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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to treat each
resident in a dignified manner by leaving a resident’s chest exposed (Resident #85) and
allowing a resident to eat lunch with wet soiled pants (Resident #84). The sample was 18.
The census was 84.
1. Review of Resident #85’s quarterly Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 10/1/18, showed:
-Brief interview for mental status (BIMS) of 7 (a score of 0 to 7 shows severe cognitive
impairment);
-No hallucinations, delusions, behaviors, or wandering;
-One person physical assist required for bed mobility, toilet use, bathing, transfers,
walking in room and corridor, locomotion on and off unit, dressing, and personal hygiene;
-[DIAGNOSES REDACTED].
Observation of the resident on 10/22/18, showed:
-At 12:22 P.M., the resident lay in bed, on his/her back, with his/her hospital gown
pulled down to his/her waist, leaving his/her breasts exposed;
-The doorway to the resident’s room visible from the dining room, where residents ate
lunch at time of observation;
-The door to the resident’s room left open;
-At 12:28 P.M., Social Worker (SW) F delivered a food tray to the resident’s room and left
without speaking to the resident or covering him/her;
-At 12:30 P.M., certified nursing assistant (CNA) I entered the resident’s room, left the
door open, and assisted the resident with putting on his/her hospital gown.
During an interview on 10/25/18 at 1:37 P.M., the administrator said staff are expected to
cover residents when they are exposed. It is not appropriate for staff to deliver a meal
tray to a resident’s room and then leave without covering the resident.
2. Review of Resident #84’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 11 out of 15 (a score of 8 to 12 shows
moderate cognitive impairment);
-No behaviors;
-Incontinent of bowel and bladder;
-Required maximum assistance from staff for transfers, dressing, hygiene and bathing.
Observation on 10/22/18 at 11:14 A.M., showed the resident sat in his/her wheelchair,
propelling him/herself to the division dining room. The front of his/her gray colored
pants were wet in the groin area on both sides. The wet area extended from the resident’s
crotch area down the legs approximately 10 inches and across the legs approximately 6
inches. At 12:22 P.M., the resident sat in his/her wheelchair in the dining room dressed
in the same wet, gray colored pants. Staff served the resident lunch without changing
his/her wet pants, and the resident had eaten all of his/her lunch. At 12:27 P.M., the
resident propelled him/herself out of the dining room.
During an interview on 10/25/18 at 1:37 P.M., the Administrator said it would never be
appropriate for a resident to be served a meal and allowed to eat that meal in wet
clothing due to dignity issues.

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have signed authorization for
management of personal funds for six out of 18 sampled residents (Resident #24, #45, #39,
#53, #4, and #16). The facility also failed to keep resident trust fund (RTF) accounts
from being overdrawn for five residents (Residents #67, #7, #340, #25, and #341). The
facility held funds for 75 residents. The census was 84.
1. Review of Resident #24’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
2. Review of Resident #45’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
3. Review of Resident #39’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
4. Review of Resident #53’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
5. Review of Resident #4’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
6. Review of Resident #16’s medical record, showed the resident was admitted on [DATE].
Review of the facility’s authorization for management of personal funds, showed no
documentation of authorization for RTF account from the resident or the resident’s
representative.
7. Review of Resident #67’s facility RTF statement, dated 7/31/18, showed a negative
balance of $35.00.
8. Review of Resident #7’s facility RTF statement, dated 7/31/18, showed a negative
balance of $10.00.
9. Review of Resident’s #340 facility RTF statement, dated 8/31/18 and 9/30/18, showed:
-On 8/31/18: A negative balance of $19.92;
-On 9/30/18: A negative balance of $19.92.
10. Review of Resident’s #25’s facility RTF statement, dated 6/30/18, showed a negative
balance of $4.57.
11. Review of Resident #341’s facility RTF statement, dated 6/30/18, showed a negative
balance of $42.87.
12. During an interview on 10/26/18 at 8:34 A.M., the corporate administrator said Social
services is responsible for obtaining the consent forms for the authorization for the
facility to hold resident funds. The authorization form is expected to have the resident’s
name and responsible party documented. She would expect social services to ensure the
resident has a consent form when they start a trust account. An audit is completed yearly,
so it is the perfect time to check the agreement.

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide spend down letters
when the balance of the Medicaid residents’ trust fund accounts exceeded $2,799.99. In
addition, the facility failed to have a system in place to show any communication was
provided inform the Medicaid residents of their account balances. This deficient practice
affected 10 sampled residents that received Medicaid assistance (Residents #24, #342, #19,
#49, #71, #59, #343, #75, #66 and #80). In addition, the facility failed to return money
in a timely manner for six residents who were discharged from the facility (Residents
#349, #351, #352, #89, #355 and #356). The facility held funds for 75 residents. The
census was 84.
1. Review of Resident #24’s resident trust fund (RTF) showed the following:
-As of [DATE], the resident had $2,976.92 in his/her account;
-As of [DATE], the resident had $2,893.40 in his/her account.
2. Review of Resident #342’s RTF showed the following:
-As of [DATE], the resident had $3,973.91 in his/her account;
-As of [DATE], the resident had $8,689.89 in his/her account;
-As of [DATE], the resident had $9,678.22 in his/her account.
3. Review of Resident #19’s RTF showed the following:
-As of [DATE], the resident had $9,382.74 in his/her account;
-As of [DATE], the resident had $9,484.37 in his/her account;
-As of [DATE], the resident had $9,485.94 in his/her account.
4. Review of Resident #49’s RTF showed, on [DATE], the resident had $3,326.47 in his/her
account.
5. Review of Resident #71’s RTF showed the following:
-On [DATE], the resident had $2,968.58 in his/her account;
-On [DATE], the resident had $2,847.05 in his/her account.
6. Review of Resident #59’s RTF showed the following:
-On [DATE], the resident had $3,293.66 in his/her account;
-On [DATE], the resident had $2,940.73 in his/her account;
-On [DATE], the resident had $4,194.68 in his/her account;
-On [DATE], the resident had $5,468.74 in his/her account.
7. Review of Resident #343’s RTF showed the following:
-On [DATE], the resident had $3,776.46 in his/her account;
-On [DATE], the resident had $3,176.58 in his/her account;
-On [DATE], the resident had $4,341.36 in his/her account;
-On [DATE], the resident had $4,342.08 in his/her account.
8. Review of Resident #75’s RTF showed the following:
-On [DATE], the resident had $4,558.90 in his/her account;
-On [DATE], the resident had $5,771.76 in his/her account;
-On [DATE], the resident had $7,203.04 in his/her account.
9. Review of Resident #66’s RTF showed the following:
-On [DATE], the resident had $19,702.44 in his/her account;
-On [DATE], the resident had $16,427.90 in his/her account;
-On [DATE], the resident had $17,245.33 in his/her account.
10. Resident of Resident #80’s RTF showed the following:

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-On [DATE], the resident had $4,555.98 in his/her account;
-On [DATE], the resident had $9,368.31 in his/her account;
-On [DATE], the resident had $10,973.98 in his/her account;
-On [DATE], the resident had $12,630.25 in his/her account;
-On [DATE], the resident had $12,632.33 in his/her account.
11. Review of Resident #349’s discharge Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility, dated [DATE], showed the resident was
discharged on [DATE].
Review of the facility RTF statement, dated [DATE], showed a balance of $290. 13.
12. Review of Resident #351’s discharge MDS, dated [DATE], showed the resident was
discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $8.00.
13. Review of Resident #352’s discharge MDS, dated [DATE], showed the resident was
discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $1,309.34.
14. Review of Resident #89’s discharge MDS, dated [DATE], showed the resident was
discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $934.01.
15. Review of Resident #355’s medical record, showed the resident was discharged on
[DATE].
Review of the RTF statement, dated [DATE], showed a balance of $550.52.
16. Review of Resident #356’s discharge MDS, dated [DATE], showed the resident was
discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $518.57.
17. During an interview on [DATE] at 3:14 P.M., the facility controller and accounts
payable staff said if the Medicaid residents are within $200 of their eligibility limit,
they bring it to the attention of social services F. Social worker F said he/she was
responsible for mailing the letters to Medicaid residents whose trust fund balances are
within the $200 eligibility limit, but had not sent any letters. He/she tried to call
resident #80’s responsible party, but did not document it. He/she was aware that a trust
fund balance over $3000 can affect their eligibility. He/she was aware there were several
residents with high trust balances that exceeded the limit. was not aware the facility
continued to hold funds for residents who were discharged . The facility controller was
not notified by staff if a resident was discharged from the facility. He/she would have to
look him/herself to see if residents were discharged because residents go to the hospital
and return. He/she would have to look more carefully.
18. During an interview on [DATE] at 8:34 A.M., the corporate administrator said she was
not aware that several residents trust fund accounts exceeded the eligibility limit.
Social worker F is responsible for sending a letter to the residents or their
responsibility party once they are within $200 of their eligibility limit. Social worker F
and accounts payable staff are both responsible for monitoring account balances so the
residents maintain their eligibility for Medicaid. She was not aware the facility
continued to hold funds for residents that were discharged . The facility controller,
accounts payable staff, and social services receive the daily census, so they would be
able to check if a resident was discharged or expired. She would expect staff to provide a
final accounting to the resident, responsible party, or DHSS within 30 days of a
resident’s discharge or if a resident expired.

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Assure the security of all personal funds of residents deposited with the facility.

Based on record review and interview, the facility failed to maintain an approved surety
bond to ensure protection of resident funds. The facility held funds for 75 residents. The
census was 84.
1. Record review of the facility’s Resident Trust General Ledger (Cash Sheet) for the
period of (MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of
$48,000.00, which would require a bond of $72,000.
Review of the Department of Health and Senior Services (DHSS) approved bond list, showed
the facility did not have an approved bond.
Review of a bond provided by the facility showed:
-A bond issued for $157,000.00;
-No documentation of approval from DHSS.
2. During an interview on 10/24/18 at 3:14 P.M., the controller said he/she was
responsible for ensuring the facility had an active bond. He/she increased the bond amount
from $120,000 to $157,000, but did not send the information to DHSS. He/she did not know
if the bond company submitted the information.
3. During an interview on 10/26/18 at 8:34 A.M., the administrator said she was
responsible for ensuring the facility had an approved bond, but she was not aware the
facility did not have one. The corporate administrator said the facility’s controller
increased the bond amount, but never received the letter from DHSS. The insurance company
usually sent the bond information to DHSS, but it fell through the cracks.

F 0571

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Limit the charges against residents’ personal funds for items or services for which
payment is made under Medicare or Medicaid.

Based on interview and record review, facility staff failed to provide a free basic
haircut for all Medicaid residents. In addition, the facility failed to inform the
residents of a free haircut. This had the potential to affect all Medicaid residents. The
census was 84.
1. Review of the facility’s current admission packet, showed the following information:
-Private Pay: Services and supplies covered by Basic Daily Rate: Personal services
required for health, safety, and personal grooming, including basic hair cut;
-Barber and beauty shop services;
-Services and supplied available, but NOT covered by the basic daily rate: Haircuts,
permanents and coloring, barber and beauty shop services.
-Medicaid: Services and supplies available, but NOT covered by Medicaid: Barber and beauty
shop services, except for basic hair care.
Review of the facility’s barber shop price list, showed the cost for a basic hair cut is
$20.
2. Review of Resident #7’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop.
3. Review of Resident #19’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop.
4. Review of Resident #21’s transaction history, showed he/she was charged $20 for beauty

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0571

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
shop on the following dates:
-June (YEAR);
-July (YEAR);
-August (YEAR);
-September (YEAR).
5. Review of Resident #64’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop.
6. Review of Resident #71’s transaction history, dated (MONTH) (YEAR), showed he was
charged $20 for beauty shop.
7. Review of Resident #59’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop charges.
8. Review of Resident #80’s transaction history, dated (MONTH) (YEAR), showed he/she was
charged $20 for beauty shop charges.
9. Observation on 10/22/18 at 11:00 A.M., a resident and his/her family member asked the
nursing staff about the process of receiving a har cut. The nurse said the stylist comes
to the facility every other Wednesday and it cost $20 for a haircut.
10. During an interview on 10/24/18 at 3:14 P.M., the facility controller, social
services, and accounts payable staff said all residents are charged $20 for a basic hair
cut including Medicaid residents. They were not aware Medicaid residents were not charged
for a basic haircut. The residents were not aware of it either. They are told upon
admission what the stylist charge. In the admission packet, the residents sign for beauty
services they want or do not want. Social services added that a hospice company has a
volunteer that comes to the facility to give free haircuts.
11. During an interview on 10/24/18 at 4:14 P.M., social worker F said he/she had a list
of residents that received a free hair cut by the hospice company. The list contained
several residents that received a free hair cut within the last two, three, or four weeks.

12. Review of the hospice haircut list, showed there were 12 residents on the list,
including:
-Resident #19;
-Resident #59;
-Resident #53.
13. During an interview on 10/25/18 at 9:15 A.M., Resident #19 said he/she went to the
stylist for his/her haircut. He/she never heard of getting a free cut. There used to be a
volunteer that would only cut the men’s hair, but not anymore. He/she confirmed the hair
cut was $20 earlier this month.
14. During an interview on 10/25/18 at 9:32 A.M., Resident #53 said it had been months
since he/she received a hair cut due to the current treatment and bandages on top of
his/her head.
15. During an interview on 10/26/18 at 7:57 A.M., social worker F confirmed that the list
was recent that the residents received a free cut hair from the hospice company within the
last month.
16. During an interview on 10/26/18 at 8:05 A.M., the activity director and social
services said the list of residents received a free hair cut by the hospice company at
some point, not necessary recently. The hospice company had not been to the facility to
give free hair cuts in two in the half months.
17. During an interview on 10/26/18 at 8:34 A.M., the corporate administrator said all
residents were aware of the free haircuts provided by the hospice company volunteers. They
are supposed to come every month, but had not been at the facility for two months. 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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0571

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
activity director coordinates it. She confirmed that the beauty shop charges $20 for a
basic haircut, but the residents have a right to choose if they want to pay for it. The
corporate administrator said she was not sure if the facility controller and the accounts
payable staff would even know about the free hair cuts. The facility controller and
accounts payable handles funds, so she would expect them to be aware that Medicaid
residents are not charged for basic haircuts and the free hair cut option. There used to
be a flyer in the admission agreement that informed the residents about the hospice
company. It is mentioned every month.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to obtain a physician’s order
for code status per their policy for two of 18 sampled residents (Residents #389 and
#339). The census was 84.
1. Review of the facility’s undated Advanced Directives policy showed:
-Prior to or upon admission of a resident, the Social Services Director or designee will
inquire of the resident, his/her family members and/or his or her legal representative,
about the existence of any written advance directives;
-Information about whether or not the resident has executed an advance directive shall be
displayed prominently in the medical record;
-The Director of Nursing Services or designee will notify the attending physician of
advance directives so that appropriate orders can be documented in the resident’s medical
record and plan of care.
2. Review of Resident #389’s medical record, showed:
-admission date of [DATE];
-A code status form, signed by the resident on 10/19/18, for full code status (all
lifesaving methods are performed). Further review of the code status form showed signed by
the physician on 10/22/18;
-A Physician Order Sheet (POS), dated 10/15/18 through 10/26/18, showed no physician order
for [REDACTED].>3. Review of Resident #339’s medical record, showed:
-admission date of [DATE];
-A code status form, signed by the resident on 10/16/18, for do not resuscitate (DNR, no
life saving methods are performed) status.
-A POS, dated 10/15/18 through 10/26/18, showed no physician order for
[REDACTED].>During an interview on 10/23/18 at 5:07 P.M., Nurse J said the were no
physician’s orders for the code status. The admitting nurse would be responsible for
entering the resident’s code status and obtaining the order for the POS.
4. During an interview on 10/26/18 at 8:35 A.M., the administrator said it is the Social
Services Director’s responsibility to obtain a resident’s code status. It is expected that
a resident’s code status be reflected on their POS.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on interview and record review, the facility failed to ensure their abuse and
neglect policy identified when, how and by whom determination of capacity to consent to
sexual contact will be made and where this documentation will be maintained. The census
was 84.
Review of the facility’s undated Abuse Prevention Plan policy, showed:
-Objective: The facility has a zero tolerance of physical, verbal, sexual and mental
abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident
property and misuse of physical or chemical restraints not required to treat a resident’s
medical symptom by: employees, family member, visitors or other residents;
-The policy failed to identify when, how and by whom determination of capacity to consent
to sexual contact will be made and where this documentation will be maintained.
During an interview on 10/23/18 at 2:42 P.M., the administrator said the facility policy
should identify when, how and by whom determination of capacity to consent to sexual
contact will be made and where this documentation will be maintained. At 3:47 P.M., the
administrator verified the facility does not have a policy to address these issues.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written transfer
notices to residents and/or their representative upon discharge to a hospital when their
return to the facility was expected. Of the 18 residents sampled, four had been recently
discharged to a hospital for various medical reasons, all were expected to return, and
none of those four had been issued a written transfer notice upon leaving the facility
(Residents #41, #38, #29 and #20). The census was 84.
1. Review of Resident #41’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned from on the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident was provided
a notice upon discharge.
2. Review of Resident #38’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation of discharge notices provided to the resident by the facility for the
2/23/18 and 10/24/18 discharges.
3. Review of Resident #29’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation of discharge notices provided to the resident by the facility for the
7/11/18 and 10/24/18 discharges.
4. Review of Resident #20’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident was provided
a notice upon discharge.
5. During an interview on 10/25/18 at 1:37 P.M., the administrator said when a resident is
sent to the hospital, a copy of the face sheet, physician order [REDACTED]. She said
within 24 hours they send a discharge notice to the hospital and the Social Worker is
responsible for sending the letters.
6. During an interview on 10/25/18 at 1:50 P.M., Social Worker F said he/she had not been
sending out any discharge notices to any resident or responsible party when the resident
had been sent to the hospital with a return anticipated. He/She was unaware he/she was
responsible for sending the letters.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for four of 18 sampled residents (Resident #41,, #38, #29 and #20). The census
was 84.
1. Review of Resident #41’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned from on the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 6/9/18 or 6/30/18.
2. Review of Resident #38’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Further review of the resident’s medical record, showed no documentation the resident or
the resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 2/23/18 or 9/20/18.
3. Review of Resident #29’s medical record, 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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Further review of the resident’s medical record, showed no documentation the resident or
the resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 7/11/18 or 10/19/18.
4. Review of Resident #20’s medical record, showed:
-admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 6/10/18.
5. During an interview on 10/25/18 at 1:37 P.M., the administrator said when a resident is
sent to the hospital, a copy of the face sheet, physician order [REDACTED]. She said they
had not been providing any information to the resident or their representative about the
facility bed hold policy upon discharge to the hospital and the Social Worker is
responsible for sending the letters.
6. During an interview on 10/25/18 at 1:50 P.M., Social Worker F said he/she had not been
sending out any bed hold policy to any resident or responsible party when the resident had
been sent to the hospital with a return anticipated. He/She was unaware was responsible
for sending the letters.

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete and electronically
transmit discharge Minimum Data Set (MDS), a federally mandated assessment instrument
completed by facility staff, for four random sampled residents (Residents #1, #2, #3 and
#6). The sample was 18. The census was 84.
1. Review of Resident #1’s medical record, showed:
-admitted to the facility on [DATE];
-Admission MDS done on 3/31/18;
-discharged on [DATE];
-No discharge MDS found.
2. Review of Resident #2’s medical record, showed:
-admitted to the facility on [DATE];
-Admission MDS done on 5/11/18;
-discharged to the hospital on [DATE];
-Did not return from the hospital;
-No discharge MDS found.
3. Review of Resident #3’s medical record, showed;
-admitted to the facility on [DATE];
-Admission MDS done on 4/24/18;

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-discharged to home on 5/11/18;
-No discharge MDS found.
4. Review of Resident #6’s medical record, showed:
-admitted to the facility on [DATE];
-Annual MDS done on 5/16/18;
-discharged on [DATE];
-No discharge MDS found.
5. During an interview on 10/23/18 at 2:20 P.M., MDS Coordinator D said he/she started
working at the facility on 8/27/18, looked on the computer, said could not find any
discharge MDS for Residents #1, #2, #3 or #6 and did not know why they were not done.
6. During an interview on 10/23/18 at 2:50 P.M., MDS Coordinator E, from a sister
facility, said he/he was at the facility and responsible for completing the MDSs during
(MONTH) and May, (YEAR). He/She was not aware the discharge MDSs were not completed for
Residents #1, #2, #3 and #6, or why they were not done as required.

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 ensure residents
had complete, accurate and individualized care plans to address the specific needs of the
residents for three residents by not addressing falls, [MEDICAL CONDITION] and indwelling
urinary catheters (a tube inserted into the bladder for the continual drainage of urine)
(Residents #61, #90 and #20). The sample was 18. The census was 84.
1. Review of Resident #61’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 7/5/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview of mental status (BIMS) score of 13 out of a possible score of 15;
-A BIMS score of 8-15, showed the resident understands and able to make self-understood;
-Supervision required for transfers;
-No falls since prior assessment.
Review of the facility’s Incidents by Incident type report, showed the following for the
resident:
-Date range: 8/1/18 through 8/31/18;
-Unwitnessed fall incident: 8/25/18 at 2:27 A.M.
Review of the resident’s progress notes, showed:
-On 8/25/18 at 2:11 A.M., the resident remains on follow up, denied complaint of pain,
reeducated about calling for assistance;
-No documentation regarding the circumstances that surrounded the fall.
Review of the facility’s Fall Protocol, dated 7/1/18, showed all incidents and accidents
must be called to the Director of Nursing (DON) or designee. Please assure the following
interventions are in place:
-The certified nursing assistant (CNA) and nurse for the resident must come together to
come up with a safe and workable intervention specific to each resident;
-Care plan to be updated by the charge nurse.
During an interview on 9/20/18 at 8:35 A.M., the administrator said the facility changed
to a new electronic medical record company in (MONTH) (YEAR) and not all of the residents’

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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)
care plans transferred over. Some are on paper and some are in the computer.
Review of the resident’s care plan, provided and reviewed on 9/20/18, showed:
-[DIAGNOSES REDACTED].
-Problem start dated 12/7/16: Cognitive loss/dementia: Impaired decision making;
-Problem start date 10/25/17: Visual function: Impaired vision;
-Problem start date 12/7/16: Activity of Daily Living (ADL)/Rehab potential: At risk for
deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion
on and off the unit, dressing, eating, toilet use and personal hygiene;
-Problem start date 10/25/17: Falls: At risk for falling related to cognitive loss,
immobility/weakness:
-Most recent approach start date, 12/25/17;
-The care plan failed to identify the resident’s transfer status;
-The care plan was not updated after the resident’s 8/25/18 fall.
Observation of the resident on 9/20/18 at 8:23 A.M., showed the resident sat in a
wheelchair in the dining room.
During an interview on 9/20/18 at 1:36 P.M., the administrator said staff know how to care
for resident’s by looking at the care plan. The facility does not utilize care cards. Care
plans should be up to date and accurate. They should be updated after a fall. The resident
require one to two person assist with transfers. The resident’s transfer status should be
identified on the care plan.
2. Review of Resident #90’s admission MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 15 out of a possible score of 15;
-Extensive assistance required for transfers.
Review of the resident’s progress note, dated 2/5/18 at 9:18 A.M., showed the resident
found on the floor in room laying on right side. Resident stated I had a [MEDICAL
CONDITION], I didn’t know where I was for a minute, I fell Resident has old raised area on
forehead which resident stated he/she bumped and complaint of left arm discomfort.
Review of the resident’s care plan, provided and reviewed on 9/20/18, showed:
-[DIAGNOSES REDACTED].
-Problem start date 12/28/18: Falls: At risk for falling related to weakness, immobility,
urinary/bowel urgency, [MEDICAL CONDITION] medication use;
-The care plan failed to address a problem, measurable goals or approaches to care related
to the [DIAGNOSES REDACTED].
During an interview on 10/23/18 09:22 A.M., the administrator said she had faxed an
updated care plan on 9/21/18 and will provide a copy of what was sent.
Review of the resident’s care plan, provided and reviewed on 10/23/18, showed:
-Problem start date 2/6/18: Psychosocial well-being: The resident experiences irregular
boy movements related to [MEDICAL CONDITION] disorder;
-Goal: The resident will not injury self secondary to [MEDICAL CONDITION] disorder;
-Approach start date 2/6/18: Assess characteristics before, during and after [MEDICAL
CONDITION]. Assess resident after [MEDICAL CONDITION], assess time, length, involved body
parts, level of consciousness, motor activity and respirator activity if [MEDICAL
CONDITION] occurs. If [MEDICAL CONDITION] occurs, remove all restrictive clothing and
objects of potential harm. Turn head to side to maintain a patent airway;
-The care plan was not updated to address a problem, measureable goals or approaches to
care related to the [DIAGNOSES REDACTED].
During an interview on 10/23/18 at 12:45 P.M., the administrator said if there was a
history of convulsions prior the resident’s [MEDICAL CONDITION] on 2/5/18, this should
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 12)
this have been indicated on the care plan prior to the resident having a [MEDICAL
CONDITION] and fall resulting in hospitalization s.
3. Review of the resident’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Cognitively impaired with short and long term memory problems;
-Indwelling urinary catheter;
-A Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or
eschar may be present on some parts of the wound bed. Often includes undermining and
tunneling.) pressure ulcer;
-Required total assistance from the staff for transfers, dressing, eating, hygiene and
bathing.
Review of the resident’s electronic physician order [REDACTED].#16 French Foley catheter
(size and type of catheter).
Review of the resident’s undated care plan, provided on 10/24/18, and in use during the
survey, showed:
-Staff care planned the resident for:
-Required one to two person dependence on activities of daily living, transfers and
mobility;
-Impaired cognitive function or impaired thought processes;
-At risk for falls related to confusion and weakness;
-Requires tube feeding (a tube surgically inserted into the stomach for the purpose of
providing liquid nutrition, hydration and medications) related to [DIAGNOSES REDACTED].
-On pain medication;
-Has a pressure ulcer to sacral area that was admitted with;
-Staff did not care plan the resident for the use of the indwelling urinary catheter.
Observation on 10/22/18 at 10:10 A.M., showed the resident lay in bed. An indwelling
urinary catheter tubing and urine collection bag hung on the side of the resident’s bed
with dark yellow urine in the collection bag.
Observation on 10/23/18 at 1:41 P.M., showed the resident lay in bed. An indwelling
urinary catheter collection bag hung on the side of the resident’s bed with dark yellow
urine in the collection bag.
During an interview on 10/26/18 at 8:35 A.M., the Administrator said the resident’s care
plan should be a complete picture of the resident and she would expected the resident’s
indwelling urinary catheter usage to be care planned.
MO 348
MO 646

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

Based on interview and record review, the facility failed to complete a comprehensive
discharge summary for one of two closed record sampled residents (Resident #89). The
census was 84.
Review of Resident #89’s closed medical record, showed the resident discharged to the
community on 6/29/18. Staff did not complete a discharge summary, which would include a
final summary of the resident’s status, a reconciliation of all pre and post discharge

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
medications and a post-discharge plan of care.
During an interview on 10/25/18 at 9:48 A.M., the Corporate Administrator said the
comprehensive discharge summary should be completed and scanned into the computer. He/she
would expect a comprehensive discharge summary to be completed for each resident
discharged from the facility. Medical records should have the comprehensive discharge
summary for any resident who had been discharged from the facility.
During an interview on 10/25/18 at 9:53 A.M., Medical Records G looked in the computer and
then looked in the residents hard copy chart, said he/she did not know what a discharge
summary was and could not find any discharge summary of the resident’s stay at the
facility.

F 0684

Level of harm – Minimal harm or potential for 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 assess, monitor
and provide treatment after a [MEDICAL CONDITION] resulting in a fall, provide oral care,
and provide treatment to a foot wound (Resident #90, #24 and #4). The sample was 18. The
census was 84.
1. Review of Resident #90’s admission Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 12/26/17, showed:
-[DIAGNOSES REDACTED].
-BIMS score of 15 out of a possible score of 15;
-Extensive assistance required for transfers.
Review of the resident’s physician order [REDACTED].
-[DIAGNOSES REDACTED].
-admitted : 12/19/17;
-An order dated 12/20/17 with an end date of 2/5/18, for levetiracetam ([MEDICATION NAME],
medication used to treat [MEDICAL CONDITION]), 250 milligram (mg) twice a day;
-An order dated 1/8/18, for neurology consult related to [DIAGNOSES REDACTED].
Review of the resident’s medical record, showed no documentation a neurology consult
completed.
Review of the facility’s [MEDICAL CONDITION] Policy, dated 7/2018, showed:
-Preface: This policy/protocol serves as a guideline to staff and it is not deemed to be
all inclusive of care and treatment of [REDACTED].
-After [MEDICAL CONDITION] care: Take vital signs and neurological (neuro) checks. Monitor
for [MEDICAL CONDITION] (inability/difficulty with swallow/talking), headache and altered
level of consciousness. Monitor for paralysis, weakness and pupillary changes;
-[MEDICAL CONDITION] documentation: Location of [MEDICAL CONDITION] activity. Type of
[MEDICAL CONDITION] activity. Duration of [MEDICAL CONDITION] activity. Level of
conscience. Any incontinent episodes. Sleeping or dazed post ictal (post [MEDICAL
CONDITION]) state after [MEDICAL CONDITION] activity. This should be documented in the
nurse’s notes. Notification of physician and family representative should also be noted.
Review of the resident’s progress notes, showed:
-On 2/5/18 at 9:18 A.M., resident found on the floor in room laying on his/her right side.
Resident stated I had a [MEDICAL CONDITION], I didn’t know where I was for a minute, I
fell Resident has old raised area on his/her forehead which resident stated he/she bumped

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
and complained of left arm discomfort;
-On 2/5/18 at 9:59 A.M., resident complained of dizziness. New order to send the resident
to the hospital;
-On 2/5/18 at 10:55 A.M. (1 hour and 37 minutes after the resident’s fall and reported
[MEDICAL CONDITION]), resident leaving escorted by emergency medical services (EMS)
workers times two on a stretcher in route to the hospital.
Review of the facility’s undated Protocol for Neuro checks, showed:
-Neuro checks must be done when: There is a complaint of a headache, there is a fall,
there is drowsiness or lethargy, there are complaints of vision problems, there are signs
and symptoms of a stroke, the resident’s assessment warrants it;
-Neuro checks will be performed as follows: Every 15 minutes times four, every hour times
four, every four hours times two, then every eight hours for 24 hours.
Review of the resident’s neurological check list for 2/5/18, showed staff completed
neurochecks up until the resident was transferred to the hospital.
Further review of the resident’s POS, showed:
-An order dated 2/5/18, may send to hospital for treatment and evaluation. Special
instructions: Fall;
-An order dated 2/5/18, for levetiracetam 250 mg three times a day.
Further review of the resident’s progress notes, showed:
-On 2/5/18 at 4:40 P.M., the resident returned to the facility at this time via stretcher
accompanied by two emergency medical technicians (EMTs). Complaint of pain on left side of
body at this time. [MEDICATION NAME] (narcotic pain medication) given. New order from
hospital to increase [MEDICATION NAME] to three times a day;
-On 2/6/18 at 2:50 P.M., resident remains on follow up. Temperature 98.4, pulse 80,
respirations 18, blood pressure 126/80.
-No further neuro checks documented after the residents returned to the facility.
Review of the resident’s hospital discharge instructions, showed:
-Diagnosis: [REDACTED].>-Increase [MEDICATION NAME] to three times daily;
-What you need to know: [MEDICAL CONDITION] is a brain disorder that causes [MEDICAL
CONDITION]. If your [MEDICAL CONDITION] are not controlled, [MEDICAL CONDITION] may become
life-threatening;
-Follow up with our neurologist (physician that specializes in neurology) as directed;
-Create a care plan;
-Ask what safety precautions you should take.
During an interview on 10/23/18 at 11:39 A.M., the administrator said neuro check were
only completed up to the point the resident went to the hospital. No neuro checks were
completed after the resident returned to the facility.
During an interview on 10/23/18 11:39 A.M., the administrator said she could not find any
documentation to show the resident’s neurology consult was completed.
During an interview on 10/23/18 at 12:45 P.M., the administrator said in an emergency, the
nurse could choose to send a resident to the hospital without notifying the physician
first. On 2/5/18, the resident was asking to go to the hospital and the nurse could have
made this choice without waiting for the physician to give an order. She would expect
staff to monitor a resident’s condition more closely after a [MEDICAL CONDITION] resulting
in a fall. This should be documented in the nurse’s notes and includes more than just the
neuro checks. She was not sure why it took so long for EMS to arrive to pick up the
resident after they were called. Staff should have been frequently assessing the resident
during the time frame between the fall and EMS arrival. She would have preferred the
resident to be sent out sooner than 1 hour and 37 minutes after the fall and [MEDICAL
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
CONDITION].
2. Review of Resident #24’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Total dependence with transfers, dressing, eating, toileting, and hygiene;
-Rarely understood;
-Feeding tube.
Review of the resident’s care plan, dated 3/6/18, and in use during the survey, showed:
-Problem: Resident required feeding tube related to dysphasia (difficulty swallowing) .
Resident is at risk for dehydration related to staff dependence for fluids;
-Approach: Administer medications via tube. Evaluate/record/report effectiveness and any
adverse side effects;
-Administer tube feeding formula as ordered via bolus to provide 355.5 kcal’s;
-Assess for complications ([MEDICAL CONDITION]/anxiety/depression, lung aspirations,
self-extubation, fever, pneumonia, SOB, displacement into lung, constipation, diarrhea,
abdominal distention/pain, respiratory problems, cardiac distress/arrest, abnormal labs);
-Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased
urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus
membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance);
-Monitor for signs of malnutrition (pale skin, dull eyes, swollen lips, swollen gums,
swollen and/or dry tongue with scarlet or magenta hue, poor skin turgor, bilateral
[MEDICAL CONDITION], muscle wasting);
-Provide frequent oral care. Lubricate lips.
Review of the resident’s POS, dated 10/1/18 through 10/31/18, showed an order, dated
10/17/18 for [MEDICATION NAME] (antifungal) suspension 0 unit/milliliter (ml). Give 5 ml
by mouth, four times a day for seven days. (MONTH) use mouth swabs to coat gums and tongue
with medication if resident unable to swish and swallow. Order was completed on 10/24/18.
Observation on 10/23/18 at 12:52 P.M. and 5:10 P.M., showed the resident lay in bed, alert
to self. His/her mouth was open exposing his/her tongue. The resident’s tongue was thick
with cracks and bumps covering the top of the tongue.
Observation on 10/24/18 at 9:45 A.M., showed the resident lay in bed with his/her eyes
closed. His/her mouth was open. His/her tongue was dry and cracked. There was a small sore
on the tip of the right side of the tongue. The resident’s breath had an odor and there
were no natural teeth seen.
During an interview on 10/24/18 at 9:57 A.M., Certified Nurse Aide (CNA) K said he/she
provided care to the resident regularly. The resident received oral care daily, with the
use of a lip sponge and mouthwash. CNA K said it was kept in the night table. He/she
checked the inside of the night table, but did not find any oral hygiene supplies. CNA K
checked the bathroom and there were no oral hygiene supplies in there.
Observation and interview on 10/24/18 at 10:24 A.M. and 10:49 A.M., the Assistant Director
of Nursing (ADON) said the nurse is responsible for providing oral care and assessing the
inside of the resident’s mouth. The ADON believed the resident had sore on his/her tongue,
but was not sure. There was something going on with the resident’s mouth, so they received
the order for the rinse. The ADON did an assessment of the resident’s tongue. She shined a
flashlight to see the inside of the resident’s mouth. The resident’s mouth remained
opened. There was raised, dry yellow substance that resembled kernels of dry yellow corn
on the resident’s tongue. The ADON said there was yellowing coating over the tongue that
was yeast. There was a black mark over the tip of his/her tongue, but it looked like the
resident bit his/her tongue. He/she had natural teeth. The black mark was approximately .2
centimeters. The nurse was responsible for administering the [MEDICATION NAME]. She would
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
expect staff to notify her or the administrator if the resident’s tongue was not
improving. She would expect the aides to provide oral care using the lip sponges and the
A&D ointment when his/her lips are dry. Lip sponges are kept in the bathroom or in the
cart. The ADON checked the [MEDICATION NAME] that was used for the resident’s tongue.
There was approximately 110 to 120 ml in the bottle. The ADON said if the order was for 5
ml, four times day, that would equal 20 ml a day, 140 ml total. She would expect there to
be less medication in the bottle if the medication was administered as ordered.
During an interview on 10/26/18 at 8:34 A.M., the administrator said the charge nurse is
responsible for administering the resident’s [MEDICATION NAME]. She would expect staff to
continue to monitor the resident’s tongue for changes of color, odors, or sores. Staff are
expected to administer the [MEDICATION NAME] as ordered and document the resident’s
assessment of the tongue.
During an interview on 10/30/18 at 11:30 A.M., pharmacist L confirmed that the resident
was ordered [MEDICATION NAME] suspension. There was a quantity of 140 ml inside the bottle
at the time it was delivered to the facility. After seven days, the amount inside the
bottle would be less than 110 or 120 ml if administered 20 ml a day.
3. Review of Resident #4’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 15 out of 15 (a score of 12 to 15 indicates cognitively intact);
-No behaviors;
-Required minimal assistance from the staff for transfers, dressing and hygiene.
Review of the resident’s POS, in use during the survey, showed:
-An order dated 10/17/18, to apply Ag Alginate (a soft, comfortable wound dressing that is
silver-impregnated calcium alginate fibers, when in contact with exudate or blood, form a
gel which creates a moist and optimal healing environment. The silver protect the dressing
from microorganisms) with dressing to wound on medial (toward middle) right heel;
-An order dated 10/17/18, to have follow up with wound care specialist;
-An order dated 10/17/18, to wear a sock only on the right foot, no shoe;
-An order dated 10/23/18, to apply Algicell Ag pad 4 and 1/4 by 4 and 1/4 inches to right
medial heel topically every day for open wound related to diabetes mellitus.
Review of the facility’s weekly wound report for the week of 10/15/18, showed:
-10/17/18 – initial assessment – right medial heel shear area measured 3.5 centimeters
(cm) long by 3.0 cm wide by 0.1 cm deep with small amount of serous (thin, bloody)
drainage. Full thickness injury related to shoe friction. Distinct wound margin. No
tunneling or undermining. Treatment: [MEDICATION NAME] (a topical antimicrobial cream).
Review of the resident’s undated care plan, in use during the survey, showed:
-Problem: At risk for pressure ulcers related to incontinence, requires staff assist with
activities of daily living;
-Goal: Skin will remain intact;
-Interventions: Conduct a systematic skin inspection weekly. Pay particular attention to
the bony prominences. Keep clean and dry as possible. Minimize skin exposure to moisture.
Keep linens clean, dry and wrinkle free. Provide incontinence care after each incontinent
episode. Avoid hot water and use a mild cleansing agent that minimizes irritation and
dryness of the skin. Avoid friction to skin. Report any signs of skin breakdown (sore,
tender, red, or broken areas);
-The care plan did not address any behaviors;
-The care plan did not address the wound on the resident’s right medial heel.
Observation on 10/22/18 at 2:49 P.M., showed the resident sat in his/her wheelchair in
his/her room. The resident said he/she had a sore on his/her right foot, removed his/her
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
shoe, showed the dressing and then put the shoe back on.
Observation on 10/23/18 at 7:40 A.M., showed the resident sat in his/her wheelchair in
his/her room without any dressing on his/her right medial heel. The area measured
approximately 4 cm long by 3 cm wide by .25 cm deep with a yellow dry and moist pink wound
bed. He/She had on a pair of black leather shoes. He/She said the dressing came off as
he/she was getting dressed this morning. At 1:24 P.M., the resident sat in his/her
wheelchair in his/her room with the black, leather shoes on both feet. The resident
removed the shoe from his/her right foot, no dressing covered the wound, put the shoe back
on his/her right foot and said he/she was still waiting for staff to come and do the
treatment to his/her foot.
Observation on 10/24/18 at 6:49 A.M., showed the resident lay in bed awake. He/she showed
his/her right foot. No dressing covered the right medial heel wound. The resident said
staff did not do the treatment on 10/23/18, and the wound had not had a dressing covering
it since it had fallen off on 10/23/18. At 10:40 A.M., the resident sat in his/her
wheelchair in the dining room at a BINGO activity. The resident had on black, leather
shoes on both feet.
Further review of the resident’s progress notes, showed:
-10/23/18 at 3:11 P.M. – Resident out of room, treatment not done this shift, report to
oncoming nurse to complete.
During an interview on 10/24/18 at 12:30 P.M., the Administrator looked in the computer,
verified the dressing change had not been done on 10/23/18 and said she would expect staff
to do the treatment as ordered. She said the resident is non-compliant about wearing
shoes, staff should document the non-compliance in the progress notes and the
non-compliant behavior should be care planned. She said there was no documentation of the
non-compliance and the behavior had not been care planned.
During an interview on 10/26/18 at 8:00 A.M., the Administrator said the wound doctor saw
and measured the resident’s wound on 10/23/18. The wound measured 2.0 cm long by 3/0 wide
by 0.1 cm deep.
MO 646

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement of indwelling urinary catheters (a tube inserted into the bladder for the
purpose of continual urine drainage.) The facility identified nine residents as having
indwelling urinary catheters. Of those nine, five were chosen for the sample. Of those
five, problems were found with one resident (Resident #83). The sample was 18. The census
was 84.
Review of the facility Indwelling Urinary Catheter Care Policy and Procedure, dated
10/24/18, showed:
-Caring for the catheter;
-Maintain a sterile, closed, gravity-drainage system and avoid breaking the system;
-Secure catheters to the upper thigh or lower abdomen to avoid bladder and urethral

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
trauma;
-Keep the collection bag below the level of the bladder at all times. Do not rest the bag
on the floor;
– Consider the patient’s privacy and cover or conceal the collection bag when the patient
is in common facility areas such as the dining room
Review of Resident #83’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/17/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview for mental status (BIMS) score of 14 out of 15 (a score of 12 to 15
indicates cognitively intact);
-No behaviors;
-Suprapubic catheter (an indwelling urinary catheter surgically inserted into the bladder
through the abdomen for continual urinary drainage);
-Required total assistance from staff for transfers, dressing, hygiene and bathing.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 7/16/18, for a suprapubic catheter;
-An order dated 7/16/18, to cleanse the suprapubic catheter area with soap and water and
apply a dry dressing every evening shift;
-An order dated 8/3/18, to change the supra pubic catheter once a month and as needed if
leaking;
-An order dated 8/3/18, to change the supra pubic catheter once a month on the 12th, use
only #20 French Foley (size and type of catheter tube) with a 10 milliliter (ml) balloon
(amount of sterile water to be used to hold the catheter in place). Catheter care to be
provided every shift and as necessary;
-An order dated 10/12/18, to administer [MEDICATION NAME] – [MEDICATION NAME]
(antiinfective used to treat urinary tract infections) 800 -160 milligrams (mg) give one
tablet by mouth two times a day.
Review of the resident’s undated care plan, in use during the survey, showed:
-Problem: Resident has history [MEDICAL CONDITION] (infection) related to suprapubic
catheter even prior to nursing home placement;
-Goal: Resident will have minimal complications of obstruction, signs of infection,
dislodgment of catheter, bowel perforation, or trauma secondary to catheter manipulation;
-Interventions included: Avoid obstructions in the drainage. Position bag below level of
bladder. Store collection bag inside a protective, dignity pouch.
Review of the resident’s laboratory test, showed:
-8/2/18 – Urinalysis – cloudy red urine (normal is clear yellow). White blood cells
greater than 50 (normal is less than 6). Leukocytes – 2 plus (normal is negative).
Bacteria – none seen (normal is negative);
-9/28/18 – Urinalysis – hazy straw urine. White blood cells – less than 1. Leukocytes –
negative. Bacteria – negative.
During an observation and interview on 10/22/18 at 12:03 P.M., showed the resident lay in
bed awake. The urinary drainage collection bag hung on the left side of the bed without
any type of privacy bag. The urinary drainage tubing hung down over the side of the bed
approximately 24 inches and then looped back upward into the collection bag. The resident
said he/she has a suprapubic catheter which was changed in the hospital on [DATE], in
outpatient surgery.
Observation on 10/23/18 at 7:26 A.M. and at 1:32 P.M., and on 10/24/18 at 9:41 A.M.,
showed the resident lay in bed. The urinary catheter collection bag hung on the left side
of the resident’s bed without any type of privacy bag. The urinary drainage tubing hung
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
down over the side of the bed approximately 18 inches and looped back up into the
collection bag without any urine in the last approximate 6 inches of the tubing where it
went into the collection bag. The tubing contained a yellow colored urine with a small
amount of white sediment in the tubing. At 9:50 A.M., Nurse A put on gloves, removed the
urinary collection bag from the left side of the resident’s bed, lifted the bag
approximately 1 foot above the resident’s bladder, urine in the tubing visibly ran back
towards the resident’s bladder. He/she walked around the end of the bed hooked the urinary
collection bag onto the right side of the resident’s bed.
During an interview on 10/25/18 at 1:37 P.M., the Administrator said the catheter
collection bag should be kept below the level of the bladder and there should be a direct
flow of urine from the resident’s bladder directly into the collection bag. It would never
be appropriate for the tubing to be looped downward and back up preventing the flow of
urine into the bag due to infection control issues and to help prevent urinary tract
infections. It would never be appropriate to hold the collection bag above the level of
the bladder.

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 provide
humidified oxygen therapy in an acceptable nursing manner for one of one sampled resident
who received continuous oxygen (Resident #41). The sample size was 18. The census was 84.
Review of the facility’s Oxygen Administration Policy and Procedure, dated (MONTH) 2010,
showed the following:
-Check the tubing connected to the oxygen cylinder to assure that it is free of kinks;
-Turn on the oxygen;
-Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal
catheter);
-Check the mask, tank, humidifying jar, etc., to be sure they are in good working order
and are securely fastened. Be sure there is water in the humidifying jar and that the
water level is high enough that the water bubbles as oxygen flows through;
-Periodically re-check water level in humidifying jar.
Review of Resident #41’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 8/31/18, showed:
-[DIAGNOSES REDACTED].
-Brief Interview for Mental Status (BIMS) score of 15 out of 15 (a score of 12 to 15
indicates cognitively intact);
-No behaviors;
-Oxygen usage;
-Required minimal assistance from staff for dressing, eating and hygiene. Required maximum
assistance from staff for bathing.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 11/20/17, to administer oxygen at 3 to 5 liters to keep oxygen saturation
(amount of oxygen in the blood) above 90%;
-No orders found to change the oxygen tubing or the humidifying bottle or how often.
Observation on 10/22/18 at 10:00 A.M., on 10/23/18 at 1:36 P.M., showed the resident lay
in bed with oxygen administered at 3 liters a minute by nasal cannula. The humidifying

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 20)
bottle, dated 7/10/18, had water in the bottle. The oxygen tubing had not been dated.
Observation on 10/24/18 at 7:36 A.M., showed the resident lay in bed with oxygen
administered at 3 liters a minute by nasal cannula. The humidifying bottle had been
changed and had a date of 10/24/18. The oxygen tubing had not been dated.
Observation on 10/25/18 at 7:09 A.M., showed the resident lay in bed with oxygen
administered at 3 liters a minute by nasal cannula. The oxygen tubing had been dated
10/24/18.
During an interview on 10/25/18 at 1:37 P.M., the Administrator said the oxygen tubing and
humidifier bottle should be changed weekly due to infection control and both should be
dated when changed.
During an interview on 10/26/18 at 8:35 A.M., both the Administrator and the Corporate
Administrator said changing the oxygen tubing and humidifying jar is a nursing measure and
it is not the facilitys policy to obtain any orders to change them.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 26 opportunities observed, two errors
occurred resulting in a 7.69% error rate (Residents #86 and #72). The census was 84.
1. Record review of Resident #86’s electronic physician order [REDACTED].
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME] (short acting) insulin [MEDICATION NAME], inject subcutaneously (SQ,
under the skin) before meals three times daily per sliding scale. For a blood sugar of 351
– 400, administer 10 units.
During an observation on 10/22/18 at 12:45 P.M., Nurse A performed the blood glucose test
with a result of 359. He/she removed the [MEDICATION NAME] from drawer, dialed up 2 units
of [MEDICATION NAME] and pressed the plunger to prime the pen prior to placing the needle
on the [MEDICATION NAME]. He/she placed the needle on the pen and dialed 8 units of
[MEDICATION NAME] and injected the insulin. At 13:05 P.M., he/she started to chart the
insulin administration and said he/she realized the resident was supposed to get 10 units
sliding scale insulin. Nurse A retrieved the resident from the dining room again, pulled
the [MEDICATION NAME] out of the drawer, primed it with 2 units of insulin, placed the
needle on after priming the pen, drew up 2 units insulin, and injected the insulin.
During an interview on 10/24/18 at 1:57 P.M., the Assistant Director of Nursing (ADON)
said it is not appropriate to prime the [MEDICATION NAME] with 2 units before placing the
needle on. Staff should place the needle on first so the resident gets the full dose.
2. Review of Resident #72’s electronic POS, showed:
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME], inject SQ before meals three times daily per sliding scale as follows:
–150 – 200 = 2 units;
–201 – 250 = 4 units;
–251 – 300 = 6 units;
–301 – 350 = 8 units;
–351 – 400 = 10 units;
–401 and up = 12 units;
–If less than 60 or over 400 call the 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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
During an interview on 10/23/18 at approximately 5:50 P.M., Nurse C said he/she was unable
to perform the blood sugar checks until after the East hall nurse completed his/her blood
sugar checks. All residents had completed their meal before he/she was able to obtain
his/her blood sugar checks. Both nurses share one glucometer for the entire second floor.
During an observation on 10/23/18 at 5:53 P.M., Nurse C performed a blood sugar check with
a result of 201. He/she removed the insulin vial from the drawer, drew up 3 units of
[MEDICATION NAME] and administered into the resident’s right upper arm.
During an interview on 10/24/18 at 1:57 P.M., the ADON said she would expect staff to
obtain resident’s blood sugar level before they have their meal.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure drugs and biologicals
used in the facility were labeled in accordance with currently accepted professional
principles, and include the appropriate accessory and cautionary instructions, and the
expiration date when applicable. In addition, the facility failed to store all drugs and
biologicals under proper temperature controls, for one of six medication carts and one of
two medication storage rooms. The census was 84.
1. Observation of the 2nd floor west hall medication cart on 10/23/18 at 11:30 A.M.,
showed:
-One open bottle of Moxifloxacin (antibiotic) eye drops with no open date on the bottle;
-One open bottle of [MEDICATION NAME] (anti-[MEDICAL CONDITION]) eye drops with no open
date on the bottle;
-One open bottle of [MEDICATION NAME] acetate (steroid) eye drops with no open date on the
bottle;
-One open bottle of [MEDICATION NAME] (antibiotic) eye drops with no open date on the
bottle;
-One open bottle of Ketotifen (treats itchy eyes) eye drops with no open date on the
bottle;
-25 Juven therapeutic nutrition powder fruit punch flavor 0.85 ounce packet with
expiration date of 8/1/18;
-One Juven therapeutic nutrition powder fruit punch flavor 0.85 ounce with expiration date
7/1/18;
-Two Juven therapeutic nutrition powder fruit punch flavor 0.85 ounce with expiration date
5/1/18;
-Four Juven therapeutic nutrition powder orange flavor 0.85 ounce with expiration date of
4/1/18;
-One Ready Care (nutritional supplement) 2.0 butter pecan flavor with open date of
10/21/18, opened in the bottom drawer, unrefrigerated.
2. Observation of the 2nd floor medication room on 10/23/18 at 11:56 A.M., showed:
-Three vials of Influenza Vaccine [MEDICATION NAME] Quadrivalent (influenza vaccination
that immunizes against both A and B influenza) (YEAR)-2018 formula, in the medication
refrigerator with an expiration date of 6/30/18;
-The medication refrigerator which contained resident medications, measured 48 degrees

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
Fahrenheit (F):
-Review of the (MONTH) (YEAR) temperature log posted on the refrigerator with only
(MONTH) 6th, 7th and 19th filled in. No other temp logs noted for (MONTH) through October;

-During an interview at this time, Nurse A said night shift is responsible for monitoring
refrigerator temps;
-The medication rerigerator contained three influenza vaccine vials, eight [MEDICATION
NAME] (insulin) [MEDICATION NAME], two Basaglar (insulin) [MEDICATION NAME], two
[MEDICATION NAME] (non-insulin treatment for [REDACTED].) 23 injection 25/0.5, nine
[MEDICATION NAME] (laxative) 10 milligram (mg) suppositories, and 12 [MEDICATION NAME]
(Tylenol) 650 mg suppositories;
-The freezer covered in ice.
Review of the Centers for Disease Control website, showed:
-The ultimate goal of temperature monitoring is to ensure the preservation of save and
effective medications;
-Refrigerate vaccines between 36 degrees F and 46 degrees F;
-The vaccine refrigeration guidelines can be applied to all medication in refrigerated
storage.
During an interview on 10/24/18 at 1:57 P.M., the Assistant Director of Nursing (ADON)
said she would expect staff to label eye drops, insulin, supplements and inhalers with the
date opened. Night shift typically check for expired medications and dispose of them.
Expired medications should not be stored in the medication cart. Night shift should check
refrigerator temperatures. It is not appropriate for expired influenza medications to be
stored in the refrigerator. Staff should monitor the medication refrigerator temperatures.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview, and record review, the facility failed to follow three
out of three pureed recipes for three residents on a pureed diet. The census was 84.
1. Observation on 10/24/18, of the pureed breaded pork chop preparation, showed the
following:
-At 10:02 A.M., the Dietary Manager (DM) chopped an unknown amount of breaded pork chop in
the blender, then scooped the chopped meat into a metal container;
-The DM told Dietary Aide (DA) H to prepare three servings of the pureed breaded pork
chops and to use half a slice of bread for each serving;
-DA H added three, 1/2 cup scoops of chopped meat, four, 1/2 cups of pork broth, and two
whole slices of bread to the blender and pureed the ingredients;
-DA H added another 1/2 cup scoop of chopped meat;
-The DM told DA H to add the remaining slice of bread to the blender instead of cutting it
in half because it was the end piece of the loaf;
-DA H added the slice of bread to the blender and pureed the ingredients for approximately
20 seconds;
-The pureed breaded pork chop appeared slightly runny;
-DA H did not use a recipe for the breaded pork chop puree.

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
Review of the facility’s undated pureed food guidelines for pureed entrees, showed each
serving as follows:
-Ingredients: 3 ounces (oz.) cooked or 1/2 cup cooked (ground) product amount, 1/2 slice
bread, broth;
-Directions: Place bread, then food to be pureed in blender or food processor. Begin with
1/2 cup liquid; puree, then continue to alternate adding liquid and pureeing until product
is correct consistency.
2. Observation on 10/25/18, of the pureed sausage preparation, showed the following:
-At 6:40 A.M., DA H said he/she was preparing four servings of pureed sausage;
-He/she added eight sausage patties and three, 4 oz. scoops of pork broth to the blender
and pureed the ingredients for 20 seconds;
-DA H added 1 oz. of thickener to the mixture and blended another 15 seconds;
-He/she did not use a recipe for the sausage puree.
Review of the facility’s undated pureed food guidelines for sausage puree, showed for each
serving, ingredients consist of two sausage patties and broth. The recipe instructs to
begin with 1/2 cup liquid; puree, then continue to alternate adding liquid and pureeing
until product is correct consistency.
3. Observation on 10/25/18, of the pureed egg preparation, showed the following:
-DA said he/she was preparing four servings of pureed egg;
-He/she added four, heaping 1/2 cups of scrambled eggs, one slice of bread, and four, 4
oz. cups that were not quite full of lactose milk to the blender;
-He/she pureed the ingredients for 30 seconds;
-He/she added another 4 oz. cup of milk, not quite full, to the blender, and pureed the
ingredients for another 10 seconds;
-He/she did not use a recipe for the egg puree.
Review of the facility’s undated pureed food guidelines for egg puree, showed for each
serving, ingredients consist of 1/2 cup scrambled eggs, 1 slice of bread, and milk. The
recipe instructs to begin with 1/2 cup liquid; puree, then continue to alternate adding
liquid and pureeing until product is correct consistency.
4. During an interview on 10/26/18 at 7:30 A.M., the DM said staff is expected to prepare
food according to the pureed food guidelines. It is important to measure ingredients and
to follow the recipes for pureed foods in order to ensure the nutritional value of the
meal is maintained.
5. During an interview on 10/26/18 at 8:35 A.M., the Corporate Administrator said it is
important for dietary staff to follow the pureed food guidelines. Pureed food recipes
should be followed in order to ensure residents receive the proper nutritional content.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure beverages were not
served after the expiration date. This deficient practice had the potential to affect all
residents who ate at the facility. The facility census was 84.
1. Observation on [DATE] at 9:16 A.M., during the initial tour of the facility kitchen,
showed 40 individual cartons of fat free milk, expired (MONTH) 16, (YEAR) and 19 fat free
milk, expired (MONTH) 19, (YEAR).

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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
Observation on [DATE] at 12:43 P.M., 12:50 P.M., 12:52 P.M., and 12:57 P.M., showed fat
free milk with an expiration date of [DATE] served to four residents in the dining room
during meal service.
Observation on [DATE] at 1:04 P.M. and 1:10 P.M., showed staff took a hall tray to a
resident’s room on the west wing. There was a fat free milk with an expiration date of
[DATE] on the tray. At 1:10 P.M., staff delivered a tray with a fat free milk with an
expiration date of [DATE] to a resident’s room on the east wing.
Observation on [DATE] at 1:44 P.M., all four residents served the expired fat free milk in
the dining room consumed 100% of the milk. The resident on the west wing consumed 100% of
the expired milk. The resident on the east wing did not consume the expired fat free milk.
2. During an interview on [DATE] at 7:30 A.M., the dietary manager said expired milk
should not be served because it can make residents sick. The dietary manager showed a
picture of individual cartons of milk that had been thrown away Monday after she became
aware of the fact that there was an abundance of expired milk in the cooler than had been
overlooked by staff.

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain medical records on
each resident that are complete, accurately documented and readily accessible, for one
resident (Resident #61) who had a fall and the circumstance surrounding the fall not
documented in the medical record. In addition, the resident was sent to the hospital and
the circumstances surrounding the transfer was not documented in the medical record. The
census was 84.
Review of Resident #61’s quarterly Minimum Data Set (MDS) a federally required assessment
instrument completed by facility staff, dated 7/5/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview of mental status (BIMS) score of 13 out of a possible score of 15;
-A BIMS score of 8-15, showed the resident understands and able to make self-understood;
-Supervision required for transfers;
-No falls since prior assessment.
Review of the facility’s Incidents by Incident type report, showed the following for the
resident:
-Date range: 8/1/18 through 8/31/18;
-Unwitnessed fall incident: 8/25/18 at 2:27 A.M.
Review of the facility’s Fall Protocol, dated 7/1/18, showed all incidents and accidents
must be called to the Director of Nursing (DON) or designee. Please assure the following
interventions are in place:
-Call to physician;
-Call to responsible part and update resident on new interventions;
-Add fall risk residents to report.
Review of the resident’s progress notes, showed:
-On 8/25/18 at 2:11 A.M., the resident remains on follow up, denied complaint of pain,
reeducated about calling for assistance;
-No documentation regarding a fall that occurred on 8/25/18 at 2:27 A.M., 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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
circumstances that surrounded the fall, if the resident sustained [REDACTED].
Review of the resident’s MDS record, showed:
-A discharge, return anticipated MDS completed on 9/5/18;
-An entry MDS completed on 9/8/18.
Further review of the resident’s progress notes, showed:
-On 9/5/18 at 1:09 P.M., the resident observed to have productive cough, greenish sputum.
Obtained new order for oxygen per nasal cannula;
-On 9/8/18 at 10:22 P.M., the resident returned from the hospital. Complaints of shortness
of breath;
-No documentation of the circumstances when the resident was sent to the hospital, what
time the resident left for the hospital, the resident’s condition at time of discharge or
notification of next of kin of the resident’s discharge to the hospital on [DATE].
During an interview on 9/20/18 at 1:36 P.M., the administrator said she would expect staff
document when a resident leaves to the hospital and when they return and the circumstances
surrounding a fall. This should be documented in the resident’s progress notes.
MO 348

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure infection
control standards were maintained during blood glucose testing for six residents’ observed
during blood glucose testing (Residents #28, #86, #52, #72, #16 and #7). The facility
census was 84.
Review of the front of the bleach wipes box, showed:
-Bactericidal, fungicidal, tuberculocidal, virucidal in 4 minutes;
-Disinfects in 4 minutes.
1. Review of Resident #28’s electronic physician order [REDACTED].
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME] (fast acting insulin) [MEDICATION NAME], Inject 7 units subcutaneously
(SQ, under the skin) three times daily.
During an observation on 10/22/18 at 12:22 P.M., showed Nurse A did the following:
-Cleansed the cart top with bleach wipes;
-Placed a clean barrier on top of the cart;
-Tried to open the electronic chart (echart) on the laptop attached to the cart. The
electronic Medication Administration Record [REDACTED]
-Went to another cart (cart #2) to use the laptop. The insulin remained on the first cart
(cart #1);
-Cleaned the top of the second cart with bleach wipes and said he/she had to let it dry
for 4 minutes before using;
-Then placed a clean barrier on the cart top without waiting for it to dry;
-Removed the tubs of alcohol prep pads, lancets and gauze 2x’s and placed them on the
clean barrier, leaving a small section to gather supplies on.
-Closed the door, after the resident entered the room, donned gloves, and placed the
glucometer (machine used to check blood sugar levels) on the barrier;
-Performed the blood glucose test;
-Cleansed the glucometer with bleach wipe for approximately 5 seconds, then wrapped 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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
glucometer in a clean paper towel and placed it on top of the first cart;
-Verified the order for [MEDICATION NAME];
-Removed the [MEDICATION NAME] vial out of the cart and drew up 10 units [MEDICATION NAME]
(without first cleaning the top rubber [MEDICATION NAME] with alcohol), cleansed the
resident’s left upper arm with alcohol and injected the insulin.
2. Review of Resident #86’s POS, showed:
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME], Inject SQ before meals three times daily per sliding scale.
During an observation on 10/22/18 at 12:45 P.M., showed Nurse A did the following:
-Unwrap the glucometer and place it on the dirty barrier, located on the cart #2;
-Donned gloves and performed the blood glucose test;
-Cleaned the glucometer with a bleach wipe for approximately 4 seconds, carried it to cart
#1, wrapped it in a tissue, took it back to cart #2 and place it on the dirty barrier;
-Checked the order for [MEDICATION NAME] sliding scale insulin;
-Removed the [MEDICATION NAME] from drawer of cart #1, dialed up 2 units and pressed the
plunger, did not clean the rubber [MEDICATION NAME] top, placed the needle tip on and
dialed the insulin;
-Injected the insulin;
-At 13:05 P.M., he/she started to chart the insulin administration and realized the
resident was supposed to get 10 units sliding scale;
-Retrieved the resident from the dining room again;
-Pulled the [MEDICATION NAME] out of the drawer, primed it with 2 units of insulin, placed
the needle on without cleaning the rubber [MEDICATION NAME], drew up 2 units insulin, and
injected the insulin;
-Charted the administration;
-Wiped the glucometer for approximately 3 seconds with a bleach wipes and wrapped it in a
tissue.
3. Review of Resident #52’s electronic POS, showed:
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME], Inject 18 units SQ three times daily.
During an observation on 10/22/18 at 1:24 P.M., showed Nurse A did the following:
-Pushed the dirty treatment cart into the resident’s room;
-Gathered the supplies onto the same barrier used for the previous resident, unwrapped the
glucometer and placed it onto the same barrier;
-Sanitized his/her hands and placed on gloves (this was the first time Nurse A washed or
sanitized his/her hand during the entire blood glucose testing and insulin administration
observation);
-Checked the resident’s blood glucose level with a result of 197;
-Cleaned the glucometer with a bleach wipe for approximately 5 seconds and wrapped it in a
paper towel;
-Checked the order for [MEDICATION NAME] insulin;
-Removed the insulin vial (with no open date on the bottle) from the drawer, cleaned the
rubber [MEDICATION NAME] with an alcohol pad, and withdrew 18 units of [MEDICATION NAME];
-Cleaned the resident’s left upper arm with alcohol, and injected the insulin;
-Removed the cart from the resident room, pushed it into the day area and parked it beside
the nurse station without cleaning it.
4. Review of Resident #72’s electronic POS, showed:
-Check and record blood glucose level three times a day related to diabetes;
-[MEDICATION NAME], inject SQ before meals three times daily per sliding scale.
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
During an observation on 10/23/18 at 5:53 P.M., showed Nurse C did the following:
-Cleaned the top of the insulin cart with a bleach wipe and placed two barriers side by
side;
-Wiped the top only of the glucometer with the same bleach wipe for approximately 2
seconds and placed it onto barrier #1;
-Gathered supplies onto the same barrier;
-Put on gloves (without washing or sanitizing hands) then retrieved the resident from the
table;
-Cleaned the resident’s left pinky with alcohol, performed check with a result of 201, and
placed the glucometer onto barrier #2;
-Changed gloves, removed the insulin vial from drawer, cleaned top with alcohol, drew up 3
units of [MEDICATION NAME], and injected into the resident’s right upper arm;
-Cleaned the glucometer with a bleach wipe with one swipe on the front and one swipe on
the back of the glucometer (approximately 2 seconds) and placed the glucometer onto
barrier #1;
-Threw all trash into the bottom unlined trashcan on the cart (the top trash can had a
liner);
-Did not wash hands his/her hands at any time.
5. Review of Resident #16’s electronic POS, showed:
-Check and record blood glucose level three times a day related to diabetes;
-Humalog (short acting insulin), inject 6 units SC three times daily.
During an observation on 10/23/18 at 6:11 P.M., showed Nurse C did the following:
-Retrieved the resident from the dinner table;
-Gloved and performed the blood glucose testing with result of 215;
-Placed the glucometer onto barrier #1;
-Remove Humalog from cart drawer, cleaned the top and drew up 3 units of insulin;
-Injected the insulin into the resident’s left abdomen;
-Removed gloves and threw gloves and all trash into lower unlined trashcan;
-Noticed the lower trash can did not have a liner and with his/her ungloved hands, grabbed
the trash out of the 3/4 full lower unlined trash can and placed it into the upper lined
trash can, using both hands;
-Did not wash his/her hands;
-Moved the supplies around on the cart;
-Picked up the glucometer and placed it onto barrier #2;
-Cleaned the glucometer with a bleach wipe for approximately 4 seconds and placed onto
barrier #1.
6. Record review of Resident #7’s electronic POS, showed:
-Check and record blood glucose level three times a day related to Diabetes;
-Humalog, inject 12 units SC three times daily.
During an observation on 10/23/18 at 6:20 P.M., Nurse C:
-Pushed the insulin cart into the resident’s room;
-Placed a clean barrier on top of a dirty barrier;
-Cleaned the glucometer with bleach wipes for approximately 4 seconds then placed it onto
the clean barrier;
-Donned gloves without washing or sanitizing his/her hands and gathered the supplies onto
the barrier;
-Checked the resident’s blood sugar with a result of 108;
-Cleaned the glucometer with a bleach wipe for approximately 3 seconds and placed on
barrier on to the barrier to dry;
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:

265672

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

10/26/2018

NAME OF PROVIDER OF SUPPLIER

DUTCHTOWN CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

3421 GASCONADE
SAINT LOUIS, MO 63118

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
-Pushed the insulin cart into the hallway and down the hall without sanitizing it.
7. During an interview on 10/23/18 at 6:35 P.M., Nurse C said he/she forgot to wash
his/her hands and has never read the instructions on the bleach wipes.
8. During an interview on 10/24/18 at 1:23 P.M., Nurse B said staff should wash hands
before and after providing care, including blood glucose testing and insulin
administration, and in between residents. Staff should glove before touching trash, if
not, at least wash their hands before doing anything else. The procedure for sanitizing
the glucometer is to wipe with bleach wipe and the let it dry 3-5 minutes or whatever the
package recommends.
9. During an interview on 10/24/18 at 1:57 P.M., the Assistant Director of Nursing (ADON)
said:
-He/she expected staff to wash hands before they started, after touching anything dirty,
between individuals, and after done with care, including blood glucose testing and insulin
administration;
-He/she expected staff to follow the manufacturer instructions on sanitizing wipes;
-He/she expected staff to wipe the glucometer with a bleach wipe, and then wait 4 minutes
then perform check;
-It was not appropriate for staff to use ungloved hands to transfer trash from one trash
can to another;
-It was not appropriate for staff to perform a blood glucose test without washing hands;
-He/she expected staff to wash their hands after touching trash, especially before care;
-The procedure for using an insulin [MEDICATION NAME] is as follows: Sanitize the rubber
[MEDICATION NAME], place the needle, prime the [MEDICATION NAME] and adjust the dial to
the amount needed.