Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Properly hold, secure, and manage each resident’s personal money which is deposited
with the nursing home.

Based on interview and record review, the facility failed to provide quarterly resident
fund statements within 30 days after the end of the quarter, failed to reconcile the
resident trust fund balance on a monthly basis, failed to balance one resident’s account,
which caused a negative balance and failed to keep one resident’s monies in an interest
bearing account. The facility holds resident funds for two residents and issues were found
with both accounts (Residents #25 and #14). The census was 36.
1. Review of the resident trust fund (RTF) documentation, showed the following:
-Monthly bank statements for the last 12 months;
-Monthly debit/credit logs for Residents #25 and #14;
-No documentation the records had been reconciled;
-No documentation quarterly statements were sent to the residents and/or their
representatives.
During an interview on 5/29/18 at 2:19 P.M., the business office manager (BOM) said the
facility currently held funds for two residents. He did not reconcile the accounts on a
monthly basis. He also did not send out quarterly statements to the residents or their
representatives.
2. Review of Resident #14’s monthly debit/credit log, showed the following:
-On 7/11/17, a balance of $53.49;
-On 8/29/17, a balance of $56.49;
-On 10/27/17, a balance of $56.49
-On 12/6/17, a negative balance of $7.51;
-Staff failed to consistently balance the credits and debits for the account.
During an interview on 6/1/18 at 8:50 A.M., the BOM said only resident #25’s money was
kept in the bank, because the facility was the representative payee. Resident #14’s money
was kept in his desk, because it never went over $50.00. He was not aware the resident’s
balance had exceeded $50.00 on multiple occasions or had a negative balance.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to revise care
plans with new interventions for falls, behaviors, oxygen and hospice services for four of
twelve sampled residents (Residents #15, #31, #2 and #27). The census was 36.
1. Review of Resident #15’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-admitted on [DATE];
-Severe cognitive impairment with disorganized thinking;
-No behaviors noted during the assessment period;
-[DIAGNOSES REDACTED].
-No falls since last review.
Review of the resident’s nurse’s notes, showed the following:
-On [DATE] at 12:30 P.M., the resident threw iced tea and coffee on nursing staff,
breaking the coffee cup. Staff brought the resident to the nurse’s station and as the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
social worker spoke to the resident, he/she smacked the social worker in the mouth and
bloodied her lip. Nursing staff contacted the primary physician and asked if the resident
could be sent to the hospital. The physician said the hospital would not keep the resident
and would send him/her right back. A nurse contacted the family member and advised the
resident needed a locked unit. Staff called an ambulance to transport the resident to the
hospital for psychiatric evaluation;
-On [DATE], a late entry note at 11:45 P.M., the resident found on floor in the middle of
hallway yelling I’m on the floor, I’m on the floor. Nurse observed resident bleeding from
an area on his/her head. Resident assisted back into wheelchair and staff observed a
laceration to the right eyebrow, which measured 2.5 centimeter in length. Staff noted the
resident currently dozing off, unable to really stay awake, not really responding to
verbal stimuli, mumbling at times but unable to communicate to the nurse. Resident will be
sent to emergency room for evaluation.
Review of the resident’s care plan, last updated on [DATE], and in use during the survey,
showed staff did not update the care plan to reflect new issues or interventions related
to the resident’s behaviors requiring hospitalization on [DATE] and his/her fall on
[DATE].
During an interview on [DATE] at 9:30 A.M., the administrator said the resident’s
behaviors and falls and specific interventions to address those issues should be included
on the care plan.
2. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
-Cognition not assessed;
-Required two or more staff for transfers and total dependence on staff for toileting;
-Impairment to bilateral lower extremities;
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes, showed on [DATE], the resident fell to the floor
during a Sit to Stand (mechanical lift used to transfer a person from a sitting to a
standing position) transfer. On [DATE], the nurse obtained a physician order [REDACTED].
Review of the resident’s care plan, updated [DATE], showed no documentation regarding the
resident’s fall on [DATE] or any new interventions. The care plan also failed to address
the change in the resident’s transfer status.
During an interview on [DATE] at 9:30 A.M., the administrator said the resident’s fall and
interventions should be added to the resident’s care plan.
3. Review of Resident #2’s quarterly MDS, dated [DATE], showed the following:
-An admission date of [DATE];
-Cognitively intact;
-[DIAGNOSES REDACTED].;
-Frequent pain;
-On [MEDICAL TREATMENT];
-Staff did not include use of oxygen therapy.
Review of the resident’s May, (YEAR) physician order [REDACTED].
Review of the resident’s care plan, last revised on [DATE], and in use during the survey,
showed no documentation regarding the resident’s use of oxygen.
Observations of the resident on [DATE] at 3:30 P.M., [DATE] at 9:48 A.M., [DATE] at 6:39
A.M. and [DATE] at 6:58 A.M., showed the resident wearing a nasal cannula (device used to
deliver oxygen with small tubes, which fit into the nostrils), attached to an oxygen
concentrator (machine which filters in air, compresses it, and delivers air continuously)
set at two liters (flow rate).
During an interview on [DATE] at 3:30 P.M., the resident said he/she wears oxygen all the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
time.
During an interview on [DATE] at 9:30 A.M., the administrator said the resident’s use of
oxygen should be included on the care plan.
4. Review of Resident #27’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Ambulated independently;
-Limited assistance with dressing;
-Prognosis of six months or less;
-Enrolled in hospice program;
-[DIAGNOSES REDACTED].
Review of the resident’s May, (YEAR) POS, showed no order for hospice services.
Review of the resident’s care plan, dated [DATE], showed no documentation regarding
hospice services.
During an interview on [DATE] at 9:30 A.M., the administrator said hospice staff document
their visits on the computer, in the progress notes and are supposed to collaborate with
the facility on the care plan.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain an order
for [REDACTED].
1. Review of Resident #2’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/1/18, showed the following:
-An admission date of [DATE];
-Cognitively intact;
-[DIAGNOSES REDACTED].
-Frequent pain;
-On [MEDICAL TREATMENT];
-Staff did not include use of oxygen therapy.
Review of the resident’s May, (YEAR) physician order [REDACTED].
Observations of the resident on 5/29/18 at 3:30 P.M., 5/30/18 at 9:48 A.M., 5/31/18 at
6:39 A.M. and 6/1/18 at 6:58 A.M., showed the resident wearing a nasal cannula (device
used to deliver oxygen with small tubes which fit into the nostrils), attached to an
oxygen concentrator (machine which filters in air, compresses it, and delivers air
continuously) set at two liters (flow rate).
During an interview on 5/29/18 at 3:30 P.M., the resident said he/she wears oxygen all the
time.
During an interview on 6/1/18 at 9:30 A.M., the administrator said residents requiring
oxygen should have orders.
2. Review of Resident #11’s quarterly MDS, dated [DATE], showed a [DIAGNOSES REDACTED].
Review of the care plan, last updated 3/6/18, showed the following:
-Category: Visual function;
-Problem-Visual deficit in left eye related to [MEDICAL CONDITION] and blind in the right
eye.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Review of the May, (YEAR) POS, showed an order, dated 11/26/12, to administer [MEDICATION
NAME] (antibiotic) ointment to the lower right eye lid twice a day for [MEDICAL
CONDITION].
During an interview on 6/1/18 at 9:30 A.M., the Director of Nursing and the administrator
said when an antibiotic is ordered the nurse should confirm a [DIAGNOSES REDACTED]. They
said the physician has been approached about a stop date and they had yet to receive a
response. They said they did not know the reason the [MEDICATION NAME] was given and
[MEDICAL CONDITION] was not an appropriate diagnosis.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow the
facility policy to provide appropriate care, tracking and monitoring to prevent the
development of pressure ulcers for two of 12 sampled residents (Residents #17 and #22).
The census was 36.
Review of the facility’s Pressure ulcer treatment policy, updated 6/20/17, showed the
following:
-Purpose: To track frequency of skin treatments necessary, body assessments and the
progress in healing;
-Policy: Any resident that is noted to have a pressure, stasis, or diabetic wound; the
nurse who received report about the wound or noted the wound will create an event in the
electronic medical record and assess the wound as indicated. The nurse will measure, take
a photo of the wound, noting length, width, and depth initially. The event will be created
and kept open until the area is healed. Orders will have the wound location, directions
for cleaning, medications orders, wound dressing to be used, frequency of change and pain
assessment. Any resident requiring pain medication should receive at minimum a dose 30
minutes prior to starting treatment;
-Documentation: Every resident that has a wound needs to have the nurse create an Event
and completely fill out the assessment, document daily that the wound dressing is dry and
intact or if dressing was found off, the treatment would be replaced. All resident wounds
need to be assessed weekly by licensed staff: measure length, width, depth, stage
character of wound bed, tunneling (channels that extend from a wound into or through
tissue or muscle), exudate (pus-like or clear fluid) amount and color, odor, surrounding
tissue and pain.
1. Review of Resident #17’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/3/18, showed the following:
-Brief Interview for Mental Status (BIMS, screening tool used to assess cognition) score
of two out of a possible score of 15, which showed severe cognitive impairment;
-Limited staff assistance required for toileting and transfers;
-Frequently incontinent of bowel and bladder;
-At risk to develop pressure ulcers (injury to the skin and/or underlying tissue, usually
over a bony prominence, as a result of pressure or friction);
-No pressure ulcers or wounds present.
Review of the resident’s care plan, updated 3/3/18, showed the following:
-Problem: At risk for pressure ulcers related to incontinence and staff assistance needed
to reposition;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-Goal: To be free from pressure ulcers and moisture associated skin damage;
-Approach: Reposition every two hours, place a pressure reducing cushion in his/her
wheelchair and a weekly skin assessment by a nurse;
-Problem: Urinary incontinence; he/she needs reminders to use the bathroom and to
thoroughly cleanse self;
-Goal: He/she will participate in the bowel and bladder program;
-Approach: Use pull ups for dignity, will participate in the bowel and bladder program
every two hours, staff will provide the resident with hygiene products and supervise
during hygiene after each incontinent episode.
Review of the resident’s skin assessment notes, showed the following:
-On 4/21/18, he/she had a red left buttock. Barrier cream applied;
-On 4/28/18, a pressure ulcer to the right buttock found. The area measured 1 centimeter
(cm) x 0.5 cm. Signs of inflammation and redness to wound area. Continue to apply barrier
cream.
Review of the resident’s electronic physician order [REDACTED].
Review of the resident’s progress notes, showed the following:
-On 5/08/2018 at 9:34 A.M., the treatment to the resident’s pressure ulcer on his/her
right buttocks looked healthy. New skin growth over the wound bed with no redness to the
surrounding tissue;
-On 5/12/2018 at 1:18 A.M., staff provided peri-care (cleaning from the front of the hips,
between the legs and buttocks and the back of the hips) during nightly rounds. An area
located to the groin and buttocks had redness. An open area to left buttock measured 0.6
cm x 0.5 cm and appeared to be smaller in size. Barrier cream applied to both areas. Will
continue to monitor;
-On 5/23/2018 at 1:07 A.M., Staff assessed the open area to the resident’s left buttock.
The area measured 0.4 cm x 0.3 cm. Minimal redness observed and no slough (yellow stringy
tissue adhered to wound bed) or drainage observed. Barrier ointment applied. Informed
staff to apply barrier cream to the resident’s buttocks at each nightly round. Will
continue to monitor.
Review of the resident’s skin assessment on 5/26/18, showed an open area to the buttock.
The area measured 0.5 cm x 0.2 cm and minimal redness to the area. Staff continued to
apply barrier cream to the area.
Further review of the resident’s progress notes, showed the following:
-On 5/29/2018 at 10:55 P.M., staff found an open area to the resident’s right buttock. The
area measured 0.5 cm x 0.4 cm with minimal redness and no drainage. Barrier cream applied
to the area. Night shift staff informed to provide good peri-care and apply barrier cream
during each nightly round. Will monitor;
-On 5/31/2018 at 12:40 A.M., the nurse assessed the open area to resident’s right buttock.
The area measured 0.5 cm x 0.4 cm. Both of the resident’s buttocks had redness. Barrier
cream applied.
During an observation and interview on 5/31/18 at 9:50 A.M., Certified Nurse Aide (CNA) B
assisted the resident to stand in the restroom. He/she pulled down the resident’s pants
and exposed the resident’s buttocks. The resident’s buttocks were red and a flaky white
substance presented on both of the resident’s buttocks. An open area to the right lower
buttock measured approximately 1 cm x 0.5 cm. The area had no treatment in place. CNA B
said the open area on the right buttock had been there for several weeks and the charge
nurses told the aides to apply barrier cream as treatment. He/she had not seen nurses
apply a treatment to the area. The aides should tell the charge nurses if the resident had
any changes in the condition of the skin. He/she would tell the charge nurse the area
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
looked bigger than yesterday.
During an interview on 5/31/18 at 12:29 P.M., Licensed Practical Nurse (LPN) A said he/she
thought the resident had an open area on his/her left buttock. The area to the left
buttock had been opened before. A treatment had been applied and the area had healed.
He/she thought the area to the left buttock had been reopened. The nurse aides should
apply barrier ointment to the resident’s buttocks for treatment. He/she did not know if
the physician had been told of any new skin issues. He/she did not know how the facility
tracked open areas or skin issues besides report or orders on the treatment administration
record (TAR). If he/she discovered an open area, he/she would document the area in the
resident’s record, notify the physician to obtain orders and pass on the findings in
report. Skin assessments are preformed on the night shift.
During an observation and interview on 5/31/18 at 1:18 P.M., LPN A provided a skin
assessment to the resident. An open area to the resident’s right lower buttocks appeared
red and measured approximately 1 cm x 0.5 cm. LPN A said the night shift nurses perform
the skin assessments and document in the computer on those areas. He/she did not know
about the open area to the right lower buttock. The area was caused from pressure and
appeared to be a stage II pressure ulcer (partial thickness wounds and may involve tissue
loss at the epidermis and dermis levels). The area should be cleaned, and a treatment
applied. The physician should be notified and orders obtained. Staff do not complete
Braden assessment scales (assessment tool used to score risk of pressure ulcer
development) on the residents.
Further review of the resident’s progress notes on 6/1/18 at 9:00 A.M., showed no
documentation that staff notified the resident’s physician, no wound measurements and no
treatment orders to the buttock wound.
Further review of the resident’s care plan on 6/1/18, showed no updates regarding wounds
or pressure ulcers.
2. Review of Resident #22’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of five out of 15, which showed severe cognitive impairment;
-Limited staff assistance needed with toileting;
-Total staff assistance needed with hygiene;
-At risk to develop pressure ulcers, no pressure ulcer present at time of assessment;
-Frequently incontinent of bowel and bladder;
-Diagnoses: [REDACTED].
Review of the resident’s care plan updated 3/4/18, showed the following:
-Problem: Urinary Incontinence related to dementia and medication, he/she requires
toileting reminders;
-Goal: He/she will be clean, dry and odor free;
-Approach: He/she prefers to wear pull ups and staff will provide incontinence care after
each episode. Staff provide toileting every two hours;
-Problem: Risk to develop pressure ulcers related to swelling, incontinence and obesity
(over weight);
-Goal: Free from infection;
-Approach: Reposition every two hours, elevate feet at night and weekly skin assessment.
Review of the resident’s POS, showed an order dated 5/18/18 for [MEDICATION NAME] ointment
and apply to buttocks every shift after incontinence care.
Review of the resident’s hospital wound nurse notes, showed the following:
-On 5/17/18 a stage II pressure ulcer to the right buttock measured 1 cm x 1 cm x 0.1 cm
deep. Recommendations to reposition every two hours and consider use of a foam dressing to
the wound for protection.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
Review of the resident’s progress notes, showed on 5/18/2018 at 4:33 P.M., the resident
returned to the facility per ambulance. The hospital nurse reported the resident had a
stage II pressure are to his/her buttocks. The pressure ulcer had no treatment and will be
left uncovered. Barrier cream applied.
Review of the resident’s skin assessments, showed the following:
-On 5/24/18 an open area to the left buttock. Staff to provide incontinence care and apply
barrier cream. Continue with current treatment;
-On 5/29/18 at 4:02 P.M., readmitted from hospital with stage II pressure ulcer to
buttock. [MEDICATION NAME] ointment applied;
-On 5/31/18 an open area to the left buttock, redness to both buttocks. Staff provide
incontinence care and apply barrier cream. Continue with current treatment;
-On 5/31/2018 at 12:45 A.M., The area to the left buttock assessed. The area remains open
and reddened at this time. The open area measured 0.5 cm x 0.5 cm, no drainage observed.
Buttocks are red as well with minimal excoriation. Barrier cream applied. Will monitor.
During an observation and interview on 5/31/18 at 8:50 A.M., showed CNA B provided
peri-care to the resident. The buttocks appeared red and inflamed. An open area to the
right lower buttock measured approximately 0.5 cm x 1 cm and red. The resident moaned out
when CNA B cleaned the area. CNA B said the resident had the open area for several weeks,
and the charge nurses told him/her to apply [MEDICATION NAME] ointment to the wound when
he/she provided care. He/she would inform the nurse the area seemed more red and painful.
Further review of the resident’s progress notes on 6/1/18, showed no new treatment orders
for the ongoing open area to the resident’s buttocks.
Further review of the resident’s care plan on 6/1/18, showed no updated documentation
regarding the open area to the resident’s buttocks or treatment.
During an interview on 5/31/18 at 10:14 A.M., the Director of Nursing said the facility
does not complete the Braden scale assessments on the residents. The charge nurses should
perform the weekly skin assessments on the residents. If a wound or pressure ulcer had not
improved over a two week period, the nurse should call the physician to get orders to
treat the area. When the wound or pressure ulcer is discovered, the nurse is responsible
to open an event under the resident’s medical record. Opening an event is used to track
the wounds. Nurses are expected to take measurements weekly and communicate wound findings
to nursing administration. The care plan should be immediately updated when a wound or
pressure ulcer is found and include treatments and measurements. Documentation should be
accurate and timely.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to adequately
assess resident falls, failed to implement timely and appropriate interventions to prevent
further falls with injury for one resident (Resident #27) and failed to follow safe
practice when transferring a resident with a sit to stand lift (mechanical lift used to
transfer a person from a sitting to a standing position) for one resident (Resident #31)
of 12 sampled residents. The census was 32.
1. Review of the facility’s Fall Policy, dated 6/1/13 and updated on 4/6/16, showed the
following;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-Purpose–intended to protect all residents from injury;
-Standard Fall Precautions:
-Orient to environment/safety teaching;
-Treaded slipper socks or shoes when up moving;
-Assistive devices in easy reach after ensuring the resident knows how to use the device;
-Hand rails and grab bars in easy reach;
-Bed in low position;
-Bed wheels and wheelchair brakes locked;
-Well lit, clutter free, spill free environment;
-Definition–a sudden uncontrolled, unintentional, downward displacement of the body to
the ground or other object. Object coming to rest on the floor unintentionally,
inadvertently coming to rest on the ground or another lower level;
-Policy–all residents are to be evaluated upon admission for fall risk by using the Fall
Observation form. All residents are again evaluated every quarter using same form. Any
resident found to be a high fall risk will have one or more interventions:
-Bed/chair alarms;
-Raised edge mattress (bumpers);
-Physical or Occupational therapy;
-A resident is considered to be a known fall risk as follows:
-Any resident ambulating without assistance;
-Any resident that has a bed or chair alarm;
-Any resident that requires a restraint.
2. Review of Resident #27’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/29/18, showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Ambulates independently;
-Limited assistance with dressing;
-No falls prior to admission;
-Two or more falls since admission;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/24/18 and reviewed/revised on 4/16/18, showed
the following:
-Problem: Has fallen and is at risk of falling related to poor balance and weakness;
-Goal: Will be free from injuries from falls;
-Approaches: Keep bed in lowest position and locked at all times. Pressure sensitive alarm
to be under resident at all times. Assess function of alarm at beginning of the shift.
Review of the nursing progress notes, showed the following:
-On 3/24/18 at 3:15 A.M., staff found him/her kneeling on the floor beside the bed. Staff
returned him/her to bed and found him/her on the floor again at 4:00 A.M. Assessment
showed left knee redness;
-On 3/27/18 at 3:01 P.M., staff found him/her on the bathroom floor. Therapy placed bed
and chair alarms and a mat on the floor next to the bed;
-On 4/4/18 at 4:20 A.M., staff found him/her on the bedroom floor with his/her legs
straight out in front of him/her. Staff returned the resident to bed;
-On 4/12/18 at 7:00 A.M., staff found him/her on the floor in the common bathroom and at
1:37 P.M. staff again found him/her on the floor;
-On 5/20/18 at 1:30 P.M., staff found him/her face down on the floor in a hallway utilized
only by staff. Upon rolling the resident to his/her back staff members noted a laceration
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
(deep cut or tear) and blood above his/her right eyebrow and a hematoma (a collection of
blood outside of a blood vessel) above the laceration.
Observations on 5/29/18 at 12:21 P.M., 5/30/18 at 6:29 A.M., 5/31/18 at 10:56 A.M. and
6/1/18 at 6:36 A.M., showed a large bruise to the resident’s right cheek approximately 2
inches by 3 inches that extended from under the right eye across the bridge of his/her
nose.
During an interview on 6/1/18 at 9:30 A.M., the administrator said when a resident falls
an assessment is completed by the nurse and new interventions are implemented. The new
interventions should be noted on the care plan so a staff members are aware.
3. Review of the facility’s undated mechanical lift policy, showed the following:
-Residents who are non-weight bearing need to be reported to the charge nurse to be
evaluated by therapy for appropriateness of which lift machine needs to be used;
-The policy covered the technique used to transfer a resident;
-The policy did not include the number of staff needed to provide safe transfers for
residents.
4. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
-Cognition not assessed;
-Required two or more staff for transfers and total dependence on staff for toileting;
-Impairment to bilateral lower extremities;
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes, showed the following:
-On 2/28/18 at 1:56 P.M., the resident was being toileted after the lunch meal via the Sit
to Stand lift. While being lifted two certified nurse aides (CNA’s) noticed the resident’s
clothes were saturated. CNA I left for the resident’s room just a few feet from the shower
room to obtain dry clothes. CNA H lowered the resident back down to his/her wheelchair
until CNA I returned. However, the resident slipped out to the right side from the Sit to
Stand and on to the floor. CNA H called for assistance and this nurse and the treatment
nurse went into the bathroom. CNA I arrived at the same time. The resident was assisted
and found no obvious injuries. Range of motion within normal limits for the resident. The
resident stated he/she hit his/her head on the small front wheel of the wheelchair. No
hematoma found during assessment. Will monitor for any bruising or complaint of pain or
discomfort for the next 3 days;
-On 3/5/2018 at 1:14 P.M., nurse obtained a physician order [REDACTED].
Review of the resident’s (MONTH) (YEAR) physician order [REDACTED].
Review of the resident’s care plan, updated 4/9/18, showed no documentation regarding the
resident’s fall on 2/28/18 or any new interventions. The care plan also failed to address
the change in the resident’s transfer status.
During an interview on 5/30/18 at 8:29 A.M., CNA B said it is the facility’s policy to
perform Sit to Stand lift transfers with two aides and that is how staff are trained.
During an interview on 6/1/18 at 7:27 A.M., CNA G and licensed practical nurse (LPN) A
said the resident always transfers using a Sit to Stand lift.
During an interview on 6/1/18 at 9:30 A.M., the administrator said she was aware of the
resident’s fall on 2/28/18 and it was due to staff not snapping the safety belt on the Sit
to Stand lift. The two aides who were involved in the bad transfer have been educated on
the facility’s policy to have two staff members for all mechanical lift transfers. The
administrator was not aware the facility’s policy did not specify how many staff were
needed for safe mechanical lift transfers. The administrator was unaware of the order to
transfer the resident using a Hoyer lift, but said staff should follow physician orders.
The resident’s fall and interventions should be added to the resident’s care plan.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, orders, monitoring and ongoing communication with the [MEDICAL TREATMENT]
center resulting in access site complications for one sampled resident (Resident #2) out
of 12 sampled residents and for one closed record (Resident #38). The census was 36.
Review of the facility’s [MEDICAL TREATMENT] Policy, dated 10/1/17, showed the following:
-Any resident required to have [MEDICAL TREATMENT] will be transported by a transportation
company to designated [MEDICAL TREATMENT] company as ordered;
-[MEDICAL TREATMENT] company will draw blood for lab values needed or request in writing
lab values to be drawn at facility;
-Any dressing applied will be assessed upon return and followed up as necessary.
Review of the facility’s undated Post [MEDICAL TREATMENT] Nursing Care Policy, showed the
following:
-Purpose: Rapid fluid and solute removal during [MEDICAL TREATMENT] may lead to
orthostatic [MEDICAL CONDITION], cardiopulmonary changes and weight loss;
-Daily weights in the morning;
-Assess and document vital signs and vascular access site condition.
1. Review of Resident #2’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/29/18, showed the following:
-An admission date of [DATE];
-Cognitively intact;
-[DIAGNOSES REDACTED].
-Frequent pain;
-Received [MEDICAL TREATMENT] prior to residing at the facility and while a resident at
the facility.
Review of the resident’s (MONTH) (YEAR) progress notes, showed the following:
-On 3/14/18 at 6:47 P.M., resident returned from [MEDICAL TREATMENT];
-On 3/21/18 at 6:00 P.M., resident returned from [MEDICAL TREATMENT];
-On 3/23/18 at 6:30 P.M., resident returned from [MEDICAL TREATMENT];
-On 3/24/18 at 6:24 A.M., this nurse was informed by the resident he/she has an extra day
of [MEDICAL TREATMENT] today. Contacted [MEDICAL TREATMENT] provided and confirmed an
11:00 A.M. chair time;
-On 3/26/18 at 7:45 P.M., resident returned from [MEDICAL TREATMENT];
-Staff did not to document they monitored or assessed the [MEDICAL TREATMENT] site upon
return from [MEDICAL TREATMENT] treatments.
Further review of the resident’s progress notes, showed the following:
-On 3/30/18 at 3:14 A.M., resident complained of nausea. Abdomen tender on palpitation.
Resident states pain in right jaw and shoulder. Resident’s physician notified;
-On 3/30/18 at 3:44 A.M., ambulance called to transport resident to the hospital;
-On 3/30/18 at 12:28 P.M., resident returned from hospital. No new orders, x-ray of chest
and shoulder completed with nothing noted. Nausea subsided. Resident returned in time to
go to [MEDICAL TREATMENT] this afternoon. Pain pill requested before [MEDICAL TREATMENT];
-On 3/31/18 at 9:30 P.M., resident returned from visiting family member and requested as
needed pain medication for shoulder and arm pain. Nurse assessed resident and noted
bruising from armpit to elbow area, appearing red and purple in color. Swelling visible to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
the area as well. Right breast appears grossly enlarged and hard and tender to the touch.
Resident had [MEDICAL TREATMENT] yesterday and was sent to the hospital for similar
complaint of right shoulder/arm pain, however swelling was not present at that time. A
chest and shoulder x-ray were completed at the hospital with negative results. Resident
reported changes occurred while out with family today. Nurse recommended for resident to
go to the hospital;
-On 3/31/18 at 10:00 P.M., ambulance arrived to transport resident to the hospital;
-On 4/1/18 at 3:45 A.M., resident returned from hospital. Areas of concern remain
unchanged, still appear swollen, hard and tender to touch, and bruising still visible.
Resident continues to complain of severe pain to these areas;
-On 4/1/18 at 6:23 A.M., resident complains of pain in right arm and breast when getting
up this morning. Unable to give as needed pain medication due to not time, Tylenol given;
-On 4/1/18 at 4:46 P.M., resident complained of pain. Cannot lift his/her right arm. Right
hand is swollen, right abdomen and side swollen and hard to touch and runs all the way up
into clavicle area. Resident very uncomfortable. Spoke with family member who expressed
unhappiness with the treatment the resident received at the hospital last night. Agreed to
send resident to a different hospital for evaluation. Resident’s port (device implanted
under the skin to deliver medication and treatments) is in right arm;
-On 4/1/18 at 6:00 P.M., ambulance arrived to transport resident to hospital;
-On 4/2/18 at 12:54 A.M., spoke with emergency room nurse, who informed this nurse the
resident would be kept overnight for observation. As of right now, they believe [MEDICAL
CONDITION] (an excess of watery fluid collecting in the cavities or tissues of the body),
pain, and bruising is from a [MEDICAL TREATMENT] bleed;
-On 4/3/18 at 5:39 P.M., resident’s primary physician made aware of discharge Diagnosis:
[REDACTED].
-Staff did not document the resident’s return from the hospital and interventions put in
place to monitor and assess the site of the fistula to prevent future complications.
Further review of the resident’s progress notes, showed the following:
-On 4/5/18 at 4:57 P.M., resident continued to have swelling in right arm and breast.
Elevated arm and placed ice on arm. Resident went to [MEDICAL TREATMENT] yesterday and was
sent back due to arm pain. He/She went back to [MEDICAL TREATMENT] today. Resident given a
pain pill;
-On 4/8/18 at 6:44 A.M., resident feeling nauseated and complained of pain all over but
mostly in the area of right shoulder and breast area. [MEDICATION NAME] (medication used
to alleviate nausea and vomiting) given for nausea and will wait 30 minutes and give
[MEDICATION NAME] for pain as requested;
-On 4/8/18 at 3:26 P.M., resident continued to feel worse as the day went by today. Vital
signs taken. Swelling to right shoulder, breast, arm and hand has worsened during the day.
Resident complained of right arm and shoulder pain. Resident stated desire to go to the
hospital but is afraid they won’t do anything for him/her;
-On 4/8/18 at 10:00 P.M., received report from emergency room nurse. The resident is
returning with no new orders, and per report, resident had CT (Computed Tomography scan
allows doctors to see inside the body) of chest with angiogram (an X-ray photograph of
blood or lymph vessels) and no leakage noted and no change since last hospital visit. It
will just take time for [MEDICAL CONDITION] and bruising to heal;
-On 4/9/18 at 6:40 P.M., resident returned from [MEDICAL TREATMENT], is in dining room
eating dinner at this time;
-On 4/11/18 at 6:37 P.M., resident returned from [MEDICAL TREATMENT] and eating and
visiting with family;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
-On 4/12/18 at 1:51 P.M., resident’s physician notified resident requested something to
decrease swelling to right breast. Ice pack for 20 minutes maximum three times a day.
Review of the resident’s care plan, last reviewed on 5/3/18 and in use during the survey,
showed staff failed to address the resident’s dependence on [MEDICAL TREATMENT] as well as
staff’s role in monitoring and caring for the access site.
Review of the resident’s (MONTH) (YEAR) POS, showed no orders for [MEDICAL TREATMENT]
treatment or monitoring and assessment of the site.
During an interview on 5/30/18 at 9:47 A.M., the resident said he/she goes to [MEDICAL
TREATMENT] on Mondays, Wednesdays and Fridays in the afternoons. Staff do not check
his/her fistula site when he/she returns from [MEDICAL TREATMENT]. The staff at the
[MEDICAL TREATMENT] center check it before he/she leaves. The site often hurts after
[MEDICAL TREATMENT].
During an interview on 5/30/18 at 10:52 A.M., the Director of Nursing (DON) said all
communication with the resident’s [MEDICAL TREATMENT] provider is documented in the
resident’s progress notes.
During an interview on 5/30/18 at 11:33 A.M., the administrator said they do not have a
[MEDICAL TREATMENT] contract with the resident’s [MEDICAL TREATMENT] provider. This is new
territory for them and they have had only one other resident on [MEDICAL TREATMENT]. The
administrator asked if she needed a contract.
During an interview on 5/31/18 at 6:52 A.M., licensed practical nurse (LPN) A said he/she
received training on [MEDICAL TREATMENT] patients, but not at the facility. The resident
goes out in the afternoons and returns in evening, so he/she is not here when the resident
returns, but he/she believes the evening nurse checks the resident’s dressing when he/she
returns.
During an interview on 6/1/18 at 9:30 A.M., the administrator said physician orders
[REDACTED]. There should also be an order for [REDACTED]. Regarding the resident’s
hemorrhage of the AV fistula on 4/1/18, the administrator would expect the hospital to
give instructions on how to care for the site to keep the nurse from thinking for
themselves.
During an interview on 5/31/18 at 9:40 A.M., the administrator said she would expect the
charge nurse to assess the site when the resident returns, but they only document the
resident returned. They do not have a policy for assessment. She does not believe nursing
staff received any [MEDICAL TREATMENT] education because she would expect nurses to know
what to do.
2. Review of Resident #38’s quarterly MDS, dated [DATE], showed:
-admitted on [DATE];
-Cognitively intact;
-Received [MEDICAL TREATMENT] while a resident;
-Diagnoses: [REDACTED].
Review of the resident’s undated care plan, showed no [MEDICAL TREATMENT] care needs, no
[MEDICAL TREATMENT] provider, no dates or times for [MEDICAL TREATMENT].
Review of the resident’s POS and Treatment Administration Record (TAR), dated 2/1/18
through 3/1/18, showed no orders for [MEDICAL TREATMENT], [MEDICAL TREATMENT] after care
or [MEDICAL TREATMENT] treatment orders.
Review of the resident’s progress notes, showed:
-On 2/10/18 at 4:20 P.M., the resident refused to go to [MEDICAL TREATMENT] today, staff
provided education on the importance of [MEDICAL TREATMENT];
-On 2/17/18 at 5:32 A.M., the resident picked up by transportation for [MEDICAL
TREATMENT];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-On 2/20/18 at 10:07 A.M., [MEDICAL TREATMENT] nurse called and said the [MEDICAL
TREATMENT] physician was going to treat the resident for [MEDICAL CONDITION] (bacterial
infection of the skin and tissues beneath the skin) in both of his/her legs;
-Staff did not document post [MEDICAL TREATMENT] assessments or care provided.
Review of the resident’s POS and TAR, dated 3/1/18 through 3/31/18, showed no orders for
[MEDICAL TREATMENT], [MEDICAL TREATMENT] after care or [MEDICAL TREATMENT] treatment
orders.
Further review of the resident’s progress notes, showed:
-On 3/1/18 at 6:31 A.M., the resident returned from [MEDICAL TREATMENT] with an antibiotic
for the [MEDICAL CONDITION];
-On 3/29/18 at 5:39 A.M., the resident left for [MEDICAL TREATMENT];
-On 3/29/18 at 12:37 P.M., the resident returned from [MEDICAL TREATMENT] with chest pain
and he/she said the [MEDICAL TREATMENT] staff provided medications to him/her. The
resident requested a pain pill and facility nurse provided ordered pain medications. The
resident went to his/her room;
-On 3/29/18 at 11:55 P.M., the resident was brought back to the nurses station by facility
staff and complained of chest pain. Ordered medication given with no relief. Vital signs
taken. 911 called due to no relief from chest pain;
-On 3/29/18 at 12:47 P.M., the [MEDICAL TREATMENT] nurse called the facility and informed
the facility charge nurse that the resident had experienced chest pain while at [MEDICAL
TREATMENT] earlier in the day. [MEDICAL TREATMENT] staff provided medication and
encouraged the resident to go to the emergency room and the resident had refused;
-On 3/29/18 at 4:37 P.M., call placed to the hospital. The hospital charge nurse said the
resident had been admitted for evaluation and treatment.
During an interview on 6/1/18 at 9:30 A.M., the Director of Nursing (DON) said she
expected staff to assess and monitor the resident after returning from [MEDICAL TREATMENT]
treatments. The facility does not often have residents that require [MEDICAL TREATMENT]
and caring for [MEDICAL TREATMENT] resident is new to the facility. No inservices had been
given to facility nurses regarding care for [MEDICAL TREATMENT] residents. The [MEDICAL
TREATMENT] center should provide report after the resident receives the treatment. She did
not know if the facility staff had regular communication with the [MEDICAL TREATMENT]
center regarding post [MEDICAL TREATMENT] care.

F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident’s drug regimen must be free from unnecessary drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to implement non-pharmacological
interventions prior to administering and adequately monitor and document the use of an
anti-anxiety medication for behavior modification. Furthermore, the facility failed to
administer medications in a manner to allow the resident to knowingly refuse and to obtain
appropriate [DIAGNOSES REDACTED].#15) out of 12 sampled residents. The facility census was
36.
1. Review of the facility’s Working with Confused and Combative Residents policy, dated
[DATE], showed the following:
-If a resident is combative, look for a pattern to the behavior (hunger, cold, hot, left
alone, after meals, etc.);
-If a resident resists care, assess and try to understand the cause;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-If a resident becomes verbally aggressive, realize these are signs they are losing
impulse control. Anything that causes stress can bring on this behavior;
-If you notice a violent episode coming, try to distract with an activity, music, etc.;
-If a resident starts a fight, recognize fighting happens most often when a resident feels
his or her personal space or possessions are threatened;
-An outburst of crying, anger or fighting is a sudden response to feeling overwhelmed. It
occurs most often in the morning, when daily care activity is at its peak;
-Combative episodes are made worse when you try to restrain the resident in order to
finish any type of care. Give the resident time to calm down and then come back.
Review of the facility’s undated [MEDICAL CONDITION] Medication Policy (any drug capable
of affecting the mind, emotions, and behavior), showed the following:
-Physicians and mid-level providers will use [MEDICAL CONDITION] medications appropriately
working with the interdisciplinary team to ensure appropriate use, evaluation and
monitoring;
-Standards:
-The facility will make every effort to comply with state and federal regulations related
to the use of psychopharmacological medications in the long term care facility to include
regular review for continued need, appropriate dosage, side effects, risks and/or
benefits;
-The facility supports the goal of determining the underlying cause of behavioral
symptoms so the appropriate treatment of [REDACTED].
-Psychopharmacological medications will never be used for the purpose of discipline or
convenience;
-[MEDICAL CONDITION] medications include anti-anxiety, antipsychotic (a class of
medication primarily used to manage [MEDICAL CONDITION], principally in [MEDICAL
CONDITION] and [MEDICAL CONDITION] disorder) and antidepressant classes of drugs
2. Review of Resident #15’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-admitted on [DATE];
-Severe cognitive impairment with disorganized thinking;
-No behaviors noted during seven day assessment period;
-No alarms used;
-Required extensive assistance from staff for transfers, limited assistance for eating,
hygiene and dressing and independent for propelling wheelchair throughout facility;
-[DIAGNOSES REDACTED].
-No falls since last review;
-Received antipsychotic medications for four of seven days assessed;
-Received antidepressant medications (used to treat [MEDICAL CONDITION], mood disorders)
for one of seven days assessed;
-Received hospice care;
-Did not receive psychological services.
Review of the resident’s care plan, last revised [DATE] and in use during the survey,
showed the following:
-Problem: Psychosocial well-being. Resident has little interest in group activities or
socializing with other residents;
-Goal: Resident will have preferences honored;
-Approach: Staff will socialize with resident daily to ensure she is happy and treated
with respect;
-Problem: Behavioral symptoms. Resident has been verbally aggressive and playing tricks on
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
his/her roommate;
-Goal: Resident will treat others with respect;
-Approaches: Staff should explain all procedures before attempting to aid resident and
obtain his/her preference. Inform resident when it is his/her shower day to determine if
he/she is willing to shower that day;
-The facility failed to individualized interventions to implement when resident displays
behaviors;
-The facility failed to include the use of a anti-anxiety for behavior modification;
-Problem: [MEDICAL CONDITION] drug use (a chemical substance that changes brain function
and results in alterations in perception, mood, consciousness, cognition, or behavior).
Resident requires antipsychotic and antidepressant to stabilize mood;
-Goal: Resident will be free of adverse effects (falls, poor appetite, decreased
cognition);
-Approaches: Resident will have behaviors documented every shift, will be followed by a
psychiatrist monthly, encourage resident to lay down at 10:00 P.M., request topical
medications to be rubbed into skin as needed related to non-compliance with oral
medications;
-The care plan contained nine staff signatures, but did not contain the resident’s or
resident representative’s signature.
Review of the resident’s psychiatric note, dated [DATE], showed the following:
-Resident has dementia and anxiety and seen for routine care;
-No agitation or evidence of [MEDICAL CONDITION];
-Oral medications were discharged due to non-compliance;
-Resident has become increasingly more agitated;
-Now has as needed (PRN) medications of [MEDICATION NAME] (anti-anxiety) and [MEDICATION
NAME] (anti-psychotic), but once his/her behavior escalates it is difficult to help keep
him/her calm even with PRN’s;
-Plan: Start [MEDICATION NAME] rub routinely, 25 mg at night and titrate as needed.
Review of the resident’s (MONTH) (YEAR) physician order [REDACTED].
-An order, dated [DATE], for [MEDICATION NAME] solution, two milligram per milliliter
(mg/ml), give 0.5 mg injection every six hours as needed for anxiety;
-An order, dated [DATE], to admit the resident to hospice due to [MEDICAL CONDITION];
-An order, dated [DATE] through [DATE], for [MEDICATION NAME] rub 100%, give 0.5 mg
topical, every 12 hours as needed for unspecified dementia with behavioral disturbance;
-An order, dated [DATE] through [DATE], for [MEDICATION NAME] cream, 25 mg per syringe.
Apply [MEDICATION NAME] rub to back of knees or back of shoulders at bedtime for
impulsiveness;
-An order, dated [DATE]/18, for [MEDICATION NAME] (antipsychotic), give 0.5 mg tablet one
time for unspecified dementia with behavioral disturbance.
-An order, dated [DATE], for [MEDICATION NAME] cream, 25 mg per syringe. Apply rub to back
of knees or back of shoulders twice a day for impulsiveness;
Review of the resident’s medical record for (MONTH) (YEAR), showed the following:
-On [DATE]:
-At 9:12 P.M., the Medication Administration Record [REDACTED]
– A nurse’s note at 9:30 P.M., showed [MEDICATION NAME] rub given for excessive wandering
and attempts to push fire door open;
-On [DATE]:
-At 3:15 P.M., a MAR indicated [REDACTED]
-No nurse’s note regarding incident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
-On [DATE]:
-At 1:10 A.M., a MAR indicated [REDACTED]
-A nurse’s note at 2:03 P.M., showed resident toileted and had been fine with no signs of
behavior when he/she bit one certified nurse aide (CNA) on the arm and breast and
scratched the left arm, bringing blood, and punched the other CNA in the face. The nurse
documented that no PRN medications help the resident’s behaviors. He/she documented that
PRN [MEDICATION NAME] had been discontinued, PRN [MEDICATION NAME] rub was changed to
every 12 hours and does not phase the resident when behaviors are present and the
[MEDICATION NAME] injection is too much and invasive. Will pass on to hospice so they
might make some medication changes;
-On [DATE]:
-At 10:51 A.M., a MAR indicated [REDACTED]
-No nurse’s note regarding incident;
-On [DATE]:
-A nurse’s note at 12:30 P.M., showed resident cleared the dining room table by throwing
iced tea and coffee on nursing staff breaking the coffee cup. Resident brought down to the
nurse’s station and as the social worker spoke to the resident, he/she smacked the social
worker in the mouth and bloodied her lip. Nursing staff contacted the primary physician
and asked if the resident could be sent to the hospital. The physician said the hospital
would not keep the resident and would send him/her right back. A nurse contacted the
family member and advised the resident needs a lock down facility. The ambulance was
contacted to transport the resident to the hospital for psychiatric evaluation;
-At 2:23 P.M., a MAR indicated [REDACTED]
On [DATE]:
-At 6:34 A.M., a MAR indicated [REDACTED]
-Staff did not document any non-pharmacological interventions attempted prior to
administering the PRN or what issue necessitated the use of the PRN;
-An administrator’s note at 9:10 A.M., showed she spoke to resident’s family member
concerning the resident staying at the facility. The family member was happy because a
different facility did not have an opening. The administrator explained taking away
[MEDICAL CONDITION] medications which the residents needs is the biggest problem and the
resident’s physician would be notified and the issue would be rectified;
-An administrator’s note at 10:23 A.M., showed she spoke to the primary physician about
the resident and his/her behaviors as a result of not being medicated routinely. The
administrator requested [MEDICATION NAME] rub to be done twice daily. The physician asked
why not use the oral form. The administrator explained the resident refused the oral
medications secondary to delusions. The physician agreed to order the [MEDICATION NAME]
cream with applicator; 25 mg; amount: 1 syringe. Apply [MEDICATION NAME] rub to back of
knees or back of shoulders twice a day;
-At 10:26 A.M., a MAR indicated [REDACTED]
-Staff did not document any non-pharmacological interventions attempted prior to
administering the PRN or what issue necessitated the use of the PRN;
On [DATE]:
-At 4:55 A.M., a MAR indicated [REDACTED]
-A nurse’s note at 4:56 A.M., showed resident’s bed alarm sounded this morning three
times. Resident attempted to get out of bed. While transferring the resident to his/her
wheelchair, the resident bit a CNA on the arm leaving a red, swollen area. Resident then
began hitting the nurse. Behaviors continued to escalate. [MEDICATION NAME] injection
administered as resident is unsafe to self and staff. Will continue to monitor behaviors;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-Review of the MAR indicated [REDACTED]
-Staff did not document any non-pharmacological interventions attempted prior to
administering the PRN;
-A nurse’s note at 5:06 A.M., showed resident obtained a skin tear to his/her left hand
as a result of combative/aggressive behaviors during a transfer;
-A nurse’s note at 5:09 A.M., showed resident roaming around hallways in his/her
wheelchair going into other resident’s rooms. Redirection attempted several times, but
unsuccessful;
-At 8:30 A.M., a MAR indicated [REDACTED]
-Staff did not document reason PRN [MEDICATION NAME] given, results or specific
interventions attempted;
-A nurse’s note at 8:56 A.M., showed resident roaming hallways. While in the dining room
the resident threw a cup of coffee across the room. PRN [MEDICATION NAME] rub given by
this nurse. Resident given another cup of coffee and threw that as well. Resident roamed
through the dining room and shoved into other residents. Administrator and physician
notified. New order for one time dose of [MEDICATION NAME] 0.5 mg. Nurse with two other
staff had to assist to keep resident from biting and hitting while giving medication. Will
monitor behaviors;
-Staff did not document the administration of the PRN [MEDICATION NAME] rub on the MAR;
-On [DATE]:
-A nurse’s note at 7:15 P.M., showed resident threw a cup of fluid at a visitor in the
dining room. Resident removed from the dining room and given PRN [MEDICATION NAME]
injection due to escalating behaviors. While administering the injection the resident
attempted to hit and bite staff. Resident began wandering the hallways, going in to other
resident’s rooms. A hall tray was offered and the resident threw it across the room. The
resident was removed from the lounge area and taken to his/her room due to continued
aggressive and combative behaviors. PRN [MEDICATION NAME] rub was applied;
-Staff did not document the administration of the PRN [MEDICATION NAME] injection or rub
on the MAR;
-Staff did not document any non-pharmacological interventions attempted prior to
administering the PRN’s.
Review of the resident’s (MONTH) (YEAR) POS, showed the following:
-An order, dated [DATE] through [DATE], for [MEDICATION NAME] solution; 2 mg/ml, give 0.5
mg injection for anxiety every six hours PRN;
-An order, dated [DATE] thorough [DATE], for [MEDICATION NAME] solution; 2 mg/ml, give 0.5
mg injection for anxiety every six hours PRN;
-An order, dated [DATE] through [DATE], for [MEDICATION NAME] rub 100%, give 0.5 mg
syringe for unspecified dementia with behavioral disturbance every four hours PRN;
-An order, dated [DATE] for [MEDICATION NAME] cream with applicator; 25 mg, give one
syringe to back of knees or back of shoulders for impulsiveness twice a day;
-An order, dated [DATE] through [DATE], for [MEDICATION NAME] tablet, 0.5 mg, crush one
tablet with water and give with syringe for anxiety twice a day;
-An order, dated [DATE], for [MEDICATION NAME] m-tab, (disintegrating tablet) 0.5 mg, give
one tablet for major [MEDICAL CONDITION] two times a day.
Further review of the resident’s medical record, showed the following:
-On [DATE] at 10:48 A.M., a MAR indicated [REDACTED]
-Staff failed to document any attempted non-pharmacological interventions attempted prior
or reason for administration;
-On [DATE]:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-At 2:37 P.M., a MAR indicated [REDACTED]
-A nurse’s note, at 2:38 P.M., showed resident started to show anxiety and
aggressiveness. PRN [MEDICATION NAME] rub given. Resident became very agitated with
another resident by grabbing the other resident’s walker hitting him/her with it. The
nurse tried to pull the resident back and the resident slid off his/her wheelchair cushion
because he/she was still holding onto the walker. Resident sat on floor with no injuries.
Three nursing staff assisted resident off the floor. The resident became combative and hit
one staff member in the face and tried to bite another staff member. Resident given
[MEDICATION NAME] injection. Will continue to monitor behaviors;
-Review of the MAR, showed no order for PRN [MEDICATION NAME] injection;
-Staff did not document administration of the [MEDICATION NAME] injection or any
non-pharmacological interventions attempted prior to administering the PRN medication;
-A late entry nurse’s note at 10:00 P.M., showed resident beginning to show
combative/aggressive behaviors. Attempted to bite and hit staff members. [MEDICATION NAME]
rub administered earlier this evening but has not seemed effective. Resident’s behaviors
tend to escalate quickly, where the resident is a danger to both himself/herself and
others. PRN [MEDICATION NAME] injection administered at 10:30 P.M. and resident assisted
to bed;
-Staff did not document administration of the [MEDICATION NAME] injection or any
non-pharmacological interventions attempted prior to administering the PRN medication;
-A late entry nurse’s note at 11:00 P.M., showed resident attempted to get out of bed.
Staff assisted resident to wheelchair. Resident roaming hallways;
-A late entry nurse’s note at 11:45 P.M., showed resident found on floor in middle of
hallway yelling I’m on the floor, I’m on the floor. Nurse observed resident bleeding from
an area on his/her head. Resident assisted back into wheelchair and staff observed a
laceration to the right eyebrow which measured 2.5 centimeter in length. Resident
currently dozing off, unable to really stay awake, not really responding to verbal
stimuli, mumbling at times, but unable to communicate to nurse. Resident will be sent to
emergency room for evaluation;
-On [DATE] at 1:46 A.M., a nurse’s note, showed resident broke his/her glasses at the time
of the fall;
-On [DATE]:
-At 12:45 P.M., a MAR indicated [REDACTED]
-Staff did not document the reason for the administration of the [MEDICATION NAME]
injection or any non-pharmacological interventions attempted prior to administering the
PRN medication;
-On [DATE] at 7:51 A.M., a nurse’s note showed a nurse mixed resident’s [MEDICATION NAME]
with apple sauce and gave between bites at breakfast. Resident took the medication with no
complications. Resident has bruising surrounding his/her right eyebrow with laceration;
-On [DATE] at 11:30 A.M., an administrator’s note showed the resident was seen by nurse
practitioner. Staff discussed trouble getting medications in resident’s mouth. Changed
[MEDICATION NAME] tablet to the m-tab to ensure it dissolves;
-On [DATE] at 10:11 P.M., a nurse’s note showed the resident was combative and aggressive
when staff attempted to change clothes and assist to bed. Staff explained they wanted to
get resident into clean, dry clothes. Resident appeared tired and did not look like he/she
needed a PRN at this time;
-On [DATE]:
-At 7:14 P.M., a nurse’s note showed the resident very aggressive this evening.
Attempting to elope, wandering into other resident’s rooms, name calling and physically
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
aggressive with other residents. PRN [MEDICATION NAME] rub given with only mild
effectiveness;
-Review of the MAR, showed staff did not document administration of the [MEDICATION NAME]
injection or any non-pharmacological interventions attempted prior to administering the
PRN medication.
Review of the resident’s psychiatric note, dated [DATE], showed the following:
-Resident has dementia, agitation and anxiety and seen for routine care;
-Since resident was last seen, [MEDICATION NAME] m-tab has been started;
-According to staff, resident is mostly compliant with medications and his/her behaviors
are generally improved;
-Plan: Generally stable, remains on hospice, no changes to medications.
Further review of the resident’s medical record, showed the following:
-On [DATE]:
-At 9:52 P.M., a certified medication technician (CMT) note. Gave [MEDICATION NAME] at
11:00 P.M. after charting not given due to condition. Resident awoke presenting behaviors
-A late entry nurse’s note at 11:00 P.M. Resident has been extremely agitated this shift.
Attempted to bite staff and did hit staff several times while providing care. Snack was
given, which resident threw across the room along with anything else in arm’s reach. PRN
[MEDICATION NAME] injection administered to left deltoid for continued escalating
behaviors;
-Staff failed document administration of the [MEDICATION NAME] injection or any
non-pharmacological interventions attempted prior to administering the PRN medication.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Physical behaviors one to three days of seven day assessment;
-Verbal behaviors one to three days of seven day assessment;
-Bed alarm and chair alarm used seven of seven days assessed;
-Received antipsychotic medications for seven of seven days assessed;
-Received antianxiety medication for two of seven days assessed;
-Received psychosocial therapy zero of seven days assessed.
Further review of the resident’s medical record, showed the following:
-On [DATE] at 9:30 P.M., a nurse’s note, showed resident observed to be tearful;
-On [DATE]:
-At 1:05 A.M., a MAR indicated [REDACTED]
-Staff failed to document administration of the [MEDICATION NAME] rub or any
non-pharmacological interventions attempted prior to administering the PRN medication;
-At 3:19 A.M., a nurse’s note. Resident tearful at times;
-On [DATE]:
-At 2:21 A.M., a nurse’s note. Resident combative and aggressive during care. PRN
[MEDICATION NAME] injection administered to right deltoid. Prior to behavior, resident was
offered to be toileted and refused. Resident requested a snack and then threw it on the
floor;
-Staff failed to document administration of the [MEDICATION NAME] injection or any
non-pharmacological interventions attempted prior to administering the PRN medication.
During an interview on [DATE] at 6:58 A.M., CNA F said he/she is newer and has not had
dementia training here. Usually two to three aides work with the resident because he/she
can hit and bite and it’s better to have more eyes. CNA F has not really dealt with the
resident when he/she gets really combative. The resident has been calm over the last few
days except for when he/she spilled his/her shake on himself/herself and then fought with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
staff when they tried to clean him/her up. CNA F is unsure of what interventions are in
place when the resident’s behaviors escalate. Staff just do what they can and then tell
the nurse and let them handle it.
During an interview on [DATE] at 9:30 A.M., LPN A said to his/her knowledge, no one has
tried to determine behavioral triggers for resident. The resident, at times, can be up for
two days and then sleep for a day. You can tell when the resident is starting to escalate.
LPN A will try to redirect with snacks, coffee and talking about family members. Nurses
document behaviors on a flow sheet in the resident’s medical record. He/she has done
better recently. He/she doesn’t like to take oral medications, so staff will try to give
[MEDICATION NAME] behind his/her knee as quickly as possible if redirection doesn’t work.
During an interview on [DATE] at 6:59 A.M., CNA G said he/she has not received any
dementia or behavioral training since he/she started working at the facility. When the
resident is escalating, CNA G tries to talk to the resident about whatever the resident is
talking about. He/she will then leave the room and come back later. They always have two
to three aides working with the resident because he/she can be so combative.
During an interview on [DATE] at 9:30 A.M., the administrator said according to the state,
a resident has the right to refuse medications. The resident is on antipsychotic
medications because he/she will beat you up if he/she isn’t. The resident is a danger to
self and others. The resident’s behaviors increased when he/she stopped taking his/her
heart medications and went on hospice. Often what triggers the resident’s behaviors is
staff trying to do something the resident does not want to do and he/she will just have an
outburst. It usually starts verbally. Staff should update the care plan to show
interventions known to work. Staff should attempt interventions prior to administering a
PRN and document effectiveness. It is up to the physician to determine the appropriate
[DIAGNOSES REDACTED].

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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, facility staff failed to ensure a
medication error rate of less than 5%. Out of 34 opportunities for error, 2 errors
occurred resulting in a 5.88 % medication error rate (Resident #22). The census was 36.
Review of the facility’s undated Medications, Administering and Storage Policy, showed the
following:
-Designated staff member will store and give medications only as ordered by the physician.
If the staff member believes the order will cause harm, they are to call the Director of
Nursing (DON). If the DON agrees he/she will call the Medical Director to discuss the
order;
-For Administering Eye Drops;
-Wash hands and apply latex gloves;
-Use baby shampoo (ratio 1:10 with water) to remove eye secretions from resident eyes;
-Verify which eye is to receive the medication;
-Have resident close eye for one to two minutes;
-Wait five minutes between different eye medications;
-Discard eye drops if the tip of the bottle touches the eye as it is now contaminated;
-Nebulizer administration not addressed.
1. Review of Resident #31’s annual Minimum Data Set (MDS), a federally mandated assessment

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 – Few

(continued… from page 20)
instrument completed by facility staff, dated 4/9/18, showed a [DIAGNOSES REDACTED].
Review of the physician’s orders [REDACTED].
-An order, dated 1/30/17, to administer [MEDICATION NAME] (used to treat eye pressure
caused by [MEDICAL CONDITION]) eye drops, one drop to each eye once a day;
-An order, dated 10/21/17, to administer [MEDICATION NAME] (a medication used to open the
lung airways) nebulizer (breathed in through the lungs) four times a day and RINSE MOUTH
AFTER EACH USE.
Observation on 5/30/18 at 11:40 A.M., showed Certified Medication Technician (CMT) C
administered one drop of [MEDICATION NAME] to each eye. He/she held the inner canthus of
each eye for 10 seconds. He/she then started the [MEDICATION NAME] nebulizer and left the
room. Approximately 10-15 minutes later he/she returned to the room to remove the
nebulizer, and but the resident had been taken to lunch. CMT C did not take the resident
back to the room to rinse his/her mouth.
During an interview on 5/31/18 at 10:20 A.M., CMT C said it is important to hold the inner
canthus of the eye for about 10 seconds after administering an eye drop and the resident
should always rinse his/her mouth after a nebulizer treatment to prevent mouth irritation.
During an interview on 5/31/18 at 1:00 P.M., the DON said it is important to hold the
inner canthus for one minute after an eye drop and to have the resident rinse his/her
mouth after a nebulizer treatment. If the resident left the room, it is the med passers
responsibility to return the resident to his/her room to rinse his/her mouth to prevent
any oral irritation.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview and record review, facility dietary staff failed to use
good handwashing techniques, properly store perishable food and failed to serve water
glasses during a meal service in a hygienic manner. The census was 36.
1. Observation of the dinner preparation on 5/29/18, showed the following:
-At 4:12 P.M., Cook K used his/her bare hands to place frozen fries into the fryer;
-At 4:15 P.M., Dietary Aide (DA) J cut lettuce with gloved hands. He/she then retrieved a
pan and placed on the counter. He/she then removed a container of sliced tomatoes from the
reach in cooler and placed on the counter. DA J walked across the kitchen and pulled a
cart to the counter and placed the pan on it. Without washing his/her hands or changing
gloves, DA J removed slices of bread from the bag and placed in the pan with his/her
gloved hands. He/she then proceeded to make bacon, lettuce and tomato (BLT) sandwiches
using his/her hands and did not wash his/her hands or change gloves. DA J made over 12 BLT
sandwiches;
-At 4:21 P.M., Cook K used his/her bare hands to assemble three BLT sandwiches and then
placed the sandwiches in the blender to be pureed;
-At 4:27 P.M., with bare hands, DA J picked up lettuce and bread off floor and threw it
away. He/she then retrieved a large piece of foil and covered the pan of BLT sandwiches
without washing his/her hands.
During an interview at 4:45 P.M., Cook K said every time he/she touches something, he/she
needs to wash his/her hands. He/she should only handle food with gloved hands.
2. Observation of the lunch preparation on 5/30/18, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 21)
-At 12:18 P.M., with gloved hands, the dietary manager (DM) removed a bowl from the reach
in freezer, unwrapped it and placed the bowl on a plate. The DM removed her gloves and
pulled a new pair of gloves from a pocket in her apron and donned them. She then used her
gloved hands to place slices of bread on plates that were served to residents;
-At 12:24 P.M., with gloved hands, the DM opened the reach in cooler door and removed two
small bowls of salad and two bottles of salad dressing. She then removed her gloves and
put on new gloves, which she obtained from the pocket in her apron. She then used her
gloved hands to place slices of bread on plates over 10 times.
During an interview on 5/31/18 at approximately 11:00 A.M., the DM said at a minimum,
staff should use sanitizer to sanitize hands between glove changes. Food should not be
touched with bare hands.
3. Observation of the kitchen on 5/29/18 at 4:30 P.M., 5/30/18 at 11:54 A.M., and 5/31/18
at 11:15 A.M., showed a half gallon plastic container labeled butter and dated 5/27/18
sitting on a counter ledge and at room temperature.
Further observation on 5/30/18, showed the following:
-At 12:00 P.M., Housekeeper L used a butter knife and removed butter from the plastic
container on the ledge and placed in a pan with two grilled cheese sandwiches;
-At 12:02 P.M., Housekeeper L added more butter to the pan from the plastic container.
Review of the packaged blocks of butter in the walk in cooler on 5/30/18 at 12:12 P.M.,
showed the following, Perishable keep refrigerated.
During an interview on 5/31/18 at approximately 11:00 A.M., the DM verified the container
on the ledge was butter. Upon reviewing the instructions on the butter package, she agreed
if it says to keep refrigerated, then it should be.
4. Observation and interview on 5/29/18, showed:
-At 11:34 A.M., dietary aide (DA) J pushed a cart from the kitchen that contained multiple
water glasses. He/she used his/her ungloved hands and grabbed the water glasses by the rim
and placed the water glasses on the tables in front of the residents. The residents drank
from the glasses.
-At 11:45 A.M., DA J pushed various residents into the dining room and did not wash or
sanitize his/her hands. He/she passed 22 water glasses out by grabbing the water glass
rims. He/she said he/she should have worn gloves to pass out food or drink to the
residents. He/she did not wash his/her hands before leaving the kitchen with the water
glasses. He/she filled the water glasses in the kitchen and then patted his/her hands dry
with a towel. If staff assist residents to move, staff should wash their hands between
tasks.
During an interview on 6/1/18 at 9:30 A.M., the administrator said staff should never
touch rims or edges of glasses with ungloved hands. Staff should serve food and drinks
with gloves hands. Touching surfaces with ungloved hands could spread infections to
residents.

F 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Conduct and document a facility-wide assessment to determine what resources are
necessary to care for residents competently during both day-to-day operations and
emergencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to conduct and document a
facility-wide assessment to determine what resources are necessary to care for its

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 22)
residents competently during both day-to-day operations and emergencies as required. The
facility census was 36.
1. Review of the facility’s Resident Census and Condition of Residents form, dated
5/29/18, showed a census of 36 and the following resident characteristics:
-Alzheimer’s/Dementia: 15;
-Documented signs and symptoms of depression: 13;
-Documented psychiatric diagnosis (exclude dementia and depression): 16;
-Behavioral healthcare needs: 9;
-On psychoactive medication: 27;
-On a pain management program: 20;
-[MEDICAL TREATMENT] treatment: 1.
During an interview on 5/30/18 at 8:45 A.M., the administrator said the facility
assessment is a maintenance issue. She did not need to complete one because the facility
is so small. The administrator knows what type of care they can and cannot provide.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide
appropriate infection control measures by failing to implement handwashing during perineal
care (peri care), failed to wear gloves to administer eye medication, failed to administer
admission purified protein derivative (PPD, skin test used to diagnose [MEDICAL
CONDITION]) testing, failed to assess and document PPD testing. This effected four of 12
sampled residents (Resident #19, #31, #138 and #188).The census was 37.
Review of the facility’s undated Hand Hygiene Policy, showed the following:
-Decontaminate hands before having direct contact with resident;
-Decontaminate hands after direct contact with a resident’s intact skin;
-Decontaminate hands after contact with body fluids or excretions, mucous membranes, non
intact skin and wound dressings;
-Decontaminate hands if moving from a contaminated body site to a clean body site during
resident care;
-Decontaminate hands after contact with inanimate objects in the immediate vicinity of the
resident;
-Decontaminate hands after removing gloves;
-After removing a soiled brief and before placing a clean brief on the resident.
1. Review of Resident #19’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/12/18, showed the following:
-No cognitive impairment;
-Dependent on staff for transfers and bed mobility;
-Continent of bowel and bladder.
Observation on 5/29/18 at 11:36 A.M., showed Certified Nurse Aides (CNA)’s D and E donned
gloves without washing their hands and with the use of a Hoyer (mechanical lift)
transferred the resident from the wheelchair into the bed. CNA E lowered the resident’s
urine dampened brief and placed a bedpan under him/her. The resident used the bedpan and
CNA E provided peri care. CNA E removed the bedpan from underneath the resident and passed
the bedpan to CNA D. CNA E applied a clean brief and pulled up the resident’s brief and
pants with the same gloves. CNA’s D and E used the same gloved hands and hooked the Hoyer

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 23)
pad to the sling and placed the resident into the wheelchair.
During an interview on 5/29/18 at 12:00 P.M., CNA E said staff hands should be cleaned and
gloves changed anytime they touch anything contaminated. Hands should be cleaned during
personal care and always before and after removing gloves.
During an interview on 6/1/18 at 9:30 A.M., the Director of Nursing (DON) said hands
should be washed before and after providing resident care and after touching body fluids
or anything contaminated.
2. Review of Resident #31 quarterly MDS, dated [DATE], showed a [DIAGNOSES REDACTED].
Review of the facility’s undated Medications, Administering and Storage Policy, showed the
following:
-For Administering Eye Drops;
-Wash hands and apply latex gloves;
Review of the physician’s orders [REDACTED].
Observation on 5/30/18 at 11:40 A.M., showed Certified Medication Technician (CMT) C
administered one drop of [MEDICATION NAME] to each eye. CMT C did not wash his/her hands
prior to the administration of the eye drops and did not wear gloves.
During an interview on 6/1/18 at 9:30 A.M., the DON said the employee’s hands should
always be cleansed before administering eye drops and he/she could not remember if staff
should wear gloves or not, but expected the staff to follow the facility’s policy.
3. Review of the facility’s undated PPD Policy for New Admissions, showed the following:
-All new admissions to facility must have a 2 step PPD unless they have a history of
exposure or allergy to the test. If allergy of test or history of exposure a chest x-ray
should be obtained to ensure no active disease;
-First step should be completed within 48 hours of admission, followed by step 2, 1-3
weeks later;
-Yearly assessment for PPD should be signs and symptoms observation.
Review of Resident #138’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s immunization record, showed the first step purified protein
derivative (PPD, determines if positive for [MEDICAL CONDITION]) administered on 4/30/18
and the second step administered on 5/3/18.
Further review of the resident’s medical record, showed the first and second step PPD’s
recorded as negative. Neither PPD testing showed a read date.
4. Review of Resident #188’s medical record, showed:
-admitted on [DATE];
-No admission two step PPD test administered.
5. During an interview on 6/1/18 at 9:30 A.M., the administrator said all new admission
residents should be administered the two step PPD. She could not locate the resident’s
admission two step PPD documentation. The first step admission PPD should be given the day
the resident enters the facility and then read three days later. A second administration
is given three weeks later for the second step and then read three days later. The
resident did not receive any of the PPD testing.
During an interview on 6/1/18 at 9:30 A.M., the administrator and DON said they were
unaware that their policy did not specify to record the date the PPD was read and said it
is best practice to note the date.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

26A490

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

06/01/2018

NAME OF PROVIDER OF SUPPLIER

FIESER NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

404 MAIN STREET
FENTON, MO 63026

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many