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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to provide the necessary
housekeeping and maintenance services to ensure a clean and sanitary environment. The
facility census was 109.
1. Review of the facility’s Admission Handbook, dated (MONTH) 2011, showed the following:
-Each resident has the right to a safe, clean, comfortable and homelike environment;
-Each resident has the right to housekeeping and maintenance services necessary to
maintain a sanitary, orderly and comfortable interior.
2. Observations and interviews on 9/19/19 and 9/20/18, during the Life Safety Code tour,
showed the following:
-In the 100 hall shower room, the metal door frame was marred with large areas of chipped
paint. The tiles on the wall just inside the door were broken and loose in the wall. Two
of the tiles near the floor had been pushed out of place creating a hole in the wall. In
the shower stall, the floor tiles were discolored. The grout in between the tiles on the
wall was brown and discolored. In the bay next the shower stall, the tiles along the floor
were chipped. The grout between the wall and floor and along the wall tiles next to the
floor was brown and discolored;
-In the janitor closet on the 300 hallway, the walls had a black mold-like substance on
them from the floor to the ceiling. The floor was dirty with a large accumulation of dirt
and debris and with chipped/missing tiles. The basin on the floor had speckles of black
debris throughout;
-In the soiled utility room on the 400 hall, the floor had a large accumulation of dirt
and debris. The floor and grout around the base of the hopper was brown and discolored.
The wall behind the hopper was damaged from water and was peeling. The cove base around
the room was soiled. The hopper bowl was heavily soiled;
-In the 400 shower room, the wall in the shower was yellowed and discolored. The grout in
the shower between the wall and the floor and between the floor tiles was brown and
discolored. The handheld shower head lay on the floor next to a soiled wet washcloth. The
wall tiles between the toilet and the shower were pulled away from the wall. The grout
around these tiles had a buildup of debris, and was brown and discolored. The tile and
grout around the base of the toilet was brown and discolored. The area around the bolt
securing the toilet to the floor was rusted and yellowed. A soiled wet washcloth lay on
the floor next to the toilet;
-In the 500 hall shower room, there was a black mold-like substance on the ceiling in the
corner of the room. The grout in between the tiles on the wall in this same area was brown
and discolored. The caulk around the floor drain in the shower area was discolored, and
the cover for the floor drain was missing. The grout along the top of the tiles around the
shower floor was discolored and turned to pinkish brown color. The maintenance supervisor
said the bathrooms, utility rooms and janitor’s closets should be in good repair;
-In unoccupied room [ROOM NUMBER], the drywall ceiling had large water stained areas that
contained a black mold-like substance;
-In unoccupied room [ROOM NUMBER], the floor under the sink area was missing multiple 12
inch by 12 floor tiles. The remaining floor tiles in this area were discolored. An area of
the wall under the sink plumbing was brown and discolored and had areas containing a black
mold-like substance. In the bathroom, there was an approximately 2.5 feet by 3 feet area
of water damaged drywall above the wall tiles. The surface of the wall was peeling and
contained areas of a black mold-like substance;

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-In unoccupied room [ROOM NUMBER], the floor around the toilet was soiled and discolored.
The wall to the right of the toilet, was heavily damaged and peeling. The floor under this
area of the wall contained a large area of a black mold-like substance. The floor tiles
under the sink plumbing were discolored. An approximately 4 inch by 12 inch area of these
tiles was covered in a black mold-like substance. The cove base also contained a large
area of black mold-like substance. The wall to the left of the sink was missing the wall
covering, was brown and had peeling drywall/drywall compound;
-In unoccupied room [ROOM NUMBER], the toilet had been removed from the room. The wall
behind and to the left of the toilet plumbing was damaged and peeling. The floor around
the base of the wall were discolored and contained a black mold-like substance;
-In unoccupied room [ROOM NUMBER], a large portion of the wall under the window was not
fully intact. The foam board insulation and drywall were broken and pulled away from the
wall. The cement block wall underneath was exposed. The exposed surfaces of the foam
insulation were covered with a black mold-like substance. The air conditioning unit did
not have a cover. The floor around the base of the wall had a heavy buildup of dirt and
debris;
-In unoccupied room [ROOM NUMBER], the wall, cove base, and flooring to the right of the
toilet had a large area of a black mold-like substance. The cove base was missing from the
corner of the wall and exposed heavily damaged drywall;
-In unoccupied room [ROOM NUMBER], an area of the wall under the sink had a black
mold-like substance;
-In unoccupied room [ROOM NUMBER], the wall within a 3 feet by 3 feet alcove was damaged.
The cove base had been removed exposing the wall behind it. There were holes in the
drywall and areas containing a black mold-like substance;
-The maintenance supervisor said the 200 hallway had been shut down for years, so repairs
have not been made in this area.
Observation of the nurse’s station area from 9/18/18 to 9/21/18 showed the outer wall that
surrounded the nurse’s station was marred and scuffed. The outer nurse’s station area was
scuffed and marred.
Observation of the 100 hall from 9/18/18 to 9/21/18 showed the following:
-The cove base along the wall was scuffed, loose and gaping away from the wall in various
areas;
-The vinyl wall covering on the lower portion of the wall was faded and stained;
-The hand rail between rooms [ROOM NUMBERS] had dried food splattered on it with tissue
wadded and shoved between the rail and the wall;
-Each door and door frame on the hall was scuffed and scratched with areas of missing
paint.
Observation of the 100 hall on 9/21/18 showed the hand rail outside room [ROOM NUMBER] was
missing the end cap leaving sharp edges exposed.
Observation of the 100 hall shower room on 9/18/18 to 9/21/18 showed the following:
-The caulk at the base of the toilet was missing in places and discolored;
-On 9/20/18 at 5:16 A.M., a soiled brief and towel lay on the floor, the room was
unoccupied;
-On 9/20/18 at 7:50 A.M., there was fecal matter in the toilet and on the floor.
During interview on 9/20/18 at 2:00 P.M., the members of the resident council said the
following:
-The shower room stinks;
-The shower room in not clean, and there are dirty linens on the floor.
Observation on 9/19/18 at 9:29 A.M., 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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-The hand rails on both sides of the 300 hall had multiple marred areas and missing paint;
-The door to room [ROOM NUMBER] had multiple areas of chipped paint;
-The door jams to resident rooms 301, 302, 303, 307, 308, 309 and 314 had multiple areas
of chipped paint;
-The doors to rooms 303, 304, 309 and 311 had multiple areas of chipped paint;
-The cross corridor doors on 300 hall had multiple areas of chipped paint at the bottom of
the doors and the door jams;
-The doors to rooms [ROOM NUMBERS] were marred.
Observation of the 400/500 hall rooms from 9/18/18 to 9/21/18 showed the following:
-In occupied room [ROOM NUMBER], the walls along the bathroom door, around the sink and on
a part of the trim along the wall were painted in a variety of mismatched colors including
a pale, beige color, cream color, and a pale mauve. The wall behind the bed closest to the
window was marred;
-In occupied room [ROOM NUMBER], the window blinds were bent and broken. The bedside table
closest to the door was marred and scratched along the top, the base of the chest against
the wall closest to the door was crumbling and deteriorating;
-In occupied room [ROOM NUMBER], the wall closest to the door was marred and the vent
cover along the wall had brown rust spots. The light cover over the second bed was
partially detached from the wall.
Observation on 9/20/18 at 7:37 A.M., showed fuzzy debris and dirt behind the cross
corridor doors at the beginning of C-hall.
3. Observations in the basement and interviews on 9/19/18 and 9/20/18, during the Life
Safety Code tour, showed the following:
-In the basement storage area to the east of the elevator, there was a large storage area
divided by walls that did not go to the ceiling. In the main storage area, there were
large shelves made of particle-type board which contained cardboard boxes of residents’
belongings. The shelves were damp and had expanded from moisture. The surfaces of the
shelves had a black mold-like substance throughout. The walls throughout the room also
contained a black, mold-like substance. The maintenance supervisor said the water and mold
in the basement had been a problem for a long time, but they did not know how bad it was
until they started cleaning items out of the storage rooms;
-In the smaller storage room adjacent to the large storage area, the walls in each outside
corner contained a black, mold-like substance. Storage shelving in this room contained
holiday decorations, not contained within boxes. The shelving had expanded from moisture
and the surfaces of the shelves had a black, mold-like substance throughout;
-In the medical records storage room, an area of the corrugated metal ceiling was covered
in a layer of rust around PVC plumbing pipes. The maintenance supervisor said the water
damage was caused from a leak in the shower room above. Observation showed there were
stacks of cardboard boxes containing paper records below this area where the leak had
occurred. Multiple cardboard boxes were heavily damaged from the moisture, and one box had
turned black in color. Areas of the walls and the drywall ceiling in this room had a
black, mold-like substance;
-In the storage room (identified as the new resident storage room), showed the wall above
the PTAC unit contained large areas of a black, mold-like substance. The wall below the
double windows leading to an adjacent room also had areas of a black, mold-like substance;
-In the therapy hallway, the walls were dirty and marred. The wall near the copy machine
contained an area of a black, mold-like substance;
-In the large storage room at the end of the therapy hallway, there were stacks of metal
bed frames with wooden headboards and footboards, mattresses, and spare wheelchairs and
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
equipment. The maintenance supervisor said staff utilize this storage if they need extra
beds, mattresses or equipment. Observation showed multiple ceiling tiles over the
bed/mattress storage area were damp, had fresh water rings, and also contained areas of a
black, mold-like substance. The maintenance supervisor said the storage area is located
under the special care unit. At times, residents’ toilets overflow (due to flushing things
down them) and cause the water to flow into the storage area below. Observation showed the
headboards on some of the beds were covered in a white, mold-like substance. The surface
of the mattresses stored in this area were covered in a white, mold-like substance. The
window ledge and the wall under the window in this area contained a black, mold-like
substance. The arm rests, push handles, and wheels on multiple wheelchairs were covered in
a powdery white substance, similar to that on the beds and mattresses. A portion of the
wall in the equipment/wheelchair storage area was discolored and contained a black,
mold-like substance. The wall board near the exit in this room had been removed exposing
the wooden studs. The wood studs/framing and the exposed wall had an accumulation of a
black, mold-like substance. In the medical storage room within this room, there were
multiple ceiling tiles that were damp and were water damaged;
-In the storage room, located near the large storage room on the therapy hallway, there
was an area of the wall at least 4 feet by 4 feet that was completely covered in a heavy
accumulation of a black, mold-like substance. The wall adjacent to this also had a black,
mold-like substance along the base of the wall. A ceiling tile in this area near a
sprinkler head was water damaged, had fresh water rings, and contained an area of black,
mold-like substance. In the bathroom area, the plumbing pipe leaked water into a 5-gallon
bucket. The bucket was full of water, and water was overflowing and pooling on the floor.
The wall by the plumbing pipe was heavily water damaged. The wall around the plumbing
fixtures and an area approximately 3 feet wide by 1.5 feet tall contained an accumulation
of a black, mold-like substance. The adjacent wall was also water damaged and had a black,
mold-like substance near the floor. The walls throughout the room were discolored and had
areas of a black, mold-like substance. A ceiling tile in the room was heavily water
damaged, was bowed and broken. The ceiling tile had a black, mold-like substance
throughout.
-In the medical records storage room on the therapy hallway, there were stacks of
cardboard boxes containing medical records throughout the room. Two ceiling tiles over the
window were water damaged. The wall below the ceiling tiles had an accumulation of a
black, mold-like substance;
-In a bathroom in the basement, the toilet bowl was heavily soiled. The floor around the
toilet was littered with debris;
-Throughout the storage rooms in the basements, there was a strong musty odor;
-The therapy room, utilized by residents for skilled therapy, was located in the therapy
hallway in the basement. Dehumidifiers were running in the therapy room. Therapy staff
said they run the dehumidifiers and keep the door to the therapy room closed in order to
keep the mold out. He/she said some residents have complained about the air in the
basement so staff have to take them back upstairs.
During interview on 9/20/18 at 9:00 A.M., the administrator said she was unaware of the
extent of the issue in the basement. She thought there was only an issue with moisture in
the basement, not mold.
4. Observations from 9/18/18 to 9/21/18 showed the residents sat in chairs in the main
dining room during each meal and throughout the day. Eight of the dining room chair seat
covers were torn and the exposed foam underneath was in contact with the residents’
bodies. The arms of the dining room chairs were marred with a white substance spattered
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
along the arms of the chairs. The arms of the chairs appeared dirty with brown debris.
Observation of the 500 hall locked special care unit showed the seats on a couple of the
dining room chairs were torn with large pieces of torn vinyl. The handrails had long
marred, scarred marks.
Observation on 9/20/18 at 5:50 A.M. showed the armrests on Resident #2’s wheelchair were
covered with vinyl which was cracked and peeling.
Observation from 9/18/18 to 9/21/18 showed the arm rests on Resident #96’s geri-chair were
covered with vinyl which was cracked and peeling exposing the yellow foam underneath.
Observations from 9/18/18 to 9/21/18 showed Resident #51 sat in a ger-chair throughout the
day. The arms of the geri-chair were cracked and exposed the foam underneath. The
resident’s arms were in contact with the arm rests.
5. Observation throughout the survey on 9/18/18 through 9/21/18 showed the 500 hall shower
room permeated with an odor. The floor was wet with water standing around the toilet and
on the surrounding floor.
During interview on 9/21/18, Certified Nurse Assistant (CNA) U said the 500 hall shower
room always had a bad odor.
Observation from 9/18/18 through 9/20/18, there was a strong odor of feces throughout the
100 hall.
During interview on 9/20/ 18 at 9:15 A.M., Resident #50 (who resided on the 100 hallway)
said the following:
-He/she has to try to stand the odor;
-The odor on his/her hall bothers him/her;
-The resident would like the room to be sprayed more often to control the odor.
6. During interview on 9/21/18 at 2:06 P.M., the director of nursing said all staff are
responsible for reporting any areas of concerns that may need the attention of
maintenance. Staff should write the problem down in the maintenance book and write out a
slip if something needs fixed.
During interview on 9/21/18 at 2:45 P.M., the administrator said whoever sees an issue
should follow their chain of command and ultimately maintenance is responsible for
repairs.
F 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to voice grievances without discrimination or reprisal and
the facility must establish a grievance policy and make prompt efforts to resolve
grievances.

Based on interview and record review, the facility failed to develop a grievance policy
and procedure that included all components required, and failed to provide a written
summary of conclusions regarding the residents’ grievances filed in resident council. The
resident council members filed grievances/complaints regarding missing items and untimely
responses to call lights and did not receive a response from staff regarding resolution of
the grievance. The facility census was 109.
1. Review of the facility’s Complaints/Grievances Process policy, dated 5/1/15, showed the
following:
-The facility will support the resident’s right to voice complaints/grievances regarding
concerns they have about services and treatment received including but not limited to
treatment, care, and lost articles;

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-After receiving a grievance/complaint, they will seek a problem resolution and will keep
the resident informed of the progress toward resolution;
-Procedures: Administrator, department manager, supervisor, and unit manager accept
grievances/complaints;
-The social worker/designee ensures all sections of the complaint/grievance report are
completed appropriately and signed by the staff completing the investigation and
developing the resolution. Ensure any supportive documentation related to the grievance
are attached such as copies of inservices, statements from residents or staff;
-Upon completion of the resolution, the administrator reviews and signs the report or the
monthly log indicating she has reviewed the complaints;
-The completed report is filed in the social service’s grievance binder;
-The complaint/grievance is recorded on the Grievance Log form and there will be one log
for each month. It will contain all grievances received that month and will be kept in the
grievance binder;
-At the end of each month, the administrator prints the reports from the grievance log and
utilizes it as a look back and summary to complete a tracking and trending of complaints
and grievances reviewing the grievance binder;
-To discuss all issues whether resolved or unresolved at the next QAPI (quality assurance)
meeting;
The policy did not address a summary statement of the resident grievance, the steps taken
to investigate, a summary of pertinent findings or conclusions regarding resident’s
concerns, a statement to whether grievance confirmed or not confirmed, corrective action
taken or to be taken by facility, date, and the written decision issued and copy given to
the resident or residents. This did not address maintaining evidence demonstrating the
result of all grievances for a period of no less than three years from issuance of
grievance decision.
2. Review of the facility Resident Council Minutes, dated 6/27/18, showed the following:
-Thirteen residents attended;
-Staff documented the residents said call lights were not being answered, and one resident
gave a list of missing clothing and hadn’t had a response from the housekeeping manager;
-Activity staff filed a grievance regarding call lights and would report residents’
complaints to the director of nursing (DON), who was the person responsible for this
grievance;
-Staff would report residents’ grievance/complaint for their missing clothing to the
housekeeping manager, who was the person responsible for finding the clothing;
-There was no documentation staff followed up with the residents’ concerns from the
meeting.
3. Review of the facility Resident Council Minutes, dated 7/25/18, showed the following:
-Eleven residents attended;
-Residents said call lights were not being answered;
-One resident said he/she had to call the front desk to get his/her call light answered;
-Staff was to report residents’ complaints to the DON, who is the person responsible;
-Residents want activities to assist in looking for their missing clothing by going
through clothing with no names or any lost clothing;
-Staff would report residents’ complaints of missing clothing to the housekeeping manager,
who is the person responsible for this.
-There was no documentation to show staff followed up on the residents’ concerns from the
meeting.
4. Review of the facility grievance log, dated 7/31/18, provided by the administrator,
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
showed the following:
-On 7/8/18, Resident #9 complained staff did not answer all lights timely. He/she waited
for two hours for the call light to be answered;
-The DON closed the grievance on 7/10/18;
-Grievance resolved satisfactorily marked in the box;
-There was no written documentation to show the summary of the investigation and any
corrective action taken by the facility.
During interview on 10/1/18 at 2:45 P.M., the DON said the following:
-She followed up on the complaint, talked with a particular staff member regarding the
issue, inserviced this person and would be inservicing all staff about answering call
lights within 15 minutes and not turning off the call light without meeting the resident’s
need;
-She signed the grievance with Resident #9, but did not give the resident a yellow carbon
copy of the grievance;
-She began as DON the last of (MONTH) (YEAR) and was not aware he/she was to give a copy
of the grievance to the residents.
5. Review of the facility Resident Council Minutes, dated 8/29/18, showed the following:
-Eleven residents attended;
-Residents said staff was not answering residents’ call lights;
-The DON informed the resident council members that she would inservice the nursing staff
on customer service and answering the residents’ call lights in a timely manner;
-Residents said grievances were not being answered in a timely manner;
-Staff filed a grievance against unanswered grievances and gave it to the social worker,
who was the person responsible for grievances;
-There was no documentation to show staff followed up on the residents’ grievance
regarding untimely response to grievances.
6. Review of the facility grievance log, dated 8/31/18, showed the following:
-On 8/29/18, the resident council filed a grievance about grievances not being addressed
in a timely manner and it was taking too long;
-Grievance closed: space left blank;
-Grievance resolved satisfactorily: left blank.
7. During the group interview on 9/19/18 at 2:00 P.M., residents in attendance said the
following:
-Staff answering their call lights on Saturday and Sunday was bad. The residents might
have to wait 45 minutes to two hours for staff to answer their call light;
-Lost clothing was a problem. The staff had found residents’ clothing in the trash;
-The facility staff did not get back with them when they filed a grievance as a resident
group at the last resident council meeting held in (MONTH) (YEAR);
-Resident #9 said the DON and/or other department heads had not gotten back to him/her
about his/her grievances;
-Social services handled grievances. There was poor communication regarding how grievances
were resolved.
8. During interview on 10/1/18 at 2:42 P.M., the Activity Director said the following:
-A resident can write a grievance on their own;
-During the resident council meeting, the Activity Director can write a grievance for the
group, then turn this in to the social worker to resolve, who will get back to the
resident council president about the results;
-If the resident council president wants to call a special meeting with the group, he/she
can to discuss the results of the grievance with the group.
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
During interview on 9/20/18 at 10:00 A.M. and 10/1/18 at 2:21 P.M., the Social Services
Director (SSD) said the following:
-The grievance process usually began with the activity director giving the grievance to
the SSD who gave this to the DON, Assistant Director of Nurses (ADON), or administrator
and they talked about these grievances in the morning department head meeting;
-When a resident fills out a grievance form, social services takes the form to the morning
department head meeting;
-A copy of the grievance is given to the appropriate department head to follow up;
-When the department head resolves the grievance, they bring the form back to social
services;
-The information regarding the grievance is documented on the grievance log;
-The grievance log shows what issues have been resolved;
-Social Services or the department head lets the resident know how the grievance was
resolved;
-The grievance log shows who notified the resident of the resolution;
-She was aware Resident #9 filed grievances in (MONTH) (YEAR) and staff followed up, but
did not give the resident a copy of the signed grievance with the resolution.
9. During interviews on 09/21/18 at 2:07 PM and 10/1/18 at 2:45 P.M., the DON said the
following:
-Grievances were given to the social service director (SSD) and to the particular
department to review;
-She provides education, corrective counseling, and inservicing to staff as needed to
resolve the grievances;
-If the facility receives grievances regarding nursing, she will report and follow up with
the resident when resolved.
-Staff document they followed up with the resident on the grievance form. The staff member
and the resident (if able) will sign the form.
-She had gotten back to particular residents about grievances but did not give a yellow
carbon copy of the results signed by her and the resident;
10. During interview on 9/21/18 at 1:00 P.M. and 9/27/18 at 11:50 A.M., the administrator
said she keeps a grievance log. The department heads were to address the grievances per
department. All department heads were to respond within 72 hours to the grievance and get
back with the residents who had the complaint. They discussed grievances and made attempts
to resolve them in their daily meetings. They had not provided a copy of the written
grievance, signed by staff and the resident and the facility response to their grievances.
F 0623

Level of harm – Potential for minimal harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide a notice of transfer
to the resident and/or resident representative when four residents (Residents #55, #71,
#87, and #80), in a review of 28 sampled residents, were transferred to the hospital. The
facility also failed to provide a copy of the notice of transfer to the ombudsman (a
resident advocate who provides support and assistance with problems and/or complaints
regarding the facility). The facility census was 109.

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 8)
1. Review of the facility’s policy, Discharge Planning and Notification, dated 5/1/15,
showed the following:
-In compliance with federal and state regulations, all transfers and discharges require
proper notification to the patient/resident and, if known, a family member or legal
representative;
-The social services staff /or designee is charged with ensuring systems are in place to
provide written notification to the resident and, if known, a family member or legal
representative prior to the resident’s transfer. The transfer/discharge notice must comply
with federal and state regulations and must contain the following information: the reason
for transfer or discharge; the effective date to which the resident is transferred or
discharged ; the location to which the resident is transferred or discharged ; a statement
that the resident has the right to appeal the action to the State; When appropriate, the
name address and telephone number of the state long term care ombudsman;
-The facility’s policy did not direct staff to provide a notice of transfer/discharge to
the Ombudsman when the facility initiated the resident’s transfer or discharge from the
facility.
2. Review of Resident #55’s Physician order [REDACTED].
-The resident was sent from the facility to the emergency room and admitted to the
hospital on [DATE];
-The resident was readmitted to the facility on [DATE];
-The resident was sent from the facility to the emergency room and admitted to the
hospital on [DATE];
-The resident was readmitted to the facility on [DATE].
Review of the resident’s medical record showed no documentation the facility notified the
resident/representative or the Ombudsman of the resident’s transfers to the hospital on
[DATE] or 6/28/18.
3. Review of Resident #71’s POS showed the following:
-The resident was sent from the facility to the emergency room and admitted to the
hospital on [DATE];
-The resident was readmitted to the facility on [DATE];
-The resident was sent from the facility to the emergency room and admitted to the
hospital on [DATE];
-The resident was readmitted to the facility on [DATE].
Review of the resident’s medical record showed no documentation the facility notified the
resident/representative or the Ombudsman of the resident’s transfer to the hospital on
[DATE] and 8/28/18.
4. Review of Resident #87’s nurse note, dated 9/10/18, showed the following:
-The resident was sent from the facility to the emergency room and admitted to the
hospital on [DATE];
-The resident was readmitted to the facility on [DATE].
Review of the resident’s medical record showed no documentation the facility notified the
resident/representative or the Ombudsman of the resident’s transfer to the hospital on
[DATE].
5. Review of Resident #80’s physician orders, dated (MONTH) (YEAR), showed the following:
-The resident was sent from the facility to the emergency room and admitted to the
hospital on [DATE];
-The resident was readmitted to the facility on [DATE].
Review of the resident’s medical record showed no documentation the facility notified the
resident/representative or the Ombudsman of the resident’s transfer to the hospital 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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 9)
[DATE].
6. During interview on 9/21/18 at 9:04 A.M., the Social Services Designee said the
following:
-She was aware of the requirement to notify the resident and responsible party of a
transfer to the hospital;
-The facility had planned on the nursing staff to be responsible for this, but had not
started it yet;
-She did not notify the Ombudsman of residents’ transfers or discharges from the facility.
F 0625

Level of harm – Potential for minimal harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform residents and resident
representatives of their bed hold policy at the time of transfer to the hospital for four
residents (Residents #55, #71, #87, and #80), in a review of 28 sampled residents. The
facility census was 109.
1. Review of the facility’s undated policy, Bed Hold Policy Notification, showed this
policy will be given to the resident or resident representative at the time of admission
and each time the resident is transferred from the facility.
2. Review of Resident #80’s physician order [REDACTED].
Review of the resident’s medical record showed no documentation the facility provided the
resident and the resident representative with written notice which specified the duration
of the facility’s bed-hold policy at the time of transfer on 9/1/18.
3. Review of Resident #55’s POS, dated (MONTH) (YEAR), showed the resident was transferred
to the hospital on [DATE].
Review of the resident’s medical record showed no documentation the facility provided the
resident and the resident representative with written notice which specified the duration
of the facility’s bed-hold policy at the time of transfer on 6/28/18.
4. Review of Resident #71’s POS, dated (MONTH) (YEAR), showed the resident was transferred
to the hospital on [DATE].
Review of the resident’s medical record showed no documentation the facility provided the
resident and the resident representative with written notice which specified the duration
of the facility’s bed-hold policy at the time of transfer on 8/28/18.
5. Review of Resident #87’s nurse note, dated 9/10/18 at 6:00 P.M., showed the resident
was transferred to the hospital on [DATE].
Review of the resident’s medical record showed no documentation the facility provided the
resident and the resident representative with written notice which specified the duration
of the facility’s bed-hold policy at the time of transfer on 9/10/18.
6. Review of Resident #99’s resident’s discharge assessment, dated 9/13/18, showed the
resident was transferred to the hospital on [DATE].
Review of the resident’s medical record showed no documentation the facility provided the
resident and the resident representative with written notice which specified the duration
of the facility’s bed-hold policy at the time of transfer on 9/13/18.
7. During interview on 9/21/18 at 9:04 A.M., the Social Service Designee said the facility

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 10)
does not notify the resident/representative of the bed hold policy upon transfer to the
hospital.
F 0655

Level of harm – Potential for minimal harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to develop a
baseline care plan for one resident (Resident #109) and failed to ensure seven residents
(Residents #23, #27, #54, #71,#84, #87, and #99), in a review of 28 sampled residents, and
their representatives were provided with a summary of the resident’s baseline care plan.
The facility census was 109.
1. During interview on 9/21/18 at 1:35 P.M., the administrator said there was no policy
for baseline care plans. The facility was aware of the requirement to provide a copy of
the baseline care plan to the resident and their representative. Staff reviewed the care
plan with the resident and family representative and they would sign it. The facility
staff did not give the resident and the family representative a copy of the baseline care
plan.
2. Review of Resident #109’s medical record showed the following:
-He/she was admitted to the facility on [DATE];
-There was no evidence a baseline care plan was completed for the resident.
During interview on 9/20/18 at 2:19 P.M., the director of nursing said the charge nurse
was responsible for completing the base line care plan at admission. A baseline care plan
was not completed for Resident #109 because it got missed.
3. Review of Resident #54’s medical record showed he/she was admitted to the facility on
[DATE].
Review of the resident’s undated baseline care plan, showed the following:
-admitted was 4/23/18;
-The resident/representative signature of receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and/or his/her representative.
4. Review of Resident #23’s medical record showed he/she was admitted to the facility on
[DATE].
Review of the resident’s baseline care plan showed it was completed on 7/17/18. The
resident/representative signature of receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and his/her representative.
5. Review of Resident #71’s medical record showed he/she was admitted to the facility on
[DATE].
Review of the resident’s baseline care plan showed it was completed on 8/29/18. The
resident/representative signature of receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and his/her representative.
6. Review of Resident #84’s medical record showed the resident was admitted to the
facility on [DATE].
Review of the resident’s undated baseline care plan, 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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0655

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 11)
-admitted [DATE];
-The resident/representative signature of receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and his/her representative.
7. Review of the Resident #27’s medical record showed the admitted was 6/22/18.
Review of the resident’s undated baseline care plan showed the following:
-admitted [DATE];
-The resident/representative signature receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and his/her representative.
8. Review of Resident #87’s medical record showed the resident’s date of readmission to
the facility was 9/14/18.
Review of the resident’s baseline care plan showed the following:
-The baseline care plan was completed on 9/14/18.
-The resident/representative signature of receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and his/her representative.
9. Review of Resident #99’s medical record showed the resident’s date of admission to the
facility was 9/17/18.
Review of the resident’s baseline care plan showed the following:
-The baseline care plan was completed on 9/17/18;
-The resident/representative signature of receipt section was left blank.
Review of the resident’s medical record showed no documentation a summary of the baseline
care plan was provided to the resident and his/her representative.
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
provided two residents (Residents #57 and #80), who were unable to perform their own
activities of daily living, the necessary care and services to maintain good personal
hygiene including oral or mouth care, in a review of 28 sampled residents. The facility
census was 109.
1. Review of the facility policy Early Morning A.M. Care, revised 7/1/16, showed the
following:
-The nursing staff will assist the resident with his/her hygiene and self-care needs
according to facility practice guidelines;
-Offer appropriate assistance for toileting or incontinent care;
-Offer appropriate assistance for personal hygiene.
2. Review of the undated Physiological Basis for Nursing Practice Unit 7 for oral hygiene
and brushing teeth, provided by the administrator, showed the following:
-Regular oral hygiene, including brushing, flossing, and rinsing, prevents and controls
plaque-associated oral diseases;
-Poor oral health to risk of impaired nutrition, stroke, poor blood sugar control in
diabetes, and nursing home-acquired pneumonia;

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-Brushing cleans the teeth of food particles, plaque, and bacteria. It enhances well-being
and comfort and stimulates the appetite;
-Brushing the teeth at least twice a day was effective oral hygiene.
3. Review of the Nurse Assistant in a Long-Term Care Facility, 2001 edition, showed the
following:
-Wash hands before meals and as needed;
-Providing hair care helps the resident maintain self-esteem and helps stimulate the
resident’s scalp;
-Oral care should be given before breakfast, after meals and at bedtime.
4. Review of Resident #57’s admission Minimum data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/1/18, showed the following:
-Severely impaired cognition;
-Limited assistance of one staff for personal hygiene.
Review of the resident’s care plan, dated 8/2/18, showed the resident required limited
assistance of one staff for personal hygiene and oral care.
Observation on 9/20/18 at 6:00 A.M. showed the following:
-Certified Nurse Aide (CNA) L and CNA K provided perineal care for the resident, assisted
the resident to dress, and transferred him/her to the wheelchair;
-CNA K combed the resident’s hair and then took the resident to the dining room;
-CNA K did not wash the resident’s hands, and did not offer to provide oral care. The
resident’s mouth was dry and crusty.
During interview on 09/20/18 at 6:55 A.M., CNA L said he/she was not sure if the resident
had a toothbrush or toothpaste since the resident was new to the facility.
5. Review of Resident #80’s admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Required limited staff assistance from one staff for personal hygiene.
Review of the resident’s care plan, dated 8/12/18, showed the resident required limited
assistance of one to two staff for personal hygiene and oral care. Staff was to allow the
resident to do as much for himself/herself as tolerated with set up assistance from staff.

Observation on 09/20/18 at 6:14 A.M., showed the following:
-CNA L and CNA K provided perineal care for the resident, assisted the resident to dress,
and transferred the resident to his/her wheelchair;
-The resident’s hair appeared greasy;
-CNA K took the resident to the dining room without brushing or combing his/her hair,
washing his/her face and hands, and offering oral care. The resident’s lips were dry and
flaky.
During interview on 8/20/18 at 7:10 A.M., CNA K said the resident recently returned from
the hospital. He/she was unsure about the resident’s teeth or dentures and wasn’t sure if
the resident even wore his/her dentures now. He/she usually washes the resident’s face and
hands but thought CNA L had done this since they work together as a team.
6. During interview on 9/21/18 at 11:15 A.M., Licensed Practical Nurse (LPN) M, charge
nurse on the special care unit, said the following:
-He/she expected staff to wash residents’ face and hands and to provide oral care during
morning cares when they first get up;
-Resident #57 needed staff to assist him/her to wash his/her hands and face. The resident
had his/her own teeth. He/she was not sure if the resident had a toothbrush and toothpaste
but had two front teeth and a partial denture. The partial denture was missing;
-Resident #80 washed his/her face and hands and used his/her razor if staff would lay it

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
out for him/her. The resident had either upper or lower dentures and kept them in a box in
the top dresser drawer and sometimes will put them in.
7. During interview on 09/21/18 at 2:07 PM, the director of nursing said she would expect
staff to provide morning cares which included washing a resident’s face and hands, and
providing oral care such as brushing teeth and putting in their dentures.
8. During interview on 09/21/18 at 2:07 PM, the director of nursing said she would expect
staff to provide morning cares including washing a resident’s face and hands, and
providing oral care such as brushing teeth or putting in their dentures.
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide an
ongoing program of meaningful activities on a daily basis to meet the interests and the
physical, mental, and psychosocial well-being of each resident, based on the comprehensive
assessment, for two residents (Residents #38 and #84) who were dependent on staff, in a
review of 28 sampled residents. The facility census was 109.
1. Review of the facility’s Admission Handbook, dated (MONTH) 2011, showed the facility
must provide for an ongoing program of activities directed by a qualified professional
designed to meet, in accordance with the comprehensive assessment, the interests and
physical, mental and psycho-social well-being of each resident.
2. Review of the facility’s activities policy, One-on-One, Individual Activity/Recreation
Programs, revised 7/1/16, showed the following:
-Staff will provide one-on-one individual programming to address individual abilities,
needs, interests, hobbies and cultural preferences;
-The activity director determines the need for one-on-one through the resident assessment
process (residents who are in isolation for medical reason, who are on physician ordered
bed rest, who is only able to participate passively in group activities, or request to not
be included in group situations);
-One-on-one/individual programs are developed and implemented on a regular basis
consistent with individualized interests, hobbies, cultural preferences, comforts, and
based on their assessment and one-on-one are included in the resident’s care plan. As a
general guideline, one-on-ones are provided three times per week for those residents
unable to attend groups and one time per week for those residents who consistently refuse
or choose not to attend groups (residents who refuse programs must be alert, oriented, and
competent in their decision-making ability).
3. Review of the Long-Term Care Facility Resident Assessment Instrument User’s Manual,
dated (MONTH) 2013, showed the following:
-Most residents capable of communicating can answer questions about what they like;
-Obtaining information about preferences directly from the resident, sometimes called
hearing the resident’s voice, is the most reliable and accurate way of identifying
preferences;
-If a resident cannot communicate, then family or significant other who knows the resident
well may be able to provide useful information about preferences;
-Quality of life can be greatly enhanced when care respects a resident’s choice regarding
anything that is important to the resident;
-Interviews allow the resident’s voice to be reflected in the 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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
-Activities are a way for individuals to establish meaning in their lives, and the need
for enjoyable activities and pastimes does not change on admission to a nursing home;
-A lack of opportunity to engage in meaningful and enjoyable activities can result in
boredom, depression, and behavior disturbances;
-Individuals vary in the activities they prefer, reflecting unique personalities, past
interests, perceived environmental constraints, religious and cultural background, and
changing physical and mental abilities.
4. Review of Resident #84’s Activities Evaluation, dated 7/21/18, showed the following:
-admitted was 7/20/18;
-Short and long-term memory problem, decision making skills severely impaired, rarely
makes self-understood, speech clarity unclear;
-Needs assistance from two staff for ambulation;
-Finds strength in his/her faith, actively participates;
-Activity pursuit patterns and preferences: current includes animal/pets, current events
and news, family/friend visits, music/radio and religious services;
-Interest in life/activities: interested;
-Motivation: motivated
-Family/friends involvement: A handwritten note completed by the activity director said
the resident’s family member helped complete the assessment and is highly involved in the
resident’s care.
Review of the resident’s care plan, last revised on 7/23/18, showed the following:
-The resident had little or no activity involvement related to major [MEDICAL CONDITION];
-Will not exhibit isolation or boredom through review date;
-Preferred activities are listening to music;
-Prefers the following radio stations 99.1;
-Staff will implement one-on-one visits with the resident once a week;
-Staff will inform the resident of current news and events;
-Provide a program of activities that accommodates the resident’s communication abilities;
-Be conscious of resident position when in groups, activities, dining room to promote
proper communication with others;
-The resident was dependent on all staff for locomotion.
Review of the resident’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 7/27/18, showed the
following:
-Long and short-term memory problems;
-Daily decision making skills severely impaired;
-It was very important to listen to music he/she liked and being around animals such as
pets;
-It was somewhat important to do things with a group;
-It was important but can’t do or no choice to do favorite activities of his/her choice,
go outside to get fresh air when the weather is good, and participate in religious
services or practices.
Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH)
(YEAR) showed the following:
-On 8/1/18, olfactory stimulation and reading/writing, passive participation;
-On 8/10/18, tactile stimulation and current news and events, passive participation;
-On 8/15/18, visual stimulation, participation;
-On 8/23/18, current news and events, passive participation;
-On 8/29/18, tactile stimulation, passive participation and current news and events,
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
active participation.
Review of the resident’s activity notes for (MONTH) (YEAR) showed the resident
participated in a group activity on 8/15/18. The resident sat and watched an arts and
crafts activities and was shown pictures of flowers and houses for visual stimulation.
There was no further documentation to show the resident participated in other group
activities during the month.
Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH)
(YEAR) showed the following:
-On 9/7/18, active tactile simulation, passive participation current news/events;
-On 9/12/18, active participation exercise/sports and tactile stimulation, passive
participation, music, reading/writing;
-On 9/17/18, active participation auditory stimulation, passive participation stimulation
in reading/writing and in current/news and events.
Review of the resident’s activity notes for (MONTH) (YEAR) showed no documentation the
resident participated in group activities during the month.
Observation on 9/18/18 at 10:55 A.M. showed the resident lay in bed. The resident’s
television and radio were turned off and the room was quiet.
Observations on 9/19/18 at 8:18 A.M., 10:00 A.M. 11:30 A.M., 3:00 P.M. and 5:00 P.M.
showed the resident lay in bed. His/her roommate’s television was turned on behind the
privacy curtain and not visible to the resident.
Observation on 9/20/18 at 7:06 A.M. showed the resident lay in bed with his/her eyes open.
His/her roommate’s television was turned on behind the privacy curtain and not visible to
the resident.
Observation on 9/20/18 at 10:07 A.M. showed the resident lay in bed and faced the door,
with his/her eyes open. The radio and television that sat on the bedside table were turned
off. The resident’s roommate’s television played quietly on his/her side of the room and
not visible to the resident.
Observation on 9/20/18 at 12:50 P.M. showed the resident lay in bed with his/her eyes
open. The resident’s television and radio were turned off and the was room quiet.
During interview on 9/21/18 at 10:00 A.M., Certified Nurse Assistant (CNA) T said he/she
had worked in this area of the facility for around a month and he/she had not assisted the
resident out of bed during that time period.
During interview on 9/21/18 at 11:56 A.M., CNA P said he/she worked the day shift in this
area routinely. He/she had not assisted the resident out of bed before today. He/she did
not know of any activities the resident was involved in or liked. The resident’s
television or radio could not be turned on because the wound vac equipment was plugged
into the outlet.
During interview on 9/21/18 at 11:05 A.M., CNA R said he/she had worked in the facility
for close to six months and during that time period, the resident had only been out of bed
a couple times. He/she was not sure why the resident never got out of bed. He/she just
followed the lead of others. Staff fed the resident his/her meals in bed. He/she just made
sure the resident was changed, repositioned and kept clean.
During interview on 10/1/18 at 2:05 P.M., the resident’s family said the following:
-The facility got the resident up out of bed at one time but after the resident stopped
physical therapy he/she seemed to not get out of bed anymore;
-He/she was not sure why the resident did not get out of bed anymore;
-He/she had Christian music tapes he/she played for the resident, but he/she wasn’t able
to play them now because the wound vac and breathing treatment equipment were plugged into
the outlets and left nowhere to plug anything in.
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
5. Review of the Resident #38’s annual MDS, dated [DATE], showed the following:
-Rarely/never understands others;
-Absence of speech;
-Preferences for customary routine and activities was not completed.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Persistent vegetative state;
-Total dependence of two staff member with transfers;
-Required extensive assistance from one staff member with locomotion on and off the unit.
Record review of the resident’s care plan, last reviewed on 7/13/18, showed the
following:
-The resident is in a semi-vegetative type state, but occasionally opens his/her eyes and
tends to track with his/her eyes;
-Per family, he/she enjoys listening to music, being read to, and having the television on
at times;
-The resident will not exhibit boredom or isolation;
-Provide one-on-one sessions one time a week;
-The resident has impaired cognition because of Alzheimer’s and is unable to speak or
communicate;
-Assist the resident to and from low functioning activities, music, parties and movies;
-Speak to the resident when in the room. Play television, radio, music if available.
-The resident has Alzheimer’s and is dependent with all activities of daily living.
Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH)
(YEAR) showed the following:
-On 8/3/18, current news and events, active participation;
-On 8/6/18, reading/writing, passive participation;
-On 8/13/18, exercise/sports, passive participation;
-On 8/21/18, visual stimulation, passive participation;
-On 8/29/18, music/current news and events, active participation.
Record review of the resident’s activity notes for (MONTH) (YEAR) showed no evidence the
resident participated in any group activities.
Review of the resident’s One-on-One Activity/Recreation Program Documentation for (MONTH)
(YEAR):
-On 9/5/18, music, passive participation;
-On 9/12/18, music, olfactory stimulation, reading/writing, tactile stimulation (touch)
television and current news and events, passive stimulation;
-On 9/17/18, auditory stimulation, active stimulation, music, reading/writing and current
news and events, passive stimulation.
Record review of the resident’s activity notes for (MONTH) of (YEAR) showed no evidence
the resident participated in any group activities.
Observations on 9/18/18 at 11:30 A.M., 12:45 P.M., and 4:44 P.M., showed the resident lay
in bed. The television in his/her room was turned off and the room was quiet.
Observations on 9/19/18 at 8:30 A.M., 10:09 A.M., 11:30 A.M., 3:00 P.M. and 5:00 P.M.
showed the resident lay in bed. The television was turned off and the room was quiet.
Observations on 9/20/18 at 6:00 A.M., 8:08 A.M. and 1:00 P.M. showed the resident lay in
bed. The resident’s room was quiet, the lights were turned off, and the door was closed.
Observations on 9/21/18 at 9:30 A.M. showed the resident lay in bed. The room was quiet.
During interview on 9/21/18 at 11:56 A.M., Certified Nurse Assistant (CNA) P said he/she
was not sure if the resident’s television worked because it was never turned on. He/she
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
was not sure of any activities the resident liked. He/she worked in this area routinely on
the day shift and had not assisted the resident out of bed before today.
During interview on 9/21/18 at 11:05 A.M., CNA R said he/she had worked in the facility
for close to six months and during that time period, the resident had only been up out of
bed three or four times. He/she was not sure why the resident never got out of bed. He/she
just followed the lead of others. He/she just made sure the resident was changed,
repositioned and kept clean.
During interview on 9/27/18 at 2:30 P.M., the resident’s family member said the following:
-He/she had not observed the resident out of bed for a long time;
-The resident listened to music and watched the television at one time, but he/she had not
seen the television or radio on in a long time;
-The resident had friends and enjoyed visiting at one time.
6. During interview on 9/28/18 at 11:00 A.M., the activity director said the following:
-He/she was unable to locate the activity evaluation that was completed on Resident #38;
-He/she set up one-on-one activities for some of the residents one time a week who also
went to attend group activities throughout the week. If the residents were not able to
attend group activities, those residents should receive one-on-one activities three times
a week per the facility policy;
-If a resident participated in a group activity, he/she documented it on the activity
notes;
-He/she thought Resident #38 had been up one time in the last couple months for a group
activity;
-Resident #84 had been up a couple times in the past month and a half for a group
activity;
-He/she had asked the nurses if there was a reason Resident #38 and Resident #84 could not
get out of bed. He/she was told there was no reason the residents could not get out of
bed;
-The staff don’t get Resident #38 and Resident #84 up out of bed for group activities and
he/she is not sure why.
7. During interview on 9/21/18 at 2:06 P.M., the director of nursing said one-on-one
activities should be conducted at least three times a week. He/she would expect staff to
turn on the residents’ televisions for stimulation. Staff should follow each resident’s
activity preferences and those should be included on the care plan.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
appropriate treatment and services to prevent urinary tract infections for one resident
(Resident #84), who had a urinary catheter (a sterile tube inserted through the urethra
into the bladder to drain urine), in a review of 28 sampled residents. The facility
reported five residents with urinary catheters. The facility census was 109.
1. Review of the Nurse Assistant in a Long-Term Care Facility, 2001 revision, showed the
following:
-The bladder is considered sterile. The catheter, drainage tubing and bag are a sterile

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
system;
-Drainage tubing/bags must not touch the floor;
-The drainage bag should always be below the level of the bladder. If moved above, urine
could flow back into the bladder.
2. Review of Resident #84’s urinalysis (the physical, microscopic, or chemical examination
of urine), dated 7/25/18, showed the following:
-Clarity: turbid (normal: clear);
-Leukocyte Esterase (the detection of leukocytes in urine usually points to the presence
of a health abnormality such as infection of the urinary system by bacteria): large
(normal: 0-4);
-White blood cell: too numerous to count per high power field (HPF, area visible under the
maximum magnification power) (normal: 0-4));
-Red blood cell: 16-25/HPF (normal: 0-4);
-Mucous: moderate (normal: none/small);
-Culture indicated: yes;
-Culture report (test to identify bacteria or fungus that can cause an infection), dated
7/27/18, showed greater than 100,000 colony forming unit (CFU) milliliter (ml) proteus
mirabilis (a gram- negative bacterium frequently a pathogen of the urinary tract)
-On the bottom of the form was a hand written physician order [REDACTED].
Review of the resident’s admission Minimum Data Set (MDS), a federally mandated assessment
completed by facility, dated 7/27/18, showed the following:
-Daily decision making skills severely impaired;
-Indwelling urinary catheter.
Review of the resident’s care plan, last revised 8/2/18, showed the following:
-[DIAGNOSES REDACTED].
-He/she was incontinent of bowel and bladder and is dependent on staff for care;
-His/her mobility is limited;
-At risk for infection;
-The care plan did not address the resident’s urinary catheter.
Observation on 9/18/18 at 2:42 P.M. showed the resident lay in a low positioned bed. The
resident’s urinary catheter drainage bag hung on the side of the bed and was not contained
within a privacy bag. The catheter drainage bag rested directly on the floor.
Observation on 9/18/18 at 4:44 P.M. showed the resident lay in a low positioned bed. The
resident’s urinary catheter drainage bag hung on the side of the bed and was not contained
within a privacy bag. The catheter drainage bag rested directly on the floor.
Observation on 9/19/18 at 8:11 A.M. showed the resident lay in a low positioned bed. The
resident’s urinary catheter drainage bag hung on the side of the bed and was not contained
within a privacy bag. The catheter drainage bag rested directly on the floor.
Observation on 9/19/18 at 3:33 P.M. showed the resident lay in a low positioned bed. The
resident’s urinary catheter drainage bag hung on the side of the bed and was not contained
within a privacy bag. The catheter drainage bag rested directly on the floor.
Observation on 9/20/18 at 5:22 A.M. showed the resident lay in a low positioned bed. The
resident’s catheter drainage bag hung on the side of the bed and was not contained within
a privacy bag. The catheter drainage bag rested directly on the floor.
Observation on 9/21/18 at approximately 11:00 A.M. showed the following:
-Licensed Practical Nurse (LPN) Q, Certified Nurse Assistant (CNA) P, and CNA T
transferred the resident to his/her wheelchair;
-The resident’s urinary catheter drainage bag (not contained within a privacy bag) dropped
onto the floor;
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
-The drainage bag remained on the floor as the three staff members adjusted the resident
in the wheelchair, applied foot pedals to the wheelchair and heel protectors to the
resident’s feet;
-LPN Q picked up the catheter drainage bag and passed the bag under the wheelchair to CNA
T who attached it to the back of the wheelchair.
During interview on 9/21/18 at 11:05 A.M., CNA T said he/she does not normally put the
urinary drainage bag on the floor but there were a lot of tubes to handle during the
resident’s transfer.
During interview on 9/21/18 at 12:55 P.M., CNA P said the urinary catheter drainage bag
should not be on the floor because it was dirty. He/she did not know it was on the floor
when he/she assisted the resident to transfer.
During interview on 9/21/18 at 2:06 P.M., the director of nursing said the urinary
catheter drainage bag should not touch the floor due to causing infections. If the
resident is in a low bed, the bed should be lowered to a point where the urinary catheter
drainage bag is off the floor. He/she would not expect the urinary catheter drainage bag
to be on the floor during transfers. Staff should hold on to the catheter drainage bag
during transfers and then place it in a privacy bag.
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, the facility failed to ensure the
medication error rate was less than five percent. Thirty-six opportunities were observed
with 13 medication errors, resulting in a medication error rate of 36 percent. Staff
provided intent to administer 11 medications to the wrong resident, administered one
medication without a physician’s order, and omitted one medication due to the medication
was not available and had not been available for multiple days. The facility census was
109.
1. Review of the facility policy Medication Management and The Pharmacy and Therapeutic
Process, dated (MONTH) 2012, showed the following:
-Administering the medication pass: the medication cart is wheeled to the
patient’s/resident’s room;
-The authorized licensed/certified staff member follows the MAR prepared for the
patient/resident by identifying the:
-The right patient/resident;
-The right drug;
-The right dose;
-The right time;
-The right route;
-The right charting;
-The right results;
-The authorized licensed/certified staff member identifies that the following information
is documented on the MAR.
-Correct physicians order;
-Medication and label are correct;
-Label and physician’s order are correct;
-The authorized licensed/certified staff member reads the label on the medication three

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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)
(3) times:
-Before moving the medication from the drawer;
-Before pouring the medication;
-After pouring the medication;
-The authorized licensed/certified staff member seeks assistance from the nursing
supervisor/designee and consulting pharmacy when any aspect of medication administration
is in question.
2. Review of the facility policy Medication Shortages and Unavailable Medications, dated
11/1/17, showed the following::
-Policy: The facility shall ensure there is always an adequate supply of medication to
administer to a resident on hand at all times and facility staff should immediately
initiate action to obtain medication from the pharmacy once a potential medication
shortage has been identified;
-Procedures: Upon discovery that the facility has an inadequate supply of a medication to
administer to a resident, facility staff should immediately initiate action to obtain the
medication from the pharmacy. If the medication shortage is discovered at the time of
medication administration, the nurse will immediately take the action;
-The nurse should contact the pharmacy to determine the status of the order. If the
medication has not been ordered, the licensed nurse should place the order or reorder for
the next scheduled delivery;
-If the next available delivery causes delay or a missed dose in the resident’s medication
schedule, the nurse should check to see if the dose can be removed from the on-site store
or the emergency medication supply to administer the dose;
-If the medication is not available in the emergency medical supply, the nurse should
notify the pharmacy and arrange for an emergency STAT delivery;
-If an emergency STAT delivery will not be in time for the next dose, or if the medication
is not in the on-site supply or emergency medication supply, the nurse should contact the
attending physician to obtain orders for directions;
-When a missed dose is unavoidable, the nurse should notify the physician and document the
missed dose on the medication administration record (MAR) or treatment administration
record (TAR)
3. Review of Resident #2’s physician’s orders, dated 8/30/18 to 9/30/18, showed the
following:
-Focus select eye vitamin with [MEDICATION NAME], take one every day at 9:00 A.M.;
-[MEDICATION NAME] (an [MEDICATION NAME]), take one tablet daily;
-[MEDICATION NAME] Propionate (an inhaled steroid) 50 microgram (mcg), one spray in each
nostril every morning at 9:00 A.M. for allergies [REDACTED].>-Losartan potassium (used
to treat high blood pressure) 25 milligrams (mg), take one tablet every day at 9:00 A.M.
for HTN;
-Polyethylene [MEDICATION NAME] (used to treat constipation) 3350, mix 17 grams (one
capful) in 8 ounces of liquid and take by mouth every day at 9:00 A.M. for constipation;
-[MEDICATION NAME] (nerve pain medication and used to treat [MEDICAL CONDITION]) 100 mg,
take two capsules (200 mg) three times a day at 8:00 A.M., 12:00 P.M. and 9:00 P.M;
-[MEDICATION NAME] HCL ER (extended release antidepressant medication) 150 mg, take one
capsule every morning with breakfast at 9:00 A.M.;
-Vitamin B12 (B12 supplement) 1,000 mcg, take one tablet every day at 9:00 A.M.;
-Vitamin D-3 (D-3 supplement) 2000 units, take one tablet every day at 9:00 A. M;
-[MEDICATION NAME] (used to treat pain) 5% patch, apply one patch topically to left
side/back every morning and remove at bedtime, on at 8:00 A.M. and off at 8:00 P.M.;
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 21)
-[MEDICATION NAME] (used to treat high blood pressure, chest pain and heart failure) 25
mg, take one tablet twice daily;
-[MEDICATION NAME] ([MEDICATION NAME], pain reliever) 325 mg, take two tablets (650 mg)
three times a day at 9:00 A.M., 3:00 P.M. and 9:00 P.M.;
-[MEDICATION NAME] 7.5 mg with a line drawn through it and a hand written note to
discontinue the medication on 7/18/18.
Review of the resident’s medication administration record (MAR), dated (MONTH) (YEAR),
showed the following:
-Focus select eye vitamin with [MEDICATION NAME], take one every day at 9:00 A.M.;
-[MEDICATION NAME] HCL 10 mg, take one tablet by mouth daily;
-[MEDICATION NAME] Propionate 50 microgram (mcg), one spray in each nostril every morning
at 9:00 A.M. for allergies [REDACTED].>-Losartan potassium 25 mg, take one tablet every
day at 9:00 A.M. for HTN;
-Polyethylene [MEDICATION NAME] 3350, mix 17 grams (one capful) in 8 ounces of liquid and
take by mouth every day at 9:00 A.M. for constipation;
-[MEDICATION NAME] 100 mg, take two capsules (200 mg) by mouth three times a day at 8:00
A.M., 12:00 P.M. and 9:00 P.M;
-[MEDICATION NAME] HCL ER 150 mg, take one capsule every morning with breakfast at 9:00
A.M.;
-Vitamin B12 1,000 mcg, take one tablet every day at 9:00 A.M.;
-Vitamin D-3 2000 units, take one tablet every day at 9:00 A.M.;
-[MEDICATION NAME] 5% patch, apply one patch topically to left side/back every morning and
remove at bedtime, on at 8:00 A.M. and off at 8:00 P.M. (the dose was circled indicating
not available on 9/1/18, 9/2/18, 9/3/18, and from 9/8/18 to 9/19/18);
-[MEDICATION NAME] 25 mg, take one tablet twice daily;
-[MEDICATION NAME] 325 mg, take two tablets (650 mg) three times a day.
-[MEDICATION NAME] (used to treat pain and inflammation caused by arthritis) 7.5 mg, take
one tablet every day at 9:00 A.M. (The resident’s (MONTH) POS did not show a current order
for [MEDICATION NAME]).
Observation on 9/19/18 at 8:13 A.M. showed Certified Medication Technician (CMT) S
prepared the following medications: [REDACTED]
-One tablet of focus select eye vitamin with [MEDICATION NAME];
-One 10 mg tablet of [MEDICATION NAME] HCL;
-One 25 mg tablet of Losartan potassium;
-Two 100 mg capsules of [MEDICATION NAME];
-One 150 mg capsule of [MEDICATION NAME];
-One 1000 mcg tablet of Vitamin B12;
-One 25 mg tablet of [MEDICATION NAME];
-Two 325 mg tablets of [MEDICATION NAME];
-One 7.5 mg tablet of [MEDICATION NAME] 7.5 mg (the resident’s (MONTH) POS did not show a
current order for [MEDICATION NAME]);
-17 grams or Polyethylene [MEDICATION NAME] 3350 in 8 ounces of liquid;
-[MEDICATION NAME] Propionate 50 mcg nasal spray.
During interview on 9/19/18 a 8:16 A.M., CMT S said the resident’s [MEDICATION NAME] 5%
patch was not available.
Observation on 9/19/18 at 8:18 A.M. showed the following:
-CMT S entered Resident #102’s room (the door was labeled with Resident #102’s name);
-CMT S said I have your medications, Resident #2 as he/she prepared to administer the
medications to Resident #102;
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 22)
-The surveyor questioned Resident #102 on his/her name prior to CMT S administering the
medications to the resident. The resident said he/she was Resident #102 (not Resident #2);
-CMT S exited the room and questioned staff in the hall where Resident #2 had been moved;
-CMT S then entered Resident #2’s (the door was labeled with Resident #2’s name) and
administered the medications to Resident #2.
During interview on 9/19/18 at 8:49 A.M., CMT S said the following:
-The MAR for Resident #2 had the wrong room number and there was not a picture on the MAR
indicating who the resident was. He/she was not sure when Resident #2 had been moved to a
different room. It was his/her error that he/she almost gave Resident #102 Resident #2’s
medications;
-Resident #2’s [MEDICATION NAME] had not been available for nine days.
During interview on 10/1/18 at 11:35 A.M., the administrator said the [MEDICATION NAME]
order was put on the resident’s MAR in error on 9/1/18 when the facility changed
pharmacies. The medication was discontinued on 7/18/18.
During interview on 9/21/18 at 2:06 P.M., the director of nursing said the following:
-Resident #2’s [MEDICATION NAME] was not available for nine days. She would have expected
staff to have notified the physician.
-Staff is to address resident’s by name when giving medications. The resident’s room
change should be conveyed in report.
During interview on 10/1/18 at 1:08 P.M., the Physician Assistant to the Medical Director
said the following:
-He/she would expect staff to notify him/her if a medication was not available so a
medication could be given to the resident during the interim;
-He/she would expect the facility to have a physician’s order to administer a medication.
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure pureed
food items were prepared properly to the meet the needs of residents with physician’s
orders [REDACTED]. The facility census was 109.
1. Review of the Diet Report, provided by the dietary manager on 9/18/18, showed nine
residents had orders for a pureed diet.
1. Review of the Diet Spreadsheet for lunch on 9/18/18 (menu cycle-week IV Tuesday) showed
residents on a pureed diet were to receive the following:
-1/2 cup pureed barbeque pork steak with pureed bread;
-1/2 cup pureed buttered corn with pureed bread.
Observation on 9/18/18 at 11:40 A.M. showed Dietary Staff W began plating pureed food
items for lunch meal trays. The texture of the pureed mixed vegetables was chunky and not
smooth. The pureed pork steak texture was stringy and not smooth.
Observation on 9/18/18 at 12:41 P.M. showed the pureed foods test tray contained pureed
mixed vegetables that were chunky and not smooth. The vegetables had visible hulls, chunks
and lumps in the pureed mixture. The pureed mixed vegetables were difficult to swallow
without chewing. The pureed pork steak was stringy and not smooth. The pureed pork steak
was difficult to swallow without chewing.
2. Review of the Diet Spreadsheet for lunch on 9/19/18 (menu cycle-week IV Tuesday) showed

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
residents with a physician’s orders [REDACTED].
Review of the undated Pureed Food Guidelines, provided by the dietary manager, showed the
following directions regarding preparation of pureed entrees:
-Product Amount: 3 ounces cooked or ½ cup cooked (ground);
-1/2 slice bread;
-Broth (use beef broth for beef, pork for pork, pork for ham, chicken for poultry, fish
for fish);
-Place bread, then food to be pureed in blender or food processor. Begin with ½ cup
liquid, puree; then continue to alternate adding liquid and pureeing until product is
correct consistency.
During an interview on 9/19/18 at 10:14 A.M., the Dietary Manager said the facility had 11
residents on a pureed diet. Bread was added during the preparation of the pureed items by
adding a half slice of bread to the mixture per serving per resident.
Observation and interview on 9/19/18 at 10:16 A.M. showed the dietary manager gathered
items to puree the Salisbury steak. She said she planned to prepare 18 servings of
Salisbury steak so there was extra leftover. She would use nine pieces of bread for the
puree preparation. The dietary manager added 11 mostly full 4-ounce ladles of broth to
five slices of bread and nine torn up Salisbury steak patties and pureed the mixture
together. The mixture was thin and chunky. She placed this mixture in a steam table pan
and started a second batch of pureed Salisbury steak in the food processor. She used nine
Salisbury steak patties, four slices of bread and ten mostly-full ladles of broth. She
pureed this mixture and added it to the steam table pan. Both final products were thin and
chunky with visible chunks of meat/bread and were not smooth. She said the puree should be
between a pudding and mashed potato consistency and not too thick and not too runny.
Purees should be smooth in texture.
Observation on 9/19/18 at 12:31 P.M. showed the pureed test tray contained pureed
Salisbury steak. The consistency of the pureed steak was very thick and chunky. The
mixture was difficult to swallow without trying to chew the bite of food.
3. During an interview on 9/19/18 at 3:30 P.M., the consultant dietician said pureed items
such as vegetables and meat should be pudding or mashed potato consistency and preferably
smooth in texture. She did not typically get a modified diet tray to sample during her
visits to the facility.
During an interview on 9/20/18 at 9:05 A.M., the dietary manager said staff should follow
the Pureed Food Guidelines when preparing pureed items. She would expect staff to follow
the spreadsheet and would expect all items to be prepared appropriately. Meat that was
grittier in texture, like the pork steak, was harder to get to a smooth consistency. The
pork steak was stringier and doesn’t puree as well. The mixed vegetables that have hulls
also don’t puree as well.
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 and interview, the facility failed to ensure the range hood was free
of grease and debris; failed to ensure trash cans were covered when not in use; failed to
ensure the walk-in cooler floor was clean and free of debris; failed to ensure dishware
was clean when utilized during meal service; and failed to ensure dishware was air dried

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 24)
and not towel dried. The facility census was 109.
1. Observation on 9/18/18 at 10:50 A.M. showed the range hood had an accumulation of
yellow grease with a buildup of dark-colored debris over the fryer and griddle.
Observation and interview on 9/19/18 at 10:35 A.M. showed the range hood baffles had
accumulated yellow grease over the fryer and griddle. Clear grease was visible on the
other remaining baffle filters. Further observation showed the range hood sticker on the
outside of the hood indicated the hood was last professionally cleaned 8/28/18 and was due
again to be cleaned in December. The dietary manager said staff cleaned the range hood
baffles weekly by running them through the dish machine. The dishwasher staff person was
supposed to clean them yesterday.
Observation on 9/20/18 at 9:02 A.M. showed the range hood baffles had accumulated yellow
grease over the fryer and the griddle. Yellow drip formations were visible on the fire
suppression piping and shielded lights inside the hood.
2. Observation on 9/18/18 at 11:14 A.M. and on 9/19/18 at 8:52 A.M. showed the dish
machine room was empty and no staff was present. A large gray rolling trash can sat
uncovered and was halfway full of food waste and paper trash.
Observation on 9/19/18 at 10:51 A.M. showed the trash can in the dish machine room was
uncovered and no staff was present in the room.
Observation on 9/19/18 at 11:55 A.M. of the dish machine room showed the trash can was 1/4
full of food waste and trash. Gray-colored liquid was present in the bottom of the trash
can. The trash can was uncovered. No staff was present in the dish room. The lunch meal
service was in progress.
3. Observation on 9/18/18 at 10:56 A.M. and on 9/19/18 at 8:58 A.M. showed the walk-in
cooler had a large amount of wet yellow-colored liquid on the floor of the cooler.
Numerous onion skins/peels were visible on the metal floor and under the metal shelves.
Observation on 9/20/18 at 9:02 A.M. showed the floor inside the walk-in cooler had dried
yellow liquid and onion skins under the shelving.
4. Observation on 9/18/18 at 12:31 P.M. showed two residents’ lunch trays were prepared
and the plates were covered with a dome lids. The lids were wet and had an accumulation of
wet food debris on the inside and outside of the covers.
Observation on 9/18/18 at 12:41 P.M. showed dietary staff covered two test tray plates
with dome lids. The inside and outside of the two plate covers were dirty with wet food
debris and water droplets.
During an interview on 9/18/18 at 12:42 P.M., Dietary Staff W said the facility does not
have enough trays or tray covers for all the residents, so the kitchen has to get them
back and wash them to be able to serve the rest of the residents.
5. Observation on 9/19/18 at 9:25 A.M. showed Dietary Staff W dried two large steam table
pans with a white cloth. He/she stacked and stored the pans on the storage rack.
6. During an interview on 9/20/18 at 9:05 A.M., the dietary manager said the following:
-The evening cook mopped the walk-in cooler floor daily. She doesn’t know what the yellow
debris is on the walk-in cooler floor and can’t get it up off the floor.
-She would expect the trash cans to be covered. She was not aware the can in the dish room
needed to be covered.
-Dishware should be air dried and not towel dried. Staff was trying to dry the dishware
before storing it;
-Plate domes and bases should be clean without food debris. The facility is running short
on lids and bases and sometimes have to reuse them during a meal. The lids and bases need
to be clean when used.
-The dishwasher staff cleaned the range hood baffles weekly on Tuesdays. The baffles had
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 25)
not been cleaned this week. Maintenance staff wiped down/cleaned the inside of the hood
weekly when the baffles were out of the hood.
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
washed their hands after each direct resident contact and when indicated by professional
standards of practice during personal care; and failed to handle linens to prevent the
transmission of infection for three residents (Residents #57, #68 and #80), in a review of
28 sampled residents. The facility census was 109.
1. Review of the facility’s policy, Handwashing/Hand Hygiene, dated 2001 and revised
(MONTH) (YEAR), showed the following:
-This facility considers hand hygiene the primary means to prevent the spread of
infections;
-All personnel shall follow the handwashing/hand hygiene procedures to help prevent the
spread of infections to other personnel, residents and visitors;
-Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following
situations: when hands are visibly soiled and after contact with a resident with
infectious diarrhea including, but not limited to infections caused by norovirus,
salmonella, shigella and [DIAGNOSES REDACTED]icile;
-Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap
(antimicrobial or non-antimicrobial) and water for the following situations: before and
after coming on duty; before and after direct contact with residents; before preparing or
handling medications; before performing any non-surgical invasive procedures; before and
after handling an invasive device (e.g., urinary catheters, IV access sites); before
donning sterile gloves; before handling clean or soiled dressing, gauze pads, etc.; before
moving from a contaminated body site to a clean body site during resident care; after
contact with a resident’s intact skin; after contact with blood or bodily fluids; after
handling used dressings, contaminated equipment, etc.; after contact with objects (e.g.,
medical equipment) in the immediate vicinity of the resident; after removing gloves;
before and after entering isolation precaution settings; before and after eating or
handling food; before and after assisting a resident with meals and after personal use of
the toilet or conducting your own personal hygiene;
-Hand hygiene is the final step after removing and disposing of personal protective
equipment;
-The use of gloves does not replace hand washing/hand hygiene. Integration of glove use
along with routine hand hygiene is recognized as the best practice for preventing
healthcare-associated infections.
2. Review of the facility policy, Personal Protective Equipment – Using Gloves, dated 2001
and revised (MONTH) 2009, showed the following:
-Gloves must be worn when handling blood body fluids, secretions, excretions, mucous
membranes and /or non-intact skin;
-Gloves shall be used only once and discarded into the appropriate receptacle located in
the room in which the procedure is being performed;
-Wash your hands before and after removing gloves.
3. Review of the facility policy from the Infection Prevention and Control Policies and

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
Procedures, revised 4/23/12, showed the following:
-Soiled linen is held away from the body;
-Soiled linen is bagged or put into carts at the location where it is used, like in the
resident’s room or in containers directly outside the resident’s room;
-Linen is transported and stored in a manner that maintains cleanliness.
4. Review of Resident #68’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument required to be completed by facility staff, dated 8/7/18, showed the resident
required extensive assistance of one staff for personal hygiene.
Observation on 9/20/18 at 10:21 A.M., showed the following:
-Registered Nurse (RN) D and Certified Nurse Assistant (CNA) O entered the resident’s
room;
-CNA O transferred the resident from his/her wheelchair to his/her bed;
-Without washing his/her hands, RN D put on gloves, removed the resident’s pants and
incontinence brief, and positioned the resident on his/her right side;
-The resident was incontinent of bowel;
-RN D cleansed the resident’s rectal area and buttocks, rolled up the soiled incontinence
brief, and tucked it under the resident;
-RN D removed his/her gloves, and without washing his/her hands, put on new gloves, picked
up a tube of barrier cream, squeezed out a small amount of cream onto his/her left hand,
and applied the cream to the resident’s buttock/rectal area;
-RN D removed his/her gloves, and without washing his/her hands, put on new gloves, and
put a new incontinence brief behind the resident;
-RN removed his/her gloves, and without washing his/her hands, put on new gloves, and
applied a dressing to the resident’s coccyx (tailbone) wound;
-RN D removed his/her gloves, and without washing his/her hands, put on new gloves,
removed the soiled incontinence brief that was tucked under the resident’s right hip, and
rolled the resident back and forth to position the clean brief;
-RN D removed his/her gloves, and without washing hands, put on new gloves, assisted the
resident to pull up his/her pants and transferred the resident back to his/her wheelchair.
During interview on 9/21/18 at 7:54 A.M., RN D said staff should wash their hands before
and after cares and in between glove changes. Staff should not touch anything after
removing their gloves and before washing their hands.
5. Review of Resident #57’s admission MDS, dated [DATE], showed the resident required
limited assistance from one staff for personal hygiene.
Review of the resident’s care plan, dated 8/2/18, showed the resident required limited
assistance from one staff for personal hygiene.
Observation on 09/20/18 at 6:00 A.M. showed the following:
-CNA L and CNA K entered the room;
-The resident wore a hospital gown and incontinence brief and sat on the edge of the bed;
-CNA K washed his/her hands, put on gloves, and assisted the resident to lay down on the
bed;
-CNA K placed wash cloths in the resident’s sink and ran water over them. CNA L put on
gloves without washing his/her hands. CNA K squeezed skin cleanser soap on the washcloths
that lay in the sink basin;
-CNA K removed the resident’s wet incontinence brief and cleansed the resident;
-Without removing his/her soiled gloves, CNA K assisted CNA L to dress the resident, and
to assist the resident to sit on the side of the bed;
-CNA K and CNA L transferred the resident from the bed to the wheelchair;
-Without removing his/her soiled gloves, CNA K combed the resident’s hair;
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
-CNA L removed the resident’s bed sheets and linens and put them in a trash bag. He/she
left the room without removing gloves. CNA L touched the key pad and put in the code to go
out of the unit door and to the soiled utility room to deposit the soiled linen bag,
touching the soiled utility room door, and then came back inside the unit door.
6. Review of Resident #80’s admission MDS, dated [DATE], showed the resident required
limited assistance from one staff for personal hygiene;
Review of the resident’s care plan, dated 8/12/18, showed the resident required limited
assistance of one to two staff for personal hygiene.
Observation on 09/20/18 at 6:14 A.M., showed the following:
-CNA L and CNA K were in the resident’s room after assisting the resident’s roommate
Resident #57 with personal cares;
-CNA K removed his/her gloves, put on new pair of gloves without washing his/her hands,
placed clean washcloths into the sink to wet them, squeezed soap on the washcloths, and
left the washcloths inside the sink while CNA L and CNA K assisted the resident to dress;
-CNA K performed perineal care, and without removing his/her gloves, assisted the resident
to the wheelchair;
-CNA K removed his/her gloves, did not wash his/her hands, placed the resident’s soiled
linens into a trash bag, and gave the bag with soiled linens to CNA L;
-CNA L removed his/her gloves, did not wash his/her hands, and held the bag of soiled
linens against the side of his/her body, picked up another bag of trash, and pushed the
resident in the wheelchair to the dining room;
-CNA L took the two bags of soiled linens, pressed the key pad to release the unit door,
walked out of the unit to the soiled utility room to deposit the linens and trash, touched
the door knob and key hanging above the door, opened the unit door and came back inside.
During interview on 9/20/18 at 6:55 A.M., CNA L said the following:
-He/she was to wash his/her hands when he/she came into the facility from outside, when
he/she dumped trash/linens, when he/she changed gloves, and before putting on gloves;
-There was no soiled linen cart for soiled linens on the special care unit.
-After providing care to Resident #80, he/she carried the two bags of soiled linens to the
soiled linen room. He/she didn’t think about the bag up against his/her clothing, but
should not have done this.
During interview on 8/20/18 at 7:10 A.M., CNA K said he/she was to wash his/her hands
before entering and leaving a resident’s room, after removing his/her gloves, and when
he/she used the bathroom;
7. During interview on 09/21/18 at 2:07 PM, the director of nursing said the following:
-She expected staff to wash their hands and put on gloves as soon as they enter a
resident’s room;
-She expected staff to remove gloves and wash hands before leaving the room;
-She expected staff to wash hands before, during, and after perineal care;
-She expected staff to remove their gloves and wash their hands when they take trash and
soiled linens out of the unit to the dirty utility room;
-Staff should not wear gloves in the hall, should not touch things with soiled gloves, and
should not place soiled linens against their body.
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
Based on interview and record review, the facility failed to vaccinate eligible residents
with the pneumococcal vaccine as indicated by the current Centers for Disease Control
(CDC) guidelines, unless the resident had previously received the vaccine, refused, or had
a medical contraindication present for four residents (Residents #23, #57, #62 and #99),
in a review of 28 sampled residents. The facility failed to develop policies and
procedures in accordance with the current CDC guidelines for administering the
pneumococcal vaccine. The facility census was 109.
1. Review of the facility policy Pneumococcal Disease: Prevention and Control, and Use of
Pneumococcal [MEDICATION NAME] Vaccine, revised 12/19/11, showed the following:
-Residents who are at risk of pneumococcal diseases will be offered the pneumococcal
vaccine as part of their therapeutic regimen unless the vaccine is contraindicated;
-Pneumococcal vaccine will be offered to all new residents upon admission after
determining, if possible, whether they have previously received the vaccine;
-Residents who refuse to accept the vaccine will be asked to sign a declination form after
the risks and benefits of receiving the pneumococcal vaccine have been fully explained to
them, or their responsible party;
-Documentation of the education provided concerning the risks/benefits of receiving the
pneumococcal vaccine, and the resident’s decision regarding whether to accept or decline
the vaccine will be entered into their medical record;
-Standing orders will be used for administration of vaccines, unless specific orders are
required per state regulations;
-Pneumococcal [MEDICATION NAME] Vaccine: there are currently two available pneumococcal
vaccines, [MEDICATION NAME] 23 and PnuImmune 23;
-Persons who should be vaccinated: Persons [AGE] years and older, persons aged 2-64 who
have chronic illness, persons aged 2-64 who are living in special environments or social
setting such as nursing homes;
-Immuno-compromised person for the potential benefits and safety of the vaccine justify
its use;
-Order vaccine and maintain a supply of pneumococcal vaccine in order to be prepared for
new admissions needing vaccination;
-The policy did not address the current Centers for Disease Control (CDC) guidelines for
the pneumococcal vaccine.
2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time
for Adults, dated 11/30/15, showed the following:
-Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate
vaccine (PCV13, PREVNAR 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23,
[MEDICATION NAME] 23):
-One dose of PCV13 was recommended for adults [AGE] years or older who had not previously
received PCV13;
-One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of
previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was
given at age [AGE] years or older, no additional doses of PPSV23 should be administered;
-For those age [AGE] years or older who had not received any pneumococcal vaccines, or
those with unknown vaccination history, administer one dose of PCV13. Administer one dose
of PPSV23 at least one year later for most adults or at least eight weeks later for adults
with immunocompromising conditions;
-For those age [AGE] years or older who previously received one dose of PPSV23 and no
doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23
for all adults regardless of medical conditions;
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
-For residents age 19-[AGE] years, administer one dose of PPSV23 at 19 through [AGE]
years. This includes adults with chronic heart or lung disease, diabetes mellitus,
alcoholism, chronic liver disease and adults who smoke;
-For residents age 19-[AGE] years, administer one dose of PCV13 then administer PPSV23 at
least eight weeks apart from the PCV13 (at 19-[AGE] years). Administer another PPSV23 at
least five years after the first dose of PPSV23(at 19-[AGE] years).
3. Review of Resident #23’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 6/18/18, showed
the following:
-Cognitively intact;
-Pneumococcal vaccine was up to date.
Review of the resident’s undated face sheet showed the resident was under age 65.
Review of the resident’s Physician Order Sheet, dated (MONTH) (YEAR), showed an order that
the resident may have [MEDICATION NAME] as indicated.
Review of the resident’s Informed Consent for Pneumococcal Vaccine, undated, showed no
evidence the pneumonia education had been addressed with the resident/representative and
the box indicating permission to receive or refuse the vaccination was left blank.
Review of the resident’s immunization record showed the following:
-The resident had received the PPSV 23 vaccination on 9/19/14;
-No evidence the resident received the Prevnar 13 vaccination.
During interview on 9/21/18 at 1:41 P.M., the resident said if his/her physician
recommended he/she should receive another vaccination for pneumonia, he/she would be
agreeable to receiving the vaccine.
4. Review of Resident #57’s face sheet showed the resident was admitted on [DATE]. The
resident was over age 65.
Review of the Pneumococcal Consent/Refusal Form showed the family representative signed
the consent form on 7/25/18 for the resident to receive the pneumococcal vaccine.
Review of the resident’s immunization record showed no pneumonia vaccine history.
Review of the resident’s admission MDS, dated [DATE], showed the following:
-Severely impaired cognition;
-Pneumonia vaccine offered and declined.
During interview on 9/21/18 at 11:05 A.M., the administrator and Director of Nursing said
they had trouble receiving the pneumonia vaccine PPSV 23 when it was ordered in (MONTH)
(YEAR). They would have administered the pneumonia vaccine to this resident within a day
or two when the consent form was signed by the family representative if the vaccine was
available. They would administer the vaccine within 24 to 48 hours of the family giving
consent.
5. Review of Resident #62’s face sheet showed the resident was admitted on [DATE]. The
resident was over age 65.
Review of the resident’s admission MDS, dated [DATE], showed the following:
-Intact cognition;
-The pneumococcal vaccine was not marked and left blank.
Review of the Pneumococcal Consent/Refusal form showed the resident signed the consent
form on 7/26/18, to receive the pneumococcal vaccine.
Review of the resident’s immunization record showed no pneumonia vaccine history.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Pneumococcal vaccine was not up to date;
-Reason: not offered.
During interview on 9/21/18 at 11:05 A.M., the administrator and Director of Nursing said
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:

265118

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

09/21/2018

NAME OF PROVIDER OF SUPPLIER

FRONTIER HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2840 WEST CLAY ST
SAINT CHARLES, MO 63301

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 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
they had trouble receiving the pneumonia vaccine PPSV 23 when it was ordered in (MONTH)
(YEAR). They would have administered the pneumonia vaccine to any residents within a day
or two when the consent form was signed by the resident and/or family representative if
the vaccine was available. They would administer the vaccine within 24 to 48 hours of the
family giving consent.
6. Review of Resident #99’s medical record showed the resident was admitted to the
facility on [DATE].
Review of the resident’s informed consent for pneumococcal vaccine, signed on 8/25/18,
showed the resident’s representative gave the facility permission to administer a
pneumococcal vaccination.
Review of the resident’s immunization record showed no evidence the resident had received
a pneumococcal vaccine.
Review of the resident’s admission MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Pneumococcal vaccine not up to date;
-Reason: not offered.
7. During interview on 9/21/18 at 2:06 P.M., the DON said the following:
-The facility followed the CDC guidelines for vaccinations.
-If a consent form was blank, then the vaccine had not been addressed;
-The admitting nurse should be addressing vaccinations on admission;
-Staff should follow-up with the resident/responsible party, hospital or physicians office
to find out immunization history;
-If a resident/representative has signed a consent, then staff should be giving the
vaccination;
-The pneumonia vaccination should be given within 24 to 48 hours after admission.
During interview on 10/1/18 at 1:08 P.M., the Physician Assistant to the Medical Director
said the following:
-He/she would expect the facility policy to include and follow the CDC guidelines for
administering the pneumonia vaccines;
-He/she would expect the facility staff to seek him/her for a resource if the pneumonia
vaccines were not available so they could discuss other possible options available.