Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0554

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Allow residents to self-administer drugs if determined clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
residents’ right to self-administer medications had been determined as clinically
appropriate for one of 26 sampled residents (Resident #114). The census was 130.
Review of Resident #114’s medical record, showed:
-An admission Minimum Data Set (MDS), a federally mandated assessment instrument completed
by facility staff, dated 12/25/18, showed [DIAGNOSES REDACTED].
-No assessment for the ability to self-administer medications.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s care plan, dated 12/25/18, showed no documentation for the
ability to self-administer medication.
Observation and interviews on 3/18/19 at 11:55 A.M. and at 1:30 P.M., showed a medicine
cup on the resident’s bedside table with nine pills inside the cup. The resident appeared
to be asleep and startled when the surveyor called out his/her name a few times. He/she
looked at the medicine cup and said, Oh, I need to take my pills. He/she was very groggy
and said he/she did not sleep much the night before. The nurse would leave his/her
medication sometimes because it was hard to wake him/her. During an interview at 1:30
P.M., the resident said staff sometimes left his/her medication on the table. The staff
had not educated him/her on self administration. Staff would know he/she took it because
he/she would use his/her call light if he/she did not have all his/her medication. He/she
liked staff to leave the medication so he/she would not have to wake up to take it so
early.
During an interview on 3/18/19 at 12:35 P.M., Licensed Practical Nurse (LPN) W said he/she
administered the resident’s medication at 9:00 A.M. He/she did not realize the resident
did not swallow the medication because he/she put the cup up to his/her mouth. The
resident had not been assessed to administer his/her own medications. He/she probably
should not have left the medication in the resident’s room.
During an interview on 3/20/19 at 5:20 P.M., the corporate nurse said the staff member
should not have left medication with the resident without an order from the physician to
self-administer.
Review of facility’s resident self administration of medications policy dated 8/1/16,
showed:
-Policy – It is the policy of the facility to provide resident centered care that
safeguards the residents right for self-administration of their own medication that
supports resident dignity and self-determination;
-The facility will not require or compel any resident to administer their own medication
if they do not desire to do so or cannot safely do so. The facility will not knowingly
permit an unsafe act for self-administration of medications. Self-administration of
medications still requires nurse observations and monitoring for effects and side-effects;
-The facility will periodically review the ability to self-administer medication based
upon change in status;
-On admission, the facility will assess the resident for safety through an IDT
(interdisciplinary team) care planning team prior to the resident exercising their right
of self-administration of drugs within 7 days after the comprehensive assessment is
completed as required by regulations;
-Procedure:
-Determine if the resident desires to self-administer medication;
*Physician/provider order is required for residents to self-administer medication;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0554

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
-Assessments will include addressing the following and documenting in the care plan:
*storage of medication;
*responsible party for storage of medication;
*documenting the administration of drugs;
*location of where the drug will be administered.

F 0561

Level of harm – Potential for minimal harm

Residents Affected – Many

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
resident has a right to make choices about aspects of his or her life in the facility that
are significant to the resident by not providing coffee in the morning prior to the
service of breakfast for one resident (Resident #86) and not providing residents access to
the dining room outside of meal service hours. This had the potential to affect all
residents who would choose to utilize the dining room during times outside of meal service
and/or drink coffee at times dietary staff are not available. The census was 130.
1. Review of Resident #86’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/8/19, showed:
-Brief Interview for Mental Status (BIMS) score of 13 out of 15;
-A BIMS score of 13-15, showed the resident cognitively intact;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed no
documentation the resident had been assessed as unsafe to drink hot liquids.
During an interview on 3/15/19 at 7:31 A.M., the resident said there was a group of 10 to
12 residents who used to go in the dining room before breakfast and drink coffee together.
Now staff will not serve coffee until breakfast is served, never before 7:30 A.M. This was
an activity that he/she really enjoyed and it was taken away. Staff keep the door to the
dining room closed and resident’s cannot even go in until breakfast time. This change
occurred when kitchen management changed.
Observation on 3/15/19 at 7:30 A.M., showed the doors to the kitchen closed and several
residents waited in the hall. Dietary staff opened the doors at 7:31 A.M. and residents
entered the dining room. Water and juice available to residents. No coffee available. At
approximately 7:40 A.M., staff started to bring cups of coffee from the kitchen to
residents who sat in the dining room.
2. Review of the list of meal times, provided by the facility, showed the following dining
room times:
-Breakfast: 7:30 A.M. through 8:30 A.M.;
-Lunch: 12:00 P.M. through 1:00 P.M.;
-Dinner: 5:30 P.M. through 6:30 P.M.
Observation on 3/14/19, 3/15/19 and 3/18/19 through 3/20/19, showed the doors to the
dining room closed when meal service not in progress.
3. During an interview on 3/20/19 at 1:48 P.M., the dietary manager said when floors are
being cleaned after a meal, doors are closed and residents cannot be in the dining room
because the floors are wet. She does not want residents in the dining room unattended. She
could see why residents believed they were not allowed in the dining room since the doors
are kept closed, but they could open the doors and come in. She did not know why the doors

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0561

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 2)
are not opened to make the room available to the residents after the floors are dry. She
is aware of the group of residents who sit and wait outside the dining room before meals,
waiting for the doors to open but the doors are not opened until the meal is ready to be
served. There is currently a group of residents that do want to come in and drink coffee,
but she is concerned with safety. She prefers not to give coffee to residents before meals
service. The facility has a safe drinking policy she is expected to follow. When residents
want coffee early, they knock on the kitchen door. Staff will not give it to them right
away after it is made because it is too hot. It is 5:30 A.M. that the residents are asking
for their coffee. They meet the dietary staff right when they are coming in to work. The
prior administrator let the residents have the coffee when they wanted, but she has not
talked about this with the current administrator. She has had to restrict residents on
their coffee consumption. Nursing staff cannot come into the kitchen and make coffee. They
have not been trained to work the equipment. Residents cannot get coffee before dietary
arrive and make it. Coffee is not made until 6:00 A.M., but staff cannot give it to
residents immediately because it is too hot. Dietary staff work from 5:30 A.M. to 8:00
P.M. Outside of these hours, the residents cannot have coffee.
4. Review of the facility’s Hot Beverage or Liquids policy, dated 3/29/18, showed:
-The facility will promote independence for safe-drinking/dining but only to the extent
the resident can perform the task safely and not endanger themselves or others around them
from hot beverage/liquid spills. Screening will include resident preferences to the extent
possible for safe hot beverage/liquid service;
-When it is determined by a thorough assessment that the resident cannot manage hot
beverages/liquids independently and safely, assistive devices will be implemented;
-Efforts that promote independence and dignity will be resident specific to guide safe
care;
-Care and care plan: Resident preferences will be considered to the extent possible for
reasons of safety to self and others nearby.
5. During an interview on 3/20/19 at 4:45 P.M., the administrator and corporate nurse said
residents should have access to common areas per their choice. Residents should be
provided coffee per their choice as long as they have not been assessed as unsafe.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility the facility failed to ensure resident
mattresses were were in good repair, control strong urine odors that did not dissipate
throughout the survey process and ensure bathroom vents had covers and were clean and in
good repair (Resident #95). The census was 130.
1. Review of Resident #95’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/17/19, showed:
-Rarely/never understood;
-Rarely/never understands;
-Extensive assistance of two (+) staff required for bed mobility and transfers;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-Risk of developing pressure ulcers: Yes;
-Skin and ulcer treatments: Pressure reducing device for bed.
Observation on 3/20/19 at 5:46 A.M., showed the resident sat in a tilt in space wheelchair
(wheelchair tilts back to recline). The resident’s bed had been stripped. Observation of
the mattress showed various stains. The area where the hips and buttocks would rest had
large ridges where the mattress top had deteriorated over time.
During an interview on 3/20/19 at 6:45 A.M., Certified Nurse Aide (CNA) GG said most of
all of the resident mattresses were in bad shape.
During an interview on 3/20/19 at 6:54 A.M., Nurse JJ looked at the mattress and said
he/she would not want to lay on the mattress even with a sheet on it.
During an interview on 3/20/19 at 7:02 A.M., CNA KK looked at the mattress and said he/she
would not sleep on that mattress even if it had a clean sheet. It’s stained and bunched up
in the middle. There would be a higher risk of skin breakdown with the mattress being
bunched up like that. When a mattress needs to be replaced, staff are supposed to put in a
work order in the tels system in the computer. Maintenance looks at the tels system daily
to see if anything needs to be fixed or replaced. He/she had not seen the mattress before
and did not know if anyone had added the poor condition of the mattress to the tels
system.
During an interview on 3/20/19 at 7:56 A.M., the administrator said the facility had been
ordering new mattresses every month to replace worn mattresses. When a mattress is noted
to be in poor condition staff are supposed to write a note in the tels system. The
maintenance department is responsible to check tels daily. She did not know if anyone had
documented the poor condition of the mattress in the tels system or not. She would not
want to sleep on that mattress and it needs to be replaced. The facility has extra
mattresses in supply.
During an interview on 3/20/19 at 10:47 A.M., the laundry/housekeeping manager looked at
the mattress. She said it upset her that no one had reported that mattress. No one should
have to lay on a mattress that looks like that. She is going to inservice her staff to
report mattresses in poor condition.
2. Observation on 3/14/19 at 8:00 A.M., showed a strong odor of urine and feces upon entry
to the facility and near the hallway of the main dining room.
Observation on 3/14/19 at 11:51 A.M., showed a strong odor of urine in the assisted dining
room.
Observation on 3/15/19 at 8:00 A.M., showed a strong odor of urine and feces throughout
the facility.
Observation on 3/18/19 at 6:00 A.M., showed a strong odor of urine and feces in the
hallway of the main dining room.
During the resident council meeting on 3/18/19 at 10:11 A.M., 11 residents were present.
All residents said they noticed odors throughout the facility. When asked specifically
what the odors were, one resident said, I mean, you smell boo boo and pee pee all the time
but you just get used to it after a while because we are here. Approximately five
residents agreed with this statement. Another resident said his/her visitors would not go
near particular areas in the facility, due to the odor of feces and urine.
Observation on 3/19/19 at 8:30 A.M., showed a strong odor of urine and feces near the
hallway of the main dining room.
Observation on 3/20/19 at 8:00 A.M., showed a strong odor of urine and feces near the
hallway of the main dining room.
During an interview on 3/20/19 at 5:30 P.M., the administrator said she was aware of the
odors throughout the facility. She believes the odors are from the carpets in the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
facility. The housekeeping staff have been cleaning the carpets to help reduce the odors.
3. Observation from 3/14/19 through 3/20/19, showed:
-room [ROOM NUMBER]: Bathroom vent with a missing cover. The exposed area underneath where
the cover should be was thick with dust;
-room [ROOM NUMBER]: Bathroom vent cover thick with dust;
-room [ROOM NUMBER]: Bathroom vent cover thick with dust.
During an interview on 3/20/19 at 7:56 A.M., the administrator said bathroom vent covers
should be cleaned routinely by the maintenance department.

F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
residents’ rights to be free from abuse were not violated as evidenced by resident to
resident physical altercations involving six of 26 sampled residents (Residents #85, #51,
#52, #127, #106 and #90). The census was 130.
1. Review of Resident #85’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility, dated 2/8/19, showed:
-Brief interview for mental status (BIMS, a screen for cognitive impairment) score of 15
out of 15 (a score of 13-15 indicates intact cognition);
-Trouble concentrating on things such as watching television and reading a newspaper;
-No behaviors;
-Extensive assistance from one staff for bed mobility, transfers, dressing and bathing;
-Mobility device, wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 2/24/19 and revision dated 3/4/19, showed:
-Problem: Potential to demonstrate verbally abusive behaviors related to mental and
emotional illness and poor impulse control, staff witnessed resident pulling and
scratching another resident;
-Goal: Resident with staff assistance will have fewer episodes of yelling out/verbal
behavior, will not harm self or others, will seek out staff/caregiver when agitation
occurs and will verbalize understanding of need to control physically aggressive behavior
through next review;
-Interventions: Analyze key times, places, circumstances, triggers and what de-escalates
behavior, assess/anticipate resident’s needs, assess resident’s coping skills/support,
contact the resident’s family when resident becomes agitated, provide physical/verbal cues
to alleviate anxiety, give positive feedback, assist to set goals for more pleasant
behavior, encourage resident to seek out staff members when agitated, monitor and document
observed behaviors and attempted interventions in the behavior log, resident was
immediately removed away from the resident (roommate) and taken out of the room on 3/3/19.
Review of the resident’s progress note dated 3/3/19 at 12:30 P.M., showed the resident was
found in his/her room, scratching and hitting his/her roommate. The incident was heard by
two nurses. They separated the resident and his/her roommate. The resident said his/her
roommate called him/her a b***h and w***e. The resident said he/she began hitting and
scratching his/her roommate. The resident’s physician was contacted.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
During an interview on 3/19/19 at 11:50 A.M., the resident said he/she recalled having an
issue with his/her roommate on 3/3/19. He/she was cursing and yelling back and forth with
his/her roommate. His/her roommate had called him/her a b***h and a w***e, so he/she hit
and scratched the roommate on his/his left arm. Staff did separate both of them and
removed him/her from the room. Staff sent him/her out to the hospital. He/she denied
having any prior issues and/or altercations with his/her roommate prior to 3/3/19.
Review of Resident #51’s admission MDS, dated [DATE], showed:
-BIMS score of 14 out of 15;
-Verbal behaviors (threatening, screaming and cussing), daily;
-Extensive assistance from one staff for bed mobility, transfers, dressing and bathing;
-Mobility device, wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/3/19, showed:
-Problem: Has poor impulse control and mental illness and demonstrated verbal and abusive
behavior towards another resident, calling him/her a b***h;
-Goal: Staff will continue to guide and assist the resident in controlling verbal, abusive
behaviors through next review;
-Interventions: Administer and monitor effectiveness/side effects of medications per
physician orders, analyze times, places, circumstances, triggers and what de-escalates
behavior, assess and anticipate resident’s needs, evaluate for side effects of medication,
assess resident’s understanding of the situation and allow time for the resident to
express self and feelings towards the situation.
Review of the resident’s progress note dated 3/3/19 at 12:20 P.M., showed the resident had
an altercation with his/her roommate. The roommate scratched his/her left arm. The
roommate was separated by staff, removed from the room and sent to the hospital.
During an interview on 3/14/19 at 5:00 P.M., the resident said he/she and his/her roommate
were cursing at each other and his/her roommate scratched his/her left arm in two
different areas. The incident occurred on 3/3/19. Staff intervened immediately, separated
both of them and removed his/her roommate from the room. The facility sent his/her
roommate out to the hospital on [DATE]. The resident had two linear healed scratches on
his/her left arm.
During an interview on 3/14/19 at 10:15 A.M., Unit Manager T said the incident between
Resident #85 and Resident #51 occurred on 3/3/19. The day shift charge nurse overheard
yelling coming from the residents’ room. The charge nurse entered the room and witnessed
Resident #85 scratching Resident #51’s left arm. Staff separated both residents, removed
Resident #85 from the room and sent Resident #85 to the hospital for an evaluation. The
unit manager said the hospital sent Resident #85 back to the facility within three hours
of being sent out. Resident #85 continued with behaviors of screaming and yelling at
staff. Staff could not redirect him/her and the resident was sent back out to a different
hospital and admitted . There were no altercations between Resident #85 and Resident #51
prior to 3/3/19.
2. Review of Resident #52’s quarterly MDS, dated [DATE], showed:
-No cognitive impairment;
-No behaviors;
-Extensive assistance with bed mobility, transfers, dressing and toilet use;
-Supervision with eating;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised dated 11/15/18, showed no documentation
regarding behaviors.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
During an interview on 3/14/19 at 10:40 A.M., the resident said he/she heard Resident #127
yelling at a female resident. Resident #52 told Resident #127 not to yell at the female
resident. Resident #127 starting cursing and hit him/her. The staff stopped it and
Resident #127 was no longer at the facility. There were no more concerns.
Further review of the resident’s care plan, showed no update regarding the incident.
Review of Resident #127’s admission MDS, dated [DATE], showed:
-No cognitive impairment;
-No behaviors;
-Supervision with bed mobility and locomotion on the unit;
-Independent with transfers, dressing, eating and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated initiated 2/18/19 and revision on 2/18/19,
showed:
-Focus: Demonstrated verbally abusive/threatening behaviors with regards to ineffective
coping skills, poor impulse control. Threatened to shoot up dietary staff because was not
served what he/she requested for an evening meal;
-Goal: Will verbalize understanding of need to control verbally abusive behavior through
the review date;
-Intervention: Intervene before agitation escalates. Guide away from source of distress.
Engage calmly in conversation. If response is aggressive, staff to walk calmly away and
approach later. Monitor resident. Document observed behavior and attempted interventions
in nurse’s notes.
Review of the facility’s investigation, dated 2/20/19, showed the residents were outside
on the patio getting ready to smoke. Resident #127 was cursing at a female resident.
Resident #52 asked Resident #127 to stop disrespecting the female resident. Resident #52
said that Resident #127 started cussing at him/her, calling him/her a b***h and a n****r
and in return Resident #52 started cussing back. Resident #127 said Resident #52 started
ramming his/her wheelchair into him/her and pushing him/her up against the table. An ash
tray was on the table and while Resident #52 kept ramming Resident #127 with his/her
wheelchair, Resident #127 said the ash tray fell . Resident #127 picked up the ash tray
and hit Resident #52 in the face several times. Resident #52 had a 2.5 centimeter
laceration to the upper lip that will require sutures. Staff was alerted and residents
were separated and Resident #127 was put on one on one monitoring.
Review of the resident’s medical record, showed the resident was issued an immediate
discharge on 2/27/19.
3. Review of Resident #106’s quarterly MDS, dated [DATE], showed:
-BIMS of 12 (Moderate cognitive impairment);
-Experienced feeling down or depressed one out of seven days;
-Exhibited no behaviors;
-Required supervision of one staff for locomotion off the unit.
Review of Resident #90’s quarterly MDS, dated [DATE], showed the following:
-BIMS of 12;
-Exhibited no behaviors;
-Required supervision for locomotion off the unit;
-[DIAGNOSES REDACTED].
Review of the facility’s undated summary of event’s, showed:
-Resident #90 was admitted to the facility on [DATE];
-On 3/19/19, close to the end of dinner, the regional director of clinical operations
heard some commotion coming from the dining room. She heard Resident #106 speaking in a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
raised voice but could not hear what was being said. She was in the Director of Nursing
(DON) office at the time of the incident. She went into the main dining room and found
Resident #90 standing up and slapping Resident #106 across the left cheek. They were
arguing over five dollars Resident #90 borrowed from Resident #106. Resident #106
requested his/her money back. Resident #90 stated to the other resident that his/her
family member did not give him/her any money, so he/she could not return the money.
Resident #90 was sent to the hospital for aggressive behaviors. He/she remained on one on
one observations until Emergency Medical Services (EMS) arrived. Resident interviews
validated the incident;
-The police department was contacted and stated because Resident #90 had a [DIAGNOSES
REDACTED].
-The families were notified;
-Resident #90 would remain on one on one observations and both residents would be kept
separated.
During an interview on 3/20/19 at 12:15 P.M., Resident #106 said Resident #90 was his/her
boyfriend/girlfriend. He/she loaned Resident #90 the money and asked for it back. Resident
# 90 said, B***h you got plenty of money, you don’t need it. Resident #106 said, It’s my
money. Resident #90 got up from his/her chair and hit Resident #106 on the face. Staff was
not around when they were arguing. After the resident hit him/her, staff responded and
moved Resident #106 out of the dining room right away. He/she was not afraid of the
resident that hit him/her, but said, It wasn’t right. The facility called the police and
he/she wanted to press charges. However, the police told him/her the facility would handle
it. Resident #90 was sent to the hospital but came right back to the facility. It was not
fair. Resident #106 contacted the local news channels because the police would not take a
report.
Observation on 3/20/19 at 12:47 P.M., showed the resident lay in bed. He/she received one
on one monitoring.
During an interview on 3/20/19 at 12:47 P.M., Resident #90 said, Ain’t nothing happen for
real, when asked about the incident. He/she did not hit the other resident, only tapped
him/her. They had an argument over five dollars. He/she and Resident #106 kind of dated
prior to the incident. When asked if he/she liked the resident, Resident #90 said, He/she
was alright. When asked what would happen going forward, the resident said, It ain’t gonna
happen again. He/she was unsure of their relationship status at the moment. When told
others witnessed Resident #90 hit Resident #106, he/she said, They just saying that.
He/she felt he/she should not have been placed on one on one monitoring because he/she did
not do anything and did not plan on doing anything going forward.
During an interview on 3/20/19 at 10:15 A.M., Nurse Y said neither resident experienced
aggressive behaviors prior to the incident. He/she thought the residents were dating one
another. Going forward, staff was expected to keep the residents separated from one
another.
During an interview on 3/20/19 at 4:00 P.M., the regional director of clinical operations
said she heard a noise in the dining room. She went to check and saw Resident #90 and #106
at the same table. However, she thought the noise was from another resident. She saw the
two residents arguing and walked towards them. Before she could reach the table, Resident
#90 stood up and slapped Resident #106 on the face. She separated the two residents and
took Resident #106 out of the dining room. Another staff took Resident #90 out of the
dining room. They contacted the police and sent Resident #90 out to the hospital. He/she
returned to the facility the same day and was placed on one on one monitoring. Going
forward, Resident #90 would remain on one on one monitoring until the psychiatrist could
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
evaluate him/her, then they would figure out what to do with him/her.
4. During an interview on 3/20/19 at 5:30 P.M., the administrator said she expected all
residents to be free from any type of abuse and neglect, including resident to resident
altercations.
5. Review of the facility’s Abuse, Neglect and Misappropriation policy and procedure,
revised (MONTH) 12, (YEAR), showed:
-Policy: It is the policy of this facility to provide resident centered care that meets
the psychosocial, physical and emotional needs and concerns of the residents and to
prevent abuse, mistreatment or neglect of the residents;
-Definitions: Abuse is the willful infliction of injury, unreasonable confinement,
intimidation, or punishment with resulting physical harm, pain or mental anguish,
deprivation by an individual, including a caretaker, or good or services that are
necessary to attain or maintain physical, mental and psychosocial well-being;
-Verbal abuse: The use of oral, written or gestured language that willfully includes
disparaging and derogatory terms to residents or their families, or within their hearing
distance, to describe residents, regardless of their age, disability, or ability to
comprehend;
-Physical abuse: Includes, but not limited to hitting, slapping, pinching, kicking or
flicking with fingers or striking in any manner that is demeaning. It also includes
controlling behavior through corporal punishment.
MO 411
MO 030
MO 259
MO 099

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to ensure newly hired employees
were screened to rule out the presence of a Federal Indicator, with the Certified Nurse
Aide (CNA) Registry, and the Employee Disqualification List (EDL). This affected two of 10
sampled employees hired since the last survey. The facility hired at least 100 new
employees since the last survey. The census was 130.
According to Missouri Department of Health and Senior Services (DHSS): Section for
Long-term Care LTC Bulletin, Volume 3 Issue 1, Fall 2004, if a CNA had or currently has
had their name on the EDL, they receive a federal marker. Those CNAs who have a federal
marker may not be employed at any time in a facility that receives Medicaid or Medicare
benefits.
According to Missouri Department of Health and Senior Services (DHSS): Section for
Long-term Care LTC Bulletin, Volume 6 Issue 1, Winter 2008, providers are required to
check the registry before hiring any individual and may not continue to employ a person
whose name appears on the registry with a federal indicator. Providers must seek registry
verification from all states believed to have information on an individual.
1. Review of the Admission Director’s employee file, showed:
-Hire date: 11/5/18;
-EDL and CNA registry check performed on 3/15/19.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 – Few

(continued… from page 9)
2. Review of the Administrator’s employee file, showed:
-Hire date: 12/3/18;
-EDL and CNA registry check performed on 3/15/19.
During an interview on 3/15/19 at 12:09 P.M., the administrator said their corporate
office, which is out of state, did not realize that Missouri regulation required the
federal indictor and CNA registry check.

F 0607

Level of harm – Potential for minimal harm

Residents Affected – Many

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on interview and record review, the facility failed to develop and implement written
policies and procedures that address prevention of resident to resident altercations
through identification and monitoring of residents with behaviors. In addition, the policy
failed to address the investigation of incidents and protection of residents if the abuser
is a visitor and/or volunteer. The census was 130.
Review of the facility’s Abuse, Neglect and Misappropriation policy, revised 10/12/18,
showed:
-It is the intent of this facility to prevent the abuse, mistreatment or neglect of
residents or the misappropriation of their property, corporal punishment and/or
involuntary seclusion and to provide guidance to direct staff to manage any concerns or
allegations of abuse, neglect or misappropriation of property;
-Prevention: The physical environment has been designed to prevent seclusion of residents,
staff members are identified by name badges, staffing is established based on census;
-The policy failed to identify prevention through an ongoing assessment, care planning for
appropriate interventions and monitoring of residents with needs and behaviors which might
lead to conflict;
-Investigation of incidents:
-In the event the alleged perpetrator is a staff member, that staff member will be
removed from areas of resident living and interviewed by nurse on duty;
-In the event the alleged abuse involved a resident-to-resident altercation, the
residents will be placed in separate areas by the staff and the appropriate physical
assessments will be completed on each resident;
-Protection from abuse:
-In the event a staff member has been accused, they will be interviewed by the executive
director or designee and be immediately escorted from the facility;
-When the alleged abuse involves a resident to resident altercation, the residents will
be separated by the staff and the appropriate physical assessments will be completed on
each resident;
-The policy failed to address the investigation of incidents and protection of residents
if the abuser is a visitor and/or volunteer.
During an interview on 3/20/19 at 4:56 P.M., the corporate nurse and administrator said
they would expect the abuse and neglect policy address the protocol for abuse prevention
for resident to resident altercations as well as investigation of incidents and protection
of residents if the abuser is a visitor and/or volunteer.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

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 and
implement a comprehensive person-centered care plan for each resident that includes
measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and
psychosocial needs for one resident, when the resident’s care needs changed (Resident
#86). The sample was 26. The census was 130.
1. Review of Resident #86’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 2/8/19, showed:
-Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicated the resident
cognitively intact;
-Wandering: Behavior not exhibited;
-Independent with mobility and locomotion.
Review of the resident’s medical record, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-At risk for communication problems. Delayed response to questions. Ensure/provide a safe
environment;
-Activity of daily living self-care performance deficit. Activity intolerance, impaired
balance/limited mobility/limited range of motion. Poor coordination. Requires staff
supervision while at the facility;
-The care plan failed to address the resident’s ability to leave independently on leave of
absence (LOA).
During an interview on 3/18/19 at 6:57 A.M., the resident said he used to live at an
apartment complex nearby and provided the name of the complex. He/she walked there over
the weekend. Staff eventually called his/her cell phone when they realized he/she was
gone. He/she went there to eat corned beef and cabbage with his/her old roommate. At 11:21
A.M., the resident said he/she left the facility Saturday (3/16/19) morning. It was
approximately six to seven hours before staff called to find out where he/she was. The
nurse who called said he/she should have signed out at the nurse’s desk. He/she knew that
he/she was supposed to do that, but just he/she did not. No one at the facility knew
he/she left the campus and/or that he/she was not coming back that night, until they
called. He/she returned before dinner the following day, 3/17/19.
Review of the facility’s LOA binder, located at the front desk, reviewed on 3/19/19,
showed:
-The resident signed out on 3/16/19 at 10:00 A.M. and returned on 3/17/19 at 4:20 P.M.;
-No documentation to show where the resident went or how long the resident’s leave was
anticipated.
Review of the resident’s LOA sign out log, located in the resident’s hard chart at the
nurse’s station, reviewed on 3/19/19, showed no documentation the resident went on LOA on
3/16/19.
During an interview on 3/19/19 at 7:01 A.M., Licensed Practical Nurse (LPN) C said he/she
was the nurse responsible for the resident on Saturday morning (3/16/19) from
approximately 6:00 A.M. to noon. He/she was not aware the resident left the facility. At
lunch he/she noticed the resident was not there eating, but did not know where he/she was
at that time.
During an interview on 3/19/19 at 9:50 A.M., with the administrator and Director of
Nursing (DON), they said they would expect staff follow their LOA policy. In the
resident’s chart, each resident has a LOA sheet. There is also a binder at the front desk.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 11)
They should be signing out on both logs, but the facility used the main one at the front
desk. The facility protocol for a resident who is leaving the property is that they let
staff know where they are going, provide a cell number and then an anticipated return
time. If a resident has an unauthorized leave of absence, when they return, administration
would talk to the resident and find out why they did not sign out. The care plan would be
updated and reeducation provided.
During an interview on 3/19/19 at 10:31 A.M., LPN O said he/she was the nurse responsible
for the resident from approximately noon until 11:15 P.M. on Saturday, 3/16/19. He/she
realized around dinner that the resident was not at the facility. He/she called the
resident’s spouse who said he/she believed the resident was with a friend and had signed
out at the front desk. When it got later in the evening and the resident still had not
returned, he/she called the resident on his/her cell phone. The resident said he/she was
with a friend and would be back in the morning. LPN O put a call out to the physician, but
never heard back. He/she called to inform the DON that the resident had left and the DON
said call the physician and document that she/she called and talked to the resident.
Further review of the resident’s care plan, reviewed on 3/20/19 at 8:15 A.M., showed the
care plan had not been updated with the resident’s unauthorized LOA and/or goals
interventions.
During an interview on 3/20/19 at 4:55 P.M., the administrator said care plans should be
up to date and accurate to the resident’s condition. Nursing is responsible to update care
plans. After a significant event, such as an unauthorized LOA, the care plan should be
updated. The resident’s care plan should be updated by now. He/she tried to leave again
today (3/20/19) and was educated.
Review of the facility’s Elopement Management policy, dated 7/1/16, showed:
-Elopement: The Centers for Medicare and Medicaid Services (CMS) defines elopement as when
a resident leaves the premises or a safe area without authorization and/or necessary
supervision. Each state may define elopement by a set of criteria for self-reporting
purposes;
-The facility is to immediately initiate procedures to locate any resident that is
unaccounted for. Notification of appropriate parties will comply with state and federal
regulations. Following location of the involved resident, the facility leadership will
review prevention systems to identify performance opportunities;
-Residents who are their own person and choose to leave the premises without staff
knowledge will be considered an Unauthorized Leave of Absence and not elopement.

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 interview and record review, the facility failed to notify physicians when
residents’ blood glucose levels exceeded parameters as ordered by those physicians. The
facility identified 23 residents that received routine blood glucose checks. Review of
their blood glucose levels, showed three exceeded parameters without the physician being
notified consistently, and one had high blood glucose levels with no parameters to notify
the physician (Residents #13, #68, #23 and #106). In addition, the facility failed to
ensure one resident’s pacemaker was monitored. (Resident #10). The census was 130.
1. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 12)
assessment instrument completed by facility staff, dated 12/9/18, showed:
-Ability to express ideas and wants: Understood;
-Understanding verbal content: Understands;
-Supervision of one person required for eating;
-[DIAGNOSES REDACTED].
-Received insulin five of the last seven days.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s blood glucose levels, showed:
-1/30/19 through 2/13/19: The parameters had not been exceeded;
-2/14/19 through 3/13/19: The parameters exceeded 250, 41 times without documentation that
staff had notified the resident’s physician;
-3/14/19 at 6:28 A.M., the resident’s blood glucose level was 442, staff notified the
physician and received an order to increase the resident’s insulin;
-3/15/19 through 3/19/19: The parameters exceeded 250, 14 times without documentation that
staff had notified the resident’s physician.
2. Review of resident #68’s quarterly MDS, dated [DATE], showed:
-Ability to express ideas and wants: Understood;
-Understanding verbal content: Understands;
-Setup help only required for eating;
-[DIAGNOSES REDACTED].
-Received insulin: Blank.
Review of the resident’s POS, showed an order dated 2/8/19, for staff to notify the
physician if the resident’s blood glucose level is below 70 or above 250.
Review of the resident’s blood glucose levels, showed from 2/8/19 through 3/18/19, the
parameters exceeded 250, 26 times without documentation that staff had notified the
resident’s physician.
3. Review of Resident #23’s quarterly MDS, dated [DATE], showed:
-Ability to express ideas and wants: Understood;
-Understanding verbal content: Understands;
-Setup help only required for eating;
-[DIAGNOSES REDACTED].
-Received insulin four of the past seven days.
Review of the resident’s POS, showed no parameters when staff should notify the physician
for low or high blood glucose levels and no documentation that staff discussed the absence
of parameters with the physician.
Review of the resident’s blood glucose levels, showed from 1/21/19 through 3/19/19, staff
documented a blood glucose level between 400 and 450, four times, a blood glucose level
between 451 and 500, five times, a blood glucose level above 500, three times and no
documentation staff notified the resident’s physician.
4. Review of Resident #106’s quarterly MDS, dated [DATE], showed:
-Ability to express ideas and wants: Understood;
-Understanding verbal content: Understands;
-Supervision of one person required for eating;
-[DIAGNOSES REDACTED].
-Received insulin seven of the last seven days.
Review of the resident’s POS, showed an order dated 2/5/19, for staff to notify the
physician if the resident’s blood glucose level is above 450.
Review of the resident’s blood glucose levels, showed from 2/27/19 through 3/19/19, staff
documented a blood glucose level above 450, five times and no documentation staff notified
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 13)
the resident’s physician.
5. During an interview on 3/20/19 at 5:48 P.M., the regional nurse director of clinical
operations said the facility did not have a policy to address when staff should notify the
physician for low or high blood glucose levels. The parameters are set by each individual
physician. She expects staff to contact the physician and document in the progress notes
when blood glucose levels are exceeded. If a resident does not have parameters, staff
should ask the physician when he/she wants to be notified.
6. Review of Resident #10’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-No short/long term memory loss;
-Required staff supervision for bed mobility, transfers, dressing, toileting, personal
hygiene and bathing;
-Incontinent of bowel and bladder;
-No special treatments.
Review of the resident’s POS, dated 3/1/19 through 3/31/19, showed:
-[DIAGNOSES REDACTED].
-No order for pacemaker checks.
Review of the resident’s care plan, updated 3/8/19, showed:
-Problem: Resident has a pace maker;
-Intervention: Blank.
During an interview on 3/14/19 at 9:10 A.M., the resident said he/she has lived at the
facility for about one year. He/she has problems with breathing and has a pacemaker.
He/she remembers having his/her pacemaker checked about a year ago.
During an interview on 3/19/19 at 10:45 A.M., Nurse C said he/she was not aware of the
resident’s pacemaker or when it was last checked.
During an interview on 3/20/19 at 11:34 A.M., Nurse C said he/she called the resident’s
cardiologist regarding the resident’s pacemaker and a cardiologist appointment was
scheduled for 3/29/19.
During an interview on 3/20/19 at 5:30 P.M., the facility’s regional nurse consultant said
she would expect the resident’s pacemaker be documented on the resident’s physician’s
orders [REDACTED].

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents received the
minimum of two showers weekly and were kept clean and dry. Of the 26 residents sampled,
seven were reviewed for routine showers and problems were found with all seven (Residents
#18, #50, #75, #79, #95, #104 and #108). The census was 130.
1. Review of Resident #18’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/19/18, showed:
-No cognitive impairment;
-No behaviors;
-Extensive assistance with personal hygiene, dressing and bed mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 12/19/18, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-Focus: Activities of daily living (ADLs) self care performance deficit with regards to
spinal cord injury;
-Goal: With staff assistance and outside therapy, the resident hopes to improve current
level of function in all aspects of ADLs through the review date;
-Interventions: Bathing: Requires two staff assistance with bathing.
During an interview on 3/19/19 at 12:40 P.M., the resident said he/she was to supposed to
get a shower on Saturday 3/16/19, but they did not have enough staff. At that time the
resident took his/her finger and scratched his/her face and flakes of dried skin came off.
The resident’s hair appeared greasy.
Review of the facility’s shower schedule, dated 6/8/18, showed the resident was scheduled
for showers on the day shift on Wednesday and Saturday.
Review of the resident’s completed shower sheets for 1/1/19 through 3/20/19, showed the
facility only presented the shower sheets for 3/13/19 and 3/20/19. There were no other
shower sheets available.
2. Review of Resident #50’s quarterly MDS, dated [DATE], showed:
-Moderate cognitive impairment;
-Exhibited other behaviors not directed towards others such as hitting, scratching self,
pacing, rummaging, public sexual acts, disrobing in public, throwing food or bodily waste,
or verbal/vocal symptoms like screaming, disruptive sounds occurred one to three days per
week;
-Required supervision of one staff for locomotion off the unit;
-Required extensive assistance of one staff for dressing, eating, toilet use and personal
hygiene;
-Required a wheelchair for mobility;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s undated care plan, showed:
-[DIAGNOSES REDACTED].
-Focus: Revised on 11/22/18, Impaired cognition;
-Goal: All needs will be anticipated and met;
-Interventions: Keep consistent routines and try to provide consistent care givers as much
as possible in order to decrease confusion;
-Focus: Revised on 11/22/18. Intermittent bowel incontinence due [MEDICAL CONDITION];
-Goal: No skin complications related to his/her incontinence;
-Interventions: Staff would check the resident at least every two hours and assist with
toileting, as needed and provide care after each incontinent episode;
-Focus: Revised on 11/22/18, Potential for complications associated with urinary
incontinence;
-Goal: Keep clean, dry and comfortable;
-Interventions: Check on the resident every two to three hours and as needed for
incontinent episodes and provide incontinence/perineal care after each incontinent
episode.
Observation on 3/14/19 at 11:51 A.M., showed a staff member propelled the resident into
the assisted dining area in his/her wheelchair. He/she pushed the resident to his/her
table, and left the dining room. Other residents were in close proximity of the resident.
The resident was visibly wet and projected a strong smell of urine. The resident remained
in the assisted dining room at 12:51 P.M.
During an interview on 3/20/19 at 4:45 P.M., the administrator, director of operations and
the regional clinical director of operations said incontinent residents should be checked
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
at least every two hours and as needed. If a resident was visibly wet or smelled of urine,
staff should provide care. The resident never should have been propelled into the dining
room by staff if he/she was visibly wet and smelled of urine.
3. Review of Resident #75’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].>-Required total staff assistance for all ADLs;
-Incontinent of bowel and bladder.
Observation on 3/14/19 at 9:20 A.M., showed the resident lay in bed awake. He/she was
unable to speak but was able to answer simple questions with a head nod.
Review of the facility’s shower schedule, dated 6/8/18, showed he/she was scheduled for
showers on the evening shift on Tuesday and Friday.
Review of the resident’s completed shower sheets for 1/1/19 through 3/18/19, showed the
facility only presented the shower sheets for 1/6/19, 1/11/19, 1/15/19 and 3/16/19. There
were no other shower sheets available.
4. Review of Resident #79’s quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
-Required total assistance of one to two staff for bed mobility, transfers, dressing,
hygiene and bathing.
Review of the facility’s shower schedule, showed he/she was scheduled for showers on the
day shift on Tuesday and Friday.
Review of the resident’s completed shower sheets provided by the facility dated 1/1/19
through 3/18/19, showed the resident received a total of six showers.
5. Review of Resident #95’s annual MDS, dated [DATE], showed:
-Rarely/never understood;
-Rarely/never understands;
-Extensive assistance of one person required for bed mobility and dressing;
-Extensive assistance of two (+) persons required for transfers;
-Total dependence of one person required for personal hygiene and bathing;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-[DIAGNOSES REDACTED].
Review of the facility’s shower schedule, showed he/she was scheduled for showers on
Monday and Thursday.
Review of the resident’s completed shower sheets provided by the facility for 1/1/19
through 3/18/19, showed the resident received four showers on 1/7/19, 1/24/19, 3/4/19 and
3/18/19.
6. Review of Resident #104’s quarterly MDS, dated [DATE], showed:
-Usually understood;
-Usually understands;
-Extensive assistance of two (+) persons required for bed mobility and transfers;
-Total dependence of one person required for dressing, personal hygiene and bathing;
-Always incontinent of bowel;
-[DIAGNOSES REDACTED].
Review of the facility’s shower schedule, showed the he/she was scheduled for showers on
Thursday and Saturday.
Review of the resident’s completed shower sheets provided by the facility for 1/1/19
through 3/18/19, showed the resident received three showers on 1/24/19, 3/14/19 and
3/16/19.
7. Review of Resident #108’s admission MDS, dated [DATE], showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-admission date of [DATE];
-Required extensive assistance of one staff with bathing;
-[DIAGNOSES REDACTED].
Review of the facility’s shower schedule, showed the resident receives showers during the
evening shift every Tuesday and Friday.
Review of the resident’s shower sheets provided by the facility dated 2/18 through
3/13/19, showed the resident received a total of six showers.
8. During an interview on 3/20/19 at 8:52 A.M., CNA M said shower sheets are completed by
the CNAs after a shower is given and then given to the nurse.
9. During an interview on 3/20/19 at 9:51 A.M., CNA K said they try to get their showers
done as assigned, but it is not uncommon for staffing to be down and they are unable to
get the showers finished.
10. During an interview on 3/20/19 at 4:45 P.M., the administrator, director of operations
and the regional clinical director of operations said they would expect staff to complete
resident showers as scheduled.

F 0678

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure cardiopulmonary
resuscitation (CPR, initiation of life sustaining measures in the event the heart stops
beating) certified staff accompanied all residents with a full code (initiate CPR in the
event the heart stops beating) status, when transported to and from appointments in the
facility van. The census was 130.
Review of Employee S’s employee file, showed:
-Hire date: [DATE];
-No documentation of CPR certification.
During an interview on [DATE], the administrator said she should ensure all transportation
drivers including Employee S has a CPR certification. Some of the resident’s transported
are full code residents. The issue must have been overlooked.

F 0684

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided consistent monitoring, assessments, documentation and physician updates for two
full code residents that experienced changes in their conditions. One was found lifeless
and unable to be revived and the other was found unresponsive and transferred to the
hospital (Residents #278 and #104). The census was 130.
Review of the facility’s policy regarding Skilled Documentation Guidelines, updated
[DATE], showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 17)
-Policy: It is the policy of this facility to provide resident centered care that meets
the psychosocial, physical and emotional needs and concerns of the residents. Daily
clinical notes are written by a licensed clinician to provide documentation/evidence that
care services meet and have been provided above the criteria for more than routine care.
Residents receiving skilled services should be assessed/evaluated overall but
documentation should reflect specific charting assessments/evaluations based on diagnosis,
physician requirements and resident needs that require a skilled clinician;
-Procedure: 1. Completed and thorough notes must be written for each resident receiving
skilled care. Each resident will have specific care needs with resident specific
documentation of care provided that will be reflected in the progress note;
-A. Clinical notes for Respiratory Conditions (pneumonia, [MEDICAL CONDITIONS] ([MEDICAL
CONDITION])) may include: Lung sounds (each shift), abnormal sounds and location, nature
of respirations, depth and rate, use of accessory muscles, sounds audible without
stethoscope, dyspnea (difficult or labored breathing) on exertion and/or at rest, cough,
productive or non productive, moist or dry, depth (deep or shallow), frequency, describe
any sputum produced (color, consistency and amount), temperature: take every four hours
while febrile (with an elevated temperature), monitor in the morning and in the evening,
hydration, resident newly ill with a respiratory disease should be on intake and output (I
& O). Note the adequacy of fluid intake and how much encouragement resident needs to
take fluids.
1. Review of Resident #278’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Short/long term memory loss;
-Limited staff assistance for personal hygiene;
-Extensive staff assistance for bed mobility and dressing;
-Total staff assistance for transfers and toileting;
-Incontinent of bowel and bladder.
Review of the resident’s physician’s orders [REDACTED].
-[DIAGNOSES REDACTED]. to an infection) and acute [MEDICAL CONDITION] with hypercapnia
(too much carbon [MEDICATION NAME] in the blood);
-Cardiopulmonary resuscitation (CPR, a medical procedure involving repeated compression of
a patient’s chest, performed in an attempt to restore the blood circulation and breathing
of a person who has suffered [MEDICAL CONDITION]);
-Vital signs every shift;
-Levalbuteral Nebulzation solution (a [MEDICATION NAME] used to prevent and treat wheezing
and shortness of breath caused by breathing problems) one vial every four hours as needed
for shortness of breath/wheezing;
-Order dated [DATE], oxygen at two L per nasal cannula every shift.
Review of the resident’s care plan, updated [DATE], showed:
-Problem: At risk for ineffective tissue perfusion (decreased in oxygen to the tissues)
related to [MEDICAL CONDITION], with a history of [MEDICAL CONDITION];
-Approach: Assist the resident/family/caregiver of signs/symptoms of respiratory
compromise. Maintain a clear airway by encouraging the resident to clear his/her own
secretions with effective coughing. Suction as needed to clear airway. Monitor/document
changes in orientation, increased restlessness, anxiety and air hunger. Monitor breathing
patterns. Report abnormalities to the physician: nasal flaring, respiratory depth changes,
altered chest excursion, use of accessory muscles, pursed lip breathing (is an act of
inhaling through the nose and exhaling slowly against pursed lips), oxygen as ordered and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 18)
oxygen saturations (O2 sat, amount of oxygen in the blood).
Review of the resident’s progress notes, showed:
-[DATE] 10:19 A.M.: Resident noted to have weakness. Skin warm and dry to the touch. Head
of bed (HOB) evaluated. Answers to name and responds to staff when name called. Resident
did not eat or drink this am. Encouraged to eat and assist given, updated the physician
and new orders noted;
[DATE] at 11:00 A.M.: Urine obtained and placed in refrigerator. 1:35 P.M.: Labs not drawn
yet. Updated responsible party on change in status and noted behaviors. Responsible party
wants resident to go to the ER, DON (Director of Nurses) aware. 2:41 P.M.: Gateway called
for transport. 2:55 P.M.: Ambulance here, given report, updated on residents condition.
5:16 P.M.: Resident admitted to hospital for altered vital signs and mental status;
-[DATE] at 10:10 P.M.: Skilled Documentation: Readmit. hospitalized with left lower lobe
pneumonia. Blood pressure: ,[DATE] (normal ,[DATE]), Temperature: 98.2 (normal 98.6),
Pulse 80 (normal 60 – 100), Respirations 20 (normal ,[DATE]). Lung sounds: Abnormal breath
sounds noted, wheezing (a high-pitched [MEDICATION NAME] sound made while breathing. It’s
often associated with difficulty breathing). Antibiotic therapy: pneumonia;
-[DATE] 10:26 P.M.: Resident returned from hospital. Alert, stable, denies pain.
Transferred to bed with assist of two without difficulty. Lungs with some wheezing on the
left side. Right lung clear to auscultation. Oxygen at 3 liters (L) per minute. O2 sat at
98% (normal ,[DATE]). Call to the physician to verify discharge orders.
Review of the resident’s Medication Administration Record [REDACTED]
-Levalbuteral HCL nebulization solution one vial orally via nebulizer every four hours as
needed for shortness of breath/wheezing. No documentation staff administered the
medication;
-Oxygen at two liters every shift. Staff documented as administered: [DATE] night shift O2
Sat of 94%; [DATE] on day shift O2 Sat of 94%, evening shift O2 Sat of 94%, nights: blank;
[DATE] on day shift O2 Sat of 95%, evening shift O2 Sat of 94% and night shift 96%.
Review of the resident’s POS, showed an order dated [DATE], to send the resident to the
hospital emergency room for evaluation.
Review of the resident’s progress notes, showed:
-[DATE] at 6:01 A.M. through 5:29 P.M., and [DATE] at 2:10 P.M., showed no documentation
regarding the order dated [DATE], to send the resident to the emergency room . No
documentation regarding the resident’s lung sounds or vital signs documented;
-No further documentation regarding the resident’s condition until [DATE] at 5:00 A.M.;
-[DATE] at 5:00 A.M.: Resident found in bed unresponsive with no pulse. Resident is a full
code. CPR initiated and 911 called. CPR in progress when paramedics entered the room.
Monitor placed on resident to determine heart activity, none noted. CPR stopped at 5:14
A.M. Physician notified, cause of death [MEDICAL CONDITIONS]. Resident’s family member
notified.
During an interview on [DATE] at 1:25 P.M., Certified Nurse Aid (CNA) EE said the resident
was in and out of the hospital. He/she didn’t recall who his/her aide was that day.
During an interview on [DATE] at 1:30 P.M., CNA FF said he/she remembered talking with
resident when he/she returned from the hospital. He/she and other staff were surprised by
the resident’s death.
During an interview on [DATE] at 1:47 P.M., Nurse W said when a resident is admitted to
the facility, the nurse should document the resident’s condition for 72 hours unless there
is problem. The nurse should continue to document until the resident is stable. The
documentation should include a full assessment including lung sounds and vital signs.
During an interview on [DATE] at 6:57 A.M., Certified Medication Technician (CMT) X said
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 19)
the resident’s respirations were bad a few days before he/she passed away.
During an interview on [DATE] at 3:02 P.M., the Medical Director said she would expect the
staff to monitor and document the resident’s vitals signs, O2 sats every shift for 7 days
and if the resident wasn’t receiving skilled services at least 72 hours.
During an interview on [DATE] at 4:05 P.M., the administrator said the resident was
receiving skilled nursing services for pneumonia. She would have expected staff to
document any abnormal findings in the nurse’s notes and notify the physician.
During an interview on [DATE] at 9:45 A.M., the administrator said if the resident is in a
skilled bed for therapy or for skilled nursing, staff should document daily, every shift
until the resident comes off skilled services.
During an interview on [DATE] at 2:33 P.M., the resident’s physician said after admission,
he would expect staff to assess and document. It is the facility’s responsibility to train
agency staff. They should document assessments after the resident was readmitted from the
hospital. Staff should document any change and notify the physician.
During an interview on [DATE] at 5:48 P.M. the facility’s regional nurse director of
clinical operations said she would expect a skilled note at least once per day. The
facility charts by exception, but if there are abnormal findings she would expect the
staff to document and call the physician.
2. Review of Resident #104’s significant change in status MDS, dated [DATE], showed:
-Adequate hearing;
-Clear speech, distinct intelligible words;
-Ability to express ideas and wants: Sometimes understands, responds to simple, direct
communication only;
-Ability to understand others: Usually understands, misses some/part of message but
comprehends most of conversation;
-Extensive assistance of two (+) persons required for transfers;
-Total dependence of one person required for dressing, eating and personal hygiene;
-[DIAGNOSES REDACTED].
-Pain in the past five days: Yes;
-Feeding tube (gastrostomy tube ([DEVICE]), a tube inserted into the the stomach through
the abdomen to infuse nutrition, water and medications).
Review of the resident’s current care plan, showed:
-Impaired cognitive functions/dementia or impaired thought processes related to short term
memory loss, long term memory loss: Discuss concerns about confusion, disease process with
resident/family. Engage resident in simple, structured activities;
-Alteration in comfort related to chronic pain, depression and limited mobility. Resident
is able to call for assist when in pain, ask for medication and say how much pain he/she
is in;
-Monitor/record/report any signs symptoms of non-verbal pain (noisy, deep/shallow or
labored breathing), vocalizations (grunting, moans, yelling out, silence), face (sad,
crying, worried, scared, clenched teeth, grimacing), body (tense, rigid, rocking, curled
up, thrashing);
-[MEDICAL CONDITION] or an acute (sudden) confusional episode related to acute disease
process dementia: Identify yourself at each interaction, face resident when speaking and
make eye contact. Resident understands consistent, simple, direct questions;
-Full code status.
Observation on [DATE] at 9:35 A.M., showed the resident lay in bed, with the head of the
bed up. The resident said he/she was fine, but would like to be repositioned.
Observation on [DATE] at 5:56 A.M., showed the resident lay in bed awake, with the head of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 20)
the bed up. He/she did not engage in conversation during the observation.
Review of the resident’s nurse’s progress notes and medical record, showed:
-[DATE] at 5:03 P.M.: The resident was in a wheelchair and noted to have a small emesis
(vomit). The resident’s tube feeding was disconnected and he/she was transferred back to
bed. Noted cough, no wheezes. Blood pressure ,[DATE], heart rate 100, temperature 100.1
degrees, axillary (underneath the arm, an axillary temperature is usually 0.5 to 1 degree
lower than an oral temperature, the average oral temperature is 98.6 degrees), oxygen
saturation rate of 94% room air. physician’s orders [REDACTED].
-[DATE] at 6:03 P.M.: Mobile x-ray here for x-ray;
-[DATE] at 9:45 P.M.: Still awaiting chest x-ray results. Resident resting in bed with the
head of the bed elevated, no other emesis noted. [DEVICE] residual 20 cubic centimeters
(cc) (residual is checked to determine volume of fluid remaining in the stomach during
feeding, a residual of 200 to 250 cc or less is considered normal). Tube feeding held. No
signs or symptoms of pain or discomfort;
-A radiology (chest x-ray) report, showed the following: Date of service [DATE], lungs
clear, normal cardiac size. Conclusion: No acute cardiopulmonary findings;
-No follow-up monitoring, assessment or physician notification (regarding the change of
condition as documented on [DATE] at 5:03 P.M.) was documented on the 11:00 P.M. to 7:00
A.M. shift (11:00 P.M. beginning on [DATE] and ending on [DATE] at 7:00 A.M.), the 7:00
A.M. to 3:00 P.M. shift for [DATE], or the 3:00 P.M. to 11:00 P.M. shift on [DATE]).
Observation on [DATE] at 6:42 A.M. and 7:34 A.M., showed the resident lay in bed with the
head of the bed up. His/her eyes were closed.
Review of the resident’s nurse’s progress notes, showed:
-[DATE] at 1:32 A.M.: At midnight rounds, the resident was found unresponsive. 911 was
called at 12:42 A.M., they arrived at 12:50 A.M. Physician and DON were notified at 1:06
A.M. Resident is on the way to the hospital;
-[DATE] at 6:26 A.M.: Call placed to hospital. The resident was admitted with a [DIAGNOSES
REDACTED].
Observation and interview on [DATE] at 6:09 A.M., showed the resident was not in his/her
room and his/her bed had been stripped. CMT X said he/she worked the midnight shift and
sent the resident to the hospital. Last night during shift report, the evening shift nurse
said the resident had been having emesis during the evening and they turned off the
resident’s tube feeding pump. They did not call the resident’s physician. He/she went in
the resident’s room around midnight. The resident had an emesis and was unresponsive.
He/she called 911. The resident was sent to the hospital and diagnosed with [REDACTED].
During an interview on [DATE] at 9:00 A.M., Nurse Y said he/she took care of the resident
on the day shift on [DATE]. He/she was in the resident’s room several times during his/her
shift. At around 10:00 A.M., CNA BB told him/her there was something on a towel that was
laying on the resident. He/she went in to the resident’s room and there was brown liquid
resembling tube feeding. He/she turned off the tube feeding pump and cleaned the
resident’s mouth. He/she did not see leaks in the tube feeding line and did not see any
brown liquid in the resident’s mouth. At around 12:00 P.M. or 1:00 P.M., he/she turned the
tube feeding pump back on. Nurse Y checked on the resident one more time before his/her
shift ended. He/she did not obtain the resident’s vital signs, assign anyone to obtain the
resident’s vital signs, or document any of his/her observations or assessments He/she did
not contact the physician regarding the resident’s emesis or turning off the tube feeding
pump. He/she informed Nurse AA (evening shift nurse) about the resident at the shift
change.
During an interview on [DATE] at 9:35 A.M., CNA Z said he/she was not the resident’s CNA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 21)
on the day shift of [DATE], but he/she did assist CNA BB in taking care of the resident.
The resident had a towel laying over him/her when they went in the room around noon. The
towel had brown spots on it. He/she helped CNA BB reposition the resident. The resident
said it hurt when they turned him/her, but that was normal for the resident. The tube
feeding was on. He/she did not see tube feeding leaking anywhere. That was the only time
he/she went into the resident’s room.
During a telephone interview on [DATE] at 11:41 A.M., CNA BB said he/she worked the day
shift on [DATE]. The resident was not feeling well, he/she was kind of throwing up a bit.
Just a little bit of throwing up. He/she asked Nurse Y to come in the room. Nurse Y placed
the tube feeding on hold. CNA BB cleaned the resident then left. Nurse Y did not ask
him/he to obtain vitals, and he/she did not see Nurse Y assess the resident or obtain
vitals. CNA BB went back to the resident’s room later, but he/she could not recall if the
tube feeding was on or off that time. Someone else, maybe a hospice person, he/she was not
sure, but it was someone that comes in every couple of days or so to see the resident,
told him/her they had to change the resident’s gown again because of an emesis. CNA BB did
not remember if he/she told Nurse Y about that or not.
During a telephone interview on [DATE] at 11:39 A.M., Nurse AA, said he/she was assigned
to the resident on the evening shift on [DATE]. He/she is new at the facility and [DATE]
was the second time he/she worked alone. He/she did not know the residents very well.
He/she arrived for work around 2:45 P.M. and received report from Nurse Y. He/she and
Nurse Y did a walking round about 3:30 P.M. Nurse Y said the resident had emesis on the
day shift. The resident did have what appeared to be emesis on a towel that laid on top of
him/her. The tube feeding had been turned off. At around 4:00 P.M., he/she went into the
resident’s room alone. The resident had another emesis. He/she asked CNA CC to clean the
resident. At around 5:30 P.M., the resident had not had another emesis, so he/she turned
the tube feeding back on. The resident moaned, kind of grimaced as if he/she wanted to be
left alone when he/she touched him/her. He/she did assess the resident’s skin, which was
warm and his/her color was good. The resident was not speaking to him/her, but since
he/she was new, he/she did not know if that was different for the resident. The last time
he/she checked the resident was around 7:00 P.M. or 7:15 P.M., and the resident appeared
to be fine. He/she did not obtain a set of vitals, document an assessment of the resident
or notify the resident’s physician regarding the emesis on the day shift or evening shift.
He/she got overwhelmed during the shift and forgot to do those things but should have. CNA
CC did not tell him/her the resident was gagging or mumbling. Had he/she been informed the
resident was gagging, he/she would have obtained a set of vitals and probably sent the
resident to the hospital.
During a telephone interview on [DATE] at 1:19 P.M., CNA CC said he/she had worked with
the resident several times. He/she made rounds around 3:00 P.M. on [DATE]. The resident
was dry at that time and seemed alright. After dinner, Nurse AA said the resident had
vomited and asked him/her to clean the resident up. He/she went into the resident’s room.
The resident had vomited a medium amount of brown colored fluid, his/her tube feeding was
still infusing. The resident was not like his/her normal self, he/she was not speaking
like he/she normally did, just grumbling and mumbling. He/she asked Nurse DD to come into
the resident’s room, because Nurse AA was passing medications. Nurse DD turned the
resident’s tube feeding pump off. CNA CC cleaned the resident, there was some brown fluid
in the resident’s mouth. He/she checked on the resident a couple more times before leaving
that evening. The last time was around 9:15 P.M. The resident was not vomiting any longer,
but he/she was gagging, like heaving. The resident was still not speaking to him/her those
last two times. The resident’s tube feeding was still off. He/she told Nurse AA about the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0684

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 22)
resident heaving and gagging.
During an interview on [DATE] at 4:46 P.M., Nurse DD said he/she worked the evening shift
on [DATE], but was not the resident’s nurse. He/she was familiar with the resident and had
cared for the resident before. The resident has been a bit more sleepy over the past week.
He/she was the nurse that wrote the nurse’s note on [DATE] at 5:03 P.M. and received the
order for the chest x-ray. He/she reported the emesis and pending chest x-ray results to
the midnight nurse at shift change on [DATE]. He/she had not worked with the resident
since that time. On the evening shift of [DATE], CNA CC asked him/her to see the resident
because the resident had an emesis. He/she went to the resident’s room and turned the tube
feeding pump off. He/she asked CNA CC if Nurse AA was aware of the emesis and the
resident’s condition. CNA CC said Nurse AA was aware, so he/she assumed Nurse AA had
assessed the resident at that point. He/she went back to his/her own side after CNA CC
told him/her Nurse AA was aware. If he/she had been the resident’s nurse that evening,
he/she would have obtained vitals, completed an assessment and called the physician.
During an interview on [DATE] at 10:21 A.M., the DON reviewed the resident’s nurse’s notes
and said staff should have documented every shift and as necessary after the first emesis.
They should have continued to assess and document until the resident was stable. The
physician should have been updated if the symptoms did not stop. She was not notified of
this, but should have been.
During an interview on [DATE] at 3:00 PM, the resident’s physician, also the facility
Medical Director, reviewed the resident’s nurse’s progress notes. She would have expected
facility staff to monitor, assess and document every shift after the first emesis was
identified on [DATE] at 5:03 P.M. She would have expected the assessments and
documentation to continue until the resident was no longer symptomatic and stable. If the
resident continued to have symptoms, she would have expected staff to contact her.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to adequately
assess, monitor and treat one resident’s pressure ulcer. The facility identified eight
residents with pressure ulcers. All eight were sampled with one additional sampled
resident to equal nine. Problems were found with the addition resident (Resident #227).
The census was 130.
Review of the facility’s policy on Skin Care and Wound Management, dated 7/1/2016, showed:
-Policy: The facility staff strives to prevent resident skin impairment and to promote
healing of existing wounds. The interdisciplinary team works with resident and
family/responsible party to identify and implement interventions to prevent and treat
potential skin integrity issues. The interdisciplinary team evaluates and documents
identified skin impairments and pre-existing signs to determine the type of impairment,
underlying condition contributing to it and description of impairment to determine
appropriate treatment;
-Each resident is evaluated upon admission and weekly thereafter for changes in skin
condition. The resident’s skin condition is also re evaluated with change in clinical
condition, prior to transfer to the hospital and upon return from the hospital;
-Prevention: Complete the Braden Scale (screening tool to determine risk of pressure
ulcers) on admission, weekly times three weeks, quarterly and change of clinical condition

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
to identify risk indications. Complete an Admission Observation Tool. Identify areas of
skin impairment and pre-existing signs. Identify [DIAGNOSES REDACTED]. Develop a care plan
with individualized interventions to address risk factors. Communicate risk factors and
interventions to the care giving team. Evaluate for consistent implementation of
interventions and effectiveness as indicated. Communicate changes to the care giver.
Review of Resident #227’s entry Minimum Data Set, a federally mandated assessment
instrument completed by facility staff, showed an entry date of 3/4/19.
Review of the resident’s Baseline Care Plan, dated 3/4/19, showed:
-Alert and cognitively intact;
-Required one person assistance for bed mobility, toileting, eating, grooming, hygiene and
bathing;
-Incontinent of bowel and bladder;
-Skin: current pressure ulcer, turn and position frequently, air mattress;
-See physician’s orders [REDACTED].
Review of the resident’s progress note, dated 3/4/19 at 11:13 P.M., showed:
-Arrived at the facility at 6:30 P.M.;
-Alert and oriented times three;
-[DIAGNOSES REDACTED].
-Resident has multiple wounds: Coccyx 5 centimeter (cm) by 5 cm wound bed is 100% pink;
Left palm 4 cm by 5 cm wound bed 50% slough (yellow dead tissue or eschar) and 50% pink;
left cheek 3.5 cm by 0.5 cm and necrotic (dead tissue); left hip 4 cm by 4 cm, no
description; left outer knee 3 cm by 3 cm, no description; right top of knee 2.5 cm by 2
cm scabbed; right inner knee 4 cm by 1 cm scabbed and necrotic.
Review of the resident’s physician’s orders [REDACTED].
-Hospice evaluation;
-Cleanse coccyx with wound cleanser and apply Allevyn (dressing used to treat chronic and
wounds with drainage) foam every Monday Wednesday and Friday on evening shift;
-Cleanse left outer knee with wound cleaner and apply Allevyn foam Monday, Wednesday and
Friday on evening shift;
-Cleanse left palm with wound cleanser and apply Allevyn foam every Monday, Wednesday and
Friday on evening shift;
-Cleanse right inner knee with wound cleaner and apply Allevyn foam every Monday,
Wednesday, Friday on evening shift;
-Cleanse top of right knee with wound cleaner and apply Allevyn foam every Monday,
Wednesday and Friday on evening shift.
Review of the resident’s Braden Observation Tool, showed:
-Risk Score of 9;
-Very high risk= 9 or below.
Review of the facility’s Weekly Wound Log, dated 3/6/19 and 3/13/19, showed:
-Complete each Thursday. Add all wounds that are currently being monitored in the facility
(surgical, pressure, non-pressure) If a wound is healed this week and was reported last
week, add that resident and state that the wound is healed. All wound documentation must
be completed in Point Click Care (facility electronic charting program) per company
policy. This does not take the place of that documentation;
-No documentation regarding the resident’s pressure ulcers.
Review of the resident’s treatment administration record (TAR), dated 3/1/19 through
3/31/19, showed:
-Cleanse coccyx with wound cleanser and apply Allevyn foam every Monday Wednesday and
Friday on evening shift. Staff documented as completed: 3/6, 3/11, 3/13, 3/13, 3/15 and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
3/18/19;
-Cleanse left outer knee with wound cleaner and apply Allevyn foam Monday, Wednesday and
Friday on evening shift. Staff documented as completed: 3/6, 3/11, 3/13, 3/13, 3/15 and
3/18/19;
-Cleanse left palm with wound cleanser and apply Allevyn foam every Monday, Wednesday and
Friday on evening shift; Staff documented as completed: 3/6, 3/7, 3/10, 3/11, 3/12, 3/13,
3/15, 3/16, 3/17, 3/18 and 3/19/19;
-Cleanse right inner knee with wound cleaner and apply Allevyn foam every Monday,
Wednesday, Friday on evening shift. Staff documented as completed: 3/6, 3/11, 3/13, 3/13,
3/15 and 3/18/19;
-Cleanse top of right knee with wound cleaner and apply Allevyn foam every Monday,
Wednesday and Friday on evening shift. Staff documented as completed: 3/6, 3/11, 3/13,
3/13, 3/15 and 3/18/19.
Observation on 3/19/19 at 1:06 P.M., showed the resident lay in bed on his/her back. The
hospice nurse said he/she was going to change the resident’s dressings. The two dressings
on the resident’s right knee were dated 3/14/19, left knee 3/14/19 and left palm 3/17/19.
The hospice nurse and hospice certified nurse aide (CNA) turned the resident to his/her
left side, revealing a saturated coccyx dressing, brief and incontinence pad. A strong
pungent odor of urine and stool permeated the room. Nurse C entered the room, assessed the
resident’s dressings and said the resident appeared not to be changed for several hours.
In addition his/her dressings were to be changed Monday, Wednesday and Friday on the
evening shift. Monday’s date was 3/18/19.
During a skin assessment on 3/20/19 at 11:56 A.M., the resident lay in bed. The treatment
nurse said she was only aware of the pressure ulcer to the resident’s left palm. No one
informed her the resident had other pressure ulcers. Staff are to complete the admission
assessment, enter it into the computer and notify her of any wounds. Her assessment
showed: Right knee cap: eschar (hard dry dead skin), 3.2 cm by 2.1 cm, unstageable (unable
to stage due to wound covered with slough), right inner knee: 2. 4 cm by 1.5 cm
unstageable, left outer knee: 3.7 cm by 2.3 cm unstageable, left palm: yellow slough, 1.9
cm by 1.1 cm unstageable and coccyx 3.8 cm by 3.5 cm unstageable.
During an interview on 3/20/19, 2:47 P.M., the resident’s physician said he would expect
the facility to monitor the resident’s wounds.
During an interview on 3/20/19 at 3:01 P.M., the treatment nurse said the resident’s
physician gave orders to continue the current treatment of [REDACTED].
During an interview on 3/20/19 at 3:09 P.M., the administrator said she expects staff to
notify the treatment nurse of any wounds. The admitting nurse is responsible to complete a
head to toe, assessment, measure, document, obtain a treatment orders and notify the
treatment nurse.

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 ensure residents
that qualified for restorative therapy services received those services. The facility
identified 20 residents with current restorative therapy orders, six were sampled and none
of them were receiving restorative therapy as ordered (Residents #75, #102, #104, #52, #14

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 25)
and #79) The census was 130.
1. Review of Resident #75’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/9/18, showed:
-Adequate hearing and vision;
-Rarely/never understands;
-Cognitive skills severely impaired;
-Extensive assistance of two (+) persons required for bed mobility, transfers, dressing,
toilet use and personal hygiene;
-Walking in room/corridor, did not occur in the past seven day period;
-Functional limitation in range of motion of upper extremity (shoulder, elbow, wrist,
hand), on one side and two lower extremities (hip, knee, ankle, foot), on both sides;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
-Currently receiving no occupational therapy or physical therapy;
-Currently receiving no Restorative Nursing Program (a program developed by a skilled
therapist and carried out by nursing staff (usually a certified nurse aide (CNA) or a
restorative aide (RA) under the supervision of a nurse).
Review of the facility’s restorative therapy (RT) caseload document dated 3/14/19, showed
Resident #75 was on the list.
Review of the facility RT nursing plan dated 1/19, showed the resident should receive
passive range range of motion (PROM) for 15 minutes a day to the right upper extremities
along with assisted active range of motion (AROM) exercises to the left upper extremities.
The tracking sheet showed 1/29/19 was the last date of documented therapy. No
documentation of RT received in (MONTH) or (MONTH) 2019.
2. Review of Resident #102’s quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Unclear speech, slurred and mumbled words;
-Rarely/never understood;
-Cognitive skills severely impaired;
-Extensive assistance of two (+) persons required for bed mobility and transfers;
-Walking in room/corridor, did not occur;
-Functional limitation in range of motion for both upper extremities;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
-Currently receiving no occupational therapy or physical therapy;
-Currently receiving no RT program.
Review of the facility’s RT caseload document dated 3/14/19, showed Resident #102 was on
the list.
Review of the facility RT nursing plan dated 1/19, showed the resident should receive AROM
for 15 minutes a day to bilateral lower extremities (BLE), three times a week. The
tracking sheet showed 1/29/19 was the last date of documented therapy. No documentation of
RT received in (MONTH) or (MONTH) 2019.
3. Review of Resident #104’s quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Clear speech;
-Usually understands;
-Intact cognition;
-Extensive assistance of one person physical assist for bed mobility and two (+) persons
required for transfers;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 26)
-Walking in room/corridor, did not occur;
-Functional limitation in range of motion for lower extremities;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
-Currently receiving no occupational therapy or physical therapy;
-Currently receiving no RT program.
Review of the facility’s RT caseload document dated 3/14/19, showed Resident #104 was on
the list.
Review of the facility RT nursing plan dated 1/19, showed the resident should receive PROM
for 15 minutes a day to bilateral upper extremities (BUE), three times a week. The
tracking sheet showed 1/29/19 was the last documented date of therapy. No documentation of
RT received in (MONTH) or (MONTH) 2019.
4. Review of Resident #52’s quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Unclear speech;
-Usually understands, clear comprehension;
-Intact cognition;
-Extensive assistance of one person physical assist for bed mobility and two (+) persons
required for transfers;
-Walking in room/corridor, did not occur;
-Functional limitation in range of motion of upper extremities, on both sides and lower
extremities, on both sides;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
-Currently receiving no occupational therapy or physical therapy;
-Received PROM and AROM.
Review of the facility’s RT caseload document dated 3/14/19, showed Resident #52 was on
the list.
Review of the facility RT nursing plan dated 1/19, showed the resident should receive AROM
for 15 minutes a day to left upper extremity, three times a week in addition to PROM to
right upper extremity. The tracking sheet showed 1/29/19 was the last date of documented
therapy received. No documentation of RT received in (MONTH) or (MONTH) 2019.
5. Review of Resident #14’s quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Unclear speech;
-Understands, clear comprehension;
-Intact cognition;
-Extensive assistance of two (+) persons physical assist required for bed mobility and
transfers;
-Walking in room/corridor, did not occur;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
-Currently receiving no occupational therapy or physical therapy;
-Currently receiving no RT program.
Review of the facility’s RT caseload document dated 3/14/19, showed Resident #14 was on
the list.
Review of the facility RT nursing plan dated 1/19, showed the resident should receive 3
pound dowel exercises for all planes for 15 minutes a day three times a week. The tracking
sheet showed 1/29/19 was the last date of documented therapy. No documentation of RT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 27)
received in (MONTH) or (MONTH) 2019.
6. Review of Resident #79’s quarterly MDS, dated [DATE], showed:
-Adequate hearing and vision;
-Unclear speech;
-Rarely/never understood;
-Cognitively skills severely impaired;
-Extensive assistance of two (+) persons physical assist required for bed mobility and
transfers;
-Walking in room/corridor, did not occur;
-Functional limitation in range of motion of upper extremity, on one side and both lower
extremities;
-[DIAGNOSES REDACTED].
-Currently receiving no RT program.
Observations between 3/14/19 and 3/20/19, showed the resident wore a splint on his/her
left hand.
Review of the facility’s RT caseload document dated 3/14/19, showed Resident #79 was on
the list.
Review of the facility RT nursing plan dated 1/19, showed the resident should receive PROM
to BUE, three times a week. The tracking sheet showed 1/31/19 was the last date of
documented therapy. No documentation of RT received in (MONTH) or (MONTH) 2019.
During an interview on 3/18/19 at 1:10 P.M., the Director of Nurses (DON) said there are
no restorative therapy notes or sessions for (MONTH) or (MONTH) because it was not done
due to staffing. There is only one restorative therapy aide and he/she was pulled to the
floor to work or to go out with residents for physician’s appointments. It has been this
way for several months. She would expect residents on restorative therapy to receive it.
7. During an interview on 3/20/19 at 10:31 A.M., RA U said the residents were not getting
RT because they have him/her on the floor or transporting residents to the doctors office.
It has happened a lot the last couple of months, at least three times a week. The other
times he/she is weighing the residents. Resident weights are a priority over RT. He/she is
the only restorative aide, there used to be more. It has only been him/her now for over a
year. When he/she cannot do it, no one else steps in to do it. The last time he/she was
able to do RT was in (MONTH) and then it was only 50/50. He/she spends two hours in the
dining room serving residents every morning. The residents are taking longer to recover
without RT. He/she is seeing residents get stiff. He/she discussed it with administration
and physical therapy. He/she had over 47 residents on his/her caseload at one time. He/she
has been telling the physical therapy staff to give the RT care plans to the administrator
since he/she cannot get to them. At one time they tried to get it done but there are no
staff available right now. There have been a lot of interim DONs who were aware of it. The
RT told the new administrator when she was hired but nothing has changed. Residents are
coming to him/her to ask about when they will get therapy He/she has seen residents who
needed more skilled physical therapy due to not receiving their RT.
8. During an interview on 3/20/19 at 10:31 A.M., rehab manager said the physical therapy
staff write up a RT program for the nursing staff when the resident has completed skilled
therapy. The nurses run the program. RT included upper and lower body exercises,
assistance with putting on and taking off splints and braces and assisting residents with
walking. The purpose of physical therapy is to build strength and the purpose of RT is to
maintain it. If the resident has a decline in strength, he or she might have to be
referred back to physical therapy. Some residents get their therapy through facility run
activities although this is not part of the care plan. It is supposed to be in addition to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 28)
RT. He/she was not aware RT was not being done for two months. He/she was aware the RT
aide was being pulled to get resident weights. There were issues with some of the
residents not having their splints or braces and no one could find them. There were some
residents who complained to him/her about not getting the RT but staff told him/her they
refused it. There could be some impact on the resident’s if they were not getting their
braces or splints applied.
9. During an interview on 3/20/19 at 6:00 P.M., the corporate nurse said the residents
should have received restorative therapy per their plans of care.
10. During an interview on 3/20/19 at 8:00 P.M., the administrator said she thought the
residents were getting some therapy although not consistently as ordered. She was unable
to provide any RT documentation after 1/19.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provided 24 hour
protective oversight and supervision for one resident when facility staff failed to
implement the facility resident leave of absence policy regarding the process to inquire
of the estimated length of absence from the facility and failed to develop a procedure to
inquire of the resident’s whereabouts while on voluntary leave for one resident (Resident
#86) who signed out to go outside the front of the building on 3/16/19 at 10:00 A.M.
Without informing staff of his/her departure, the resident walked approximately 6.7 miles
through a heavily populated area and across four lane roads with an estimated 2 hour and
17 minute walking distance. The resident did not receive his/her medications during the
time out of the facility and did not return to the facility until 3/17/19 at 4:20 P.M. The
census was 130.
Review of the facility’s Elopement Management policy, dated 7/1/16, showed:
-Elopement: The Centers for Medicare and Medicaid Services (CMS) defines elopement as when
a resident leaves the premises or a safe area without authorization and/or necessary
supervision. Each state may define elopement by a set of criteria for self-reporting
purposes;
-The facility is to immediately initiate procedures to locate any resident that is
unaccounted for. Notification of appropriate parties will comply with state and federal
regulations. Following location of the involved resident, the facility leadership will
review prevention systems to identify performance opportunities;
-Residents who are their own person and choose to leave the premises without staff
knowledge will be considered an Unauthorized Leave of Absence (LOA) and not elopement.
Review of the facility’s Resident Leave of Absence policy, dated 7/1/16, showed:
-A resident who is cognitively intact with independent decision making with a physician’s
orders [REDACTED]. In the event the resident exits the facility without signing out on the
log, the facility will initiate an investigation in an attempt to locate the resident.
Upon the resident return to the facility, appropriate reeducation for the LOA procedure
will be completed;
-For residents that sign out for a LOA, the resident or family/responsible party will
indicate the anticipated time of return at the time they sign out;
-Procedure:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
-Obtain a physician’s orders [REDACTED].
-Instruct resident and/or family/responsible party on facility procedures for a leave of
absence;
-Instruct the resident or family/responsible party to complete the LOA log with date,
time and signature;
-Enter the date, time and signature on the LOA log when the resident returns;
-Contact the resident or family/responsible party if they have not returned within one
hour of the anticipated return time;
-The policy failed to identify a procedure to inquire about the resident’s whereabouts
while on voluntary leave.
Review of Resident #86’s quarterly Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 2/8/19, showed:
-Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicated the resident
cognitively intact;
-Wandering: Behavior not exhibited;
-Independent with mobility and locomotion.
Review of the resident’s medical record, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-At risk for communication problems. Delayed response to questions. Ensure/provide a safe
environment;
-Activity of daily living self-care performance deficit. Activity intolerance, impaired
balance/limited mobility/limited range of motion. Poor coordination. Requires staff
supervision while at the facility;
-The care plan failed to address the resident’s ability to leave independently on LOA.
Further review of the residents care plan, reviewed on 3/20/19 at 8:15 A.M., showed the
care plan had not been updated with the resident’s unauthorized LOA and/or goals
interventions.
Review of the resident’s electronic physician order [REDACTED].>-An order dated 2/1/19,
for tamsulosin HCL (medication used to treat [MEDICAL CONDITION]) 0.4 milligram (mg) by
mouth one time a day;
-An order dated 2/1/19, for [MEDICATION NAME] HCL (used to treat high blood pressure), 10
mg by mouth three times a day for high blood pressure;
-No order for LOA.
Review of the resident’s electronic Medication Administration Record, [REDACTED]
-[MEDICATION NAME] HCL not administered on the 3/16/19 at 1:00 P.M. and 5:00 P.M. and on
the 3/17/19 at 9:00 A.M., and 1:00 P.M. Reason: Resident out of facility;
-Tamsulosin HCL not administered on the 3/17/19 at 9:00 A.M., reason: Resident out of
facility.
Review of the resident’s progress notes, showed:
-On 3/16/19 at 9:11 P.M., resident remains on LOA at this time. Contacted on cell phone.
Resident states he/she is fine with a friend and will return in the morning to the
facility;
-No documentation when the resident went on LOA;
-No documentation the physician or management notified that the resident went on leave
without medications;
-No documentation on 3/17/19, when the resident returned from leave, the resident’s
condition at the time he/she returned and/or documentation staff attempted to contact the
resident when he/she did not return on 3/17/19 in the morning as indicated by the resident
when the nurse called the evening prior.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
During an interview on 3/18/19 at 6:57 A.M., the resident said he used to live at an
apartment complex nearby and provided the name of the complex. He/she walked there over
the weekend. Staff eventually called his/her cell phone when they realized he/she was
gone. He/she went there to eat corned beef and cabbage with his/her old roommate. At 11:21
A.M., the resident said he/she left the facility Saturday (3/16/19) morning. It was
approximately six to seven hours before staff called to find out where he/she was. The
nurse who called said he/she should have signed out at the nurse’s desk. He/she knew that
he/she was supposed to do that, but just he/she did not. No one at the facility knew
he/she left the campus and/or that he/she was not coming back that night, until they
called. He/she returned before dinner the following day, 3/17/19. It took an hour or more
to make the walk. He/she did not receive any of his/her medications while away from the
facility. When he/she signed out at the front desk, staff did not ask where he/she was
going. He/she does leave and walk to the store a lot. On 3/19/19 at 6:25 A.M., the
resident said he/she did not take his/her wheelchair when he/she left. He/she walked.
He/she had a jacket and had no injuries or accidents. His/her main issue is his/her
vision. He/she cannot see far distances.
Review of the facility’s LOA binder, located at the front desk, reviewed on 3/19/19,
showed:
-The resident signed out on 3/16/19 at 10:00 A.M. and returned on 3/17/19 at 4:20 P.M.;
-No documentation to show where the resident went or how long the resident’s leave was
anticipated.
Review of the resident’s LOA sign out log, located in the resident’s hard chart at the
nurse’s station, reviewed on 3/19/19, showed no documentation the resident went on LOA on
3/16/19.
Review of an online map, showed the apartment complex located 6.7 miles from the facility
and an approximate two hours and 17 minute walk.
Review of the resident’s vital sign documentation in the electronic medical record,
reviewed on 3/19/19, showed no blood pressure, heart rate, oxygen saturation (percentage
of oxygen in the blood) and/or temperature documented on 3/17/19, after the resident’s
return from LOA.
Further review of the resident’s progress notes, showed no documentation of an assessment
completed on 3/17/19, after the resident’s return from LOA.
During an interview on 3/19/19 at 7:00 A.M., Nurse R said he/she was the nurse assigned to
the resident on the night shift of Saturday 3/16/19 through 3/17/19 from approximately
11:00 P.M to 6:00 A.M. All he/she was told from the off-going nurse was that the resident
was on LOA. He/she did not know where the resident was or when he/she would be back.
During an interview on 3/19/19 at 7:01 A.M., Licensed Practical Nurse (LPN) C said he/she
was the nurse responsible for the resident on Saturday morning (3/16/19) from
approximately 6:00 A.M. to noon. He/she was not aware the resident left the facility. At
lunch he/she noticed the resident was not there eating, but did not know where he/she was
at that time.
During an interview on 3/19/19 at 8:18 A.M., Receptionist Q said he/she usually works day
shift Monday through Friday and was not working at the facility on Saturday, 3/16/19. When
residents sign out, he/she documents the date and time the resident left. He/she is not
required to notify the nurse when a resident signs out. He/she is not required to ask
residents where they are going, but he/she usually does. If he/she does ask and the
resident refuses to say, that is their right. He/she does try to get an idea about how
long residents will be gone so he/she can tell the nurse if they are out longer than
expected.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
During an interview on 3/19/19 at 8:43 A.M., Receptionist P said he/she did work Saturday
3/16/19 and was at work at 10:00 A.M., when the resident signed out. He/she does not
usually ask residents where they are going. Sometimes they say they are going to the
store. He/she cannot recall if the resident told him/her where he/she was going. When
residents sign out, he/she is only required to sign that the resident left the building.
He/she does not inform the nurse that the resident left. He/she does not know how long the
resident was gone but he/she had since heard the resident was on LOA until the next day.
During an interview on 3/19/19 at 9:50 A.M., with the administrator and Director of
Nursing (DON), they said they would expect staff follow their LOA policy. In the
resident’s chart, each resident has an LOA sheet. There is also a binder at the front
desk. They should be signing out on both logs, but the facility uses the main one at the
front desk. Residents should have an order to go on LOA. The order should identify if the
resident is able to go on leave and how much supervision they require. The facility
protocol for a resident who is leaving the property is that they let staff know they are
going, provide a cell number and then an anticipated return time. This information should
be obtained by the nurse so they can determine if the resident needs medications. Also,
the staff at the front desk should ask the resident where they are going. If a resident
has an unauthorized leave of absence, when they return, administration would talk to the
resident and find out why they did not sign out. The care plan would be updated and
reeducation provided. If a resident leaves on an unauthorized leave of absence and missed
medications, the physician should be notified. This notification should be documented in
the nurse’s notes. The resident does not require the use of a wheelchair. He/she just uses
it at times because he/she wants to. He/she used to require it but his/her condition
improved. Staff should document if the resident leaves on LOA, where they are going and
when they plan to return. When residents leave the facility, the receptionist should call
the nurse’s desk to make sure they are aware. When the resident returned, staff should
have completed an assessment to include taking his/her blood pressure. They were not aware
the resident had an unauthorized leave of absence over the weekend. They only heard he/she
had a leave of absence. They did not know staff were not aware the resident had left, that
he/she missed medications or that he/she walked a far distance to get there. They were not
informed of the leave until Monday morning, 3/18/19. Staff should have called management
immediately, if the resident had an unauthorized leave of absence. Their understanding was
that he/she left LOA with a friend. There have been no interventions put in place as of
now because they were not aware there was an issue. The resident does not have a history
of leaving the facility without telling staff. The resident provides his own care;
however, staff are still expected to check on the resident every two hours. If the
receptionist would have asked the resident where he/she was going before the resident left
and if the resident would have said he/she was walking to where he/she went, they would
have stepped in and intervened.
During an interview on 3/19/19 at 10:31 A.M., LPN O said he/she was the nurse responsible
for the resident from approximately noon until 11:15 P.M. on Saturday the 3/16/19. He/she
realized around dinner that the resident was not at the facility. He/she called the
resident’s spouse who said he/she believed the resident was with a friend and had signed
out at the front desk. When it got later in the evening and the resident still had not
returned, he/she called the resident on his/her cell phone. The resident said he/she was
with a friend and would be back in the morning. He/she put a call out to the physician,
but never heard back. He/she called to inform the DON that the resident had left and the
DON said call the physician and document that she/she called and talked to the resident.
During an interview on 3/19/19 at 11:58 A.M., Certified Nursing Assistant (CNA) A and CNA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
B said staff are expected to check on residents every two hours and as needed. If a
resident cannot be located, they would report it to the charge nurse and then start
searching for the resident.
During an interview on 3/19/19 at 12:01 P.M., LPN C said staff are expected to check on
residents every two hours or more if needed. If a resident’s family signs the resident out
on leave, staff determine where they are going and when they will be back. The nurse will
determine if medications need to be sent with the resident. If a resident does not sign
out and/or does not return when they said they would, the nurse would call them or the
person they left with to determine what is going on and when they will be back, then call
the DON.
During an interview on 3/19/19 at 12:01 P.M., LPN D said staff should check on residents
every two hours. If a resident cannot be located, administration needs to be notified.
During an interview on 3/19/19 at 2:56 P.M., Physician E said he/she was not aware the
resident left the facility for so long over the weekend. If a resident missed medications
for that length of time, he/she would expect staff notify him/her.

F 0692

Level of harm – 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 follow
physician’s orders for weight loss prevention and nutritional needs and ensure acceptable
parameters for nutritional status were maintained to prevent severe weight loss for one
resident, who experienced a 12.01% weight loss within a three month period and another
sampled resident who experienced weight loss. The facility identified 10 residents who
received tube feedings. Of those 10, four were chosen for the sample of 26 and problems
were found with two (Residents #5 and #102). The census was 130.
1. Review of Resident #5’s Admission Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/3/18, showed:
-Entry date of 11/26/18;
-Severely impaired cognitive skills for daily decision making;
-Altered level of consciousness;
-Required total assistance of one staff for eating;
-[DIAGNOSES REDACTED].
-Required a feeding tube (gastrostomy tube ([DEVICE]) a tube inserted through the abdomen
that delivers nutrition directly to the stomach);
-Proportion of calories received while tube feeding was 26 to 50%;
-Height and weight: Blank.
Review of the resident’s weight summary sheet, showed the resident weighed 143.2 pounds
(lbs) on 12/10/18.
Review of the resident’s undated care plan, showed:
-Focus: Initiated on 12/4/18, the resident had a nutritional problem and required eternal
nutrition and hydration via feeding tube to meet his/her needs;
-Goal: Maintain adequate nutritional and hydration status as evidenced by maintaining
weight within 5% for one month and 10% within six months, no signs and symptoms of
malnutrition (lack of proper nutrition caused by not having enough to eat) or dehydration
to meet estimated needs through the next review date;
-Focus: Initiated on 12/28/18, the resident had impaired mobility and no means of verbal

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 – Actual harm

Residents Affected – Few

(continued… from page 33)
communication. He/she required total assistance with all activities of daily living care;
-Interventions: The resident received nothing by mouth (NPO). He/she required total
assistance for tube feeding;
-Interventions: Initiated on 1/2/19, the resident was NPO. Administer [MEDICATION NAME]
1.5 (therapeutic nutrition that provides complete, balanced nutrition for patients who are
tube fed, with increased calorie and protein needs, or those with limited volume
tolerance), at 55 cubic centimeter (cc) per hour for 20 hours, allowing four hours for the
resident to be detached for care. Continue to monitor weight.
Review of the resident’s electronic physician’s order sheet (POS), dated 1/1/19 through
3/31/19, showed:
-[DIAGNOSES REDACTED].
-NPO diet due to a stroke, beginning 11/27/18;
-On 2/27/19, an internal feed order every shift until 3/1/19. Increase [MEDICATION NAME]
1.5 to 35 cc per hour continuously. The order was completed;
-On 2/27/19, an internal feed order every shift until 3/1/19. Increase [MEDICATION NAME]
1.5 to 45 cc per hour continuously. The order was completed;
-On 2/27/19, an internal feed order every shift for [MEDICATION NAME] 1.5 at 55 cc per
hour continuously from 4:00 A.M. to 12:00 A.M. Start date was 3/3/19.
Review of the resident’s nurse’s note, dated 1/31/19 at 11:40 A.M., showed a weight
warning. The resident weighed 139.6 lbs. Recommended tube feeding change to [MEDICATION
NAME] 1.5 at 55 cc per hour, allowing four hours for the resident to be detached for care.
Further review of the resident’s nurse’s note, dated 2/20/19 at 2:31 P.M., showed a weight
warning. The resident weighed 131.3 lbs. The resident was reviewed for significant weight
loss. He/she remained NPO and required internal nutrition to meet 100% of nutritional and
hydration needs. The resident was placed on tube feeding of Ensure (a nutritional
supplement) 30 ml per hour from 6:00 A.M. to 12:00 A.M. This would provide a total of 501
kcals (kilo calorie, a unit of energy of 1000 calories) (30% of estimated needs) and 20.5
grams of protein (37 percent of estimated protein needs). Weight loss related to
inadequate internal nutrition. Recommended tube feeding change to [MEDICATION NAME] 1.5 at
55 cc per hour, allowing four hours for the resident to be detached for care. Start tube
feeding at 25 ml per hour and increase by 10 cc per hour every day until final rate of 55
cc per hour is met in three days. Continue to monitor weights.
Further review of the resident’s weight summary sheet, showed the resident weighed 131.0
lbs on 3/11/19.
Review of the resident’s paper POS, showed an order dated 3/14/19, for a tube feeding
change. Ensure Plus, 30 milliliters (ml) per hour from 6:00 A.M. until midnight (12:00
A.M.).
Further review of the resident’s electronic POS, showed an order, dated 3/14/19, for
Ensure Plus Liquid. Give 30 ml per hour via feeding tube every 18 hours for tube feeding,
starting at 6:00 A.M. and off at 12:00 A.M. The order was discontinued.
Review of the resident’s Medication Administration Record [REDACTED]
-Internal Feed Order every shift for [MEDICATION NAME] 1.5 at 55 cc per hour continuously
from 4:00 A.M. until 12:00 A.M., signed it was given from 3/3/19 through 3/19/19;
-Ensure Plus Liquid. Give 30 ml per hour via feeding tube every 18 hours for tube feeding
starting at 6:00 A.M. and off at 12:00 A.M., signed it was given on 3/15/19, 3/16/19,
3/17/19 and 3/18/19.
Further review of the MAR, showed the Ensure was discontinued on 3/18/19.
During an interview on 3/18/19 at 1:20 P.M., the registered dietician (RD) said the
resident was supposed to receive [MEDICATION NAME] 1.5 at 55 ml cc per hour for 20 hours.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 – Actual harm

Residents Affected – Few

(continued… from page 34)
The order began on 2/27/19. The [MEDICATION NAME] started at 35 cc per hour and progressed
within a three day period, until it reached 55 ml. She never recommended Ensure. It would
not have met the resident’s nutritional needs. The resident was on hospice and the hospice
company could change the resident’s orders. However, the resident was doing well and had
shown progress. They were thinking about taking him/her off hospice to place him/her in
speech therapy because he/she could now respond to verbal prompts. The resident had a
significant weight loss due to his/her tube feeding not meeting his/her nutritional needs.
The resident never received Ensure while in the facility. She was not sure why it was
listed on the POS. The RD would make the recommendations and provide the information to
the unit nurse. The unit nurse was responsible for ensuring her recommendations were
communicated with the physician and placed on the resident’s POS. The orders should have
been clear and easy to comprehend.
During an interview on 3/19/19, at 7:06 A.M., Social Worker II said he/she was not aware
of a discussion regarding taking the resident off hospice. The hospice company was at the
facility frequently. The resident made tremendous progress and was able to respond
verbally to prompts.
Observation on 3/14/19 at 8:47 A.M., showed the resident lay in bed and received his/her
tube feeding. [MEDICATION NAME] 1.5 at 55 cc, dated 3/14/19 at 4:00 A.M. to 12:00 A.M.,
with 500 ml left to count. The pump was infusing at 35 ml per hour with 100 ml flush per
hour.
Observation on 3/14/19 at 11:15 A.M., showed the resident lay in bed and received his/her
tube feeding. [MEDICATION NAME] 1.5 at 55 cc, dated 3/14/19 at 4:00 A.M. to 12:00 A.M.,
with 350 ml left to count. The pump was infusing at 35 ml per hour with 100 ml flush per
hour.
Observations on 3/18/19 at 7:06 A.M., 9:30 A.M., and 1:42 P.M., showed the resident lay in
bed and received his/her tube feeding. [MEDICATION NAME] 1.5, dated 3/18/19 at 6:00 A.M.
The running feed rate was 30 ml per hour.
Observation on 3/18/19 at 12:40 P.M., showed Restorative Therapy Aide (RTA) U and
Certified Nurse Aide (CNA) EE weighed the resident. His/her weight was 126 lbs. This was a
total weight loss of 12.01%, since his/her beginning weight of 143.2 lbs on 12/10/18.
(Centers for Medicare & Medicaid Services (CMS), guidelines define severe weight loss
as a loss of greater than 5% in one month, greater than 7.5% in three months and greater
than 10% in six months).
During an interview on 3/18/19 at 2:20 P.M., Nurse N said the resident was supposed to
receive 30 ml per cc of [MEDICATION NAME] 1.5. The last time he/she checked the resident’s
orders, he/she received 30 ml and was off for four hours.
During an observation and interview on 3/18/19 at 2:21 P.M., Nurse N checked the
resident’s electronic POS and said the resident was supposed to receive [MEDICATION NAME]
1.5, infusing at 55 cc per hour. He/she thought it was for 30 cc per hour. Due to the
resident not receiving the proper amount, it could have caused a significant weight loss.
During an interview on 3/19/19 at 7:22 A.M., the Director of Nurses (DON) said hospice
changed the resident’s order to Ensure back in January. When she was shown the order for
Ensure dated 3/14/19, she said she was not aware of the order. If the order was for
[MEDICATION NAME] at 55 cc per hour, the resident should have received the [MEDICATION
NAME] at 55 cc per hour. If he/she received 30 cc per hour, he/she would not have his/her
nutritional needs met and would have lost weight. 143 lbs to 126 lbs within a three month
period was a significant weight loss. The orders should have been clear. She said she
could not explain the 3/14/19 order for Ensure.
During an interview on 3/19/19 at 2:10 P.M., the DON and regional director of clinical
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 – Actual harm

Residents Affected – Few

(continued… from page 35)
operations said Nurse N signed off that he/she gave the resident Ensure and [MEDICATION
NAME], but the resident never received Ensure. This was verified by the RD.
Observation on 3/19/19 at 2:17 P.M., showed the resident lay and bed and received
[MEDICATION NAME] 1.5 at 30 cc per hour.
During an interview on 3/19/19 at 2:15 P.M., Nurse N said there was a paper physician’s
order for Ensure at 30 cc per hour. He/she never gave the resident Ensure because he/she
was on [MEDICATION NAME] 1.5 at 55 cc per hour. He/she was confused about the order. Today
(3/19/19) the resident was placed back on Ensure at 30 cc per hour due to not being able
to tolerate 55 cc per hour. Hospice gave the order because they would not pay for
[MEDICATION NAME]. He/she infused the [MEDICATION NAME] at 30 cc since the Ensure was to
be infused at 30 cc per hour.
During an interview on 3/19/19 at 2:20 P.M., Physician E said hospice could recommend an
order, but it had to be approved by her. It was possible the resident received an order
for [REDACTED]. This would cause a significant weight loss because the resident would not
have received the adequate protein intake. The resident experienced a significant weight
loss within a three month period because he/she received the [MEDICATION NAME] at 30 cc
per hour. The resident never received Ensure and the nurse should not have signed the MAR
indicated [REDACTED].
During an interview on 3/20/19 at 9:49 A.M., the administrator said they did not have a
policy on the prevention of weight loss. They have a facility meeting every Wednesday for
a risk review and weight loss is discussed. They follow the parameters of Center for
Medicare Services (CMS) regarding weight loss.
During an interview on 3/20/19 at 4:45 P.M., the administrator, and the regional director
of clinical operations said staff was expected to follow the physician’s orders. The
resident experienced a significant weight loss within the three month time frame. The
orders should have been clear to read so staff could determine what the resident was
supposed to receive.
2. Review of Resident #102’s quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-No behaviors;
-Total dependence with activities of daily living;
-[DIAGNOSES REDACTED].
-Weight: 224 lbs;
-Weigh loss of 5% or more in the last month or loss of 10% or more in the last six months:
Yes;
-Feeding tube;
-51% or more of total calories through the tube feeding.
Review of the resident weight change note, dated 1/21/19, showed he/she was reviewed for
significant weight loss times three months. The resident remains NPO and requires 100% of
nutrition and hydration via [DEVICE]
Review of the resident’s POS, showed an order dated 2/12/19, for a tube feed order every
fours, Formula: Glucerna 1.5 (Specialized high-calorie nutrition with a unique
carbohydrate blend for enhanced glycemic control), give one can (237 cc) via feeding tube.
Review of the resident’s care plan, updated on 2/14/19, showed:
-Focus: Requires tube feeding with regards to a stroke;
-Goal: Will maintain adequate nutritional and hydration status and a stable weight with no
sign or symptoms of malnutrition or dehydration through the next review date;
-Intervention: Dependent with the tube feeding and water flushes. See the resident’s
physician’s orders for current feeding orders.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 – Actual harm

Residents Affected – Few

(continued… from page 36)
Review of the resident’s MAR, dated (MONTH) 2019, showed blank spots for Glucerna on the
following days:
-2/14, 2/15, 2/16, 2/17 at 1:00 A.M. and 5:00 A.M.;
-2/21 at 1:00 A.M.;
-2/27 at 5:00 A.M.
Review of the resident’s MAR, dated (MONTH) 2019, showed blank spots for Glucerna on the
following days:
-3/1 and 3/2 at 5:00 A.M.;
-3/3 and 3/4 at 1:00 A.M. and 5:00 A.M.;
-3/7, 3/9, 3/14 and 3/15 at 1:00 A.M. and 5:00 A.M.;
-3/18 at 5:00 A.M.
Review of the resident’s medical record, showed the following weights for (MONTH) 2019 and
(MONTH) 2019:
-February (unknown date): 223.6 lbs;
-3/13: 203 lbs;
-3/14 (reweigh): 214 lbs;
-3/20: 213 lbs. (This represents a 10.6 lb or 4.75% weight loss in one month).
Observation on 3/18/19 at 12:30 P.M., of central supply room [ROOM NUMBER], showed cans of
Glucerna available for use.
During an interview on 3/20/19 at 2:45 P.M., the Registered Dietitian (RD) said the
resident’s Glucerna order is a carbohydrate steady nutritional drink which meets 100% of
the resident’s nutritional needs. It is very important for the resident to receive the
nutritional drink as ordered. She reviewed the resident’s MAR, and was aware the resident
was not receiving the nutritional drink as ordered. She reported the concern to the DON
and the regional director of clinical operations during the stand up meetings, but did not
know if the concern was addressed. The resident has lost 50 pounds since being admitted to
the facility in (MONTH) of (YEAR).
During an interview on 3/20/19 at 2:55 P.M., the regional director of clinical operations
said the RD brought the concern to her attention. They did do a can count of the
nutritional drink but did not knows the exact count. If the MAR indicated [REDACTED]. She
would expect the nutritional drink to be administered as ordered.

F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that feeding tubes are not used unless there is a medical reason and the
resident agrees; and provide appropriate care for a resident with a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed physician orders [REDACTED]. The facility identified ten residents who received
tube feedings. Of those ten, five were chosen for the sample of 26 and problems were found
with two (Residents #79 and #95). The census was 130.
1. Review of Resident #79’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/5/19, showed:
-Severe impaired cognition;
-Total assistance from one staff with bed mobility, transfers, dressing, eating, hygiene
and bathing;
-Gastrostomy tube ([DEVICE], a tube surgically inserted into the stomach to provide
nutrition, hydration and medication) with tube feedings;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
-Proportion of calories received while tube feeding was 51% or greater.
Review of the resident’s admission face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 4/23/18 and revised 11/12/18 and in use during
the survey, showed:
-Problem: Requires tube feeding related to swallowing problem;
-Goal: Will remain free of side effects or complications related to tube feeding, maintain
adequate nutrition/hydration status, stable weight and no signs of malnutrition through
next review;
-Interventions: Check for [DEVICE] placement/gastric contents/residual volume per facility
protocol, dependent with tube feeding/water flushes as ordered, monitor for signs of
aspiration (sucking food into the airway), registered dietician (RD) to evaluate quarterly
and as needed (PRN) and speech therapy evaluation/treatment as ordered.
Review of the resident’s nutritional assessment dated [DATE], showed the resident’s diet,
for [MEDICATION NAME] 1.5 (liquid nutritional feeding) at 65 cubic centimeters (cc)/hour
for 22 hours with 150 cc of water flushes every four hours per [DEVICE]. Resident’s
current body weight 197.6 pounds with resident’s ideal body weight of 175-185 pounds.
Resident with significant weight gain and no nutritional recommendations at this time.
Review of the resident’s physician’s orders [REDACTED].
-An order dated 1/8/19, to administer 150 cc of water flushes every four hours per
[DEVICE];
-An order dated 2/4/19, to administer [MEDICATION NAME] 1.5 at 65 cc/hour (stop tube
feeding at bedtime and restart at 4:00 A.M.).
Observations of the resident during the survey, showed:
-On 3/14/19 at 11:25 A.M., the resident lay in bed with head of bed elevated greater than
45 degrees. The resident’s tube feeding formula of [MEDICATION NAME] 1.5 (1,500 cc bottle)
connected to his/her [DEVICE] and infused at 80 cc/hour via tube feeding pump.
Documentation on the bottle showed it was hung 3/14/19 at 4:00 A.M., rate 65 cc/hour with
approximately 1,100 cc left in the bottle to be infused;
-On 3/15/19 at 5:40 A.M. and 8:35 A.M., the resident lay in bed with head of bed elevated
greater than 45 degrees. The resident’s tube feeding formula of [MEDICATION NAME] 1.5
(1,500 cc bottle) connected to his/her [DEVICE] and infused at 80 cc/hours via tube
feeding pump. Documentation on the bottle showed it was hung 3/15/19 at 5:00 A.M., rate 80
cc/hour with 1,500 cc left in the bottle to be infused;
-On 3/18/19 at 7:50 A.M. and 11:20 A.M., the resident lay in bed with head of bed elevated
greater than 45 degrees and the resident’s tube feeding pump turned off. Documentation on
the [MEDICATION NAME] 1.5 bottle showed it was hung 3/18/19 at 5:00 A.M. with
approximately 1,500 cc left in the bottle to be infused.
During an interview on 3/18/19 at 11:20 A.M., Nurse W said the resident’s tube feeding
pump was turned off due to audible wheezes in his/her lungs and awaiting a return
telephone call from the physician. Nurse W reviewed the resident’s orders on the computer
and verified the tube feeding order for 65 cc/hour. Nurse W turned on the tube feeding
pump, placed the pump on hold and verified the tube feeding is programmed for 80 cc/hour,
not 65 cc/hour.
During an interview on 3/19/19 at 3:10 P.M., the Medical Director said she expected the
charge nurse to monitor the resident’s tube feeding to ensure the tube feeding is infused
at 65 cc/hour as ordered.
During an interview on 3/2019 at 5:30 P.M., the regional director of clinical operations
said it is the charge nurse’s responsibility to monitor the resident’s tube feeding to
ensure the correct rate of 65 cc/hour is being infused as ordered.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
2. Review of Resident #95’s quarterly MDS, dated [DATE], showed:
-Rarely/never understood;
-Rarely/never understands;
-Extensive assistance of two (+) staff required for bed mobility and transfers;
-Extensive assistance of one person required for dressing;
-Total dependence of one person required for eating;
-[DIAGNOSES REDACTED].
-Weight of 122 lbs;
-No significant weight gain/loss;
-Feeding tube and mechanical altered diet;
-Proportion of total calories the resident received through the feeding tube: 51% or more.
Review of the resident’s POS, dated 1/19/19 through 3/31/19, showed an order for
[REDACTED].M. and stop at 7:00 A.M.
Observation showed the following:
-3/18/19 at 6:19 A.M., showed the resident lay in bed. The tube feeding pump had been
turned off and there was no tube feeding hanging on the pump;
-3/19/19 at 6:16 A.M., showed the resident lay in bed. The tube feeding pump had been
turned off. An unopened bottle of [MEDICATION NAME] 1.5 hung on the pump;
-3/20/19 at 5:46 A.M., showed the resident sat in a tilt in space wheelchair (wheelchair
tilts back to recline). The tube feeding pump had been turned off and there was no tube
feeding hanging on the pump. During an interview, Certified Nurse Aide GG said the
resident was restless in bed so he/she got the resident up about 30 minutes to an hour
ago. Nurse JJ tuned the feeding pump off at that time. Nurse JJ said the resident was
pulling the tubing apart when she was restless in bed. After the resident got up, he/she
did not re-start the pump.
During an interview on 3/20/19 at 7:56 A.M., the administrator said the resident should
receive the tube feeding as ordered, otherwise staff are not following the physician’s
orders [REDACTED].

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident with a continuous positive airway pressure ([MEDICAL CONDITION], a machine used
for sleep apnea (a sleep disorder in which breathing repeatedly stops and starts))
received the treatment as ordered (Resident #10). The census was 130.
Review of Resident #10’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/9/18, showed:
-[DIAGNOSES REDACTED].
-No short/long term memory loss;
-Required staff supervision for bed mobility, transfers, dressing, toileting, personal
hygiene and bathing;
-Incontinent of bowel and bladder;
-No special treatments.
Review of the resident’s physician’s orders [REDACTED].
-[DIAGNOSES REDACTED].
-No documentation regarding a [MEDICAL CONDITION].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
Review of the resident’s care plan, updated 3/8/19, showed:
-Problem: Altered respiratory status/difficulty breathing related to sleep apnea and
[MEDICAL CONDITION];
-Approach: Assist resident/family caregiver in learning signs of respiratory compromise.
[MEDICAL CONDITION] settings are titrated pressure via (nasal pillow, nose mask or full
face mask). Monitor/document changes in orientation, increased restlessness, anxiety and
air hunger. Monitor for signs and symptoms of respiratory distress and report to the
physician as needed (decreased pulse, increased heart rate, restlessness, sweating,
headache, lethargy, confusion, cough, accessory muscle usage and skin color changes).
During an interview on 3/14/19 at 9:10 A.M., the resident said he/she has lived at the
facility for about one year. He/she has problems with breathing and is supposed to use a
[MEDICAL CONDITION] at night. He/she hasn’t used the [MEDICAL CONDITION] for a while
because it is broken. It has been in the closet since it stopped working. This surveyor
encouraged the resident to report his/her concerns to the staff.
Observation on 3/15/19 at 5:14 A.M., showed the resident sat in his/her recliner next to
the bed sleeping without his/her C-PAP machine. No [MEDICAL CONDITION] was noted at the
bedside.
During an interview on 3/15/19 at 7:56 A.M., the resident said he/she told a nurse he/she
had difficulty breathing when she walked in his/her room yesterday, 3/14/18. He/she also
informed the nurse his/her [MEDICAL CONDITION] machine was broken. He/she couldn’t
remember who he/she spoke to. The resident asked this surveyor to check his/her closet for
the [MEDICAL CONDITION] machine. The [MEDICAL CONDITION] machine remained in the
resident’s closet in a plastic basket.
Observation on 3/18/19 at 7:18 A.M., showed the resident asleep in his/her recliner
without his/her [MEDICAL CONDITION] machine. The [MEDICAL CONDITION] machine remained in
the resident’s closet.
During an interview on 3/19/19 at 10:45 A.M., Nurse C said he/she was unaware the resident
had a [MEDICAL CONDITION] machine and that it was in the resident’s closet. He/she
reviewed the resident’s POS at that time and said there wasn’t an order for [REDACTED].
During an interview on 3/20/19 at 11:34 A.M., Nurse C said the resident’s physician gave
new orders for the [MEDICAL CONDITION] machine, [MEDICATION NAME] (medication used to
remove excess fluids), BMP (basic metabolic panel, a blood test that gives doctors
information about the body’s fluid and electrolyte balance), CBC (complete blood count, a
blood test used to evaluate overall health and detect a wide range of disorders including
[MEDICAL CONDITION], infection and [MEDICAL CONDITION]) and a chest x-ray. The [MEDICAL
CONDITION] machine works and will be placed on the resident.

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, monitoring and ongoing communication with the [MEDICAL TREATMENT] (process
for removing toxins from the blood for individuals with kidney failure) center for
residents on [MEDICAL TREATMENT]. In addition, the facility failed to have signed [MEDICAL
TREATMENT] agreements/contracts for residents who received [MEDICAL TREATMENT]. The
facility identified seven residents who received [MEDICAL TREATMENT]. Of those seven, five
were selected for the sample of 26 and issues were found with three (Residents #51, #108

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 40)
and #109). The census was 130.
1. Review of Resident #51’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/14/18, showed:
-Brief interview for mental status (BIMS, a cognitive impairment screening tool) score of
14 out of 15;
-A BIMS score 13-15, showed intact cognition;
-Required extensive to total assistance of one staff with bed mobility, transfers,
dressing, hygiene and bathing;
-Diagnoses included end stage [MEDICAL CONDITION] ([MEDICAL CONDITION], chronic
irreversible kidney failure) and dependence on [MEDICAL TREATMENT];
-Treatment: [MEDICAL TREATMENT].
Review of the resident’s admission nurse’s assessment dated [DATE], showed he/she was
admitted with a [MEDICAL TREATMENT] port/catheter (a special tube which is surgically
inserted into the neck, collarbone or top of leg to allow access for [MEDICAL TREATMENT])
in his/her right upper chest. The resident received [MEDICAL TREATMENT] three times a week
(Tuesday, Thursday and Friday).
Review of the resident’s comprehensive care plan, dated 11/12/18, showed:
-Problem: Has [MEDICAL CONDITION] and received [MEDICAL TREATMENT];
-Goal: Will have no signs and/or symptoms of complications from [MEDICAL TREATMENT]
through next review;
-Intervention: Check/change dressing daily at access site, receives [MEDICAL TREATMENT]
three/times a week (Tuesday, Thursday and Friday) at named [MEDICAL TREATMENT] center,
monitor/document/report signs of infection, swelling, bleeding or drainage to access
site/report to physician, observe/report signs of complications to physician and obtain
vital signs/weights per protocol.
Review of the resident’s physician’s orders [REDACTED].
-An order dated 10/18/18, for [MEDICAL TREATMENT] treatments three times a week (Tuesday,
Thursday and Friday) with location of [MEDICAL TREATMENT] center;
-An order dated 3/14/19, to check shunt (an artificially formed link between an artery and
a vein using synthetic tubular material/fistula) for pain, redness, bleeding, swelling or
non-functioning access site after [MEDICAL TREATMENT] every Tuesday, Thursday and Friday;
-An order dated 3/14/19, to complete pre and post [MEDICAL TREATMENT] assessments every
Tuesday, Thursday and Friday;
-An order dated 3/14/19, to obtain vital signs and weight on [MEDICAL TREATMENT] days
(weight should be post [MEDICAL TREATMENT] dry weight) every Tuesday, Thursday and Friday;
-No orders for checking the [MEDICAL TREATMENT] shunt/port, pre/post [MEDICAL TREATMENT]
assessments and/or obtaining vital signs/weights until 3/14/19.
Review of the resident’s nurse’s notes dated 2/1/19 through 3/20/19, showed no continual
thorough assessments of the resident’s condition before/after [MEDICAL TREATMENT],
assessment of the resident’s [MEDICAL TREATMENT] port/catheter for signs of infection,
bleeding, redness or swelling and no on-going communication between the [MEDICAL
TREATMENT] center and facility.
Review of the resident’s pre/post [MEDICAL TREATMENT] assessments in the computer, showed:
-10/14/18, completed post [MEDICAL TREATMENT] assessment;
-3/15/19, completed post [MEDICAL TREATMENT] assessment;
-No other pre/post [MEDICAL TREATMENT] assessments.
Review of the resident’s weights in the computer, medication administration record (MAR)
and treatment administration record (TAR), showed no post [MEDICAL TREATMENT] weights.
Observation on 3/14/19 at 4:13 P.M., showed the resident’s [MEDICAL TREATMENT]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 41)
port/catheter with dry dressing intact to his/her right upper chest.
2. Review of Resident #108’s admission MDS, dated [DATE], showed:
-admission date of [DATE];
-BIMS score 15 out of 15;
-Limited assistance of one staff with bed mobility and transfers;
-Extensive assistance of one staff for bathing;
-Diagnoses included [MEDICAL CONDITION];
-Treatment: [MEDICAL TREATMENT].
Review resident’s comprehensive care plan, dated 2/17/19, showed:
-Problem: Has kidney failure and received [MEDICAL TREATMENT];
-Goal: Will have no signs and/or symptoms of complications from [MEDICAL TREATMENT] and
immediate intervention should any signs/symptoms of complications through next review;
-Intervention: Check/change dressing daily at access site, receives [MEDICAL TREATMENT]
three/times a week (Monday, Wednesday and Friday) at name of [MEDICAL TREATMENT] center,
do not draw blood or take blood pressure in arm with graft/shunt, monitor/document/report
signs/symptoms of infection, bleeding, redness, swelling or warmth to [MEDICAL TREATMENT]
to physician and monitor/report laboratory test results to physician.
Review of the resident’s POS, dated 1/19/19 through 3/31/19, showed:
-An order dated 3/14/19, for [MEDICAL TREATMENT] three times a week (Monday, Wednesday and
Friday) with location of [MEDICAL TREATMENT] center;
-An order dated 3/14/19, check [MEDICAL TREATMENT] shunt/catheter for pain, redness,
bleeding, swelling and non-functioning access site after [MEDICAL TREATMENT] every Monday,
Wednesday and Friday;
-An order dated 3/14/19, complete pre/post [MEDICAL TREATMENT] assessments every Monday,
Wednesday and Friday;
-An order dated 3/14/19, to obtain vital signs and weight (weights should be post [MEDICAL
TREATMENT] for dry weight) every Monday, Wednesday and Friday;
-No orders for [MEDICAL TREATMENT], checking the [MEDICAL TREATMENT] shunt/catheter,
completing pre/post [MEDICAL TREATMENT] assessments and obtaining vital signs and weights
until 3/14/19.
Review of the resident’s nurse’s notes dated 2/14/19 through 3/20/19, showed no continual
thorough assessments of the resident’s condition before/after [MEDICAL TREATMENT],
assessment of the resident’s [MEDICAL TREATMENT] port/catheter for signs of infection,
bleeding, redness or swelling and no on-going communication between the [MEDICAL
TREATMENT] center and facility.
Review of the resident’s pre/post [MEDICAL TREATMENT] assessments in the computer, showed:
-3/18/19, completed post [MEDICAL TREATMENT] assessment;
-No other pre/post [MEDICAL TREATMENT] assessments.
Review of the resident’s weights in the computer, MAR and TAR, showed no post [MEDICAL
TREATMENT] weights.
Observation on 3/14/19 at 5:07 P.M., showed the resident’s [MEDICAL TREATMENT]
port/catheter with dry dressing intact in his/her left upper chest.
3. Review of Resident #109’s quarterly MDS, dated [DATE], showed:
-No cognitive impairment;
-No behaviors;
-Supervision with bed mobility, locomotion on the unit, dressing, eating and toilet use;
-Diagnoses of [MEDICAL CONDITIONS], high blood pressure and depression;
-No diagnoses of [MEDICAL CONDITION] Listed;
-Treatment: [MEDICAL TREATMENT].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 42)
Review of the resident’s facesheet, printed on 3/20/19, showed a [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 5/29/18, showed:
-Focus: Required hemo-[MEDICAL TREATMENT] in regards to [MEDICAL CONDITION] on Monday,
Wednesday and Friday;
-Interventions: Monitor/Document/Report to the physician as needed for signs and symptoms
of the bleeding, hemorrhage, bacteremia, septic shock. Obtain vital signs and weight
protocol. Report significant changes in pulse, respiration and blood pressure immediately.

Review of the resident’s POS, dated 1/20/19 through 3/20/19, and in use during the survey,
showed:
-An order dated 3/14/19, to check shunt for pain, redness, bleeding, swelling or
non-functioning access site after [MEDICAL TREATMENT] every Monday, Wednesday and Friday;
-An order dated 3/14/19, to complete pre and post [MEDICAL TREATMENT] assessments every
Monday, Wednesday and Friday;
-An order dated 3/14/19, for [MEDICAL TREATMENT] at named location, Monday, Wednesday and
Friday;
-An order dated 3/14/19, to obtain vital signs and weight on [MEDICAL TREATMENT] days
(weight should be post [MEDICAL TREATMENT] dry weight) every Monday, Wednesday and Friday;
-No orders for checking the [MEDICAL TREATMENT] shunt/port, pre/post [MEDICAL TREATMENT]
assessments and/or obtaining vital signs/weights or location of the [MEDICAL TREATMENT]
center until 3/14/19.
Review of the resident’s nurse’s notes dated 2/6/19 through 3/11/19, showed no continual
thorough assessments of the resident’s condition before/after [MEDICAL TREATMENT],
assessment of the resident’s [MEDICAL TREATMENT] port/catheter for signs of infection,
bleeding, redness or swelling and no on-going communication between the [MEDICAL
TREATMENT] center and facility.
Review of the resident’s MAR dated 1/1/19 though 3/14/19, showed no orders or
documentation for checking the [MEDICAL TREATMENT] shunt/port, pre/post [MEDICAL
TREATMENT] assessments and/or obtaining vital signs/weights or location of the [MEDICAL
TREATMENT] center until 3/14/19.
Review of the resident’s weights in the computer, MAR and TAR, showed no post [MEDICAL
TREATMENT] weights.
4. Review of the facility’s signed/dated [MEDICAL TREATMENT] contracts/agreements provided
by the facility, showed:
-A [MEDICAL TREATMENT] contract/agreement signed/dated 2/13/18, but not signed by the
[MEDICAL TREATMENT] center;
-A [MEDICAL TREATMENT] contract/agreement signed/dated 3/14/19 by the [MEDICAL TREATMENT]
center, but not the facility;
-A [MEDICAL TREATMENT] contract/agreement signed/dated 3/15/19 by the facility and
[MEDICAL TREATMENT] center;
-No other signed/dated [MEDICAL TREATMENT] contracts/agreements were provided.
5. During an interview on 3/20/19 at 8:15 A.M., the administrator said the facility should
have contracts/agreements with each [MEDICAL TREATMENT] center that residents go to for
treatments. She verified the facility only had the three [MEDICAL TREATMENT]
contracts/agreements and two of the contracts were dated 3/14/19 and 3/15/19.
6. During an interview on 3/20/19 at 5:30 P.M., the regional director of clinical
operations said she expected nursing staff to assess and monitor the resident’s condition
before/after [MEDICAL TREATMENT] and monitor the resident’s [MEDICAL TREATMENT] for signs
of redness, bleeding and/or infection. She expected the nursing staff to complete the pre

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 43)
and post [MEDICAL TREATMENT] assessment form on each resident who received [MEDICAL
TREATMENT]. She said the charge nurses should have obtained orders regarding [MEDICAL
TREATMENT] prior to 3/14/19. She expected nursing staff to follow the facility’s [MEDICAL
TREATMENT] policy and procedure regarding care for all residents who received [MEDICAL
TREATMENT]. The regional director of clinical operations said it is important to have
signed [MEDICAL TREATMENT] contracts/agreements between the facility and [MEDICAL
TREATMENT] centers to provide each resident who received [MEDICAL TREATMENT] continuity of
care services.
7. Review of the facility’s Policy and Procedure of [MEDICAL TREATMENT] (kidney [MEDICAL
TREATMENT]) Care and Monitoring, dated 11/1/13 and revised dated 3/23/18, showed:
-Policy: Residents will be individually evaluated by a nephrologist (physician who
specializes in kidney disease) for [MEDICAL TREATMENT] and will have a Vascular Access
Device (VAD) for [MEDICAL TREATMENT] access placed specific to their needs;
-Procedure: Responsibilities for the provision of [MEDICAL TREATMENT] care and services;
-Provide a method for on-going communication and collaboration for the development and
implementation for the [MEDICAL TREATMENT] care plan will be established;
-The facility maintains responsibility for the overall quality of care the resident
receives and will provide the same services to a resident who is receiving [MEDICAL
TREATMENT] as it furnishes to its residents who are not receiving [MEDICAL TREATMENT];
-General Vascular Access Device:
-The type of VAD is determined by the nephrologist;
-The nurse will be aware of the specific type of VAD the resident has, for assessment and
monitoring purposes;
-Signs and Symptoms to monitor:
-Nausea;
-Fatigue greater than baseline;
-Pain;
-Pruritus (itchy) skin;
-Signs/symptoms of infection;
-Bleeding;
-Lack of bruit (the sound heard with a stethoscope as blood flows through a shunt) and
thrill (the vibration felt as blood flows through a shunt/fistula) at the access site;
-Pre-[MEDICAL TREATMENT]:
-Evaluation completed within four hours of transportation to [MEDICAL TREATMENT] to
include, but not limited to:
-Accurate weight;
-Blood pressure, pulse, respirations and temperature;
-Medication administered or withheld prior to [MEDICAL TREATMENT];
-Provide meal or snack prior to leaving facility for [MEDICAL TREATMENT] unless otherwise
ordered;
-Send copy of nursing evaluation with resident to [MEDICAL TREATMENT] center;
-Post-[MEDICAL TREATMENT];
-Nurse to review notes from [MEDICAL TREATMENT] center;
-Review resident tolerance to treatment;
-Review medications that may have been given during [MEDICAL TREATMENT];
-Post [MEDICAL TREATMENT] notes will be uploaded into the electronic health record (EHR)
or placed on hard medical record;
-Nurse to complete the post-[MEDICAL TREATMENT] evaluation upon return from [MEDICAL
TREATMENT] center;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 44)
-Absence or presence of thrill and/or bruit;
-Pulse in access limb;
-Blood pressure, pulse, respirations and temperature upon return to the facility;
-Visual inspection of access site for bleeding, swelling and or other abnormalities;
-Any abnormal or unusual occurrence resident reports while at [MEDICAL TREATMENT] center;
-Shared Communication:
-A 24 hour per day communication method is established to communicate resident clinical
status between the [MEDICAL TREATMENT] center and facility;
-The care of the resident receiving [MEDICAL TREATMENT] services will include on-going
communication, coordination and collaboration between the [MEDICAL TREATMENT] center and
the facility.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Observe each nurse aide’s job performance and give regular training.

Based on interview and record review, the facility failed to ensure each nurse aide had no
less than twelve hours of in-service education per year based on their individual
performance review, calculated by their employment date rather than the calendar year, for
eight of eight sampled certified nursing assistance (CNAs) employed at the facility for
more than a year. The census was 130.
1. Review of CNA F’s employee file and training records, showed:
-Date of hire 3/17/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
2. Review of CNA G’s employee file and training records, showed:
-Date of hire 1/15/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
3. Review of CNA H’s employee file and training records, showed:
-Date of hire 11/8/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
4. Review of CNA I’s employee file and training records, showed:
-Date of hire 8/3/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
5. Review of CNA J’s employee file and training records, showed:
-Date of hire 3/24/15;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
6. Review of CNA K’s employee file and training records, showed:
-Date of hire 1/6/12;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 45)
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
7. Review of CNA L’s employee file and training records, showed:
-Date of hire 7/6/17;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
8. Review of CNA M’s employee file and training records, showed:
-Date of hire 3/3/14;
-Training records provided consisted of copies of policies and some written tests. No
indication of the amount of time each in-service consisted of, sign in sheets or a
tracking of hours.
9. During an interview on 3/20/19 at 12:30 P.M., the Director of Nursing said the staff
coordinator position has been open for approximately a year. Until it is filled, she is
responsible for staff education. CNAs should receive 12 hours of training per year.
Currently, there is no process to log or track training hours. In-services are provided,
usually in the activity room. If staff do not attend, the in-servicing is completed one on
one when the staff comes in to work. There is a routine set of trainings that are
provided, no specific trainings based on individual CNA’s needs. Looking at the stack of
documents provided, she could not say how much time each in-service was worth or how many
hours each CNA has.

F 0745

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide medically-related social services to help each resident achieve the highest
possible quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to allow one of 26
sampled residents to make a choice regarding his/her code status (Resident #227). The
census was 130.
Review of Resident #227’s entry Minimum Data Set (DS), a federally mandated assessment
instrument completed by facility staff, showed an admission date of [DATE].
Review of the resident’s physician’s orders [REDACTED].
-[DIAGNOSES REDACTED].
-[DATE]: Hospice evaluation and treatment;
-[DATE]: Do not resuscitate (DNR).
Review of the resident’s Baseline Care Plan, dated [DATE], showed:
-admitted : [DATE];
-Code status: blank;
-Alert and cognitively intact;
-Social services: Resident recognized the need to be in long term care.
Review of the resident’s Outside the Hospital Do Not Resuscitate Order, dated [DATE],
showed:
-Agree to the Outside the Hospital Do not Resuscitate Order;
-May revoke this order at anytime;
-Signed by the resident’s family member;
-Signed by the hospice physician.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 0745

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 46)
Review of the resident’s progress notes, completed by the social service director, dated
[DATE], showed:
-11:01 A.M.: admitted to the facility from the hospital;
-The resident is his/her own responsible party and wishes to be a full code;
-The resident is alert and oriented;
-Thought processes appeared to be fairly well connected;
-8:02 P.M.: Correction: Resident is on hospice and is a DNR. When social history was
completed earlier today, [DATE], the resident stated he/she was a full code. This was an
error and the resident is a DNR.
During an interview on [DATE] at 12:30 P.M., the resident said he/she was unaware he/she
wasn’t a full code. He/she requested to be a full code. When asked if he/she understood
what full code versus DNR meant, the resident said he/she wanted to be revived if his/her
heart stopped.
During an interview on [DATE] at 6:48 A.M., the social service director said when she
first interviewed the resident, he/she wanted to be a full code. After she reviewed the
resident’s DNR Advance Directive she spoke to the resident and reminded him/her that
he/she was on hospice and a DNR. The resident is alert and oriented. She doesn’t know who
the family member was who signed the DNR advance directive.
During an interview on [DATE] at 7:05 A.M., the social service director said she does the
advance directives. She explained what a full code was to the resident. Hospice had a
signed DNR in his chart. She did not call hospice to determine where the DNR came from. If
some one is their own responsible party they are able to make decisions regarding their
code status.
During an interview on [DATE] at 9:21 A.M., the social service director said she spoke to
the resident and asked if he/she wanted to be a full code or DNR. She explained the
difference between full code and DNR. The resident said he/she wanted to be a full code.
The family member who signed the DNR sheet, was his/her nephew and it was signed in the
hospital. She explained to the resident he/she had a right to make his/her own decisions
regarding his/her code status even though the family member was his/her power of attorney.
The resident was not incapacitated.
During an interview on [DATE] at 7:24 A.M., the administrator said the facility has no
written policy regarding Advance Directives. The resident has the choice to make decisions
regarding his/her code status.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure hot foods
were at least 120 degrees Fahrenheit (F) when served and cold foods were at 41 degrees F
or less when served. This potentially could effect all residents who ate in the facility.
The census was 130.
1. Observation of the Serenity hall trays on 3/18/19 at 8:11 A.M., showed:
-Eggs: 112 degrees F;
-Cinnamon roll cold to touch with a temperature of 100 degrees F;
-Orange juice: 60 degrees F.
2. Observation of the [MEDICATION NAME] hall trays on 3/18/19 at 8:10 A.M., showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
-Eggs: 90 degrees F;
-Oatmeal: 109 degrees F;
-Orange juice: 59 degrees F.
3. During an interview on 3/20/18 at 1:51 P.M., the dietary manager said hot food should
be kept at 135 degrees F or above and cold drinks should be kept at 41 degrees F or below.
It is important to ensure food is maintain at the proper temperature to prevent food borne
illness and preserve the quality of the food for the residents.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 staff
used acceptable infection control procedures during two blood glucose tests (BGT) and two
of three observations of incontinence care (Residents #38, #56, #15 and #227). The census
was 130.
1. Review of Resident #38’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 3/15/19 at 6:25 A.M., showed Nurse HH sanitized his/her hands, applied
gloves and cleaned the glucometer (machine used to test blood sugar levels) prior to use
with hand gel alcohol sanitizer. The nurse obtained the resident’s BGT, removed his/her
gloves, sanitized his/her hands and cleaned the glucometer machine after use with hand gel
alcohol sanitizer. Further observation, showed no disinfecting agent and/or bleach wipes
available on the medication cart.
2. Review of Resident #56’s medical record, showed a [DIAGNOSES REDACTED].
Observation on 3/15/19 at 6:35 A,M., showed Nurse HH sanitized his/her hands, applied
gloves and obtained the resident’s BGT. Nurse HH removed his/her gloves, sanitized his/her
hands and cleaned the glucometer machine after use with hand gel alcohol sanitizer.
3. Review of Resident #15’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/12/18, showed:
-Severe impaired cognition;
-[DIAGNOSES REDACTED].>-Incontinent of bowel and bladder.
Observation on 3/15/19 at 5:20 A.M., showed the resident lay on a wet incontinence pad.
Certified Nurse Aide (CNA) GG did not wash his/her hands, applied gloves and provided
perineal care (washing the front and back of the hips, genitals, anal area and buttocks).
The CNA did not remove his/her gloves, turned the resident from side to side, washed the
resident’s buttocks and applied a clean incontinence brief. With the same gloves, CNA
picked up the resident’s clothes and dressed the resident before removing his/her gloves.
4. Review of Resident #227’s entry MDS, showed an admission date of [DATE].
Review of the resident’s Baseline Care Plan, dated 3/4/19, showed:
-Alert and cognitively intact;
-Required one person assistance for bed mobility, toileting, eating, grooming, hygiene and
bathing;
-Incontinent of bowel and bladder.
Observation on 3/20/19 at 11:42 A.M., showed the resident lay in bed. CNA LL washed
his/her hands, applied gloves and provided perineal care. He/she turned the resident onto
his/her right side, washed the resident’s buttocks, applied a clean brief, straightened
the covers and touched other clean items before removing his/her gloves.
During an interview on 3/20/19 at 12:05 P.M., CNA LL said he/she should have removed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265607

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

03/20/2019

NAME OF PROVIDER OF SUPPLIER

CRYSTAL CREEK HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

250 NEW FLORISSANT ROAD SOUTH
FLORISSANT, MO 63031

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 – Few

(continued… from page 48)
his/her gloves before touching clean items.
5. During an interview on 3/20/19 at 5:30 P.M., the regional director of clinical
operations said she expected nursing staff to clean the glucometer machine before/after
use and between each resident with a disinfecting wipe and/or bleach wipe. Nursing staff
should not use the hand gel alcohol sanitizer because alcohol does not provide infection
control, as it doesn’t kill all germs or viruses. Nursing staff should change their gloves
when going from dirty to clean and should not touch residents and/or clean items with the
same gloves they used during perineal care due to infection control concerns.
6. Review of the facility’s Cleaning and Disinfecting of Glucometer Meter (machine) dated
2/1/12 and revised 10/8/18, showed:
-Policy: The purpose of this policy is to provide guidance for the proper use of personal
protection devices (PPEs) and hand hygiene prior to performing any procedure that may
expose or potentially expose the worker to infectious materials, including point-of-care
testing devices and to prevent the spread of pathogens (germs) to others. This facility
uses shared devices for glucose testing and will perform cleaning and disinfecting
procedures between each resident;
-Procedure:
-Proper PPEs are to be used when providing cleaning and disinfecting of glucose testing
devices;
-Clean and disinfect the glucometer meter after each use with an approved disinfecting
agent that is effective [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION];
-Alcohol wipes are not appropriate for cleaning/disinfecting a used glucometer.
7. Review of the facility’s Perineal Policy dated 4/20/17, showed:
-Policy: Providing personal care services promotes a sense of well-being and meets hygiene
standards of care. Perineal care is performed on residents who are unable or unwilling to
maintain body cleanliness and/or who are incontinent of bowel and bladder;
-Procedure: Wash hands, apply gloves, wash perineal area wiping front to back, removed
gloves, wash hands, apply gloves, wash buttocks, remove gloves and wash hands.