled residents (Residents #6, #208, #17 and #35). The
census was 60.
1. Review of Resident #6’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/14/18, showed the following:
-admitted to the facility on[DATE];
-Brief Interview for Mental Status (BIMS), a screening tool used to assess cognitive
impairment, score of 9 out of 15, which showed moderate impairment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:-An order, dated 1/1/00, for
full code;
-Full code noted on the face sheet;
-The facility code status form, originally signed on 1/19/04 and last updated on 1/19/06,
showed full code;
-No further updates documented in the chart.
2. Review of Resident #208’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-BIMS score of 15 out of 15, which showed no cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-An order, dated 4/29/15, for full code;
-Full code noted on the face sheet;
-The facility code status form, signed on 3/9/15, showed full code;
-No further updates documented in the chart.
3. Review of Resident #17’s medical record, showed the following:
-admission date of [DATE];
-A facility code status form, signed on 6/4/14, showed full code;
-Review of the (MONTH) (YEAR) physician order [REDACTED].
-Readmission date of [DATE];
-Order, dated 9/10/17, for full code;
-No further documentation showing the facility reviewed the resident’s code status since
2014.
4. Review of Resident #35’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of 11 out of 15, which showed moderate impairment;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED].
Further review of the medical record, showed the following:
-An 8 inch by 10 inch green sheet of paper in the front of the chart that read FULL CODE;
-Full code noted on the face sheet.
5. During an interview on 3/9/18 at 10:45 A.M., the administrator said she expected each
resident’s code status to be reviewed at least yearly but preferably with each care plan
session. The face sheet, code status form and POS should all match.
F 0582

Level of harm – Potential for minimal harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to provide a Skilled Nursing
Facility Advanced Beneficiary Notice (SNFABN, form CMS- ) or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits for residents who
remained in the facility upon discharge from Medicare A services. The sample was 20 and
two of those remained at the facility after discharge from Medicare A. Of those two,
problems were found with both (Residents #9 and #46). The census was 60.
Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification
memo (S&C-09-20), dated 1/9/09, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0582

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 2)
-The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS- ) is issued when all
covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident’s stay
that Medicare will not pay for skilled nursing or specialized rehabilitative services and
the provider believes that an otherwise covered item or service may be denied as not
reasonable or necessary, the facility must inform the resident or his/her legal
representative in writing why these specific services may not be covered and the
beneficiary’s potential liability for payment for the non-covered services. The SNF’s
responsibility to provide notice to the resident can be fulfilled by the use of either the
SNFABN (form CMS- ) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to
pay for them him/herself or through other insurance they may have;
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits, the provider has met
its obligation to inform the beneficiary of his/her potential liability for payment and
related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys
notice to the beneficiary of his/her right to an expedited review of a service
termination.
1. Review of Resident #9’s Skilled Nursing Facility Beneficiary Protection Notification
Review, completed by facility staff on 3/8/18, showed the following:
-Medicare part A skilled services episode start date 9/6/17;
-Last covered day of Medicare part A service on 12/1/17;
-The facility initiated the discharge from Medicare part A services when benefit days were
not exhausted;
-Facility staff could not provide documentation the resident received the SNFABN form CMS-
or the NOMNC form.
2. Review of Resident #46’s Skilled Nursing Facility Beneficiary Protection Notification
Review, completed by facility staff on 3/8/18, showed the following:
-Medicare part A skilled services episode start date 1/24/18;
-Last covered day of Medicare part A service on 2/15/18;
-The facility initiated the discharge from Medicare part A services when benefit days were
not exhausted;
-Facility staff could not provide documentation the resident received the SNFABN form CMS-
or the NOMNC form.
3. During an interview on 3/8/18 at approximately 1:20 P.M., the administrator said it is
the responsibility of the Social Service Designee (SSD) to provide residents with all
Medicare discharge forms. The SSD was terminated last week and the administrator had no
way of knowing if residents received the forms.
F 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that each resident is free from the use of physical restraints, unless needed
for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide ongoing
re-evaluation of the need for a seat belt for one of 20 sampled residents (Resident #30).
The census was 60.
Review of Resident #30’s quarterly Minimum Data Set (MDS), a federally mandated assessment

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
instrument completed by facility staff, dated 1/31/18, showed the following:
-Upper and lower extremity impairment;
-Incontinent of bowel and bladder;
-Trunk restraint used daily;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 11/14/17, showed the following:
-Problem: At risk for falls related to involuntary movements and immobile related to[DIAGNOSES REDACTED].
-Goal: Free from falls and injuries;
-Approach: Make sure seat belt was in place due to [MEDICAL CONDITION] and [MEDICAL
CONDITION].
Review of the resident’s Device Decision Guide, dated 3/26/17, showed staff determined the
seat belt not to be a restraint.
Review of the resident’s computer medical record, showed no further Device Decision Guide
assessments after 3/26/17.
Observations of the resident, showed the following:
-On 3/7/18 at 7:53 A.M. and 3/8/18 at 8:16 A.M., the resident sat in a tilt-in-space
wheelchair (designed for pressure relief and positioning) at a dining room table and wore
a seat belt around his/her waist;
-On 3/8/18 at 11:13 A.M., the resident sat in a tilt-in-space wheelchair in the dining
room, in front of the television, and wore a seat belt around his/her waist;
-On 3/9/18 at 8:22 A.M., the resident sat in a tilt-in-space wheelchair at the dining room
table as a certified nurse aide (CNA) fed him/her breakfast and he/she wore a seat belt
around his/her waist.
During an interview on 3/9/18 at 10:45 A.M., the administrator said the resident’s seat
belt should be assessed at each care plan. Assessments should be in the computer system.
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 record review and interview, the facility failed to check the Nurse Aide Registry
to ensure new employees did not have a Federal Indicator (which means the individual
cannot ever work in a certified long-term care facility) prior to hire for three out of
nine sampled employees. The census was 60.
1. Review of Licensed Practical Nurse A’s employee record, showed the following:
-Date of hire: 1/23/18;
-No record of a Federal Indicator check.
2. Review of Activity Director H’s employee record, showed the following:
-Date of hire: 11/9/17;
-No record of a Federal Indicator check.
3. Review of Social Service Designee I’s employee record, showed the following:
-Date of hire: 11/9/17;
-No record of a Federal Indicator check.
4. During an interview on 3/9/18 at 9:20 A.M., the administrator said due to turnover and
a fragmented process, new hire paperwork, including Federal Indicator checks, have not
been completed as they should. This issue will be added to the Quality Assurance and
Performance Improvement plan.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop, update
and maintain a person centered comprehensive care plan to meet preferences and goals and
address the medical, physical, mental and psychosocial needs for one of 20 sampled
residents and one closed record sampled resident (Residents #58 and #5). The census was
60.
1. Review of Resident #58’s electronic medical record, showed the following:
-admitted to the facility on [DATE];
-admitted to hospice services on [DATE];
-[DIAGNOSES REDACTED].
-expired on [DATE].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-Moderately impaired cognition;
-Independent to limited assistance for activities of daily living (ADLs).
Review of the resident’s progress notes, showed the following:
-On [DATE], the resident had dusky (gray) nail beds. Staff applied oxygen, notified the
physician and obtained a new order to send him/her out to the hospital;
-On [DATE], the facility nurse spoke to the nurse at the hospital. The resident was on
ventilator in the hospital;
-On [DATE], the resident readmitted to the facility with [DIAGNOSES REDACTED].
Review of the resident’s significant change MDS, dated [DATE], showed the following:
-Level of cognition: Not listed;
-Resident requires total staff assistance with ADLs;
-Always incontinent of bowel and bladder;
-Hospice services.
Further review of the progress notes, dated [DATE], the resident on incident follow up
regarding a fall on [DATE].
Review of the resident’s comprehensive care plan, updated [DATE], showed the following:
-Problem: At risk for falls (no update regarding a fall on [DATE]);
-Problem: Communication deficit;
-Problem: Dementia, memory loss;
-The care plan did not address the hospice service provider or admission to hospice, care
coordination services with hospice, ADL care needs, medications or activities.
2. Review of Resident #5’s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
-Dependent on staff for ADLs including hygiene, toileting, bed mobility, transfers in and
out of bed, movement around the facility and eating;
-Nutrition provided by a feeding tube (a tube surgically inserted through the abdomen into
the stomach to provide hydration, nutrition and medications);
-Received hospice care.
Review of the resident’s (MONTH) (YEAR) physician order [REDACTED].
Review of the resident’s medical chart, showed no care plan.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
Observations of the resident on all days of the survey, from [DATE] through [DATE], showed
him/her lay in bed on his her back, with a fall mat in place to the right of the bed. A
tube feeding pump infused formula and water to the resident’s abdomen on a continuous
basis.
During an interview on [DATE] at approximately 9:00 A.M., the MDS nurse said the resident
did not have a care plan. The resident should have a care plan.
3. During an interview on [DATE] at 10:45 A.M., the administrator said every resident
should have a care plan that reflects their current care needs.
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**

Based on interview and record review, the facility failed to review resident’s care plans
after each assessment and revise them based on changing goals, preferences and needs of
the resident for four of 20 sampled residents (Resident #35, #9, #208 and #36). The census
was 60.
1. Review of Resident #35’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/25/18, showed the following:
-Brief Interview for Mental Status (BIMS), a screening tool used to assess for cognitive
impairment, score of 11 out of 15, which showed moderate impairment;
-Limited to extensive assistance needed for personal care;
-Unable to ambulate;
-[DIAGNOSES REDACTED].
Review of the physician order [REDACTED].
Review of the resident’s care plan, dated 11/13/17, showed the following:
-Problem: At risk for pressure ulcers;
-Goal: Skin will remain intact;
-Approaches included:
-Keep skin clean and dry;
-Keep linens dry and wrinkle free;
-Use cushion for pressure reduction when in the chair and pressure reducing mattress;
-Conduct a skin inspection (weekly, daily, etcetera);
-(No documentation regarding the lower back wound or treatment order).
During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing (DON) said it is the
nursing staffs’ responsibility to update the care plan when there is a change in the
resident’s condition. She would expect the wound and treatment for [REDACTED].
2. Review of Resident #9’s quarterly MDS, showed the following:
-BIMS score of 15 out of 15, which showed no cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED].
Review of the care plan, dated 6/6/17 and in use during the survey, showed no
documentation regarding the use of [MEDICATION NAME] or signs/symptoms to monitor for
regarding the medication.
3. Review of Resident #208’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of 15 out of 15, which showed no impairment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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)
-A [DIAGNOSES REDACTED].
Review of the care plan, dated 3/19/15, showed the following:
-Problem: Falls, impaired balance during transfers and ambulation;
-Goal: Safely transfer self with assist of one and wheeled walker device;
-Approach: Use wheeled walker for transfers.
Review of the nurse’s notes, showed the following:
-Fall on 11/25/17 at 5:24 P.M.;
-Fall on 12/15/17 at 3:38 P.M.;
-Fall on 2/22/18, no time noted.
Further review of the care plan, updated on 12/15/17, showed the following:
-No documentation regarding the fall on 11/25/17;
-Resident fell from the bed on 12/15/17, because his/her feet tangled in the blankets.
Isolated incident;
-No changes to goals;
-No changes to approach;
-No documentation regarding the fall on 2/22/18.
During an interview on 3/9/18 at 10:45 A.M., the DON said care plans should be updated
after every fall with new interventions to help prevent further falls.
4. Review Resident #36’s quarterly MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Total dependence on staff for eating;
-Nutrition provided by tube feeding ([DEVICE], a tube surgically inserted through the
abdomen into the stomach to provide hydration, nutrition and medications).
Review of the resident’s (MONTH) (YEAR) POS, showed the following:
-A diet order, dated 6/28/17, for tube feeding;
-An order, dated 11/03/17, for [MEDICATION NAME] 1.5 (type and strength of tube feeding
formula) to be infused at 65 milliliters an hour continuously;
-All oral medications to be given via [DEVICE].
Review of the resident’s care plan, provided by the facility on 3/9/18 and in use during
the survey, showed the following:
-Care plan last reviewed/revised on 11/14/17;
-Problem: Impaired swallowing related to dysphagia;
-Goal: Resident will maintain weight with feeding tube;
-Approach:
-Crush medications. Mix medications with pudding or apple sauce before administering;
-Monitor and record intake of food;
-Praise resident attempts to complete meal;
-Provide supplements: Boost VHC (type of supplemental nutrition drink which provides
additional calories);
-Report and document when resident leaves 25% or more food uneaten;
-Thicken liquids to nectar consistency before serving;
-Staff failed to update the care plan’s approaches to reflect the resident’s current[DEVICE] and nutritional care needs.
During an interview on 3/9/18 at 10:45 A.M., the administrator and DON said care plans
should reflect the resident’s current condition and should be updated at least quarterly.
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain orders
for oxygen use, self medication administration and seat (waist) belt use, clarify
conflicting insulin (medication used to regulate blood sugar) orders and provide diagnoses
for medication use for five of 20 sampled residents (Residents #37, #30, #6, #49 and #47).
The census was 60.
1. Review of Resident #37’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/7/18, showed the following:
-No cognitive impairment;
-Lower extremity impairment on both sides;
-Pain score of 8 on a 10-point scale, with 0 being no pain and 10 being the worst possible
pain;
-Received oxygen therapy;
-Received [MEDICAL TREATMENT] (the process of filtering toxins out of the blood for
individuals with kidney failure);
-Diagnoses included high blood pressure, diabetes, anxiety, depression and [MEDICAL
CONDITION] ([MEDICAL CONDITION]-[MEDICAL CONDITION] lung disease that causes obstructed
airflow from the lungs).
Review of a faxed order from the [MEDICAL TREATMENT] center, dated 12/12/17, showed
Patient is prescribed [MEDICATION NAME] and [MEDICATION NAME], a topical local anesthetic,
to be applied in a thin layer to intact skin over [MEDICAL TREATMENT] access and cover
with an occlusive dressing at least one hour prior to [MEDICAL TREATMENT].
Review of the resident’s physician’s orders [REDACTED].
-No order for [MEDICATION NAME] and [MEDICATION NAME] topical anesthetic;
-No order for the resident to self administer medications;
-No order for oxygen administration or related care.
Review of the resident’s care plan, updated 3/7/18, showed the following:
-Problem: Used oxygen related to desaturation (low levels of oxygen) during periods of
anxiety;
-Goal: Use least amount of supplemental oxygen needed to maintain oxygen saturation above
90%;
-Approach: Provide oxygen per physician’s orders [REDACTED].>Observations of the
resident, showed the following:
-On 3/6/18 at 5:14 P.M., the resident sat in a wheelchair in his/her room and wore oxygen,
via nasal cannula
(NC, a device used to deliver supplemental oxygen through a lightweight tube placed in the
nostrils). The resident said he/she used oxygen all the time and received 2 liters (L);
-On 3/7/18 at 11:39 A.M., the resident sat in a wheelchair in the doorway to his/her room
and wore oxygen via NC;
-On 3/8/18 at 8:07 A.M., the resident sat in a wheelchair at the dining room table, wore
oxygen via NC at 2L and ate breakfast.
During an interview on 3/8/18 at 2:07 P.M., Licensed Practical Nurse (LPN) D said the
topical [MEDICATION NAME] had been discontinued as of 3/8/18. The resident did not want to
use it. He/she used it for a brief time, maybe a week or so, and documentation could be
found on the treatment administration record.
During an interview on 3/9/18 at 7:05 A.M., Nurse G said the resident kept the topical[MEDICATION NAME] in his/her room to apply before [MEDICAL TREATMENT].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
During observation and interview on 3/9/18 at 7:20 A.M., the resident sat in a wheelchair
at a table in his/her room and wore oxygen via NC. A small plastic cup sat on the table
and contained an assortment of approximately 8 pills. The resident told Nurse G he/she did
not have all of his/her pills. Nurse G stood outside the room at the medication cart with
his/her back to the resident. Another cup on the table held a tube of 2.5% [MEDICATION
NAME] and 2.5% [MEDICATION NAME], with a refill date of 2/13/18.
During an interview on 3/9/18 at 9:08 A.M., the resident said staff gave him/her
medications in a cup and he/she took them on his/her own. He/she had done that for years.
The [MEDICATION NAME] topical really worked and he/she always applied it to his/her arm
before [MEDICAL TREATMENT] (helps filter waste, excess fluid and toxins from the blood).
During an interview on 3/9/18 at 11:00 A.M., the administrator said there should be orders
on the POS for oxygen administration and related care, the topical [MEDICATION NAME] and
for the resident to self administer medications and apply the topical anesthetic.
2. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Upper and lower extremity impairment;
-Incontinent of bowel and bladder;
-Trunk restraint used daily;
-Diagnoses included [MEDICAL CONDITION] (brain damage causing loss or impairment of motor
function) and [MEDICAL CONDITION].
Review of the resident’s care plan, updated 11/14/17, showed the following:
-Problem: At risk for falls related to involuntary movements and immobile related to[DIAGNOSES REDACTED].>-Goal: Free from falls and injuries;
-Approach: Make sure seat belt was in place due to [MEDICAL CONDITION] and [MEDICAL
CONDITION].
Review of the resident’s POS, dated 3/1/18 through 3/31/18, showed no order for a seat
belt.
Observations of the resident, showed the following:
-On 3/7/18 at 7:53 A.M. and 3/8/18 at 8:16 A.M., the resident sat in a tilt-in-space
wheelchair (designed for pressure relief and positioning) at the dining room table and
wore a seat belt around his/her waist;
-On 3/8/18 at 11:13 A.M., the resident sat in a tilt-in-space wheelchair in the dining
room, in front of the television and wore a seat belt around his/her waist;
-On 3/9/18 at 8:22 A.M., the resident sat in a tilt-in-space wheelchair at the dining room
table as a certified nurse aide (CNA) fed him/her breakfast. He/she wore a seat belt
around his/her waist.
During an interview on 3/9/18 at 11:00 A.M., the Director of Nursing (DON) said there
should be an order for [REDACTED].
3. Review of Resident #6’s annual MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Brief interview for mental status (BIMS), a screening tool to assess cognitive
impairment, score of 9 out of 15, which showed moderate impairment;
-[DIAGNOSES REDACTED].>-Dependent on staff for mobility and personal hygiene.
Review of the POS [REDACTED].
Observations on 3/6/18 at 10:54 A.M., 3/7/18 at 10:48 A.M., 3/8/18 at 6:29 A.M. and 3/9/18
at 6:28 A.M., showed the resident sat in a wheelchair with a seat belt on, secured around
his/her waist.
During an interview on 3/9/18 at 10:45 A.M., the DON said she was not aware the resident
used a seat belt. The administrator said the resident does wear a seat belt and an order
should be obtained for the use of it.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
4. Review of Resident #49’s annual MDS, a federally mandated assessment instrument
completed by facility staff, dated 1/25/18, showed the following:
-BIMS score of 14 out of 15, which showed little or no cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED] -An order, dated 5/4/17, to check blood sugar twice a day at 6:00 A.M. and 4:00 P.M. and
administer [MEDICATION NAME] (fast acting) insulin per sliding scale (dose determined by
blood sugar result);
-An order, dated 5/4/17, to administer Humalog (fast acting) insulin per sliding scale
twice a day at 9:00 A.M. and 5:00 P.M.
Review of the Medication Administration Record [REDACTED] -[MEDICATION NAME]administered twice a day at 6:00 A.M. and 4:00 P.M.;
-Humalog insulin written on the MAR indicated [REDACTED].
During an interview on 3/9/18 at 10:45 A.M., the DON, said she would not expect two fast
acting insulins to be ordered for the same resident; especially around the same hour of
the day. She would expect the nurse to contact the physician for clarification and not
just write duplicate on the MAR; especially since the two medications are not the same.
5. Review of Resident #47’s admission MDS, dated [DATE], showed the following:
-admission date of [DATE];
-No cognitive impairment;
-Independent with all activities of daily living;
-Pain score of 7 on a 10-point scale, with 0 being no pain and 10 being the worst possible
pain;
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated 3/1/18 through 3/31/18, showed the following orders,
dated 1/12/18:
-[MEDICATION NAME] (used to treat high blood pressure) 5 milligrams (mg), take two tables
by mouth once daily;
-Aspirin (used to treat pain, fever or inflammation) 81 mg, once daily;
-Tamsulosin HCL (used to treat difficulty urinating) 0.4 mg, once daily;
-[MEDICATION NAME] (muscle relaxer) 20 mg twice daily;
-[MEDICATION NAME] (used to treat high blood pressure) 50 mg, one tablet every 12 hours;
-[MEDICATION NAME] (narcotic pain reliever) 10 mg, one tablet twice daily;
-[MEDICATION NAME] (used to treat inflammation) 5 mg, twice daily;
-[MEDICATION NAME] (used to treat anxiety) 10mg three times daily;
-Quetiapine [MEDICATION NAME] (antipsychotic medication) 100 mg at bedtime.
Further review of the resident’s POS, showed no diagnoses for the administration of any of
the medications.
During an interview on 3/9/18 at 11:00 A.M., the DON said the resident’s POS should have
diagnoses for each of the medications administered.
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
restorative nursing therapy for three of 20 sampled residents (Residents #208, #48 and
#32). The census was 60.
1. Review of Resident #208’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/2/18, showed the following:
-Brief Interview for Mental Status (BIMS), a screening tool used to assess cognitive
impairment, score of 15 out of 15, which showed no impairment;
-Extensive assistance with personal care and mobility;
-Supervision needed for meals;
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
Further Review of the POS [REDACTED].
Review of the RT documentation, showed the following:
-Resident received RT one time in March, (YEAR), on the 5th.
-Received 20 repetitions of range of motion (ROM, the full movement potential of a joint)
to both legs with use of two pound weights;
-Application of protective headgear.
During an interview on 3/9/18 at 8:56 AM rehabilitation manager said he/she spoke to the
previous Director of Nursing (DON) about ordering protective headgear for the resident but
was unsure if that DON pursued the recommendation.
During an interview on 3/9/18 at 10:45 A.M. the DON said the resident did not have an
order for [REDACTED].
2. Review of Resident #48’s annual MDS, dated [DATE], showed the following:
-Cognitively intact;
-Functional ROM in upper extremities (shoulder, elbow, wrist, hand) impairment on one
side;
-[DIAGNOSES REDACTED].
-Zero days of restorative therapy, including splint/brace placement assistance, for seven
of seven days assessed.
Review of the resident’s medical record, showed the following:
-A hand written physician’s orders [REDACTED].
-A January, (YEAR) POS: No RT order;
-A February, (YEAR) POS: No RT order;
-A March, (YEAR) POS: No RT order;
-No documentation regarding RT on the care plan.
Review of the resident’s RT record for February, (YEAR), showed the following:
-an order for [REDACTED].>-Staff documented RT provided 13 out of 28 opportunities.
Observations on 3/7/18 at 2:16 P. M., 3/8/18 at 1:37 P.M. and 3/9/18 at 8:22 A.M., showed
a gray wrist splint lay on the over-bed table in the resident’s room.
During an interview on 3/8/18 at 1:37 P.M., the resident said staff do not put his/her
splint on every day. He/she usually wears it a couple of times a week.
3. Review of Resident #32’s significant change MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-Zero days of RT, including active ROM (AROM, the performance of an exercise to move a
joint without any assistance or effort of another person to the muscles surrounding the
joint) and passive ROM (PROM, the movement of a joint through the range of motion with no
effort from the patient) and ambulation, for seven of seven days assessed.
Review of the resident’s medical record, showed the following:
-A physician’s orders [REDACTED]. Restorative program established for ambulation and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
bilateral lower extremity exercises;
-A February, (YEAR) POS: No RT order;
-A March, (YEAR) POS: No RT order;
-No documentation regarding RT on the care plan.
Review of the resident’s February, (YEAR), RT record, showed the following:
-Exercise AROM and PROM of both lower extremities, three pound ankle weights, 20
repetitions;
-Ambulation exercise within the facility 300 feet times two;
-Staff failed to document the ordered frequency for the therapy to be provided;
-Staff documented providing AROM, PROM and ambulation therapy on nine occasions during the
month.
During an interview on 3/9/18 at approximately 10:45 A.M., the Director of Nursing, said
she expects staff to follow physician orders. The night nurse is responsible for ensuring
orders are carried over on the POS. Restorative Therapy Aide (RTA) J is responsible for
providing RT for the residents. RTA J was off on 3/8/18 and had to work as a certified
nurse aide (CNA) on 3/9/18. If RTA J is not available, the resident’s nurse or CNA should
provide the therapy.
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a timely
response to the registered dietician’s recommendation regarding weight loss of 14.75 %
over a six month period for one of 20 sampled residents (Resident #208). The census was
60.
Review of Resident #208’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/2/18, showed the following:
-Brief Interview for Mental Status (BIMS), a screening tool used to assess cognitive
impairment, score of 15 out of 15, which showed no impairment;
-Extensive assistance with personal care and mobility;
-Supervision needed for meals;
-[DIAGNOSES REDACTED].
Review of the resident’s weight record, showed the following:
-Weight of 160 pounds (#) recorded on 10/17/17;
-Weight of 160# recorded on 11/3/17;
-Weight of 153.4# recorded on 12/12/17;
-Weight of 153.1# recorded on 1/12/18;
-Weight of 144.7# recorded on 1/17/18;
-Weight of 147.2# recorded on 2/1/18;
-Weight of 143.8# recorded on 2/9/18.
Review of the progress notes, dated 2/23/18, showed a note written by the dietician with a
recommendation to move the resident to a table where he/she would receive assistance with
meals and add shakes to lunch and supper.
Review of the physician order [REDACTED].>Further review of the resident’s weight
record, showed the following:
-Weight of 143.2# recorded on 2/26/18;
-Weight of 136.4# recorded on 3/5/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
Observation on 3/7/18 at 8:53 A.M., showed the resident sat alone at the dining room
table, feeding him/herself.
Observation on 3/7/18 at 1:47 P.M., showed the resident sat alone at the dining room table
and a staff member assisted him/her eat. Staff did not serve him/her a shake.
Observation on 3/08/18 at 8:59 A.M. and 1:22 P.M., showed the resident sat alone at the
dining room table, feeding him/herself. Staff did not serve him/her a shake.
During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing said when a dietician
makes a recommendation, he/she makes a carbon copy of the request and gives that to the
charge nurse. The dietician is not allowed to write orders and it is the nurses’
responsibility to follow up with the doctor regarding the recommendation.
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, orders, monitoring and ongoing communication with [MEDICAL TREATMENT] (the
process of filtering toxins from the blood for individuals with kidney failure) center.
The facility identified three residents who received [MEDICAL TREATMENT]. Two of those
were selected for the sample of 20 and problems were found with one of them (Resident
#17). The census was 60.
Review of the facility’s [MEDICAL TREATMENT], Care of a Resident Receiving policy, dated
(MONTH) (YEAR), showed the following:
-Nurses will:
-Check the thrill (pulse) of the fistula (connection or passageway between an artery and
a vein, surgically created for [MEDICAL TREATMENT] treatments) daily and document in the
resident’s treatment administration record (TAR);
-Watch for bleeding after [MEDICAL TREATMENT];
-The policy failed to show staff should obtain physician orders [REDACTED].
-The policy failed to show staff should obtain physician orders [REDACTED].
-The policy failed to show staff should document ongoing communication with the [MEDICAL
TREATMENT] center;
-The policy failed to require checking the bruit (placing a stethoscope over the fistula
and hear the blood rush through the connection of the artery and vein) daily.
Review of Resident #17’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/18/17, showed the following:
-Moderately impaired cognition;
-Understands and able to be understood;
-[DIAGNOSES REDACTED].
-Received [MEDICAL TREATMENT].
Review of the resident’s care plan, last reviewed/revised on 12/26/17, showed the
following;
-Problem: Resident required [MEDICAL TREATMENT];
-Goal: Resident would not exhibit signs of fluid volume excess;
-Approaches:
-Assess for fluid excess;
-Assure medications are administered before and after [MEDICAL TREATMENT] as ordered by
the physician to ensure maximum effectiveness and to avoid adverse effects of the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
medications;
-Monitor lab work. If lab work is performed at [MEDICAL TREATMENT] clinic, request copies
for facility medical record;
-Staff failed to address the need for monitoring/assessment of the resident’s shunt site;
-Staff failed to address need for ongoing communication between the facility and [MEDICAL
TREATMENT] center.
Review of the resident’s (MONTH) (YEAR) physician order [REDACTED].
-[DIAGNOSES REDACTED].
-An order, dated 1/30/18 for [MEDICATION NAME] ([MEDICATION NAME], blood thinner) 6
milligrams (mg) once a day;
-No orders for [MEDICAL TREATMENT] treatment;
-No orders for assessments or monitoring of the shunt bruit and thrill.
Review of the resident’s (MONTH) (YEAR) TAR, showed no documentation of thrill
assessments.
Review of the resident’s (MONTH) (YEAR) nurses’ notes, showed the following:
-No documentation regarding the resident’s [MEDICAL TREATMENT] treatments or assessments
and monitoring of the shunt site;
-On 2/16/18 at 4:00 P.M., resident observed bleeding from site of [MEDICAL TREATMENT] shunt area. The nurse applied pressure with dry dressing and noted the site continued to
bleed. Staff notified the resident’s physician, who ordered the resident to be sent to the
emergency room .
Review of the resident’s hospital discharge record, showed the following:
-Resident discharged from the hospital on [DATE];
-Chief complaint of bleeding from left upper external AV fistula;
-Initial international normalized ratio (INR, a laboratory measurement of how long it
takes blood to form a clot) of 4.8 (desired range is between 2.0 and 3.0), [MEDICATION
NAME] held and INR drifted down, now 2.16;
-Order for [MEDICATION NAME] 4 mg to be taken every day.
Further review of the resident’s (MONTH) (YEAR) nurses’ notes, showed the following:
-On 2/18/18 at 9:56 P.M., the resident returned from the hospital via ambulance. He/she
had a large bandage over the left arm shunt site with no complaints of discomfort voiced;
-No further documentation regarding the resident’s [MEDICAL TREATMENT] treatments or
assessments and monitoring of the shunt site.
Review of the resident’s (MONTH) (YEAR) POS, showed the following:
-An order, dated 2/20/18, for [MEDICATION NAME] 6.5 mg every evening;
-No orders for [MEDICAL TREATMENT] treatment;
-No orders for assessments or monitoring the shunt bruit and thrill.
Review of the resident’s (MONTH) (YEAR) TAR, showed no documentation of thrill
assessments.
Review of the (MONTH) (YEAR) nurses’ notes, showed no documentation regarding the
resident’s [MEDICAL TREATMENT] treatments, assessments or monitoring of the shunt site.
During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing (DON) said residents
who receive [MEDICAL TREATMENT] should have physician orders [REDACTED]. [MEDICAL
TREATMENT] care should also be included on the resident’s care plan.
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 – Some

(continued… from page 14)
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
psychiatric medications had supporting diagnoses and as needed (PRN) psychiatric
medications were re-evaluated after 14 days of use for three of 20 sampled residents
(Residents #17, #32 and #9). The census was 60.
1. Review of Resident #17’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/18/17, showed the following:
-Moderately impaired cognition;
-No symptoms of depression;
-Understands and able to be understood;
-Diagnoses included end stage [MEDICAL CONDITION] (longstanding disease of the kidneys,
leading to [MEDICAL CONDITION]), diabetes and muscle weakness;
-Received antidepressant medication for seven of seven days assessed.
Review of the physician order [REDACTED].
-No diagnoses for any mood related illnesses or pain;
-An order, dated 9/1/17, for [MEDICATION NAME] HCL (medication used to treat used to treat
major [MEDICAL CONDITION], anxiety and panic disorder) 75 milligrams (mg) tablet once a
day.
Review of the Medication Administration Record [REDACTED].
Review of the resident’s care plan, provided by the facility on 3/9/18 and in use during
the survey, showed no indication why the resident needed or received anti-depression
medication.
2. Review of Resident #32’s significant change MDS, dated [DATE], showed the following:
-Sometimes understands and is sometimes understood;
-Not evaluated for cognition;
-No signs or symptoms of depression;
-[DIAGNOSES REDACTED].>-Received antipsychotic medication (a class of medication
primarily used to manage [MEDICAL CONDITION], principally in [MEDICAL CONDITION] and[MEDICAL CONDITION] disorder) and antidepressant medication for seven of seven days
assessed.
Review of the POS [REDACTED] -Diagnoses included dementia and [MEDICAL CONDITION];
-An order, dated 12/10/17, for [MEDICATION NAME] (antipsychotic medication used to treat[MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 0.25 mg once a day;
-An order, dated 12/30/17, for [MEDICATION NAME] (sedative used to treat anxiety) 0.5 mg
every four hours PRN for agitation.
Review of the (MONTH) (YEAR) MAR, showed the [MEDICATION NAME] administered as ordered.
The resident did not receive the PRN [MEDICATION NAME] from 3/1/1/-3/9/18.
Review of the resident’s care plan, provided by the facility on 3/9/18 and in use during
the survey, showed no indication why the resident needed or received anti-psychotic or
sedative medications.
3. Review of Resident #9’s quarterly MDS, showed the following:
-No cognitive impairment;
-[DIAGNOSES REDACTED].
-No [DIAGNOSES REDACTED].
Review of the POS [REDACTED]. twice daily PRN with no diagnosis listed.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 – Some

(continued… from page 15)
Review of the care plan, dated 6/6/17 and in use during the survey, showed no indication
why the resident needed or received the mediation.
Review of the MAR, dated 2/1/18 through 2/28/18, showed the resident received [MEDICATION
NAME] 0.5 mg a total of 42 times.
Review of the MAR, dated 3/1/18 through 3/9/18, showed the resident received [MEDICATION
NAME] 0.5 mg. a total of 11 times.
4. During an interview on 3/9/18 at 10:45 A.M., the Director of Nursing (DON) said ordered
medications should have a supporting [DIAGNOSES REDACTED]. Psychiatric type medications
that are ordered on a PRN basis can not be used any longer than 14 days without the
physician reviewing the medication and the resident’s condition. The nurse should have
spoken to the physician regarding supporting diagnoses and if the medication is
appropriate to continue or discontinue.
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 30 opportunities observed, 10 errors
occurred, resulting in a 33.3% error rate (Residents #5, #22 and #37). The census was 60.
Review of the facility’s oral medication administration policy, dated (MONTH) (YEAR),
showed the following:
-Purpose: Medications are given to benefit a resident’s health as ordered by the
physician;
-Self administration of drugs is permitted with the written order of the resident’s
physician;
-Read the label three times before administration of the medication:
-First when comparing the label with the medication sheet;
-Second when setting up the medication;
-Third when preparing to administer medication to the resident;
-To administer tablets or capsules: Certain medications should never be crushed, refer to
the pharmacy manual to verify what medications can be crushed.
Review of the gastrostomy tube ([DEVICE], hollow tube placed into the stomach for
nutrition) medication administration policy, dated (MONTH) (YEAR), showed the following:
-Do not mix medications together unless ordered by the physician;
-Turn off feeding pump;
-Verify tube placement and check for residual and return to stomach if greater than 100
milliliters (ml) of residual. If less than 100 ml of residual, return to the stomach and
flush with amount of water ordered;
-Give medications only by gravity, never force with a plunger.
1. Review of Resident #5’s physician order [REDACTED].
-Nothing by mouth, [DEVICE] feedings;
-An order, dated 9/1/17, for aspirin (used as a blood thinner) 81 milligrams (mg), take
one daily;
-An order, dated 9/1/17, for [MEDICATION NAME] sulfate (iron) 325 mg, take one daily;
-An order, dated 9/1/17, for [MEDICATION NAME] (used to treat high blood pressure) 20 mg,
take one daily;
-An order, dated 9/1/17, for carvedilol (used to treat high blood pressure) 25 mg once

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
daily;
-An order, dated 9/1/17, for [MEDICATION NAME] (used to treat depression) 40 mg once
daily;
-An order, dated 9/1/17, for levetiracetam (used to treat [MEDICAL CONDITION]) 100mg/5
milliliters (ml), give 7.5 ml daily;
-An order, dated 9/1/17, for atorvastatin (used to reduce high cholesterol) 10 mg daily;
-An order, dated 9/1/17, for potassium chloride (potassium supplement) give 15 ml once
daily.
Observation on 3/9/18 at 8:22 A.M., showed Licensed Practical Nurse (LPN) A dispensed the
pill form medications into a single plastic cup and poured the liquid medication into two
separate cups. He/she placed the pills into a small plastic sleeve and crushed the
medications together and poured them into a plastic drinking cup. He/she entered the
resident’s room, greeted the resident and placed the crushed medications and the liquid
medication onto the night stand next to the bed. He/she took the plastic cup that
contained the crushed medication and entered the resident’s bathroom and poured
approximately 60 ml of tap water into the cup. He/she placed a clean washcloth under the
tube feeding ports. He/she used the large syringe and drew up 60 ml of the crushed
mediation with the water. He/she removed placed the syringe of medication into the feeding
tube port and used the syringe plunger to administer the medications to the resident.
Crushed medication remained visible on the sides and bottom of the plastic cup. He/she
removed the syringe and closed the tubing port. He/she removed the plunger from the
syringe and reinserted the syringe into the feeding tube port. He/she poured the liquid
medication one at a time into the syringe and allowed the medication to be administered by
gravity. He/she flushed the tubing with 150 ml of tap water. He/she did not administer the
medications separately, did not provide a water flush after each separate medication and
administered the crushed medication with force via use of the syringe plunger. During an
interview at that time, LPN A said she did not know that crushed medications should be
administered separately. There should be no residual mediation left in cups, water can be
used to rinse the cup and then administered to the resident so he/she gets the ordered
medication.
During an interview on 3/8/18 at 10:25 A.M., the Director of Nursing (DON) said
medications given by [DEVICE] should be crushed and administered separately and each
medication should be followed with a water flush. No medication residual should be left in
plastic cups.
2. Review of Resident #22’s POS, dated 3/1/18 through 3/31/18 showed an order, dated
1/17/18, for [MEDICATION NAME] (inhaler used to control symptoms of [MEDICAL CONDITIONS] by relaxing the airways and keeping them open) 18 micro grams (mcg) inhale one capsule by
mouth once daily.
During an observation and interview on 3/8/17 at 8:07 A.M, showed LPN A did not administer
the ordered inhaler treatment to Resident #22. He/she said Resident #22 can administer
his/her own inhaler treatments.
Further Review of the POS [REDACTED].
3. Review of Resident #37’s POS, dated 3/1/18 through 3/31/18, showed an order, dated
11/30/17, for [MEDICATION NAME] (used to treat elevated eye pressure) 0.25 %, administer
one drop into each eye daily.
During an observation and interview on 3/8/18 at 7:15 A.M., Certified Medication
Technician (CMT) B administered two drops of the [MEDICATION NAME] into each of the
resident’s eyes. CMT B did not hold the inner canthus of either eye.
During an interview on 3/8/18 at 10:25 A.M., the DON said when eye drops are administered
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
the inner canthus should have pressure applied to prevent absorption of the medication
into the residents system. All medications should be given as ordered by the physician.
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure insulin (used to
regulate blood sugar levels) vials were labeled with the resident’s name, were labeled
with legible dates and discard outdated insulin flex pens (prefilled injectable insulin
pens) and vials of insulin on two of four medication carts, for five out of 13 insulin
flex pens and vials observed. The census was 60.
1. Observation on [DATE] at 10:26 A.M., of the 100 wing medication cart, showed the
following:
-One opened vial of Humalog (fast acting) insulin, with a date opened of [DATE];
-One opened vial of Humalog ,[DATE] (mixture of fast acting and long acting) insulin, with
no resident name;
-One opened vial of [MEDICATION NAME] (fast acting) insulin, with an illegible date when
opened;
-One opened vial of [MEDICATION NAME] (long acting) insulin, with an illegible date when
opened.
During an interview on [DATE] at 10:30 A.M., Licensed Practical Nurse (LPN) D said all
insulin vials and pens are good for 30 days and if a date or name is illegible, it is the
nurses’ responsibility to throw it away.
2. Observation on [DATE] at 10:35 A.M., of the 400 wing medication cart, showed one opened
flex pen of [MEDICATION NAME], dated [DATE].
During an interview on [DATE], LPN A said all insulin pens and vials are good for 30 days.
3. During an interview on [DATE] at 9:00 A.M., the Director of Nursing said there is no
system in place to check the insulin vials or pens. There are a lot of new staff at the
facility and she has been trying to educate the nurses over time and several of the nurses
are resistive to learning. The insulins expire 28 days after opening and the charge nurse
is responsible to verify the dates on the insulin before administration to the resident
and make sure the insulin has not expired.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview and record review, the facility failed to ensure the
sanitizer in the sink was at the appropriate level to sanitize dishware, by not having the
appropriate testing strips available. This deficient practice had the potential to affect
all residents who ate at the facility. The census was 60.
During observation and interview on 3/6/18 at 11:03 A.M., the Dietary Manager (DM) said
the low temperature chemical sanitizing dishwasher stopped working on the evening of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
3/2/18. Staff had been handwashing all dishes using the sanitizing sink. A part for the
dishwasher had been ordered and was coming from Mexico but should arrive tomorrow. The
company that serviced the machine would come out and install it as soon as it arrived. The
DM took a chlorine test strip from the container and dipped it into the sanitizing sink.
The strip turned a light shade of purple and did not indicate the sanitizer was at the
proper level. The DM drained the sink and refilled it with water. The sanitizer dispensed
automatically from a tube connected to a gallon jug of sanitizing solution,
called(NAME)Laboratory, Inc. Sanitime. The DM dipped another test strip into the sink and
it changed to a darker purple color. The DM said the solution should be at least 100 parts
per million (PPM). The DM then matched the strip to the color coded area on the container
and said it was the right shade and indicated the sanitizer was at the appropriate level
to ensure the dishes were sanitized.
Review of the product specification sheet for Sanitime, showed the following:
-Sanitime is a quaternary ammonium chloride (QAC-type of disinfectant derived from
ammonium) sanitizer;
-Sanitime is an effective Environmental Protection Agency (EPA) registered sanitizer when
used at 200 to 400 PPM.
During an interview on 3/6/18 at 3:30 P.M., the dishwasher representative who routinely
serviced the dishwasher and ordered the new part, said Sanitime sanitizer is effective at
a minimum of 200 PPM. The facility should be using QAC strips, not the chlorine test
strips that turned shades of purple, to check the sanitizer level in the sink. The proper
test strip was plastic and only the tip turned a different color. He had supplied the
facility with the plastic strips in the past, but did not know when the last time was.
During an interview on 3/6/18 at 3:44 P.M., the DM said he recalled using the plastic
strips, but the registered dietician told him they were not the right ones. He thought the
test strips that turned purple were the correct ones. He would look to see if he still had
any of the plastic ones. A few minutes later, the DM said he must have discarded the
plastic strips.
During an interview on 3/6/18 at 4:00 P.M., the administrator said she would send someone
out to get enough paper, plastic and aluminum service-ware to use until the dishwasher was
fixed. She was not aware they did not have the appropriate test strips for the sink.
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 ensure each resident’s
written plan of care included both the most recent hospice plan of care and a description
of the services furnished by the facility to attain or maintain the resident’s highest
practicable physical, mental and psychosocial well-being. The facility identified three
residents as receiving hospice care. Of those three, two were selected for the sample of
20 and issues were identified with both of those (Residents #5 and #36). The census was
60.
Review of a list of residents on hospice, provided by the facility on 3/6/18, showed
Resident #5 and #36 listed as currently receiving hospice services.
1. Review of Resident #5’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/6/18, showed the resident did

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265709

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

03/09/2018

NAME OF PROVIDER OF SUPPLIER

BELLEFONTAINE GARDENS NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

9500 BELLEFONTAINE ROAD
SAINT LOUIS, MO 63137

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 19)
not have a life expectancy of less than six months.
Review of the facility’s Hospice Company Binder, showed the resident received hospice
services.
Review of the resident’s medical record, showed the following:
-admission date of [DATE];
-No care plan in the electronic medical record or the hard chart;
-No documentation of routine communication with the hospice company or description of
services provided by hospice in the progress notes;
-No documentation of routine communication with the hospice company, no coordination of
care or documentation of the hospice services the resident received;
-No order for hospice services on the (MONTH) (YEAR) physician order [REDACTED].
2. Review of Resident #36’s quarterly MDS, dated [DATE], showed a life expectancy of less
than six months.
Review of the Hospice Company Binder, showed the resident received regular hospice
services.
Review of the resident’s medical record, showed the following:
-admission date of [DATE];
-A care plan, last reviewed/revised on 11/14/17, showed no documentation regarding hospice
services;
-No documentation of routine communication with the hospice company or description of
services provided by hospice in the progress notes;
-No documentation of routine communication with the hospice company, no coordination of
care or documentation of the hospice services the resident received;
-No order for hospice services on the (MONTH) (YEAR) POS.
3. During an interview on 3/7/18 at 2:09 P.M., Licensed Practical Nurse (LPN) A, (charge
nurse for Resident #5 and #36’s hall) said when hospice visits, they document in a binder.
Otherwise, he/she is not sure how they communicate with the facility. He/she sees them
write in the computer.
4. During an interview on 3/9/18 at 10:45 A.M., the administrator said if a resident
received hospice services, it should be reflected on the care plan. Every resident should
have a care plan that reflects their current care needs. The facility and the hospice
company should coordinate care. This collaboration should be reflected on the care plan to
show who is responsible for what.
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