Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

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

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

Based on observation, interview, and record review, the facility failed to ensure staff
treated eight out of 23 sampled residents (Resident #4, #19, #21, #23, #29, #278, #435,
and #436) and four additional residents (Resident #3, #429, #437 and one anonymous
resident) in a manner to maintain their dignity when staff made inappropriate comments to
residents during care, stood while assisting multiple residents with feeding and failed to
respond in a timely manner to requests for assistance. The facility had a census of 80.
1. Observation on 08/28/18 at 10:00 A.M., showed Resident #3 and Certified Nurses Aide
(CNA) H in the resident’s bathroom. Observation showed the resident provided pericare to
him/herself. CNA H and CNA J assisted the resident in transferring to his/her wheelchair
without a brief or pad under the resident. CNA H told the resident, Lift your legs in an
abrupt manner. Observation showed the resident sigh and lift his/her legs and the CNA
placed the resident’s brief and pants on his/her lower extremities. CNA H began pushing
down on the resident’s knees. When the resident did not lower his/her legs while the CNA
pushed on them, the CNA said put your legs down, in an abrupt manner. Observation showed
the resident sigh and place his/her head down. The CNA’s told the resident to stand up
while they pulled up the resident’s pull-up and pants.
2. Review of the Resident #4’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 8/25/18, showed
the following:
– Brief interview for mental status (BIMS) score of 8 (cognitively impaired);
– Required extensive assist of one to two staff for activities of daily living;
– Frequently incontinent of bladder and always incontinent of bowel;
– At risk for pressure sores.
Observation on 8/27/18 at 4:00 P.M., showed Certified Nurse Aide (CNA) N and CNA O
provided incontinence care to the resident. Further observation showed the resident was
very anxious, making repeated statements to staff not to hurt him/her as he/she had been
through a lot. CNA O said to the resident in a harsh tone What have you been through? The
resident did not respond to the CNA.
During an interview on 9/4/18 at 6:01 P.M., Resident #4’s family members (FM) said the
following:
-The resident’s family member said the resident was half out of his/her wheelchair,
sliding out, and it took 30 minutes to find staff to transfer the resident to bed on
9/4/18 around 2:30 P.M.; -Staff told them they were going to clean the resident up and
it’s been three hours;
-The resident was still in his/her same clothes and needed his/her incontinence brief
changed;
-Hospice staff were coming today to evaluate the resident for hospice services.
Observation on 9/4/18 at 6:10 P.M., showed the resident lay in bed sleeping, partially
dressed and staff had not come in to provide assistance.
During an interview on 08/31/18 at 11:07 A.M., the Director of Nurses (DON) said the
facility had a recent in-service on resident rights and dignity is a work in progress.
He/She said it was not appropriate for staff to say that to a resident.
3. Review of Resident #19’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severe cognitive impairment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 1)
-Minimal depression;
-No behaviors or rejection of care;
-Required extensive assist of one staff with bed mobility, dressing, and bathing;
-Required limited assist of one staff with personal hygiene and eating;
-Dependent on one staff for toileting and two staff for for transfers;
-Always incontinent of bowel and bladder;
-Had one fall;
-Received 51% or more of daily nutrition and 501 cubic centimeters (cc) or more of daily
fluids through tubefeeding;
-At risk for pressure ulcers.
Review of the resident’s care plan, dated 6/19/18, showed staff assessed the resident as
at risk for his/her needs not being met related to memory impairment and relying on staff
for most decision-making. Staff are directed to anticipate and provide daily care as
indicated, provide/encourage activities that promote memory, promote dignity, converse
with the resident and ensure privacy while providing care, and identify themselves with
each contact.
Additionally, staff documented the resident is at risk for episodes of pain and may forget
to alert staff. Staff should monitor for s/s of pain. Staff are directed to
administer/observe for effectiveness and possible side effects from pain medication,
administer as needed pain medication, notify physician if resident does not
state/demonstrate relief or reduction of pain after one hour of receiving the first
intervention, and observe and report to nurse signs/symptoms of pain such as crying,
resists moving, resists cares, agitation, grimaces, signs/symptoms of worsening pain.
Review of the resident’s physician order [REDACTED].
-Assess pain every shift;
-[MEDICATION NAME] 325 milligrams (mg) two tabs per gastronomy-tube ([DEVICE]) every six
hours as needed; and
-[MEDICATION NAME] (pain medication) 50mg/325 mg one tab by mouth as need prior to wounds
treatment change ordered on [DATE].
Review of the resident’s Medication Administration Record [REDACTED]
-[MEDICATION NAME] 5 mg/325mg on tablet administered on 8/22/18 at 1:30 P.M., 8/23/18 at
08:00 A.M., and 8/29/18 at 12:00 P.M.
-[MEDICATION NAME] 325 mg two tablets on 08/21/18 at 8:00 A.M., 8/28/18 at 9:45 A.M., and
8/30/18 at 7:20 P.M.
Observation on 08/28/18 at 09:14 A.M., showed the resident lay on his/her left side with
tube feeding infusing and head of bed slightly elevated. Observation showed the resident
moaned out loud and staff walked by the room without stopping to assist the resident.
Observation on 8/28/18 at 04:29 P.M., showed the resident lay flat in bed, and screamed
out. Observation showed the resident stared at a blank TV screen and no staff stopped to
address the resident’s needs.
Observation on 08/29/18 at 08:36 A.M., showed Registered Nurse (RN) R entered the
resident’s room, without pulling the privacy curtain, turned off the resident tube
feeding, disconnected the tubing, administered the resident’s medication, and reattached
the tube feeding. RN R did not speak to the resident or inform the resident what he/she
was doing.
Observation on 8/29/18 at 9:00 A.M., RN R said the resident is out of pain medication that
he/she needs before his/her treatment is completed. The RN said he/she will have to pull
some from the emergency kit (e-kit).
Observation on 8/29/18 at 10:58 A.M., showed the resident on his/her left side with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 2)
feeding infusing, moaning out loud Help. Observation showed no staff enter the resident’s
room.
Observation on 08/29/18 at 03:30 P.M., showed physical therapy (PT) assistant complete the
resident’s wound treatment. Observation showed the resident moan out with facial grimacing
multiple times through the procedure. The PT assistant did not address the resident’s
moaning and facial grimacing. The PT assistant said he/she has been working with resident
for about 2 weeks because the resident’s wound deteriorated.
Observation on 08/29/18 at 04:34 P.M., showed the resident hollered out help and could be
heard at the nurses station. Further observation showed the unidentified nurse enter the
resident’s room and tell the resident that he/she knows how to use his/her call light. The
nurse said he/she would be back after administering medication and then walked past
the room. Observation showed the resident continued to yell please help me.
Observation on 08/29/18 at 04:40 P.M., showed an unidentified nurse enter the resident’s
room. Observation showed the nurse tell the resident to keep it in the bed referring to
the resident’s call light.
Continuous observations on 08/30/18 from 02:41 A.M. to 03:47 A.M., showed the resident’s
door shut to his/her room. Upon entering, observation showed the resident lay on his/her
back with the head of bed flat, the resident’s tube feeding machine beeping, and the
resident moaning out loud with intermittent coughing. No staff entered the room to address
the resident’s needs.
Observation on 08/30/18 at 03:48 A.M., showed LPN E placed a new bottle of tube feeding
and flush bag and connect the feeding to the resident. Observation showed the resident
continued to moan out with head of bed not elevated. Observation showed the LPN hold a
wash cloth up to the resident’s mouth and tell him/her to spit out the saliva and mucous
in his/her mouth. The LPN left the room and the resident continued to moan.
Observation 08/30/18 at 03:56 A.M., showed CNA C placed the tube feeding on hold and asked
the resident to spit into a towel. The CNA pulled down the resident’s blanket and removed
his/her brief from the front, then turned the resident side to side providing pericare.
Observation showed the resident cried out with facial grimacing with turning and
repositioning. The CNA asked the resident what was wrong after he/she positioned the
resident’s legs in the bed and the resident said ouch. The resident did not respond. The
CNA asked if the resident needed something for pain and the resident shook his/her head
yes.
Observation on 08/30/18 at 04:18 A.M. to 5:24 A.M., showed the CNA did not report to the
nurse when he/she left the resident’s room that the resident was in pain and asked for
medication. Observation showed the resident continued to holler out help me and loudly
moaned.
During an interview on 08/30/18 at 05:25 A.M., LPN E said the resident moans out sometimes
when he/she has stuff in his/her mouth. The LPN said he/she gave him Tylenol earlier and
he/she plans on going back.
Review of the resident’s MAR, dated (MONTH) (YEAR), showed no documentation of Tylenol
administered to the resident on 8/30/18 during the 11:00 P.M. to 7:00 A.M. night shift
hours.
4. Review of Resident #21’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severe cognitive impairment;
-Required extensive assistance of two staff with bed mobility, toileting, and transfers;
-Required extensive assistance of one staff for dressing and personal hygiene;
-Dependent on one staff for bathing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 3)
-Always incontinent of bowel and bladder; and
-Receives 51% or more of daily nutrition by tubefeeding.
Observation on 08/28/18 at 08:57 A.M., showed the resident positioned in front of the
nurses station with blanket off to the side, shirt raised and abdomen showing, and pant
legs pulled up to the resident’s knees. Observation showed staff at the nurses desk and
staff walking by the resident.
Observation on 08/28/18 at 04:20 P.M., showed the resident reclined back in his/her
geri-chair with shirt pulled up exposing [DEVICE] and pant legs pulled up above the
residents knees.
Observation on 08/31/18 at 10:22 A.M., showed the resident up in his/her geri-chair by the
nurses station with his/her eyes open. Observation showed the resident’s [DEVICE] exposed
with his/her shirt up raised up to the resident’s chest.
5. Review of Resident #23’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Mild cognitive impairment;
-Minimal depression;
-No behaviors, rejection of care, wandering, or [MEDICAL CONDITION];
-Required extensive assistance of one staff for bed mobility, dressing, eating, and
personal hygiene;
-Required extensive assistance of two or more staff for transfers;
-Dependent on one staff for bathing;
-Required set-up assistance with eating;
-No limitations in range of motion (ROM);
-Wheelchair for mobility;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-No falls;
-At risk for pressure ulcer development with pressure reducing device in chair and bed;
-Received antidepressant medication for the last seven days;
-No plans for discharge.
Review of the resident’s care plan, updated 6/20/18, showed the resident is at risk for
psychosocial well-being problem related to the [DIAGNOSES REDACTED].
-Arrange for clergy or spiritual leader of choice to visit, if requested or desired;
-Assist in learning stress management/relaxation technique;
-Assure the resident that symptoms of grieving are normal and will improve with time;
-Determine the resident’s executions and discuss each in realistic terms;
-Discuss coping strategies with the resident;
-Discuss with the resident concerns/fears of being unwanted or feeling useless; and
-Give positive reinforcement as initiative/involvement improves/attempts to solve
conflicts.
Additionally, staff are directed to invite, encourage, remind, and escort the resident to
activity programs consistent with the resident’s interests, promote dignity, and converse
with the resident and ensure privacy while providing care.
Review of the resident’s Social Service Assessment, dated 12/17/17, showed the social
service director (SSD) assessed the resident as:
-Adjusting well;
-Alert and oriented to person, place, time, and occasionally situation, modified
independence with decision making;
-Able to make needs known;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 4)
-Received [MEDICATION NAME] (antidepressant) 60 milligrams (mg) daily;
-Anticipated discharge to an assisted living facility (ALF); and
-Enjoys cooking, sewing, singing, reading, and use to play the piano.
Review of the resident’s Social Services note, dated 8/23/18, showed the SSD documented
the resident’s daughter reported that the resident expressed that he/she has thought about
suicide. When the daughter asked why the resident had thought about suicide, the resident
replied, They don’t like me here. The resident’s daughter asked why he/she thinks that no
one likes him/her at the facility, the resident replied, He/she has been stealing all of
their men/women. The SSD spoke with the resident whom stated that she has thought about
suicide. The SSD asked the resident if he/she had a plan and the resident replied he/she
has been thinking about what he/she will wear and he/she will use gas. The resident did
not report any further plans. The resident stated that he/she feels useless and has no
friends. The SSD provided active listening, validation, and encouragement. The Daughter
and SSD spoke with the nurse practitioner (NP) who said that he/she will review the
resident’s medications. an order for [REDACTED]. The DON and administrator made aware. The
DON stated that he/she will have staff observe the resident. Social Services will continue
to follow as appropriate.
Further review of the social services notes, did not show any further documentaion
regarding the resident’s suicidal thoughts or follow-up.
Review of the resident’s nurses note, dated 7/22/18, showed staff documented the resident
had been screaming out and crying at the start of the shift. Also the resident has shown
this behavior over the past week around the same time of day. When asked if something is
wrong, the resident is unable to verbalize any specific complaints. When the resident was
asked if he/she would like to lay down, the resident agreed. After laying down in bed, the
resident became more calm.
Review of the resident’s nurses note, dated 7/31/18, showed staff documented the resident
was yelling out this afternoon in dining room and was redirected a few times by SSD, CNA,
and occupational therapist (OT). At this time the resident is by the nursing station
showing no apparent unmet needs after he/she was assisted to the restroom.
Observation on 8/27/18 at 02:10 P.M., showed the resident sat up in his/her wheelchair,
positioned by CNA H at the nurses station, crying. CNA H said to the resident, You are
really going to have to quit that crying. There is nothing wrong with you. Observation
showed the resident began crying louder and harder. The CNA then asked the resident what
he/she had for lunch. The resident responded, I did not eat lunch, and the CNA said, Yes
you did. The resident continued to cry harder.
Further observation showed the resident stopped crying, began to smile, and answered in a
positive manner, when the surveyor asked the resident about his/her stuffed animal that
he/she held.
During an interview at the same time, RN R said the resident has been crying out more here
lately. Staff just have to talk to him/her and he/she will stop crying and perk up.
Observation on 08/28/18 at 09:09 A.M., showed the resident sat up in his/her wheelchair,
with wheelchair positioned against the wall and facing the nurses station. Observation
showed the resident’s feet on the foot pedals, eyes closed, and head down with a blanket
over him/her.
Observation on 8/28/18 at 10:30 A.M., showed the resident remained his/her wheelchair
facing the nurses station, with his/her eyes closed and no change in position.
Observation on 08/28/18 at 01:24 P.M., showed the resident sat up in his/her wheelchair
facing the nurses station, with his/her eyes closed.
Continuous observations on 8/29/18 from 8:45 A.M. to 9:15 A.M., showed the resident in
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 5)
his/her wheelchair with both foot pedals, sitting in common TV area staring at the TV.
Observation on 8/29/18 at 9:26 A.M., showed the resident say to CNA H, he/she did not want
to watch the show on TV. The CNA did not acknowledge or speak to the resident. CNA H
walked by the resident and went down hall without addressing the resident
Continuous observation on 8/29/18 at 9:30 A.M. to 9:55 A. M, showed the resident remained
in the common area staring at the TV.
Observation on 8/29/18 at 9:56 A.M., showed the resident in the common area repetitively
screaming, I have to get out of here, my daughter is waiting for me. An unidentified CNA
walked by and said, Give me just a minute, I will be right back after I finish this. The
CNA went into another resident’s room. The resident began repetitively screaming loudly, I
can’t get out. Observation showed the resident began crying.
Continuous observations on 8/29/18 from 9:57 A.M. to 10:03 A.M., showed the resident
continued to repetitively scream, I cant get out while crying.
Continuous observations on 8/29/18 from 10:04 A.M. to 10:09 A.M., showed the resident
hollered out HELP, I am going to freeze, while continuing to cry. Further observations
showed a CNA walk down the hall multiple times and did not stop to assist the resident.
Observation on 8/29/18 at 10:10 A.M., showed the resident continued to holler out and cry.
The administrator propelled the resident in front of nurses station and positioned the
wheelchair next to other residents against the wall facing the nursing station, and talked
with the resident. The resident smiled and talked calmly.
Continuous observations on 8/29/18 from 10:11 A.M. to 10:18 A.M., showed the resident
continued to holler out and cry. During the observation at 10:14 A.M., the resident
hollered out I’m still breathing to four different staff members as they walked by. Staff
did not stop to assist the resident.
Observation on 8/29/18 at 10:19 A.M., showed the housekeeping supervisor stop and inform
the resident that exercise will be at 10:30 A.M. in the dining room. The resident said I
do not want to do that. Staff asked the resident what he/she wanted to do and the resident
said, I want to go to bed. Observation showed the housekeeping supervisor propel the
resident to his/her room and position the wheelchair next to his/her bed.
Continuous observations on 8/29/18 from 10:20 A.M. to 10:28 A.M., showed the resident in
his/her room crying. During the observation at 10:28 A.M. an unidentified CNA exited
another resident’s room and asked Resident #23, What is wrong? Before the resident could
respond the CNA said, We are going to get you down to activities and exited the room.
Observation showed the resident started crying out loudly and repetitively saying I want
to get out of here.
Observation on 08/29/18 at 10:29 A.M., showed the Activity Director asked the resident
What is wrong as he/she was walking by the resident’s room. The resident said, I want to
get out of here. An unidentified CNA entered the room and began propelling the resident
down the hall without informing the resident where they were going. The resident asked
where they were going and the CNA told the resident that they were going to activities.
Observation showed the resident said to the CNA that he/she did not want to go to
activities. The CNA continued to propel the resident into the main dining room.
Observation on 8/29/18 at 10:30 A.M., showed the Activity Director and Activity Assistant
position multiple residents in a circle and hand them a handle attached to a parachute.
Activity personnel placed a ball in the center of the parachute. Further observation
showed the resident positioned by a table several feet away from the group performing the
activity by himself/herself. Staff did not encourage or ask the resident if he/she would
like to participate.
Continuous observation on 8/29/18 from 10:30 A.M. to 11:29 A.M., showed the resident
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 6)
remained positioned off to the side of the activity. Further observation showed staff did
not encourage or attempt to get the resident to participate.
Observation on 8/29/18 at 11:30 A.M., showed staff moved the resident from his/her
position during the activity to the dining room table for lunch.
Continuous observations on 8/29/18 from 11:31 A.M. to 12:27 P.M., showed the resident
remained in the dining room Observation showed the resident fed himself/herself and staff
did not engage in conversation with the resident.
Observation on 8/29/18 at 12:28 P.M., showed staff propelled the resident down the hall
and positioned the resident facing the nurses station. Observation showed staff did not
offer to toilet or lay the resident down in bed.
Continuous observation on 8/29/18 from 12:30 to 1:00 P.M., showed the resident remained at
the nurses station without staff acknowledging the resident.
Continuous observations on 8/29/18 from 02:00 P.M. to 3:26 P.M., showed the resident
positioned against the wall facing the nurses station with a blanket on his/her lap. The
resident cried and said he/she needed to go home. Observation showed staff walked by the
resident without addressing the resident’s needs.
Observation on 8/29/18 at 3:27 P.M., showed the resident drank water out of a plastic cup
and straw. Resident #35 place his/her hand on the resident’s arm and the resident began to
cry and holler out. Observation showed staff did not address the resident crying and
hollering.
Continued observations on 08/29/18 from 03:28 P.M. to 03:38 P.M., showed the resident sat
in his/her wheelchair positioned against the wall facing the nurses station, crying out I
want to go home. Observation showed two unidentified nurses sat at the nurses station and
staff walked by. Staff did not acknowledge that the resident was crying or attempt to
redirect the resident.
Observation on 08/29/18 at 03:39 P.M., showed the resident continued to cry. Licensed
practical nurse (LPN) Q asked the resident if he/she wanted to take a nap. The resdient
did not respond to the nurse.
Observation on 08/29/18 at 04:07 P.M., showed an unidentified CNA propel the resident to
the dining room and position him/her at a table in the center of the dining room with only
one other resident in the dining room, and the CNA exited the dining room.
Observation on 08/29/18 at 04:15 P.M., showed the resident in the dining room crying with
no staff present. The surveyor asked the resident how he/she was doing and the resident
replied not good but was unable to answer why he/she was not good. Observation showed the
resident calmed down and quit crying when the surveyor spoke with the resident.
Observation on 08/29/18 at 04:21 P.M., showed the Activity Director walked into the main
dining room and positioned the resident at his/her dining room table without telling the
resident what he/she was doing. Observation showed the Activity Director talking to
another resident about playing bingo earlier. Resident #23 said I do not like bingo, and
the Activity Director responded loud and harsh, I know that’s why I didn’t bring you down
here. The resident looked down at the table.
Continued observations on 8/29/18 from 04:22 P.M. to 04:40 P. M, showed the resident
remained positioned at the dining room table. Observation at 4:41 P.M. showed the surveyor
requested staff to toilet the resident. CNA U propelled the resident to his/her room. The
resident said he/she has not gone to the bathroom all day and probably leaked a little
bit.
Observation on 8/29/18 at 04:45 P.M., showed CNA U left the resident’s room and CNA T
provided pericare.
Observation on 08/31/18 at 10:28 A.M., showed the resident sat up in his/her wheelchair
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 7)
positioned facing the nurses station. Observation showed the resident had a blanket on
his/her lap and sang with intermittent crying. CNA J asked the resident what was wrong as
he/she walked by but did not stop for the resident to respond.
Continuous observations on 8/31/18 from 10:29 A.M. to 10:42 A.M., showed the resident
remained in the same position and continued to sing and cry out without staff attempting
to stopping to see what the resident needed.
Observation on 08/31/18 at 10:43 A.M., showed the resident remained positioned against the
wall facing the nurses station crying and asking to go to his/her room. The Staffing
Coordinator asked RN R if it was ok for the resident to go to his/her room and the RN said
yes. The staffing coordinator propelled the resident to his/her room and positioned
him/her by his/her bed
During an interview on 8/29/18 at 2:40 P.M., CNA H said the resident had recently started
crying out and doesn’t tell staff what is wrong. The resident does this frequently now and
the other day he/she had been doing this all shift. If staff talk with him/her, the
resident will normally stop crying and that is why he/she was at the nurses station with
the CNA. The CNA said the other day he/she had lost patience because he/she was at the end
of shift and attempting to document for the day. The CNA said he/she just got frustrated.
Usually when we ask the resident if he/she needs to use the restroom or wants to lay day,
or if he/she needs something else, the resident will calm down and is able to answer yes
or no, but that day he/she was not saying what he/she needed.
6. Observation on 8/29/18 at 11:45 A.M., showed Resident #29 in his/her wheelchair rolling
up to a table in the dining room and reaching for the salt shaker. At this time, the
Activity Director approached the resident and hollered out and said harshly Don’t you get
into that! I will get you! The resident tensed up and hollered back at the Activity
Director, I will get you!
7. Review of Resident #278’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severe cognitive impairment;
-No behaviors;
-Required extensive assistance of one staff with bed mobility, toilet use, eating, and
personal hygiene.
-Required limited assistance of one staff with dressing;
-Dependent on one staff for bathing;
-Frequently incontinent of bladder and always incontinent of bowel;
-[DIAGNOSES REDACTED].>-Had a fall in the last month;
-Had an unstageable pressure ulcer and a lesion on the foot; and
-Received antidepressants three out of the last seven days prior to the assessment.
Observation on 08/27/18 at 01:55 P.M., showed the resident lay in bed. An unidentified CNA
entered the resident’s room without knocking or announcing themselves.
Observation on 8/27/18 at 5:30 P.M., showed the resident lay in his/her bed uncovered,
with no pants on his/her lower extremities, brief showing and legs off the side of the
bed. Further observation showed the resident was visible from the hallway as staff and
visitors walked by the resident’s room.
Observation on 08/31/18 at 10:37 A.M., showed the resident’s shirt had multiple spots with
food on it.
8. Review of Resident #429’s MDS, dated [DATE], showed:
– Modified independence in decision making, short and long term memory okay;
– No mood or behavior issues;
– Required extensive assist of one staff for all activities of daily living;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 8)
– Incontinent of bladder and bowel;
– One stage II pressure sore (partial thickness loss of dermis presenting as a shallow
open ulcer with a red or pink wound bed, without slough. (MONTH) also, present as an
intact or open/ruptured blister);
-[DIAGNOSES REDACTED].
Observation on 08/27/18 from 5:43 P.M. to 5:48 P.M., showed an unidentified CNA stood to
the side of Resident #429 and fed the resident. Observation showed the CNA entered and
exited the assisted dining room multiple times while he/she assisted the resident with
eating.
During an interview on 09/04/18 at 02:55 P.M., the resident said over the weekend he/she
had been up in his/her geri-chair since early morning and was not put to bed until 12:00
A.M. The resident said he/she asked the staff to please put him/her to bed as his/her leg
and bottom were hurting. He/she said staff never got the nurse to assess for pain
medication. He/she said the two staff took him/her to his/her room and said they were
going to put others to bed and be back to help him/her. The resident said staff just left
me in the room and I was hurting so bad. When staff returned to assist the resident to bed
they wouldn’t listen to him/her before trying to transfer him/her. The resident said
he/she told the staff to get his/her chair closer to the bed. The staff picked him/her up
without using a gait belt, one staff grasped his/her arms and the other staff grasped
his/her legs. The resident said one staff complained about his/her back hurting. The
resident said staff never notified the nurse of his/her pain and he/she did not receive
any pain medication.
9. Observation on 8/27/18 at 05:35 P.M., showed an unidentified CNA delivered trays to the
assisted dining room. Observation showed the CNA tell another CNA Resident #435 is a
feeder as he/she walked away from the food cart.
Observation on 8/27/18 at 5:39 P.M., showed an unidentified CNA stood and fed Resident
#435 a bite, then walked over to another resident and cut up their food. Observation
showed the CNA then left the dining room.
10. Review of Resident #436’s medical record showed the resident admitted to facility on
7/22/18, with [DIAGNOSES REDACTED].
Review of the resident’s admission MDS, dated [DATE], showed staff assessed the resident
as:
– BIMS score of 15 out of 15 (cognitively intact);
– Required limited to extensive assistance of one staff with all activities of daily
living;
– Frequently incontinent of bowel and bladder;
– At risk for pressure sore development;
– Occupational and physical therapy five days a week.
Review of the resident record showed the 48 hour care plan was blank.
During an interview on 08/29/18 at 09:28 A.M., Resident #436 said staff woke him/her up at
3:30 AM to pre-dress him/her in bed. The resident said that was very unusual. He/She said
the staff did not know how to get his/her brace on and had to find the therapy aide to
assist them. The resident said sometimes he/she has to wait two hours for staff to come
change him/her. A few time he/she had incontinence accidents with urine all over the
floor. He/She said residents have to wait for assistance on all shifts.
11. Review of Resident #437’s medical record showed the resident admitted to the facility
on [DATE], from the hospital for physical therapy after suffering a fall at home.
Review of the 48 hour care plan on 8/30/ (TRUNCATED)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Actual harm

Residents Affected – Few

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to obtain the decision to appeal
the denial of skilled Medicare services for three of three sampled residents (Resident
#11, #60 and #278) for notification of appeal rights when skilled services were deemed as
no longer necessary. The facility census was 80.
1. Review of Resident #11’s Notice of Medicare Non-Coverage CMS- form, dated 06/22/18,
showed the resident’s representative signed the document acknowledging the receipt of
their notice of non-coverage of services under Medicare. Additional review showed the
resident’s spouse did not receive the liability notice form, Skilled Nursing Facility
Advanced Beneficiary Notice CMS- form, offering the resident the options of (A) I want my
bill submitted to the intermediary for a Medicare decision and (B) I do not want my bill
submitted to the intermediary for a Medicare decision. The facility did not obtain from
the resident a decision as to whether they wanted to appeal the denial of services by
having the bill submitted to the intermediary for a review of Medicare’s decision.
2. Review of Resident #60’s Notice of Medicare Non-Coverage CMS- form, dated 08/27/18,
showed the resident’s representative signed the document acknowledging the receipt of
their notice of non-coverage of services under Medicare. Additional review showed the
resident’s spouse did not receive the liability notice form, Skilled Nursing Facility
Advanced Beneficiary Notice CMS- form, offering the resident the options of (A) I want my
bill submitted to the intermediary for a Medicare decision and (B) I do not want my bill
submitted to the intermediary for a Medicare decision. The facility did not obtain from
the resident a decision as to whether they wanted to appeal the denial of services by
having the bill submitted to the intermediary for a review of Medicare’s decision.
3. Review of Resident #278’s Notice of Medicare Non-Coverage CMS- form, dated 06/04/18,
showed the facility staff (due to the resident’s cognition and absence of family or
representative) signed the document acknowledging the receipt of their notice of
non-coverage of services under Medicare. Additional review showed the resident’s spouse
did not receive the liability notice form, Skilled Nursing Facility Advanced Beneficiary
Notice CMS- form, offering the resident the options of (A) I want my bill submitted to the
intermediary for a Medicare decision and (B) I do not want my bill submitted to the
intermediary for a Medicare decision . The facility did not obtain from the resident a
decision as to whether they wanted to appeal the denial of services by having the bill
submitted to the intermediary for a review of Medicare’s decision.
4. During an interview on 09/5/18 at 6:40 P.M., the Social Service Designee said she/he
did not give the 1055 form to any of the residents upon discharge to home. Further, the
Social Service Designee said she/he thought it was only provided if the resident was going
to stay in the facility after being discontinued from Medicare.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility staff failed to provide written
notification of transfer to the resident or the resident’s representative for one resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
(Residents #29) who transferred to the hospital and two residents (Residents #49 and #60)
who transferred to another skilled nursing facility. Further, the facility failed to
provide a written notification of transfer to home for one resident (Resident #431). The
facility census was 80.
1. Review of the facility discharge plan policy, dated 10/1/17, showed the following:
– Purpose: Interdisciplinary team participates in developing an effective discharge
planning process based on the patient’s active participation in determining his/her
discharge goals to effectively transition him/her to post-discharge care and reduce
factors leading to preventable readmissions
2. Review of Resident #29’s Discharge Assessment showed staff sent the resident to an
acute care hospital on [DATE] with his/her return anticipated.
Review of the resident’s Reentry Tracking Form showed the resident returned to the
facility on [DATE].
Review of the resident’s medical record showed staff did not provide written notification
to the resident or resident’s representative upon transfer to the hospital.
3. Review of Resident #431’s discharge summary, dated 9/4/18, showed the following:
– Reason for resident’s discharge, therapy/insurance based discharge;
– List of the resident’s current diagnosis;
– List of vital signs: blank;
– Medications listed;
– Recapitulation of Stay:
– Dietary summary – blank;
– Activity summary – blank;
– Nursing summary – blank,
– Pertinent lab tests and results – blank;
– Pertinent Radiology and other test results – blank;
– Pertinent Consultations Findings and Recommendations – blank;
– Rehabilitation Therapy – blank;
– Social services discharge summary: Resident will be discharged to home with medications,
standard wheelchair (16 x 16) with seat cushion, removable arm rest and elevating leg
rest, raised toilet seat, tub transfer bench. Home health support provided;
– Further review showed the discharge did not include a statement of the resident’s appeal
rights, including the name, address (mailing and email), and telephone number of the
entity which receives such requests; and information on how to obtain an appeal form,
assistance in completing the form, and submitting the appeal hearing request. The name,
address (mailing and email) and telephone number of the Office of the State Long-Term Care
Ombudsman was not included in the discharge information.
Review of the resident’s record showed the resident discharged home on[DATE], with a
family member.
4. Record review of Resident’s #49’s face sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].>-Intestinal Obstruction- (gastrointestinal
condition in which digested material is prevented from passing normally through the
bowel);
-Alcoholic [MEDICAL CONDITION] of Liver- (advanced form of liver disease related to
drinking alcohol);
-Chronic Pain – (persistent pain that last weeks to years); and
-Abdominal Pain.
Record review of the resident’s Care Plan, dated 7/13/18, showed:
-The resident had a decline in mobility and strength;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
-Required assistance with all Activities of Daily Living Needs (ADL’s);
-Required minimal assistance with bed mobility, dressings, locomotion, toilet use and
personal hygiene.
Record review of the resident’s undated discharged Summary, showed:
-The resident was discharged to a skilled nursing facility on 8/21/18.
Record review of the resident’s closed record, dated 8/31/18, showed the facility did not
provide the resident and/or the resident’s representative with written notice of transfer
or discharge when the resident was transferred to a skilled nursing facility.
5. Record review of Resident’s #60’s face sheet showed he/she was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].>-Mild Cognitive Impairment (the stage between the
expected concisely decline of normal aging and the more serious decline of dementia. It
can involve problems with memory, language, thinking and judgement);
-Dysphasia (language disorder marked by deficiency in the generation of speech or due to
brain disease or damage); and
-Type II Diabetes.
Record review of the resident’s medical record, dated 8/31/18, showed there was no written
notice of transfer or discharge to the resident and/or the resident’s representative when
the resident transferred to a skilled nursing facility or home.
During an interview on 8/31/18 at 1:30 P.M., the Medical Records staff said he/she was
unable to find a copy of the resident’s Discharge Summary in the resident’s medical
record.
Record review of the resident’s Medical Record dated 8/31/18, showed no record of the
Discharge Summary in the resident’s medical record.
During an interview on 09/04/18 at 4:47 P.M., the administrator said he sends the transfer
form (Nursing home transfer form for hospital), but does not send anything to the resident
or resident representative.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to complete a significant
change Minimum Data Set (MDS), a federally mandated assessment tool, within 14 days as
directed by the Resident Assessment Instrument (RAI) manual, after staff identified two or
more areas of significant change for three residents (Resident #19, #23, and #278) of 23
sampled residents. The facility census was 80.
1. Review of the facility’s RAI and Care Plan policy, last revised 11/28/16, showed the
following:
-The MDS uses assessment, patient observation, staff, family and patient interviews to
form the foundation of the comprehensive assessment;
-MDS assessments are completed at a minimum upon admission, quarterly, annually, and with
a significant change in patient status;
-The information identified using the MDS and Care Area Assessment (CAA) process is used
to develop an individualized person-centered Care Plan that includes the patient’s voice,
the patient’s goals while residing in the facility, and for discharge that assist the
patient to attain and/or maintain their highest practicable level of well-being.
2. Review of Resident #19’s annual MDS, dated [DATE], showed staff assessed the resident
as the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Severe cognitive impairment for daily decision making with a BIMs (brief interview for
mental status) score of 3;
-Required extensive assistance of one staff for bed mobility, dressing, toileting,
personal hygiene, and bathing;
-Required extensive assistance of two or more staff for transfers;
-Dependent on one staff for eating;
-No limitations to range of motion (ROM) to both upper and lower extremities;
-Rarely had mild pain;
-No falls;
-Had a significant weight loss, weight 106 pounds (lbs);
-Received 25% or less of daily calories by a feeding tube;
-At risk for pressure ulcers; and
-No current skin breakdown.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as the following:
-Severe cognitive impairment for daily decision making with a BIMs score of 6;
-Required extensive assistance of one staff for bed mobility, dressing, and bathing;
-Required limited assistance of one staff for eating and personal hygiene;
-Dependent on two or more staff for transfers;
-Dependent on one staff for toileting;
-Had limited ROM to both lower extremities;
-No pain;
-Had one fall since the previous assessment;
-No significant weight loss, weight 115 lbs;
-Received 50% or more of daily calories by a feeding tube;
-At risk for pressure ulcers;
-No current skin breakdown.
Further review of the resident’s annual MDS and quarterly MDS, showed staff did not
complete a significant change MDS assessment, as directed by the RAI manual, for the
resident’s changes in his/her Activities of Daily Living (ADL’s) care requirements,
cognitive status, tube feeding caloric intake, and falls.
Review of the resident’s physician order [REDACTED].
-[MEDICATION NAME] 1.2 calorie 0.6 gram (gm), 1.2 kilocalorie (kcal)/milliliter (ml)
liquid to infuse via [DEVICE] ([DEVICE]) at 70 ml/hour continuously (ordered 5/18/18);
-Barrier cream to affected areas with pericare as needed (5/18/18);
-Cleanse wound to sacrum with normal saline, may apply skin prep to the peri wound, apply
Manuka Pli (sterile honey gel ointment) to wound bed and cover with a dry dressing daily
and as needed (ordered 7/3/18);
-Mechanical soft diet for pleasure eating (ordered 5/18/18).
Review of the resident’s nurses notes, dated 5/16/18, showed the nurse documented the
resident readmitted from the hospital and is alert and oriented to two. The resident had
an admitting [DIAGNOSES REDACTED].
Review of the the nurse’s notes, dated 5/17/18, showed the resident is alert and oriented
to one or two (person, place, and time), requires total care, is incontinent of bowel and
bladder, [DEVICE] checked for placement, and the resident receives nothing by mouth.
Review of the nutrition note, dated 7/24/18, showed the Registered Dietician (RD)
documented the resident was being reviewed due to an unstageable wound. The resident’s
tube feeding meets nutritional needs. Diet is mechanical soft for pleasure feeding only
and has chosen to not eat by mouth recently.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
Review of the nurses notes, dated 6/4/18 through 8/14/18, showed the resident had a
non-injury fall and staff found the resident on the floor on 6/4/18 and 6/17/18. Further
review showed the resident had a fall out of bed receiving an abrasion to the chin and
complained of pain all over on 8/13/18.
Review of the resident’s physician progress notes [REDACTED]. The resident is to continue
with local wound treatment.
Further review of the resident’s medical record, showed staff did not complete a
significant change MDS assessment within 14 days of identifying a significant change in
status, after the resident’s quarterly assessment on 6/18/18. Review showed the resident
had a minor injury fall on 8/13/18, developed a facility acquired unstageable pressure
ulcer, and declined in his/her ADL abilities in (MONTH) through August.
3. Review of Resident #23’s admission MDS, dated [DATE], showed staff assessed the
resident as the following:
-Moderate cognitive impairment for daily decision making with a BIMs of 10;
-Felt tired or had little energy 12-14 days (nearly every day);
-Required extensive assistance of one staff for bed mobility and dressing;
-Required extensive assistance of two or more staff for transfers;
-Required limited assistance of one staff for eating, toileting, and personal hygiene;
-Dependent on one staff for bathing;
-Frequently incontinent of bladder; and
-Occasionally incontinent of bowel.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as the following:
-Cognitively intact for daily decision making with a BIMs of 15;
-Felt tired or had little energy zero days (none);
-Required extensive assistance of one staff for bed mobility, transfers, dressing,
toileting, and personal hygiene;
-Required limited assistance of one staff for eating;
-Dependent on staff for bathing;
-Always incontinent of bladder; and
-Frequently incontinent of bowel.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as the following:
-Moderate cognitive impairment for daily decision making with a BIMs of 13;
-Felt tired or had little energy 2-5 days (several days);
-Required extensive assistance of one staff for bed mobility, dressing, toileting, and
personal hygiene;
-Required extensive assistance of two staff for transfers;
-Required set-up assistance with eating;
-Dependent on staff for bathing;
-Always incontinent of bladder; and
-Frequently incontinent of bowel.
Further review showed the resident had a decrease in cognitive impairment and mood,
required more assistance with toileting and personal hygiene, less assistance with
transfers, and an increase in incontinence status for bowel and bladder between the
resident’s admission MDS and the 3/19/18 quarterly MDS. Additionally, the resident had an
increase in his/her BIMs, mood, and an increase in the number of staff required to
transfer the resident. The facility staff did not complete a significant change MDS within
14 days of identifying a significant change.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
4. Review of Resident #278’s admission MDS, dated [DATE], showed staff assessed the
resident as the following:
-Moderate cognitive impairment with a BIMs score of 13;
-Felt tired or had little energy 2-6 days (several days);
-Required limited assistance of one staff for transfers and personal hygiene;
-Required limited assistance of two or more staff for bed mobility, dressing, and
toileting;
-Required extensive assistance of one staff with bathing;
-Occasionally incontinent of bladder;
-Frequently incontinent of bowel;
-No falls;
-No skin breakdown or wounds;
-Did not receive antidepressants.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as the following:
-Severe cognitive impairment;
-Felt tired or had a little energy zero days (none);
-Required limited assistance of one staff with dressing;
-Required extensive assistance of one staff with bed mobility, eating, toileting, and
personal hygiene;
-Dependent on staff for bathing;
-Frequently incontinent of bladder;
-Always incontinent of bowel;
-Had a fall in the last month;
-Had one unstageable pressure ulcer with slough and a lesion on the foot;
-Received antidepressant medication three out of the seven look back days or since
admission.
Further review showed staff did not complete a significant change MDS within 14 days of
identifying the resident developed an unstageable pressure ulcer, had a decline in
cognitive status, ADL ability, bowel and bladder continence, began receiving
antidepressants and had falls.
5. During an interview on 9/5/18 at 6:33 P.M., MDS/Care Plan Coordinator A said he/she
reviews residents’ notes, physician history and physicals (H&P), Certified Nurses Aide
(CNA) ADL documentation, interviews with residents and nurses, and looks at the nurses
notes before completing the MDS assessments. A significant change requires three things to
change such as a weight loss, decline in ADL’s, significant change in cognitive status,
discharge from hospice or removal of a foley catheter. He/she compares the information
between the quarterly assessments, if the resident develops a wound. The wound nurse will
provide him/her with the wound measurements.

F 0655

Level of harm – Minimal harm or potential for actual 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 interview and record review, facility staff failed to complete a baseline care
plan within 48 hours of admission and failed to document the baseline care plan was

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
reviewed with the resident or responsible party for eight residents (Residents #23, #278,
#77, #433, #431, #436, #60, and #178) out of 23 sampled residents. The facility census was
80.
1. Review of Resident #23’s admission Minimum Data Set (MDS), a federally mandated
assessment tool, dated 12/24/17, showed staff assessed the resident as follows:
-admitted [DATE];
-Moderate cognitive impairment;
-Required extensive assistance of one staff for bed mobility, dressing, and bathing;
-Required extensive assistance of two or more staff for transfers;
-Required limited assistance of one staff for eating, toilet use, and personal hygiene;
-Frequently incontinent of urine;
-Occasionally incontinent of bowel;
-Had falls in the last six months prior to admission;
-At risk for pressure ulcers; and
-Received antidepressants six out of seven days and antibiotics four out of seven days,
during the last seven days or since admission/entry if less than seven days.
Review of the resident’s baseline care plan, undated, showed staff documented the
following:
-The resident is a do not resuscitate (DNR);
-At risk for falls related to unsteady ambulation;
-Needed assistance with Activities’s of daily living (ADLs) related to impaired mobility.
The resident wished to improve ability to dress, perform personal hygiene, walking, and
transferring;
-Resident to receive Physical therapy (PT), Occupational therapy (OT), and Speech therapy
(ST); and
-Occasionally incontinent of bowel and bladder and needs toileting assistance.
Further review of the resident’s 48 hour baseline care plan, showed staff did not document
problem start dates, include signatures of staff who added the intervention, did not
complete all sections, did not include the care plan conference review, and signatures
that the resident or resident representative reviewed and received a copy of the baseline
care plan, and physician orders.
2. Review of Resident #278’s admission MDS, dated [DATE], showed staff assessed the
resident as the following:
-Date of admission 3/7/18;
-No cognitive impairment for daily decision making;
-No behaviors;
-Minimal depression;
-Required limited assistance of two staff for bed mobility, dressing, and toileting;
-Required limited assistance of one staff for transfers, eating, and personal hygiene;
-Required extensive assistance of two staff for bathing;
-Occasionally incontinent of bladder;
-Frequently incontinent of bowel;
-No falls;
-At risk for developing pressure ulcers;
-Received antibiotics for six out of seven days prior to assessment;
-Had an active discharge plan to the community; and
-Received PT, OT, and ST.
Review of the resident’s 48 hour admission baseline care plan, dated 8/30/18, showed staff
documented the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-Safety goal of home with caregiver with scheduled appointments (no discipline marked);
-At risk for falls initiated by nursing services related to new environment, unable to
understand safety strategies, recent falls. The staff are to provide education with the
mechanical lift and minimizing fall risk, call light use, wearing nonskid footwear;
-Incontinence problem start 8/30/18. The resdient is occasionally incontinent and requires
assistance with toileting and hygiene. Staff are to educate and provide pericare as
needed.
Further review showed staff did not complete the baseline care plan within 48 hours of
admission, did not complete all care areas related to the resident, and did not contain
signature from the resident or resident representative that the baseline care plan and
physician orders [REDACTED].
3. Review of Resident #178’s Admission MDS, a federally mandated assessment tool, dated
3/5/18, showed the staff assessed the resident as follows:
-admitted [DATE];
-Required extensive assistance with bed mobility, transfers, dressing, toileting, and
personal hygiene;
-[DIAGNOSES REDACTED].
-Falls prior to admission;
-Received insulin in last 7 days;
-Received Physical Therapy, Occupational Therapy and Speech Therapy.
Review of the resident’s 48 hour baseline care plan, showed staff did not complete the
form and it was not signed by the resident or his/her representative.
4. Review of Resident #60’s Admission MDS, dated [DATE], showed the staff assessed the
resident as follows:
-admitted [DATE];
-Required extensive assistance with bed mobility, transfers, dressing and toilet use;
-Occasional incontinence of urine;
-Frequently incontinence of stool;
-[DIAGNOSES REDACTED].
-Falls since admission;
-Received insulin injections in last 7 days;
-Received Physical Therapy, Occupational Therapy and Speech Therapy in the last 7 days.
Review of the resident’s 48 hour baseline care plan, showed staff did not complete the
form and it was not signed by the resident or his/her representative.
5. Review of Resident #77’s physician order [REDACTED].
Review of the physician order [REDACTED].
Review of the resident’s 48 hour admission care plan showed the form was not completed and
signed by the resident or his/her representative.
6. Review of Resident #431’s medical record showed the resident admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Review of medical record showed the 48 hour care plan was blank.
Review of the resident’s minimum data set (MDS), an assessment instrument required to be
completed by facility staff, dated 6/15/18, showed staff assessed the resident as follows:
-admitted : 6/1/18;
-Cognitively intact;
-Required assisting of one staff for activities of daily living;
-Incontinent of bowel and bladder;
-Had mild to moderate pain frequently;
-At risk for pressure sore development.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
During an interview on 8/29/18 at 2:21 P.M., the resident said he/she:
-Had a catheter when he/she first came to facility, but it was removed;
-Received IV antibiotics for urinary tract infection;
-Receives physical therapy and they assist him/her with ambulating/using prosthesis;
-Plans to return home upon discharge;
-Not aware or provided a copy of care plan upon admission.
7. Review of Resident #433’s medical record showed the resident admitted on [DATE], with
[DIAGNOSES REDACTED].
Review of the resident’s medical record showed the 48 hour care plan was blank.
During an interview on 8/28/18 at 10:18 A.M., the resident said he/she had a recent hip
replacement and [MEDICAL CONDITION]. The resident said the surgeon must have hit a nerve
during the surgery, as he/she has pain that goes all down his/her leg. The resident said
he/she had his/her other hip replaced and didn’t have any problems. He/She said the staff
have to be very careful when getting him/her up into the chair or to bed. The resident
said he/she did not receive a copy of a care plan after admission.
8. Review of Resident #436’s medical record showed the resident admitted on [DATE], with
[DIAGNOSES REDACTED].
Review of the resident’s admission MDS, dated [DATE], showed staff assessed the resident
as follows:
-BIMS score of 15 out of 15, cognitively intact;
-Required limited to extensive assistance of one staff with all activities of daily
living;
-Frequently incontinent of bowel and bladder;
-At risk for pressure sore development;
-Occupational and physical therapy five days a week.
Review of the resident record showed the 48 hour care plan was blank.
During an interview on 8/29/18 at 9:28 A.M., the resident said he/she developed a pressure
sore on his/her foot after coming here. The wound nurse got him/her boots to wear at
night. He/She said it is getting better. The resident is not sure how/why the wound
developed. He/She said he/she couldn’t get up when first admitted . He/She said staff had
him/her doing his/her own repositioning and the wound developed a few weeks after
admission to facility. The resident said he/she did not know about the initial plan of
care and staff did not provide him/her with a copy of it.
Review of the resident’s wound report, dated 8/8/18, showed the following:
– Date of origin 8/02/18;
– Stage II pressure sore measuring 2 cm by 2 cm with no depth;
– Wound base closed blister;
– Treatment response- improving;
– Assess every seven days;
– Physician order [REDACTED].
9. During an interview on 9/05/18 at 6:51 P.M., Licensed Practical Nurse (LPN) A said the
charge nurses are responsible for completing the 48 hour care plan for new admissions.
Staff talk with the resident face to face and assess health needs they have. The nurses
also receive and review reports from the hospital. LPN A said staff perform skin
assessments and orient the residents to the facility.
10. During an interview on 9/05/18 at 7:03 P.M., the social service designee (SSD) said
she was involved in the 48 hour care plan. The SSD said for a while it was the admission
staff’s responsibility and sometimes social services. She was not aware a copy of the 48
hour care plan is to be provided to resident or representative. She said she completes the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
brief interview for mental status, nursing performs the physical assessment, and each
department head completes their assessment portion.
11. During an interview on 9/5/18 at 6:58 P.M., the director of nursing (DON) said the
charge nurses are responsible for filling out the 48 hour baseline care plan. The baseline
care plan is part of the admission paperwork that goes to the nurse. There is not
currently a plan in place to ensure the baseline care plan is completed.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide care
in a manner which met professional standards of quality for three residents (Residents
#13, #19 and #278) of a sample of 23 residents. The facility census was 80.
1. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 6/16/18, showed staff assessed the resident as follows:
-[DIAGNOSES REDACTED].
-Received 51% or more of his/her nutrition through a feeding tube.
Review of the resident’s comprehensive care plan, dated 3/19/18, directed staff on the
following interventions:
-Observe for [MEDICAL CONDITION] activity and report to physician;
-Observe lab values for therapeutic level of anticonvulsant medications;
-Observe status after [MEDICAL CONDITION].
Further review showed the comprehensive care plan did not address the need for suctioning
the resident.
Review of the resident’s physician’s orders [REDACTED]. Further review of the POS showed
the physician ordered [MEDICATION NAME] (anticonvulsant) daily.
Observation on 0/29/18 at 8:23 A.M., showed the resident lay in bed with the head of the
bed elevated 45 degrees. The resident had sputum oozing out of her/his mouth. Further
observation showed there was an empty suction machine on the table next to the resident’s
bed.
During an interview on 9/5/18 at 11:15 A.M., Licensed Practical Nurse (LPN) Y said when
he/she reviewed the resident’s medical record he/she was unable to find an order to
suction the resident as needed. Further, LPN Y could not find an order to check the
[MEDICATION NAME] level within the last 12 months. During the interview a Nurse
Practitioner said the [MEDICATION NAME] level is recommended to be checked every 3-6
months.
2. Review of Resident #19’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Severe cognitive impairment;
-Minimal depression;
-No behaviors or rejection of care;
-Required extensive assist of one staff with bed mobility, dressing, and bathing;
-Required limited assist of one staff with personal hygiene and eating;
-Dependent on one staff for toileting and two staff for transfers;
-Always incontinent of bowel and bladder;
-Had one fall;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-Received 51% or more of daily nutrition and 501 cubic centimeters (cc) or more of daily
fluids through tube feeding;
-At risk for pressure ulcers.
Review of the resident’s care plan, dated 6/19/18, showed staff assessed the resident as
at risk for his/her needs not being met related to memory impairment and relying on staff
for most decision-making. Staff are directed to anticipate and provide daily care as
indicated, administer fluids per [DEVICE] ([DEVICE]) as ordered, administer tube feeding
formula and flushes as ordered, check the [DEVICE] placement by draw back aspiration and
auscultation prior to administering any bolus enteral feeding, keep head of bed up at
least 30 degrees, observe for [MEDICAL CONDITION] activity and report to the resident’s
physician, observe for side effects of anticonvulsant medications, observe lab values for
therapeutic level, observe status after [MEDICAL CONDITION], and report any changes in
cognition or behavior to resident’s physician.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the physician
ordered the following:
-Check and verify placement of the [DEVICE] prior to enteral feedings, water flushes, and
medication administrations;
-Flush [DEVICE] with 10 milliners (ml) of water between each medication during
administration;
-[MEDICATION NAME] 1.2 Cal 0.06 gram/1.2 kilocalories (kcal)/ml liquid at 70 ml/her
continuously;
-[MEDICATION NAME] ([MEDICAL CONDITION] medication) 500 mg table by mouth two times daily;

-[MEDICATION NAME] ([MEDICAL CONDITION]) 5 mg tablet by mouth daily;
-Alsatian (blood pressure) 100 mg tablet per [DEVICE] daily;
-[MEDICATION NAME] sprinkles (antiepileptic drug) 125 mg capsule 3 capsules per [DEVICE]
two times daily;
-[MEDICATION NAME] (blood pressure) 50 mg tablet per [DEVICE] three times daily;
-[MEDICATION NAME] (high blood pressure and chest pain) 10 mg tablet per [DEVICE] daily;
-Carvedilol (blood pressure) 25 mg tablet per [DEVICE] twice daily;
-[MEDICATION NAME] (treat allergy symptoms and hives) 10 mg by mouth daily;
-Cleanse the wound to sacrum with normal saline, may skin prep to periwound, apply manuka
pli to wound bed and cover with dry dressing daily and as needed.
Review of the resident’s pharmacy consultation, dated 6/1-26/18, showed the pharmacist
recommended the following:
-[MEDICATION NAME], please administer by mouth-can be hazardous to employee crushing
medication;
-Levetiracetam ([MEDICATION NAME]), please administer by mouth.
Further review showed the physician accepted the recommendations on 7/2/18.
Review of the resident’s telephone order sheet (TOS), dated 7/2/18, showed staff
documented an order from the physician for the [MEDICATION NAME] and [MEDICATION NAME] to
be administered by mouth and do not crush.
Review of the resident’s telephone order sheet, dated (MONTH) (YEAR), showed the staff
received orders for the following:
-8/10/18 Registered dietician (RD) recommends adding Prosource 30 ml /day;
-8/18/18 skin prep to wound to right scapula and cover with a dry dressing, change every
three days, continue with low air loss mattress;
-8/21/18 RD recommends increasing Prosource to 30 ml twice daily.
Review of the resident’s medication administration record (MAR), dated (MONTH) (YEAR) to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
(MONTH) (YEAR), showed the following:
-[MEDICATION NAME] 5 mg tablet at 9:00 A.M., circled on 6/23 and 6/24 without
documentation to show why the medication was not given;
-[MEDICATION NAME] 50mg tablet at 6 A.M., 1 P.M., and 5 P.M., missing initial of
administration on 6/3 at 1 P.M.; and
-[MEDICATION NAME] 500 mg by mouth at 9 A.M. and 5 P.M. showed missing initials and
documentation of administration on 7/7, 7/16, 7/20, 7/23, 8/3, 8/20, and 8/24 at 5 P.M.,
and 8/2 and 8/24 at 9 A.M.;
-[MEDICATION NAME] Sprinkles 125 mg 3 capsules missing initials on 8/27 at 9 A.M., and
7/16, 7/20, 7/25, 8/3, 8/20, 8/24, and 8/25;
-Prosource 30 ml per [DEVICE] at 9 A.M. and 5 P.M., showed circled medication on 8/29 and
8/30 circled at 9 A.M., and 8/28, 8/29, 8/30, and 8/31 circled at 5 P.M. Review showed
staff documented on 8/29/18 at 8:30 A.M.-out of prosource.
Review of the resident’s treatment administration record (TAR), dated (MONTH) (YEAR) to
(MONTH) (YEAR), showed the following:
-After cleansing wound to sacrum with normal saline, apply skin prep to the periwound,
apply Manuka pli to wound bed and cover with dry dressing, change daily and as needed
(7/3/18). Review showed no staff initials to show completion of the treatment on 7/4, 7/5,
7/6, 7/9, 7/10, 7/14, 7/19, 7/30, 7/31, 8/18, and 8/19.
Observation on 8/29/18 at 8:36 A.M., showed Registered Nurse (RN) R placed the resident’s
[MEDICATION NAME] 500 mg 1 tab and [MEDICATION NAME] sprinkle 125 mg 3 caps into a
medicine cup after crushing the [MEDICATION NAME]. The RN popped the resident’s Losartan
100 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 25 mg,
crushed the medication and placed in a medication cup and last crushed [MEDICATION NAME] 5
mg and [MEDICATION NAME] 10 mg and placed them into a third medication cup. The RN added
about 10 cc water to each cup and and mixed the medication into the water. The RN entered
the resident’s room, turned off the tube feeding and disconnected it from the resident,
hung the tubing over the pole without a cap on the end, and placed the syringe into the
resident’s [DEVICE]. Observation showed the RN poured 30 cc water into the syringe without
checking placement with auscultation and/or aspiration. The RN poured the resident’s blood
pressure medications into the syringe, followed by the [MEDICATION NAME] and [MEDICATION
NAME] and last the [MEDICATION NAME] and [MEDICATION NAME] sprinkles. The RN did not flush
with any water between the medications. After the [MEDICATION NAME] and [MEDICATION NAME]
sprinkles drained into the tube, the RN flushed with 30 cc of water, reconnected the tube
feeding and turned on the tube feeding pump.
During an interview at the same time, the RN said he/she checked the placement of the
[DEVICE] earlier and he/she didn’t need to check placement again.
Observation on 8/30/18 at 3:48 A.M., showed the resident lay flat in the bed with a moist
cough. LPN E hung a new bottle of [MEDICATION NAME] tube feeding, and attached the tubing
to the pump. The LPN used a flush syringe to pull back 30 cc of water, inserted the
syringe into the [DEVICE] and pushed the water through the [DEVICE]. Observation showed
the LPN attached the tubing to the [DEVICE] and primed the tubing into the resident’s
[DEVICE]. Further observation showed the LPN did not check placement of the [DEVICE] prior
to the flush or initiating a new bottle of tube feeding. The LPN raised the head of the
bed and assisted the resident in spitting out a mouth full of mucus/saliva.
3. Review of Resident #278’s POS’s, dated (MONTH) (YEAR) to (MONTH) (YEAR), showed the
physician directed staff to administer the following:
-Prosource 10 gm-100 kcal/30 ml twice daily;
-Santyl 250 unit/G topical ointment, apply twice daily to affected area;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-[MEDICATION NAME] (reduces gastric acid) 40 mg tablet, delayed release twice daily;
-Accuchecks daily at bedtime;
-[MEDICATION NAME] (diabetic) XR 50 mg -100 mg twice daily with morning and evening meal;
-[MEDICATION NAME] (antibiotic) 300 mg twice daily.
Review of the POS’s, showed no order for manuka pli and dry dressing change daily and as
needed.
Review of the resident’s TAR, dated (MONTH) (YEAR) to (MONTH) (YEAR), showed the
following:
-After cleansing sacral/coccyx wound with normal saline, apply manuka pli, cover with dry
dressing change daily (ordered 5/25/18). Review showed no staff initials to show
completion of the treatment on 5/29, 6/1 and 6/4. On 6/8/18 documentation showed the
resident was in the hospital;
-After cleansing right posterior foot under 2nd digit with normal saline, apply
[MEDICATION NAME], cover with dry dressing, and change daily and as needed. Review showed
no staff initials to show completion of the treatment on 5/29, 6/1 and 6/4. On 6/8/18
documentation showed the resident was in the hospital;
-After cleansing sacral/coccyx wound with normal saline, apply manuka pli/max, may apply
skin prep to periwound, cover with gauze, abdominal pad, and change daily and as needed
(ordered 6/12/18). Review showed no staff initials to show completion of the treatment on
7/4, 7/5, 7/6, 7/12, 7/14, 7/19, 7/20, and 7/23;
-Santyl 250 units/gram topical ointment apply twice daily to affected area (ordered
6/11/18), showed on the (MONTH) TAR with a line through the treatment with changed
(undated) written across the order. Review of the (MONTH) TAR showed no line through the
order and staff administered the treatment on 8/1 and 8/6 days and evenings, 8/2, 8/3, 8/4
on days. No staff initials for evenings on 8/2, 8/3, 8/4, 8/5 and days on 8/6/18.
Review of the resident’s MAR, dated (MONTH) (YEAR) to (MONTH) (YEAR), showed the
following:
-[MEDICATION NAME] 40 mg at 6 A.M. missing staff initials and no documentation on the back
of the MAR on 7/9, 8/4, and 8/5 and 5 PM on 7/2, 7/20, and 7/23;
-Accuchecks missing initials and documentation on the back of the MAR on 6/1, 6/4, 6/5,
6/15, 6/25, 7/5, 7/6, and 7/16;
-[MEDICATION NAME] XR 50 mg -100 mg twice daily with morning an evening meal, missing
initials and documentation on the back of the MAR on 7/4 and 7/22 at 8 A.M., and 7/23, 8/3
and 8/4 at 5 P.M.
4. During an interview on 9/05/18 at 6:58 P.M., the Director of Nurses (DON) said when the
nurse changes a resident’s tube feeding to a new bottle or is administering medications,
the nurse should date and time the new feeding, initial, connect and prime the tubing,
ensure the head of the bed is elevated to a 45 degree angle and is not lying flat. Before
the nurse attaches the tubing to the [DEVICE] the nurse needs to check for
residual/placement. The nurse also needs to look at the site to ensure no signs of
infection or stomach acids leaking around the tube. Staff are expected to check placement
prior to administering medication even if they checked it a little while earlier. The DON
said staff are expected to initial the MARs and TARS and if the the medication or
treatment was not completed they need to circle their initials and document a reason on
the back. If they were not able to get a treatment completed on their shift they need to
pass that onto the next shift to complete and document it on the 24 hour nurse shift
report. The facility is going to a different software and medications will be online and
there will be a report that he/she can run.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, facility staff failed to complete a discharge
summary, provide documentation the discharge summary was provided to the resident or
resident’s representative and transferring provider for four residents (Resident #49, #60,
#178, #431) discharged from the facility. The facility census was 80.
1. Review of the facility discharge plan policy, dated 10/1/17, showed the following:
– Purpose: Interdisciplinary team participates in developing an effective discharge
planning process based on the patient’s active participation in determining his/her
discharge goals to effectively transition him/her to post-discharge care and reduce
factors leading to preventable readmissions.
2. Review of Resident #178’s Physician order [REDACTED].
Review of the resident’s discharge summary, dated 3/27/18, showed staff did not complete
the following sections of the summary:
-Physical and mental function;
-Special treatments and procedures;
-Activities;
-Nutritional Status;
-Vision;
-Communication;
-Advanced Directives;
-Skin Condition;
-Continence;
-Pre and Post Discharge medication reconciliation list.
Further review in the resident’s medical record showed the staff did not provide a copy of
the discharge summary to the resident or representative and did not provide documentation
that a copy was sent to the transferring home health agency.
3. Review of Resident #431’s discharge summary, dated 9/4/18, showed the following:
-Reason for resident’s discharge – therapy/insurance based discharge;
-List of the resident’s current diagnosis;
-List of vital signs – blank;
-Medications listed;
-Recapitulation of Stay:
-Dietary summary – blank;
-Activity summary – blank;
-Nursing summary – blank,
-Pertinent lab tests and results – blank;
-Pertinent Radiology and other test results – blank;
-Pertinent Consultations Findings and Recommendations – blank;
-Rehabilitation Therapy – blank;
-Social services discharge summary: Resident will be discharged to home with medications,
standard wheelchair (16 x 16) with seat cushion, removable arm rest and elevating leg
rest, raised toilet seat, tub transfer bench. Home health support provided.
Further review showed the discharge did not include a statement of the resident’s appeal
rights, including the name, address (mailing and email), and telephone number of the
entity which receives such requests; and information on how to obtain an appeal form and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
assistance in completing the form and submitting the appeal hearing request. The name,
address (mailing and email) and telephone number of the Office of the State Long-Term Care
Ombudsman were not included.
Review of the resident record showed the resident discharged home on[DATE] with a family
member.
4. Record review of Resident’s #49 Discharge Summary, dated 8/20/18, showed staff did not
include the following information:
-Medication information;
-Resident’s needs, strengths, goals, life history and preferences;
-Dietary summary;
-Pertinent lab tests and result notes;
-Rehabilitation/therapy;
-Advance Directives;
-The right to appeal to the State;
-Information on how to request hearing;
-Had no written information on how to obtain assistance in completing and submitting the
appeal request;
-No contact information such as name, address (mail and email), and telephone number of
the State entity which receives appeal hearing requests.
5. Record review of Resident’s #60’s Discharge Assessment, dated 8/31/18, showed the
resident discharged from the facility with return not anticipated.
Record review of the resident’s medical closed record on 8/31/18 showed staff did not
document a Discharge Summary for the resident.
During an interview on 8/31/18, the administrator said:
-He/she was unable to find a copy of the resident’s Discharge Summary in the resident’s
medical record.
6. During an interview on 9/5/18 at 6:40 P.M. the Social Services Designee said she was
not aware of the requirements that needed to be addressed in the discharge summary and
only filled out the sections she thought were required. Further, the Social Service
Designee was not aware the resident or representative had to sign the discharge summary
and a copy had to be provided to the transferring provider.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility staff failed to provide
thorough cleansing after incontinent episodes for four residents (Residents #3, #19, #77,
and #278), failed to provide repositioning and incontinent care for three residents
(Residents #11, #13 and #23), who sat for long periods of time without staff assistance.
The facility census was 80.
1. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 6/16/18, showed staff assessed the resident as follows:
-Short and long term memory loss;
-Severely impaired for daily decision making;
-Required extensive assistance with two staff members for bed mobility;
-Required extensive assistance from staff with dressing and toileting;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-Always incontinent of bowel and bladder;
-At risk for the development of a pressure ulcers;
-[DIAGNOSES REDACTED].
-Received 51% or more of nutrition through a feeding tube.
Review of the resident’s comprehensive care plan, dated 3/19/18, showed staff addressed
the resident’s care needs as follows:
-A hoyer lift for all transfers;
-Always incontinent, the resident relies on staff to provide incontinent care;
-At risk for the the development of a pressure ulcer.
Review of the resident’s comprehensive care plan, dated 3/19/18, instructed staff to:
-Provide assistance with incontinent care every two hours and as needed;
-Minimize pressure over bony prominences;
-Reposition at least every 2-4 hours as consistent with over all patient goals and medical
condition.
Observations on 9/4/18 from 1:00 P.M. to 4:44 P.M., showed the resident in a reclined
position in a geri-chair in his/her room with eyes closed. The hoyer lift pad remained
positioned underneath the resident.
Observation on 9/4/18 at 4:45 P.M. to 5:59 P.M., showed the resident in a reclined
position while in a geri-chair in his/her room with eyes closed. Observation showed the
resident’s tube feeding pump alarmed and facility staff walked back in forth outside of
the resident’s room.
Observation on 9/4/18 at 6:00 P.M., showed the resident in a reclined position while in
the geri-chair in his/her room with eyes closed.
During an interview on 9/5/18 at 6:40 P.M., Certified Nurses Aide (CNA) L said staff are
expected to provide incontinent care and/or reposition the resident every two hours for
residents who are dependent upon staff for assistance.
2. Observation on 8/30/18 at 2:45 A.M., showed CNA A entered Resident #11’s room and
applied gloves without washing his/her hands. Observation showed the resident’s pants
pulled down to his/her ankles under the covers. The CNA cleansed the resident’s abdominal
fold and frontal perineal area with a wipe. The CNA turned the resident to his/her right
side. Observation showed a strong urine odor and brown ring on the cloth incontinence pad
with the resident’s brief saturated through to the pad. Observation showed a large amount
of scattered superficial (shallow) open #2 pencil eraser size red areas and scarring to
the resident’s gluteal crease, ischium (lower back part of the hip bone), and left thigh.
The CNA provided perineal care to the resident. CNA A placed the soiled linens in bag on
bedside table and left the room with gloves on and bagged linens. Further observation
showed the soiled linens leaked through the plastic bag and left a wet spot on the bedside
table. The CNA said he/she was the only CNA on that hall during the shift.
3. Observation on 8/30/18 at 10:00 A.M., showed Licensed Practical Nurse (LPN) G and CNA Z
entered the room to provide a treatment for [REDACTED]. The resident lay in bed
incontinent of urine and stool. CNA Z applied gloves and assisted to remove the resident’s
soiled brief. CNA Z and LPN G assisted the resident to his/her side and CNA Z cleansed the
resident’s back, buttocks and groin areas. CNA Z then turned the resident back over onto
his/her back and placed the clean brief up through the resident’s legs and fastened the
brief. CNA Z did not not provide perineal cleansing to the front peri area within the
folds of the skin after the incontinent episode.
4. Observation on 8/28/18 at 10:00 A.M., showed Resident #3 sat in his/her restroom on the
toilet, and CNA J cleansed liquid stool off of the resident’s wheelchair and placed clean
washcloths into the sink. CNA H removed the resident’s liquid stool covered pull-up and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
assisted the resident to a standing position. CNA H cleansed the stool off of the
resident’s periarea. Observation showed the CNA used the same cloth and cleansed back and
forth from the frontal periarea to the back, and back to the front, then used a dry towel
and wiped back and forth to dry the resident. The CNA’s assisted the resident to his/her
chair and placed a clean brief and pants.
5. Observation on 8/30/18 at 3:56 A.M., showed CNA C pushed the hold button on the feeding
pump, asked Resident #19 to spit into a towel, and then lowered the head of the bed. The
CNA pulled down the resident’s covers, cleansed the front creases by the resident’s legs.
Observation showed the CNA did not provide thorough frontal pericare and cleansing to the
frontal folds. The CNA turned the resident onto his/her side, tucked a clean brief under
the resident. Observation showed the resident had a small stool and cleansed the stool off
of the resident from back to front.
6. Review of Resident #23’s quarterly MDS, dated [DATE], showed staff assessed the
resident as:
-Mild cognitive impairment;
-Minimal depression;
-No behaviors, rejection of care, wandering, or [MEDICAL CONDITION];
-Required extensive assistance of one staff for bed mobility, dressing, eating, and
personal hygiene;
-Required extensive assistance of two or more staff for transfers;
-Dependent on one staff for bathing;
-Required set-up assistance with eating;
-No limitations in range of motion (ROM);
-Wheelchair for mobility;
-Always incontinent of bladder;
-Frequently incontinent of bowel;
-No falls;
-At risk for pressure ulcer development with pressure reducing device in chair and bed;
-Received antidepressant medication for the last seven days;
-No plans for discharge.
Review of the resident’s care plan, updated 6/20/18, showed staff documented the resident
is frequently incontinent of bladder and occasionally incontinent of bowel. The plan
directed staff to:
-Observe for non-verbal cues that the resident may need to use the toilet;
-Provide prompt peri-care as needed for incontinent episodes;
-Provide extensive assistance for toileting;
-Resident uses the toilet and bedpan for elimination;
-Use adult brief for dignity.
Continuous observations on 8/29/18 from 8:45 A.M. to 9:15 A.M., showed the resident in
his/her wheelchair with both foot pedals, sitting in the common TV area staring at the TV,
with no change in position.
Observation on 8/29/18 at 9:26 A.M., showed the resident say to CNA H he/she did not want
to watch the show on television. The CNA did not acknowledge or speak to the resident. CNA
H walked by the resident and went down hall without addressing the resident. The resident
remained in the same position and no staff assisted the resident.
Continuous observation on 8/29/18 from 9:30 A.M. to 9:55 A. M, showed the resident
remained in the common area staring at the TV with no changes in position or staff
assistance.
Observation on 8/29/18 at 9:56 A.M., showed the resident in the common area repetitively
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
screaming, I have to get out of here, my daughter is waiting for me. An unidentified CNA
walked by and said, Give me just a minute, I will be right back after I finish this. The
CNA went into another resident’s room. The resident began repetitively screaming loudly, I
can’t get out. Observation showed the resident began crying. No staff stopped and assisted
the resident or assisted with toileting or changing position.
Continuous observations on 8/29/18 from 9:57 A.M. to 10:03 A.M., showed the resident
continued to repetitively scream, I cant get out while crying. Observation showed staff
did not address the resident’s needs or attempt to change his/her position.
Continuous observations on 8/29/18 from 10:04 A.M. to 10:09 A.M., showed the resident
hollered out HELP, I am going to freeze, while continuing to cry. Further observations
showed a CNA walk down the hall multiple times and did not stop to assist the resident.
Observation showed the resident remained in the same position without staff assisting the
resident with his/her needs.
Observation on 8/29/18 at 10:10 A.M., showed the resident continued to holler out and cry.
The administrator propelled the resident in front of nurses station and positioned the
wheelchair next to other residents against the wall facing the nursing station, and talked
with the resident. The resident smiled and talked calmly. Observation showed staff did not
help the resident change position or provide toileting.
Continuous observations on 8/29/18 from 10:11 A.M. to 10:18 A.M., showed the resident
continued to holler out and cry. During the observation at 10:14 A.M., the resident
hollered out I’m still breathing to four different staff members as they walked by. Staff
did not stop to assist the resident, address his/her needs, or offer toileting.
Observation on 8/29/18 at 10:19 A.M., showed the housekeeping supervisor stopped and
informed the resident that exercise will be at 10:30 A.M. in the dining room. The resident
said I do not want to do that. Staff asked the resident what he/she wanted to do and the
resident said, I want to go to bed. Observation showed the housekeeping supervisor
propelled the resident to his/her room and position the wheelchair next to his/her bed.
Staff did not assist the resident to reposition in the wheelchair or offer fluids or
toileting.
Continuous observations on 8/29/18 from 10:20 A.M. to 10:28 A.M., showed the resident in
his/her room crying. During the observation at 10:28 A.M., an unidentified CNA exited
another resident’s room and asked Resident #23, What is wrong? Before the resident could
respond the CNA said, We are going to get you down to activities and exited the room.
Observation showed the resident started crying out loudly and repetitively saying I want
to get out of here. The CNA did not address the resident’s needs or offer fluids or
toileting.
Observation on 8/29/18 at 10:29 A.M., showed the Activity Director asked the resident What
is wrong as he/she was walking by the resident’s room. The resident said, I want to get
out of here. An unidentified CNA entered the room and began propelling the resident down
the hall without informing the resident where they were going. The CNA continued to propel
the resident into the main dining room and positioned the resident outside of the group.
The CNA did not offer toileting or fluids to the resident.
Observation on 8/29/18 at 10:30 A.M., showed the Activity Director and Activity Assistant
position multiple residents in a circle and hand them a handle attached to a parachute.
Activity personnel placed a ball in the center of the parachute. Observation showed staff
did not address the residents needs or offer toileting or fluids.
Continuous observation on 8/29/18 from 10:30 A.M. to 11:29 A.M., showed the resident
remained positioned off to the side of the activity. Further observation showed staff did
not encourage or attempt to get the resident to participate or offer to get nursing staff
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
for toileting or repositioning.
Observation on 8/29/18 at 11:30 A.M., showed staff moved the resident from his/her
position during the activity to the dining room table for lunch, without offering fluids
or toileting.
Continuous observations on 8/29/18 from 11:31 A.M. to 12:27 P.M., showed the resident
remained in the dining room Observation showed the resident fed himself/herself and staff
did not engage in conversation with the resident.
Observation on 8/29/18 at 12:28 P.M., showed staff propelled the resident down the hall
from lunch and positioned the resident facing the nurses station. Observation showed staff
did not offer to toilet or lay the resident down in bed.
Continuous observations on 8/29/18 from 12:30 to 1:00 P.M., showed the resident remained
at the nurses station without staff acknowledging the resident. Staff did not address the
resident’s needs, offer fluids, or toileting assistance.
Continuous observations on 8/29/18 from 02:00 P.M. to 3:26 P.M., showed the resident
positioned against the wall facing the nurses station with a blanket on his/her lap. The
resident cried and said he/she needed to go home. Observation showed staff walked by the
resident without addressing the resident’s needs, offering fluids, or toileting.
Observation on 8/29/18 at 3:27 P.M., showed the resident drank water out of a plastic cup
and straw. Resident #35 placed his/her hand on the resident’s arm and the resident began
to cry and holler out. Observation showed staff did not address the resident crying and
hollering. Additionally, staff did not offer to take the resident to the bathroom.
Continued observations on 8/29/18 from 3:28 P.M. to 3:38 P.M., showed the resident sat in
his/her wheelchair positioned against the wall facing the nurses station, crying out I
want to go home. Observation showed two unidentified nurses sat at the nurses station and
staff walked by. Staff did not acknowledge that the resident was crying or attempt to
redirect the resident. Additionally, staff did not offer to assist the resident with
toileting or address the resident’s needs.
Observation on 8/29/18 at 3:39 P.M., showed the resident continued to cry. Licensed
Practical Nurse (LPN) Q asked the resident if he/she wanted to take a nap. The resident
did not respond to the nurse. The nurse did not offer the resident toileting assistance or
address any other needs before walking away from the resident.
Observation on 8/29/18 at 4:07 P.M., showed an unidentified CNA propelled the resident to
the dining room and position him/her at a table in the center of the dining room with only
one other resident in the dining room, and the CNA exited the dining room without offering
to take the resident to the restroom and/or offering fluids.
Observation on 8/29/18 at 4:15 P.M., showed the resident in the dining room crying with no
staff present. The surveyor asked the resident how he/she was doing and the resident
replied not good, but was unable to answer why he/she was not good. Observation showed the
resident calmed down and quit crying when the surveyor spoke with the resident.
Continued observations on 8/29/18 from 4:22 P.M. to 4:40 P. M, showed the resident
remained positioned at the dining room table with a foul odor coming from the resident.
Observation at 4:41 P.M. showed the surveyor requested staff to toilet the resident. CNA U
propelled the resident to his/her room. The resident said he/she has not gone to the
bathroom all day and probably leaked a little bit.
Observation on 8/29/18 at 4:45 P.M., showed CNA U left the resident’s room and CNA T
pulled the resident’s pants down and unfasted the resident’s brief. Observation showed the
brief was wet and the resident had a small amount of stool. The resident’s buttock had
dried stool in the crease of the buttock and red in color. The CNA cleansed the resident’s
buttock, pulled his/her pants up and set the resident back into his/her wheelchair on a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
pressure relieving cushion.
7. Review of Resident #278’s quarterly MDS, a federally mandated assessment tool, dated
6/14/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-Required extensive assistance of one staff with bed mobility, toilet use, eating, and
personal hygiene;
-Required limited assistance of one staff with dressing;
-Dependent on one staff for bathing;
-Frequently incontinent of bladder and always incontinent of bowel;
-Had an Unstagable pressure ulcer and a lesion on the foot.
Review of the resident’s care plan, last updated on 8/30/18, showed the resident had
activity of daily living (ADL) self-care deficits and is at risk for falls related to
weakness, physical limitations, incontinence, and alteration in mobility and safety.
Review showed staff were directed to do the following:
-Provide the amount of assistance/supervision that is needed;
-Report changes in ADL self performance to the nurse.
Observation on 8/29/18 at 2:06 P.M., showed CNA H and CNA I transferred the resident from
his/her bed to his/her wheelchair using the sit to stand mechanical lift. The CNA’s said
the resident had a liquid bowel movement and care was already provided. Observation showed
liquid stool on the mattress, sheet, hospital gown, resident’s back, buttocks, and
dressing to the coccyx. CNA H tucked the brief around the resident’s frontal periarea,
with nothing on buttocks. Without cleansing the resident, the CNA propelled the resident
out into the hallway. Further observation showed liquid stool on the resident’s hospital
gown and on his/her left leg. CNA I rolled up the section of the hospital gown and placed
a blanket over the resident.
Observation on 8/29/18 at 2:38 P.M., showed Certified Occupational Therapy Assistant
(COTA) A and CNA H and transferred the resident back to his/her bed. Observation showed a
dressing on the resident’s coccyx with serosanguineous drainage and feces on the bottom of
the dressing and the resident’s groin excoriated. The CNA placed a brief on the resident
after tucking in a positioning sheet. LPN G entered the room and assisted CNA H in
positioning the lift sheet and incontinence pad under the resident, while smearing liquid
stool. Observation showed the resident continued to have liquid stool on the lift sheet,
brief, dressing to coccyx, in his/her groin, his/her upper leg, the mattress, and on the
incontinence pad. The CNA and LPN left the room without providing incontinence care or
cleansing the stool off of the resident or mattress.
Observation on 8/30/18 at 3:28 AM, showed the resident slid out of bed and staff assisted
the resident back to bed. Observation showed staff pulled on the resident’s brief to stand
him/her up to transfer to his/her chair and then bed. The resident’s brief ripped in the
center of the backside and was wedged between the resident’s buttocks. Further observation
showed the resident had liquid stool and a large amount serosanguineous drainage on the
end of his/her dressing to the coccyx. The staff raised the head and foot of the bed, and
did not adjust the air mattress setting that was set to fully inflated or provide
incontinence care including changing the resident’s ripped brief before leaving the room.
Observation on 8/30/18 at 4:07 A.M., showed the head and foot of the resident’s bed
elevated, and the resident lay on the right side with legs toward the edge of the bed.
Observation showed CNA B lowered the foot of the bed and left the room without providing
incontinence care, changing the ripped brief, or getting the nurse to change the
resident’s soiled dressing to his/her coccyx.
Observations on 8/30/18 showed the resident remained in the soiled ripped brief from 3:28
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
A.M. to 5:47 A.M., when the surveyor asked to observe pericare on the resident.
Observation on 8/30/18 at 5:47 A.M., showed CNA C unfastened the residents brief.
Observation showed dried brown stool to the resident’s buttocks and groin, with
excoriation. Further observation showed three yellow/white pimple like areas on the
resident’s upper left side of the buttock. The CNA cleansed the crease of the buttock, but
did not cleanse the sides or groin to remove feces. The dressing to the resident’s coccyx
remained with serosanguineous drainage and feces.
8. During an interview on 9/5/18 at 6:40 P.M., CNA L said staff are expected to provide
thorough perineal cleansing after each incontinent episode making sure to cleanse from
front to back and in the folds of the skin.
During an interview on 9/5/18 at 7:10 P.M., LPN V said staff are expected to cleanse from
front to back, groin and back area after each incontinent episode.
Interview on 9/05/18 at 6:58 P.M., the director of nursing (DON) said staff are to
complete turning and repositioning rounds every two hours and check to see if the resident
is soiled and if they are, they need to provide pericare to the resdient. When staff are
providing pericare they should cleanse from front to back, and cleanse the entire soiled
area to remove all stool and urine from the resident’s skin. Residents need to be turned
to the opposite side that they were laying on if they are in bed. If resident’s are
observed sleeping in chairs or are very restless, staff need to offer to lay the residents
down in bed. Residents that have wounds, he/she would prefer to only see them up in the
chair for meals.

F 0686

Level of harm – Actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, facility staff failed to provide
treatment and services to prevent the development of and/or promote the healing of
pressure ulcers. Facility staff failed to implement interventions, complete treatments as
ordered, and assess and monitor pressure ulcers for eight residents (Residents #11, #14,
#18, #19, #53, #278, #435, and #436) with facility acquired pressure ulcers. The facility
census was 80.
Review of the Pressure Ulcer/Injury Prevention Policy, dated 11/20/17, directed staff on
the following:
-A comprehensive skin assessment on admission and re-admission to center may identify
pre-existing signs of possible deep tissue damage already present;
-A risk assessment tool, Braden Scale (determines the resident’s risk for pressure ulcer
development), score is documented on the tool and placed in the patients’s medical record;

-A skin assessment should be performed weekly by a licensed nurse;
-Measures to maintain and improve the patient’s tissue tolerance to pressure are
implemented in the plan of care:
-Skin inspections with particular attention to bony prominences;
-Skin cleansing with appropriate cleanser at the time of soiling and at routine
intervals;
-Treat dry skin with moisturizers;
-Minimize skin exposure to incontinence using devices and skin barriers;
-Minimize injury due to shear and friction through proper positioning, transfers and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 30)
turning schedules;
-Encourage oral food and fluid intake;
-Improve patient’s mobility and activity when potential exists.
-Measures to protect the patient against the adverse effects of external mechanical
forces, such as pressure, friction, and shear are implemented in the plan of care:
-Reposition at least every 2-4 hours as consistent with overall patient goal and medical
condition;
-Utilize positioning devices to keep bony prominences from direct contact;
-Ensure proper body alignment when side-lying;
-Heel protection/suspension should be implemented while the patient is in bed;
-Maintain head of bed at the lowest degree of elevation consistent with the medical
condition;
-Use lift devices to move patients in the bed;
-A pressure reduction mattress replacement is placed under the patient;
-When positioned in a wheelchair, the patient is to be placed on a pressure-reduction
device and repositioned;
-When positioned in a wheelchair, consideration is given to postural alignment,
distribution weight, balance and stability.
-Patient and significant others involved in the patient’s care are educated regarding the
preventive skin care plan;
-When skin breakdown occurs, it requires attention and a change in the plan of care to
appropriately treat the patient;
-Certain risk factors have been identified that increase a patient’s susceptibility to
develop or impair healing of pressure ulcers. Examples include, but are not limited to:
-Impaired/decreased mobility and decreased functional ability;
-Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease, diabetes mellitus,
or other end of life concerns;
-Drugs, such as steroids, that may affect wound healing;
-Impaired diffuse or localized blood flow (for example: generalized [MEDICAL CONDITION]
or l lower extremity arterial insufficiency);
-Patient refusal of some aspects of care and treatment, especially in multi-system organ
failure or end-of-life conditions;
-Cognitive impairment;
-Exposure of skin to urinary and fecal incontinence;
-Under nutrition, malnutrition, and hydration deficits;
-[MEDICAL CONDITION]; and
-A history of a healed ulcer.
1. Review of Resident #14’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 9/1/18, showed the facility staff assessed the resident as follows:

-Brief interview for mental status (BIMS) score of 9 (moderately cognitively impaired);
-Requires extensive assistance from staff with bed mobility, transfers dressing, eating,
toileting and personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-At risk for the development of a pressure ulcer;
-Open lesion on the foot;
-Application of a dressing on the feet;
-Pressure reducing device on the bed.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 31)
Further review showed staff assessed the resident’s right medial plantar foot wound as a
medical device related pressure ulcer on the MDS dated [DATE].
During an interview on 9/5/18 at 6:45 P.M., Licensed Practical Nurse (LPN) G said the
wound developed from a brace to the right foot and is located in an area where there is
pressure.
Review of the resident’s comprehensive care plan, dated 6/6/18, directed staff on the
following interventions for friction and shearing to the right foot:
-Complete Braden Scale quarterly and PRN (as needed);
-Complete weekly skin report;
-Inspect skin during bathing, especially over bony prominences;
-Observe for signs and symptoms of infection or delayed healing and report to physician as
needed any redness, drainage that is bloody or purulent (infection);
-Refer to therapy as needed;
-Report changes in skin status to physician, provide wound care as ordered, and observe
effectiveness of response to treatment as ordered.
Review of the resident’s medical record showed staff documented a skin assessment with an
open area on the right plantar foot, dated 5/21/18.
Record review of the physician’s orders [REDACTED].>Review of the resident’s wound
module for the right medial plantar (inner and bottom) foot showed staff documented the
following:
– 5/21/18- Date of Origin for facility acquired right medial plantar foot, measured 3.00
(centimeter) cm x 3.00 cm x 0.10 cm, serous (watery) drainage, no undermining (destruction
of tissue under the skin edges) or tunneling (a passageway of tissue destruction under the
skin surface that has an opening at the skin level from the edge of the wound), 25%
[MEDICATION NAME] in the wound bed. Further review showed staff did not indicate a Stage
for the wound;
– 5/29/18- Staff documented the wound measured 3.00 cm x 3.00 cm x 0.10 cm with light
serosanguineous (bloody) drainage, no undermining or tunneling, 40% [MEDICATION NAME] and
60% other in the wound bed. Further review showed staff did not indicate a Stage for the
wound;
– 6/7/18- Staff documented the wound measured 1.00 cm x 1.00 cm with no drainage, no
undermining or tunneling, 40% [MEDICATION NAME] (thin tissue covering body surfaces) and
50% eschar (dead tissue) in the wound bed. Further review showed staff did not indicate a
depth or a stage for the wound;
– 6/20/18 (13 days since last wound assessment)-Staff documented the wound measured 0.50
cm x 0.50 cm with no drainage, no undermining or tunneling, 100 %eschar in the wound bed.
Further review showed staff did not indicate a depth or a stage for the wound;
– 6/27/18-Staff documented the wound measured 0.40 cm x 0.40 cm with light serosanguineous
drainage, no undermining or tunneling, 100% granulation in the wound bed. Further review
showed staff did not indicate a depth or a stage for the wound,
– 7/13/18 (16 days since last wound assessment)-Staff documented the wound measured 2.00
cm x 2.00 cm with no drainage, no undermining or tunneling, 100% granulation in the wound
bed. Further review showed staff did not indicate a depth or a stage for the wound;
– 7/25/18 (12 days since last wound assessment)-Staff documented the wound measured 2.00
cm x 2.50 cm with no drainage, no undermining or tunneling, 100% granulation in the wound
bed. Further review showed staff did not indicate a depth or a stage for the wound;
– 7/31/18-Staff documented the wound measured 1.00 cm x 1.00 cm with no drainage, no
undermining or tunneling, 100% eschar in the wound bed. Further review showed staff did
not indicate a depth or a stage for the wound;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 32)
– 8/27/18 (27 days since last wound assessment)-Staff documented the wound measured 1.00
cm x 0.80 cm with no drainage, no undermining or tunneling, 100% eschar in the wound bed.
Further review showed staff did not indicate a depth or a stage for the wound.
Review of the resident’s Treatment Administration Record (TAR), dated (MONTH) (YEAR),
showed staff did not provide the treatment using [MEDICATION NAME] (an antiseptic used to
kill bacteria and prevent infection) to the right foot wound everyday. Review showed staff
did not provide the treatments on 8/2/18, 8/11/18, 8/19/18, 8/25/18, 8/26/18, and 9/4/18.
Observation on 8/31/18 at 9:45 A.M., showed LPN G entered the resident’s room to provide
wound care. LPN G applied gloves and removed the soiled dressing. Observation showed the
wound located on the right outer foot just below the 5th toe (an area over a bony
prominence). Observation showed the wound covered with hard eschar, approximate dime size
with a hard callus surrounding the wound. LPN G cleansed the wound then applied
[MEDICATION NAME] to the wound, covered it with gauze and secured it with roller gauze.
During this time, LPN G said the resident developed a blister on his/her right lateral
foot from a brace and the resident has had the wound for about two months. LPN G said
staff are to provide the treatment daily and keep a pillow under the resident’s right foot
for pressure relief.
During an interview on 9/4/18 at 3:50 P.M., the resident said she/he developed a blister
from the use of a heavy black boot. Further, the resident said that the staff don’t always
keep her/his foot elevated at night on a pillow while in bed and staff forget to do the
treatment sometimes.
Observation on 9/05/18 at 9:10 A.M., showed the last time staff changed the dressing to
the resident’s right foot was 9/3/18. Observation showed staff hand wrote 9/3/18 directly
on the dressing for the right foot wound.
2. Review of Resident #11’s quarterly MDS, dated [DATE], showed the facility staff
assessed the resident as follows:
-BIMS 10 (moderate cognitive impairment);
-Requires extensive assistance from staff with bed mobility, transfers, dressing and
toileting;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-At risk for the development of a pressure ulcer;
-Pressure relieving devices on the bed and chair.
Review of the resident’s comprehensive care plan, dated 2/27/18, showed staff updated the
care plan to include pressure ulcers to the left and right heels as a problem to be
addressed on the care plan. Staff updated the resident’s care plan to include the
following:
-8/7/18-wound to left heel, Stage III (Full-thickness loss of skin, in which subcutaneous
fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges)
are often present. Slough and/or eschar may be visible but does not obscure the depth of
tissue loss), treatment as ordered and heel lift boots,
-8/22/18-wound to right heel, Stage III, treatment as ordered and heel lift boots.
Further review showed the comprehensive care plan, updated 8/7/18, directed staff with the
following interventions:
-Assist to reposition and shift weight to relieve pressure;
-Complete the Braden scale risk assessment quarterly and PRN;
-Complete weekly skin assessments;
-Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises,
discoloration noted during bathing or daily care;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 33)
-Provide pressure relieving or reduction device, pressure relieving mattress and chair
cushion;
-Refer to therapy as needed;
-Report changes to physician.
Review of the resident’s medical record, dated 8/7/18, showed staff identified a Stage III
pressure ulcer on the resident’s left heel. Further review showed the wound measured 4.6
cm x 5.00 cm, slough tissue present. Further review showed staff did not include in the
wound assessment the depth of the wound.
Review of the residents wound module for the left plantar calcaneus (heel) showed staff
documented the following:
– 8/7/18-Staff documented 8/7/18 as the date of origin, facility acquired. Further review
showed staff documented the wound measured 4.6 cm x 5.00 cm, Stage III, moderate amount of
serosanguineous drainage, no undermining or tunneling, 10% of slough and 90% of
granulation in the wound bed. Further review showed staff did not include the depth of the
wound in the assessment;
– 8/14/18-Staff documented the wound measured 4.5 cm x 5.00 cm, Stage III, light amount of
serosanguineous drainage, no undermining or tunneling, 5% of slough and 95% of granulation
in the wound bed. Further review showed staff did not include the depth of the wound in
the assessment;
– 8/14/18 (Staff documented two different wound assessments for the same date)-Staff
documented the wound measured 2.5 cm x 5.00 cm, Stage III, light amount of serosanguineous
drainage, no undermining or tunneling, 10% of slough and 80% of granulation in the wound
bed. Further review showed staff did not include the depth of the wound in the assessment.
Review of the physician’s orders [REDACTED]. Further review dated 8/22/18, showed the
physician ordered to cleanse with normal saline then apply manuka pli to the right heel
wound, cover with a dry dressing and roller gauze everyday and as needed.
Review of the resident’s TAR for (MONTH) (YEAR), showed staff did not provide the
treatment using manuka to the left heel wound everyday as ordered by the physician. Review
of the TAR showed staff did not document that the treatment was provided to the left heel
on 8/11, 8/12, 8/18, 8/19 and 8/21.
Review of the resident’s medical record, dated 8/22/18, showed staff first identified a
Stage III pressure ulcer to the resident’s right heel. Further review showed the wound
measured 3.0 cm x 5.00 cm, slough tissue present, full thickness, red and beefy tissue and
loose skin to the edges. Staff did not include in the wound assessment the depth of the
wound. Further, staff documented the wound started out as a blood blister.
Review of the resident’s wound module for the right plantar calcaneus (heel) showed staff
documented the following:
– 8/22/18-Staff documented 8/22/18 as the date of origin, facility acquired. Further
review showed staff did not include an assessment of the right plantar calcaneus wound
with measurements, drainage, wound bed and stage;
– 8/27/18- Staff documented the right plantar calcaneus measured 3.00 cm x 5.00 cm, light
serosanguineous, no tunneling or undermining, granulation 70%, slough 20% to the wound
bed. Further review showed staff assessed the resident’s wound as a Stage III and did not
address the depth of the wound.
Observation on 8/30/18 at 2:45 A.M., showed staff did not apply the heel boots while the
resident was in bed. Staff placed a pillow underneath the resident’s heels, but
observation showed both heels lying directly on the mattress.
Observation on 8/30/18 at 11:30 A.M., showed LPN G provided the treatment to the
resident’s heels. LPN G said the right heel wound is new and currently measured 2.5 cm x
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 34)
4.7 cm. Observation showed the right heel wound bed pink, surrounding skin red and
[MEDICAL CONDITION] (swollen). Observation showed the left heel wound measured 2.2 cm x 5
cm with approximately 25% of slough in the wound bed, red and [MEDICAL CONDITION]. During
this time, LPN G said both pressure ulcers were facility acquired, full thickness and at a
Stage III. LPN G said the staff are expected to keep the pressure relieving boots on the
resident at all times.
During an interview on 8/31/18 at 9:45 A.M., LPN G said she/he is the wound nurse and
provides all of the treatments during the week and weekly wound assessments, but has been
pulled from her/his position to perform charge nurse duties. LPN G said she/he was pulled
from her/his wound treatments to perform charge nurse duties three times in the last seven
days.
During an interview on 9/5/18 at 6:15 P.M., LPN V said professional staff are responsible
for providing the wound treatments as ordered by initialing the TAR to show documentation
that they were completed.
3. Review of Resident #435’s medical record showed [DIAGNOSES REDACTED].
Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows:
-BIMS score of 12 out of 15 (cognitively intact);
-Required extensive assistance of one to two staff with all activities of daily living;
-Incontinent of bowel and bladder;
-admitted with three Stage III pressure sores measuring 4.0 centimeters (cm) by 4.0 cm,
slough and one pressure sore healed;
-Received antibiotics seven out of seven days.
Review of the resident’s care plan, dated 3/7/18, showed an unstageable pressure sore on
coccyx, and directed staff to:
-Assist as needed to reposition/shift weight to relieve pressure;
-Complete weekly skin checks;
-Discuss non-compliance issue with resident/responsible party;
-Notify nurse immediately of any new skin breakdown;
-Observe effectiveness of treatment as ordered;
-Monitor labs as ordered by physician;
-Provide incontinence care after each incontinence;
-Pressure relieving mattress and chair cushion;
-Provide diet as ordered, provide protein supplement;
-Wound care as directed by physician.
Review of the resident’s POS dated 6/06/18, showed an order to cleanse coccyx wound with
normal saline (may apply skin prep to peri wound) apply Manuka Pli and cover with dry
dressing daily.
Review of the resident’s wound reports showed the following:
-Coccyx pressure sore date of origin 2/27/18, prior to admission;
-First documented assessment dated [DATE] showed staff assessed the coccyx area wound as a
Stage III, measuring 2.80 cm by 3.50 cm with 0.30 cm depth, total area measured 9.80 cm,
light serosanguineous drainage with no undermining/tunneling, no incision, wound base 10%
[MEDICATION NAME], 80% granulation, 10% slough, wound edge unattached, and surrounding
skin intact and response to treatment improved;
-7/4/18 and 7/12/18, blank except documentation that surrounding skin intact and response
to treatment improved;
-7/16/18, Stage III measuring 1.00 cm by 1.00 cm with 0.50 cm depth, light serosanguineous
drainage with no undermining/tunneling, no incision, 10% [MEDICATION NAME], 80%
granulation, 10% slough, wound edge unattached and surrounding skin intact, response to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 35)
treatment improved;
-7/25/18, Stage III measuring 3.00 cm by 3.00 cm by 0.50 depth, light drainage, 10%
[MEDICATION NAME], 80% granulation, 10% slough, wound edge attached, surrounding skin
intact, response to treatment deteriorated;
-8/7/18, stage III measuring 3.00 cm by 2.50 cm by 0.40 depth, moderate drainage, 90%
granulation, 10% slough, wound edge unattached, surrounding skin intact, response to
treatment improved.
Review of the medical record showed the resident was sent out to hospital for left above
the knee amputation and resident was re-admitted on [DATE].
Review of the wound report, dated 8/22/18, showed the coccyx pressure sore was unstageable
(full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer
cannot be confirmed because the wound bed is obscured by slough or eschar), slough and/or
eschar, light drainage, no undermining/tunneling or incision, 20% [MEDICATION NAME], 10%
granulation, 10% slough, wound edge unattached, surrounding skin intact [DIAGNOSES
REDACTED], macerated, response to treatment not assessed.
Review of the resident’s TAR, dated (MONTH) (YEAR), showed staff documented the treatment
to the coccyx was not completed on 7/5, 7/6, 7/13, 7/14, 7/16, 7/19, 7/30, and 7/31.
Review of the TAR, dated (MONTH) (YEAR), showed staff documented the treatment to the
coccyx was not completed on 8/2/18 and 8/11/18. Review of the weekly summary on the back
of the TAR, showed staff documented attempted to change resident’s dressings but resident
refused. The resident yelled at this nurse to go away and leave him/her alone. Incoming
nurse aware. Further review of the TAR dated 8/12/18, showed staff documented the
treatment was completed.
During an interview on 8/29/18 at 9:00 A.M., the wound nurse (LPN G) said he/she was gone
from the facility the entire month of (MONTH) and did not return until (MONTH) (YEAR). LPN
G said while he/she was gone the charge nurses were responsible for wound
treatments/assessments. LPN G said when he/she returned, he/she tried to obtain
information on residents wounds from the charge nurses as there was little documentation.
Observation on 08/29/18 at 4:57 P.M., showed Certified Nurses Aide (CNA) W and LPN G wore
gowns and gloves and entered the resident’s room. The resident had liquid feces on his/her
buttocks. LPN G cleansed the resident’s buttock and changed his/her gloves and removed the
resident’s old dressing from his/her coccyx. Observation showed a a large amount of blood
tinged drainage on the old dressing and a large uneven circular wound to the resident’s
coccyx. LPN G cleansed the wound with normal saline and 4 x 4 inch gauze. The LPN said the
wound to the coccyx is unstageable with 80% slough and eschar in the center with
maceration around the bottom periwound. Observation showed the resident continued to have
liquid stool. LPN G cleansed the stool and changed gloves without washing his/her hands,
placed skin prep around the wound edges, then applied a half dollar size amount of manuka
pli directly onto 4 x 4 gauze and placed the 4 x 4 gauze onto the wound bed. The LPN
cleansed liquid stool from the resident’s bottom, removed gloves, did not wash his/her
hands, and applied abdominal wound dressing (used to manage heavy drainage) and adhesive
tape over the dressing. Observation showed the LPN applied barrier cream to the buttocks
and groin.
Further observation showed the LPN changed his/her gloves, without washing his/her hands,
removed the resident’s right heel lift boot, cut off the dressing to the right foot.
Observation showed scant (small) amount of serosanguineous drainage on the soiled dressing
and a moon shaped black eschar wound to the resident’s outer heel and a dime size circle
black eschar area to the lateral right foot. The LPN cleansed both areas, changed gloves
without washing hands or sanitizing, applied manuka pli to 4 x 4 gauze and wrapped the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 36)
foot with kerlix gauze.
During the same time, LPN G said when went the resident went to the hospital the wound was
a Stage III pressure ulcer with very little slough to the coccyx. The resident was
admitted with multiple other areas and some have healed, but these have gotten worse since
the resident went back to the hospital. Staff just received a verbal order for the
resident to start Closed Pulse Irrigation (CPI) treatment.
During an interview on 8/30/18 at 12:19 P.M., the Medical Director/resident’s physician
said the resident has very bad [MEDICAL CONDITION], which was the cause of wounds on lower
legs/feet. The resident’s toes then became infected and he/she was placed on [MEDICATION
NAME]. He consulted with the resident’s podiatrist and they agreed it would be best to
amputate above the knee to give the resident the best chance of healing. He said the
resident is not compliant with being positioned on his/her side and will move about until
he/she gets back on his/her back. He said the resident’s nutrition is bad, some days the
resident will eat, but it may be two or three days before he/she will eat very much again.
He thought the resident should be on hospice due to the resident’s poor condition. He said
the resident developed [MEDICAL CONDITION] as a result to all the antibiotics. He said the
resident’s health shakes were held because they can cause diarrhea due to high sugar
content. He said the resident’s family brought in protein shakes, which contain 30 grams
of protein.
During an interview on 8/31/18 at 09:00 A.M., the resident’s family member said the
resident had been living at home alone, then had a stroke and was admitted to the
hospital. The resident was at another facility and developed pressure sores which got
infected and was transferred back to hospital then came to the facility. The family member
said the resident’s physician had talked with them about his/her vascular disease causing
the pressure sores to develop because of poor circulation. The family member said they are
very involved with care, have had meetings with management staff regarding concerns with
care issues. The family member said wound care on weekends does not happen.
4. Review of Resident #18’s physician’s progress note, dated 6/17/18, showed the physician
documented the resident has a few complaints of some care issues and are not as responsive
as they should be. Review showed the physician documented sacral Decubitus (ulcer) healing
well.
Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident
as the following:
-Modified independence with cognitive skills for daily decision making;
-No behaviors, rejection of care, wandering, or changes in behavior;
-Required extensive assistance of one staff with bed mobility, transfers, toileting,
bathing, and personal hygiene;
-Limited assistance of one staff for dressing;
-Set-up help only for eating;
-Limited range of motion (ROM) to both upper and lower extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Occasional moderate pain;
-Stage III pressure ulcer measuring 1.4 cm by 1.4 cm by 0.2 cm with granulation tissue;
and
-Has a pressure reducing device in chair and bed, nutrition interventions, and receives
pressure ulcer care.
Review of the resident’s care plan, dated 6/18/18, showed the resident has a stage III
pressure ulcer to his/her bottom, incontinence, and impaired mobility secondary
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 37)
to(NAME)Chiari syndrome and sympathetic neuroosteodystrophy (a complex reflex pain
disorder). Staff are directed to do the following:
-Assist to reposition/shift weight to relieve pressure as needed;
-Complete Braden scale risk assessment quarterly as needed;
-Complete weekly skin assessment;
-Float heels when in bed;
-Minimize pressure over bony prominences;
-Notify the nurse immediately of any new areas of skin breakdown, redness, blisters,
bruises, discoloration noted during bathing or daily care;
-Observe lab results as ordered and report abnormal results to physician;
-Position with pillows to maintain proper body alignment;
-Provide diet as ordered and observe nutritional status and dietary needs, provide
supplemental protein, amino acids, vitamins, minerals as ordered by physician to promote
wound healing;
-Provide incontinence care after incontinence episodes. Apply barrier cream as needed;
-Provide pressure relieving or reduction device, pressure reduction mattress, and chair
cushion;
-Refer to therapy for positioning as needed;
-Report changes in skin status to physician;
-Turning and repositioning program every two hours as needed;
-Use lifting device, draw sheet to reduce friction;
-Avoid skin to skin contact;
-Discuss non-compliance issues with the resident/responsible party;
-Educate resident/responsible party about pressure ulcer etiology, primary risk factors,
treatment, and prevention;
-Encourage use of the side rails and/or trapeze to assist turning in bed;
-Notify resident/responsible party of any new areas of skin breakdown;
-Observe effectiveness of/response of treatments as ordered;
-Observe for pain and medicate as needed per physician orders.
Review of the physician’s progress note, dated 7/26/18, showed the physician documented
the resident is upset because he/she was left uncleaned from 12:00 A.M. to 4:00 A.M. Stage
IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle,
tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on
some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often
occur)sacral wound examined with the corporate nurse. Wound has worsened and enlarged,
wound is bone deep. Can palpate bone, however, wound is clean without significant
discharge. Discussed wound care, check C-reactive protein (CRP) and Sedimentation (Sed)
rate, will be difficult to heal wound.
Review of the resident’s Braden Scale Risk Assessment, dated 7/27/18, showed staff
assessed the resident at moderate risk for skin breakdown, related to decreased or
impaired bed/chair mobility, existing pressure ulcer, history of pressure ulcers,
incontinence of bowel and bladder, and pain.
Review of the resident’s physician order [REDACTED].
-Health shakes with breakfast and dinner (12/15/17);
-Cleanse coccyx with normal saline, apply [MEDICATION NAME] (sterile, freeze dried matrix
composed of collagen a ND oxidized regenerated cellulose) to the wound bed and cover with
dry dressing daily and as needed, ordered 3/13/18 and discontinued 7/27/18;
-Low air loss mattress (ordered 2/27/17); and
-Cleanse coccyx wound with normal saline, apply santyl (enzymatic deriding ointment) and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Actual harm

Residents Affected – Some

(continued… from page 38)
dry dressing, change daily and as needed (no order date).
Review of the resident’s telephone order sheet (TOS), dated 7/27/18, showed the physician
directed staff to clean the coccyx wound with normal saline, apply santyl, and dry
dressing daily and as needed.
Review of the resident’s TOS, dated 8/7/18, showed the physician directed staff to
discontinue santyl, after cleaning wound to coccyx with normal saline, apply manuka pli
and saline moistened gauze, cover with dry dressing daily and as needed. Further review
showed staff initialed the order was placed on the treatment sheet and in the nurses
notes. Review showed staff did not initial the order documented on the POS.
Review of the resident’s TOS, dated 8/31/18, showed the physician ordered physical therapy
(PT) to evaluate and treat wound to coccyx.
Review of the resident’s physician progress notes [REDACTED].
Review of the resident’s physician progress notes [REDACTED].
Review of the resident’s treatment administration records (TAR), dated (MONTH) (YEAR)
through (MONTH) (YEAR), showed facility staff documented the following:
-Cleanse wound with normal saline, apply [MEDICATION NAME] to wound bed, and apply dry
dressing daily. Review showed no initials to show completion of treatment on 5/6/18,
5/8/18, 5/26/18, 6/2/18, 6/17/18, 6/22/18, 7/2/18, 7/4/18, 7/6/18, 7/13/18, 7/14/18,
7/18/18, and 7/20/18. Order discontinued on 7/26/18;
-Cleanse wound with normal saline, apply Santyl, and dry dressing, change daily and as
needed. Review showed staff did not initial to show completion of the treatment on 7/29/18
and 7/31/18, order discontinued on 8/7/18;
-Cleanse wound with normal saline, apply manuka pli and saline moistened gauze, cover with
dry dressing, change daily and as needed. Review showed staff did not initial to show
completion of the treatment on 8/11/18 and 8/19/18.
Review of the resident’s electronic medical record (EMR) skin assessments, showed staff
documented the following:
-5/16/18 coccyx pressure ulcer intact, improving, treatment to coccyx. The resident has an
o

F 0689

Level of harm – Immediate jeopardy

Residents Affected – Few

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

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

Based on observation, interview, and record review, facility staff failed to assess,
monitor, and develop interventions to prevent one sampled resident (Resident #278) out of
23 residents, with a history of falls and positioning his/her legs off the bed, from
falling, failed to ensure the resident’s low air loss mattress was set at the appropriate
setting and the mattress fit the bed according to manufacturer guidelines. Additionally,
facility staff failed to transfer two sampled residents (Resident #4, and #278) safely and
effectively. The facility census was 80.
1. Facility fall management policy, revised 11/2016, showed the facility will implement a
fall management system that results in reducing patient falls by:
-All patients will be assessed for fall indicators upon admission, readmission, quarterly,
change in condition and with any fall event;
-An individualized fall management care plan will be developed and initiated upon all
patient admissions and readmissions;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 39)
-The interdisciplinary team (IDT) will review and revise, if indicated, all patients’ fall
management care plans upon the completion of each comprehensive, significant change and
quarterly MDS, upon a fall event and as needed thereafter. Care plan revisions will be
made at this time as indicated;
-Fall management training will be provided to all associates upon hire, annually and as
indicated by Fall Management Performance Improvement Plans (PIPs);
-Patients and/or family members will receive education on the patient’s fall management
care plan and provided opportunity for feedback;
-Accurate and thorough assessment of the patient is fundamental in determining indicators
for potential falls;
-Reporting tools that aggregate and collect patient assessment and other information of
fall indicators will be utilized in the facility’s Fall Management Quality Assurance
Performance Improvement activities and are therefore not considered part of the patient’s
medical record.
2. Review of Resident #278’s face sheet showed the resident was originally admitted on
[DATE]. Further review showed the resident had a [DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
tool, dated 6/14/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-No behaviors;
-Required extensive assistance of one staff with bed mobility, toilet use, eating, and
personal hygiene;
-Required limited assistance of one staff with dressing;
-Dependent on one staff for bathing;
-Frequently incontinent of bladder and always incontinent of bowel;
-[DIAGNOSES REDACTED].
-Had a fall in the last month prior to admission;
-Had no falls since last assessment dated [DATE];
-Had an unstagable pressure ulcer and a lesion on the foot; and
-Received antidepressants three out of the last seven days prior to the assessment.
Review of the resident’s care plan, last updated on 8/30/18, showed the resident has
activity of daily living (ADL) self-care deficits and is at risk for falls related to
weakness, physical limitations, incontinence, and alteration in mobility and safety.
Review showed staff were directed to do the following:
-Provide the amount of assistance/supervision that is needed;
-Report changes in ADL self performance to the nurse;
-Side rail(s) as an enabler (1/2 rails);
-Fall risk assessment;
-Provide environmental adaptation such as call light within reach and area free of
clutter;
-Remind the resident and reinforce safety awareness by locking brakes on bed and chair
before transferring, appropriate footwear, and educate/remind resident to request
assistance prior to ambulation;
-Report falls to physician and responsible party;
-Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle)
to coccyx, provide treatment as ordered and has a low air loss mattress;
-At increased risk for falls related to self reports of alcohol consumption while on leave
of absence (undated);
-3/21/18 had fall on floor, educate on waiting for assistance;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 40)
-5/6/18 had a fall with no injury, monitor and redirect, assist with transfers, remind to
lock wheelchair, call light within reach, and frequent monitoring required to monitor safe
environment;
-6/3/18 had a fall in television room, slid off of couch without injury;
-8/23/18 bed in low position always, resident tries to get up without assistance, ensure
call light is within reach, remind to call for help when needed;
-8/30/18 new bed, slid off the bed, ensure bed is as low as possible and call light is
within reach.
Review of the resident’s hospital records, dated 8/15/18-8/19/18, showed the physician
documented the resident was admitted for altered mental status, [MEDICAL
CONDITION]-fibrillation (A-Fib)(irregular heart beat), [MEDICAL CONDITION] (kidney
infection),[MEDICAL CONDITION] (life-threatening complication of an infection), metabolic
[MEDICAL CONDITION] (abnormalities of chemicals that adversely affect the brain function),
dementia, and [MEDICAL CONDITION]. Review of the hospital records showed a positive urine
culture for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) and a bone scan on 8/17/18
positive for [MEDICAL CONDITION] metastasis. The resident presented with a fever of 102
degrees Fahrenheit.
Review of the resident’s hospital discharge orders, dated 8/19/18, showed the physician
ordered the resident to take [MEDICATION NAME] (antibiotic) 875-125 milligrams (mg) by
mouth every 12 hours for 10 days, and [MEDICATION NAME] (anticonvulsant) 500 mg twice
daily.
Review of the resident’s physician order [REDACTED].
Review of the resident’s telephone order sheet (TOS), dated (MONTH) (YEAR), showed staff
received the following orders from the physician:
-8/21/18 discontinue [MEDICATION NAME] after four days;
-8/25/18 send the resident to the emergency room (ER);
-8/27/18 obtain an x-ray of the resident’s right lower extremity;
-8/27/18 low air loss mattress;
-8/30/18 verbal order for resident to receive physical therapy (PT), occupational therapy
(OT), and speech therapy (ST) evaluation and treatment;
-8/30/18 OT clarification: resident to be seen five times per week for 12 weeks including
there-ex, therapeutic activities and wheelchair management.
Review of the resident’s treatment administration record (TAR), dated (MONTH) (YEAR),
showed the resident is to have a low air loss mattress. Review showed no documentation to
show what setting the mattress was to be on for the resident’s weight and firmness.
Review of the resident’s nursing notes, showed staff documented the following:
-3/21/18 Resident was found on the floor beside his/her bed, had increased lower extremity
weakness. Resident reported sliding from the bed, found on his/her knees, and when he/she
transferred back to bed could not bear weight;
-3/22/18 Resident found on floor at approximately 3:00 P.M. with feces on the floor.
Resident had no complaints of pain or discomfort and placed at nursing station for further
evaluation;
-4/22/18 Resident is alert and oriented to person, place, and time, on follow-up for fall,
range of motion (ROM) within normal limits (WNL), no injuries, voiced general discomforts,
educated to use call light to prevent further falls;
-5/6/18 Resident is alert and oriented, able to transfer self in wheelchair, needs
assistance with hygiene care. Resident found sitting on the floor in his/her room. The
resident reported he/she was trying to sit in the wheelchair and sat on the floor. ROM to
all extremities, no injury, and denies pain. Resident assisted to bed with call light
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 41)
within reach;
-5/14/18 Resident up in wheel chair resting in room with some confusion. Therapy assisted
into wheelchair but once up CNA and nurse had difficulties. Resident has decreased
strength and is unable to stand. Sit to stand mechanical lift is to be used for transfers;
-5/26/18 Resident found sitting on the floor diagonal to the wheelchair that is behind the
resident. The resident does not appear to have hit his/her head. Resident reported trying
to get to bed. Call light was in reach and the CNA and nurse used a gait belt to transfer
to bed;
-5/28/18 Resident is alert and oriented to name, requires total care including
turning/repositioning in bed. Call light is within reach. Monitor resident for kicking
his/her legs out of the bed, and keep bed in the lowest position;
-6/1/18 Resident continues to be non-compliant with transfers. Refused to allow CNA to
assist to wheelchair this morning and then was found 45 minutes later on the floor sitting
on bottom with legs in front of him/her. Non skid footwear was in place to both feet. The
resident stated he/she thought he/she could do it by him/herself. The resident requires
assistance of one to two staff;
-6/3/18 Resident found sitting on the floor in front of his/her wheelchair. Resident
stated that he/she lowered him/herself from his/her wheelchair to the floor. No injuries
noted, will continue to monitor, recommend frequent room checks or remove wheelchair to
discourage unassisted transfers to the wheelchair;
-6/4/18 Resident on the floor, slid off the couch in the television room. Staff assisted
resident into wheelchair and then into bed. Call light is within reach, bed in lowest
position, and no injuries observed;
-6/5/18 Resident lying in bed with bed in low position, locked, and a low air loss
mattress. Requires assistance of one to two staff with ADLs and transfers;
-6/7/18 Resident transferred to ER related to being lethargic and unable to bear weight;
-6/11/18 Resident returned to the facility with [DIAGNOSES REDACTED]. The resident is able
to express wants and needs, but has difficulty following directions at this time. Is on
antibiotic for VRE;
-6/12/18 Maintenance informed about low air loss mattress low pressure. Maintenance stated
that the hose needs to be fixed and reconnected, awaiting completion;
-6/22/18 Resident found on floor again next to bed. The resident stated that the bed was
too low. Range of Motion (ROM) WNL, neuro checks completed and resident denied hitting
head. Recommendation of frequent rounds, bed alarm or keep up in the chair next to nursing
station. The resident has been given teaching many times, but continues to try and perform
ADLs, and resident is very weak in lower extremities;
-7/27/18 Resident found on the floor by staff. Resident stated that he/she slid out of the
bed trying to look for his/her book. Bed is in the lowest position and call light is
within reach. No injuries observed and resident denies pain. Reminded resident to use call
light for assistance;
-8/15/18 Resident sent to ER because he/she is unable to follow commands, very confused,
and a temp of 102 degrees;
-8/19/18 Resident returned to the facility, is dependent on staff for ADLs and transfers,
bed lowered to floor, call light within reach. Will continue to monitor;
-8/25/18 Resident was at nurses station and started hitting head against the wall, with
his/her eyes rolling back, and shaking, resident sent to ER;
-8/25/18 Resident found on the floor before breakfast in front of his/her wheelchair on
the right side of nurses station. Resident was assisted with two staff back to the
wheelchair. The resident complained of pain to the right lower extremity. The resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 42)
right foot is swollen and no redness/warmth was observed. Physician notified and received
order for an x-ray to the right lower extremity;
-8/25/18 Resident returned from hospital with new [DIAGNOSES REDACTED]. Received a new
order for antibiotic, potassium, and [MEDICATION NAME];
-8/30/18 Resident found sitting on the floor at the side of the bed. Resident stated
he/she slid off of the bed. No injuries were observed and message left for physician. The
bed was placed as low as it would go.
Review of the resident’s medical record on 8/28/18, showed the resident did not have an
assessment or consent for the use of bed rails.
Review of the resident’s medical record on 8/31/18, showed a blank bed rail assessment in
the resident’s chart without a signature of consent.
Review of the Gendon Bariatric Bed manufacturer instructions, undated, showed the mattress
should be sufficiently wide enough to prevent any part of the patient’s body from falling
between the side rail and mattress.
Observation on 8/27/18 at 1:55 P.M., showed the resident lay in bed on his/her back with
his/her knees bent and feet pressed against the foot board. Low air loss mattress inflated
and set on level 3. Observation showed the resident’s call light lay on the floor at the
head of the bed.
Observation on 8/27/18 at 5:30 P.M., showed the resident lay in his/her bed uncovered,
with his/her legs off the side of the bed. Further observation showed the resident was
visible from the hallway as staff and visitors walked by the resident’s room.
Observation on 8/28/18 at 9:07 A.M., showed the resident sat up in bed eating breakfast,
air mattress on and call light on floor at the head of the bed. Observation showed the
resident’s bed had 1/2 bed rails with a 2-3 inch opening between the mattress and bed
rail, on each side.
Observation on 8/28/18 at 3:58 P.M., showed the resident resting in bed with 1/2 bed rails
on both sides and the mattress about 2-3 inches from the siderails on both of the sides.
Observation on 8/29/18 at 10:24 A.M., showed the resident attempted to remove the pressure
relieving boots. Observation showed the head of the bed elevated, lift sheet and resident
slid down from head of the bed with the resident unable to straighten his/her legs. The
resident lay on his/her right side near the edge of the bed, kicking his/her legs off the
side of the bed. Side rails on both sides continue to have a 2-3 inch gap between the
mattress and the bed rail and low air loss mattress set at a level 3.
Observation on 8/29/18 at 12:33 P.M., showed the resident with his/her head of the bed
elevated and feeding him/herself lunch. The low air loss mattress inflated to a level 3 on
firmness and both 1/2 side rails up with the mattress 2-3 inches away from the bed rails
on each side.
Observation on 8/29/18 at 12:27 P.M., showed the resident lay in bed pulling at the sheets
and attempting to remove pressure relieving boots. Observation showed the resident pulling
at the sheet and both legs off the side of the bed with both 1/2 side rails up and the
mattress 2-3 inches away from the bed rails on each side.
Observation on 8/29/18 at 2:06 P.M., showed CNA H and CNA I position the sit to stand lift
facing the resident, positioned the resdient’s feet on the lift with knees positioned
against knee pads. The CNAs placed the sling around the resident’s torso and attached the
sling end loops to the machine. CNA I began lifting the resident with the lift.
Observation showed the resident remained in a sitting like position with knees bent and
arms extended above his/her head with the sling bunched up under his/her arms. Staff asked
the resident to stand up and the resident was unable to bear weight. CNA H and CNA I did
not lower the resident back to the bed. Observation showed CNA H began turning the lift
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 43)
toward the chair while CNA I pushed on the resident’s bottom. The CNAs lowered the
resident into the wheelchair while saying the resident needs to be transferred with a
hoyer lift (mechanical lift). CNA H said they are changing the resident’s bed to a
bariatric bed, because he/she is too long for his/her current bed.
Observation on 8/29/18 at 2:15 P.M., showed housekeeping staff push the resident’s bed out
into hall. Observation showed housekeeping staff place the resident’s mattress from
his/her bed onto the bariatric frame. Housekeeping staff moved the bariatric bed into the
resident’s room, placed the headboard, footboard, new 1/2 bed rails, and air mattress
overlay machine for the end of the bed. Observation showed housekeeping staff attached the
air mattress to the pump and turn it on. Housekeeping staff attempted to place a
positioning wedge at the foot of bed to fill the gap. Observation showed the wedge fell
through the gap twice before staff layed it partially on the mattress. Housekeeping staff
left the room. Observation showed the resident’s low air loss mattress was set on level 5,
the highest setting, indicating the mattress was fully inflated at the firmest level and a
three to four inch gap between the resident’s left side bed rail and the mattress.
Observation on 8/29/18 at 2:38 P.M., showed CNA H propelled the resident from the hall
into his/her room and placed the resident’s feet on the sit to stand lift. Certified
occupational therapy assistant (COTA) A and CNA H placed a gait belt around the resident’s
chest and then the sling to the the lift, placing the loops on the end of the sling over
the knobs on the lift. The CNA instructed the resident to hold onto the lift, while
placing the resident’s hands onto the bar of the lift. The CNA lifted the resident with
the sit to stand lift, while COTA A held onto the gait belt. Observation showed the
resident’s knees remained bent in a sitting position and his/her arms fully extended above
his/her head with the sling bunching under the resident’s arms and the resident was unable
to bear weight and assist with standing. The CNA and COTA transferred the resident to
his/her bed, while holding onto his/her pants and gait belt while positioning the lift
feet under the bed. Observation showed three to four inches between the bed rail on the
resident’s left side and the mattress.
Observation on 8/30/18 at 2:39 A.M., showed the resident lay on his/her left side with one
leg off the left side of the bed. Observation showed both 1/2 side rails up with about
four inches between the mattress and bed rail on the resident’s left side of the bed and a
fall mat on the resident’s right side of the bed. The resident’s roommate moaned out and
his/her tube feeding pump beeped.
Observation on 8/30/18 at 2:45 A.M., showed the resident’s roommate continued to moan out
and his/her tube feeding pump beeped. Observation showed Resident #278 had both legs off
the left side of the bed and the sheet pulled away. The resident’s call light was
positioned above the resident’s head on the mattress.
Observation on 8/30/18 at 3:02 A.M., showed LPN E peek into the room, but did not go in to
reposition the resident or fix the resident’s roommate’s tube feeding machine. Further
observation showed CNA DD walked down the hall to another resident’s room.
Observation on 8/30/18 at 3:26 A.M., showed CNA A entered the resident’s room and the
resident was on the floor between his/her bed and his/her roommate’s bed. The CNA got the
nurse and re-entered the resident’s room.
Observation on 8/30/18 at 3:28 A.M., showed CNA A and LPN E entered the resident’s room.
Observation showed the resident’s air mattress set on level 5, fully inflated. The
resident lay on his/her back between his/her bed and his/her roommate’s bed. The
resident’s head was positioned on his/her roommate’s small wedge at the foot of the bed,
with the call light cord wrapped around the resident’s lower legs and the blankets and
sheets wrapped around the resident’s torso. A fall mat was positioned on the other side of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 44)
the bed, but not on the resident’s left side of the bed. The LPN asked the resident if
he/she could sit up and the resident said yes. Observation showed the LPN pulled on the
side of the resident’s arm and torso, but the resident did not move. The LPN told CNA A to
go and get some other staff to help get the resident back to bed. The resident said, I
slid out of bed. The LPN and CNA C both placed an arm under the resident’s arms and turned
the resident to a sitting position on the floor with his/her back resting against his/her
roommate’s bed and feet under his/her bed. The resident moaned out while saying ough as
staff sat the resident up. The LPN asked the resident if he/she was okay after sitting the
resident up and the resident said yes. The LPN did not complete ROM or ask the resident if
he/she hit his/her head to ensure the resdient did not have any pain or injuries prior to
moving the resident. CNA C, CNA K, and CNA CC placed a gait belt around the resident’s
torso. The three CNAs and LPN unsuccessfully attempted to lift the resident to a standing
position and into his/her wheelchair with the gait belt and pulling on his/her brief three
times. Observation showed the resident’s legs stayed out in front of the resident and the
resident unable to assist the staff. The resident said loudly, No, that’s not going to
work. The CNA’s and LPN lowered the resident back down with the resident’s back scraping
down the side of his/her roommates’s bed frame and hitting his/her foot on the resident’s
bedframe. The LPN asked the CNA’s if the bed would lower down any further and the CNA said
this new bed will not go down as far as the other bed would. Observation showed the staff
move the resident’s bed closer to the door away from the resident and position his/her
wheelchair closer to the resident. CNA B, CNA C, CNA K, CNA CC, and LPN E attempted to
lift the resident with the gait belt and pulling on the resident’s brief four more times
with the resident’s brief ripping and wedging between the resident’s gluteal crease and
staff lowering the resident to the floor each time. On the fifth attempt, observation
showed the CNA’s and LPN held onto the gait belt and brief, and lifted on the resident’s
buttocks to get him/her in the wheelchair. The CNAs and LPN positioned the wheel chair
close to the bed, and with the gait belt and holding onto the resident’s ripped brief
stood the resident up and transferred him/her to the bed. Observation showed the resident
was unable to bear weight and assist staff and staff started to lower the resident down
towards the ground when CNA CC and the LPN lifted under the resident’s upper thighs,
barely getting the resident onto the left side of the bed. Staff positioned the resident
on his/her right side and covered up the resident. CNA C asked the LPN where to place the
single fall mat. The LPN said he/she was on the other side earlier when he/she fell . The
CNA placed the fall mat on the right side of the bed and placed the call light by the
resident’s head of the bed. CNA B raised the head and foot of the bed 30 to 40 degrees
before leaving the room. The CNA’s and LPN did not position the resident at the head of
the bed and the resident told the staff that he/she could not straighten his/her legs,
because they were pressed against the footboard. The staff did not check the settings of
the low air loss mattress prior to leaving the resident’s room.
During an interview at the same time, LPN E said the resident’s bed was switched out
earlier in the day and is not a good fit for the resident. The LPN said the resident slid
out of it twice tonight.
Observation on 8/30/18 at 4:07 A.M., showed the resident’s legs toward the edge of the bed
on the right side. Observation showed CNA B lower the foot of the bed and the resident was
able to straighten out his/her legs. The resident’s 1/2 side rail and mattress remained
about 4 inches from each other on the resident’s left side.
Observation on 8/30/18 at 4:14 A.M., showed LPN E call the physician and notify him/her
that the resident slid off of the bed twice and that there were no injuries either time.
Observation on 8/30/18 at 4:30 A.M. showed the low air loss mattress as an Easy Air
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 45)
Pressure Guard. The mattress was shorter than the frame and there was approximately five
inches between the mattress and the foot of the bed. The mattress was observed to have
slid to the right side of the frame causing a four inch gap between the bed rails and the
mattress on the left side of the bed.
Observation on 8/30/18 at 5:12 A.M., showed the resident lay on his/her right side toward
the edge of the mattress holding onto the side rail. The low air loss mattress remained
fully inflated to a level 5 firmness.
During an interview on 8/30/18 at 5:19 A.M., CNA A said the resident slid off the bed
during transitioning from evening to night shift and then again this morning. When staff
arrive to work, the CNA’s conduct rounds about every two hours at 1 A.M., 3 A.M., and 5
A.M. When the resident places his/her feet out of the bed staff should assist the resident
in putting them back in bed or ask the resident to put them back if he/she is able to.
He/she was conducting rounds when he/she heard the resident’s roommate moaning. He/she
entered the room, saw the resident on the floor and went to get the nurse.
Review of the nurses 24 hour report of resident’s conditions, dated 8/30/18, showed the
nurse documented the resident was found sitting on the floor with no injuries. The
resident said he/she slid off the bed.
Observation on 8/30/18 at 5:24 A.M., showed the resident remained on his/her right side,
with a four inch gap between the left bed rail and the mattress, and the air mattress set
at level 5, fully inflated.
During an interview on 8/30/18 at 5:25 A.M., LPN E said the resident fell twice tonight,
the first time was when night shift staff first came in. The LPN said he/she did not know
anything about the settings for the air mattress and what the resident’s should be set at.
He/she is unsure who is responsible for adjusting the settings. When the resident is in
the bed, the bed is supposed to be in its lowest position, fall mats on the side of the
bed, and call light in place. The resident frequently calls out and throws his/her legs
over the side of the bed. The resident can have his/her door closed, but it is usually
open. If staff find a resident on the floor the nurse is to assess the resident, ask if
they are hurt, and get them off of the floor. Staff should take the resident’s vital signs
and complete IFU (incident report for falls) in the software, notify the physician and
director of nursing (DON) and send to the ER if they are hurt or provide a treatment if
they received a wound or injury. LPN E said he/she usually has the resident move his/her
extremities, to check for ROM. The LPN said he/she had the resident move his/her
extremities with the first fall last night and didn’t ask him/her to do so with the second
fall. The resident normally transfers with two staff. The resident is different and more
confused. He/she has become more dependent on staff, and he/she is heavy with not being
able to bear weight. Trying to get the resident on a hoyer lift pad would have been
difficult. At the beginning of the night, he/she was bearing more weight.
During an interview on 8/30/18 at 5:38 AM. CNA C said he/she helped transfer the resident
back to bed earlier in the night when he/she fell . The resident was able to assist at
that time and he/she was able to stand with assistance. The resident was on the side by
the bathroom when he/she fell at the change of shift. When a resident is found on the
floor, the CNA’s are expected to notify the nurse. The CNA should make the resident
comfortable until the nurse can assess him/her prior to getting the resident off of the
floor. The resident is always in bed on night shift. The CNA was told in orientation to
not lift residents off of the floor after a fall. Staff are expected to use the hoyer lift
to get them up. The CNA said he/she suggested using the hoyer with the resident, but the
other staff said the hoyer wouldn’t fit. The CNA said he/she even suggested moving the bed
out of the way to get the hoyer lift in the room and they said no. The staff should remind
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

(continued… from page 46)
residents about the call light. He/she said he/she only used the gait belt to assist with
transferring the resident. The CNA said he/she is unsure how to adjust the airflow or what
the setting should be on for the air mattress. He/she is unsure who is responsible for
ensuring the airlflow is at the right setting. He/she has not received training on the air
mattress settings.
During an interview on 8/30/18 at 9:41 A.M., the Maintenance Director said that the
facility is to get measurements from the bed frame, then fit the air bed to the frame. The
Maintenance Director said he did not have the users manual for the bed or the air
mattress. The Maintenance Director said nursing staff changed out the mattress.
During an interview on 8/30/18 at 10:07 A.M., the DON said during the last week, the
resident acted like he/she wanted to get up so staff were getting him/her up in the
wheelchair. Staff have been told to do rounds and check on the resident frequently. If
staff observe the resident throwing his/her legs off of the bed, staff are expected to ask
the resident why he/she is trying to get up. If the resident is up in the wheelchair staff
should place him/her in a field of vision. Since the resident has had frequent falls,
staff have been instructed to ensure the bed is in the lowest position and they
implemented fall mats last Saturday, the same day the resident began having [MEDICAL
CONDITION] with no previous history or diagnosis. The resident [MEDICAL CONDITION] with
metastasis to the bone and they are thinking that [MEDICAL CONDITION] may be in the brain
now. On Monday or Tuesday, staff reported the resident would not stay in the bed so they
decided the resident needed a bigger bed. The resident was a little bit too long for the
other bed. The DON said he/she was not aware that staff put the resident’s previous
mattress on the new bed frame and unaware of the changes to the air mattress pump/machine.
The DON said he/she guessed that whoever delivered the bed sets up the mattress. The wound
nurse should know the settings, but the DON has never looked at the setting. He/she would
go by the manufacturer’s recommendations. Housekeeping staff should not plug in or set up
the level of firmness on the air mattress settings. The DON said they already started
educating on the sit to stand lift transfer yesterday. If a CNA notices a change in the
residents transfer status or a decline, they need to report it to the nurse. The nurse
should assess the resident to see if transfer status changed. If the resident is on the
floor, the nurse should complete ROM and if the resident has pain, assess to see if they
could have bumped their head. The assessment should be done before they are moved off of
the floor. ROM assessment should have been completed even if it was completed during the
previous fall, because the resident could have still injured him/herself. The resident’s
door should be open because staff need to see if the resident’s legs are off of the bed.
The resident should have a mat on both sides of the bed. The DON said he/she doesn’t know
why the resident did not have fall mats on the floor prior to the one on the right side of
the resident’s bed after the resident’s first fall last night.
During an interview on 8/30/18 at 12:20 P.M., the Medical Director said the resident’s bed
should have been in the the lowest position, because he/she wiggles out and was recently
diagnosed with [REDACTED]. If the resident is unable to bear weight, staff should use the
hoyer lift to transfer the resident from the floor to the bed.
During an interview on 8/30/18 at 4:07 P.M., the bed frame manufacturer representative
said a two inch gap on each side is too much. The sides should be flush with the bed
rails, and two inches would be okay at the head and foot of the bed only.
NOTE: At the time of the survey, the violation was determined to be at the immediate and
serious jeopardy level J. Based on observation, interview and record review completed
during the onsite visit, it was determined the facility had implemented corrective action
to address and low (TRUNCATED)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Immediate jeopardy

Residents Affected – Few

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to have a system
in place for the ongoing communication and collaboration between the facility and [MEDICAL
TREATMENT] center for two residents (Resident #29 and #77) and failed to assess the access
site immediately following [MEDICAL TREATMENT] for one resident (Resident #29). The
facility census was 80.
Review of the facility’s skilled nursing facility outpatient [MEDICAL TREATMENT] services
agreement, effective (MONTH) (YEAR), showed the obligations of nursing facility and/or
owner includes the following:
1. End Stage [MEDICAL CONDITION] (ERSD) resident information: The nursing facility shall
ensure that all appropriate medical and administrative information accompanies all ERSD
residents at the time of referral to the ERSD [MEDICAL TREATMENT] Unit. This information
shall include, but is not limited to the following:
-Appropriate medical records, including history of the ERSD resident’s illness, laboratory
and x-ray findings;
-Treatment presently being provided to the ERSD residents, including medications;
2. Interchange of Information: The Nursing Facility shall provide for the interchange of
information useful or necessary for the care of the ERSD resident, including a Registered
Nurse as a contact person at the facility whose responsibilities include oversight of
provision of services to the ERSD resident;
D. Mutual Obligations- Collaboration of Care: Both parties shall ensure that there is
documented evidence of collaboration of care and communication between the nursing
facility and ERSD [MEDICAL TREATMENT] Unit. Documentation shall include, but not be
limited to, participation in care conferences, continual quality improvement program,
annual review of infection control of policies and procedures, and the signatures of team
members from both parties on a short term care plan (STCP) and long term care plan (LTCP).
Team members shall include the physician, nurse, social worker and dietician from the
[MEDICAL CONDITION] [MEDICAL TREATMENT] Unit and a representative of the nursing facility.
The ERSD [MEDICAL TREATMENT] Unit shall keep the original STCP and LTCP in the medical
record of the ERSD resident and the nursing facility shall maintain a copy.
1. Review of Resident #77’s medical record showed the resident’s [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED]. Although usually heard with the
stethoscope, such sounds may occasionally also be palpated as a thrill) every shift.
Further review showed no order for fluid restrictions.
Review of the resident’s Minimum Data Set (MDS), a federally mandated assessment
instrument, dated 8/16/18, showed staff assessed the resident as follows:
-Moderate to severe cognitive impairment;
-Required extensive assistance of one to two staff for activities of daily living;
-Incontinent of bowel and bladder;
-Height and weight left blank;
-At risk for pressure sore development.
Review of the resident’s plan of care, dated 8/28/18, showed the following:
-Resident on fluid restrictions;
-Check shunt site three times a week and as needed;
-Communicate labs, medications, and diet, with [MEDICAL TREATMENT].
-Resident on fluid restrictions.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 48)
Review of the resident’s physician order [REDACTED].
Review of the resident’s progress note, dated 8/26/18, showed resident alert, makes
connections, eats intermittently, speech recommended pureed diet with thicken liquids.
Family bringing in regular food and sodas against medical advice.
Review of a nutrition note, dated 8/28/18, showed interdisciplinary team met to discuss
with the resident’s family member diet texture change and family preference. Diet
downgraded to puree texture in attempt to increase intake from 10 percent to 75 percent
with feeding assistance however significantly decreased back to 10 percent. Diet returned
to mechanical soft diet that resident prefers.
Review of the resident’s nursing progress notes, dated 9/3/18, showed staff documented
received a call from [MEDICAL TREATMENT] center nurse that the resident was sent to
hospital emergency room due to low blood pressure. Call placed to spouse to make aware.
4. Review of Resident #29’s annual MDS, dated [DATE], showed staff assessed the resident
as follows:
-Moderately cognitive impairment;
-Required extensive assistance from staff with bed mobility, transfers, dressing,
toileting and personal hygiene;
-Frequently incontinent of bowel;
-Occasionally incontinent of bladder;
-[DIAGNOSES REDACTED].
-Diuretic medication in the last 7 days;
-Received [MEDICAL TREATMENT] while a resident;
-Weight is not present.
Review of the resident’s comprehensive care plan, dated 6/27/18, directed staff on the
following interventions for potential for complications from [MEDICAL TREATMENT]:
-Administer medications and observe effectiveness of medications as ordered;
-Check shunt site for signs and symptoms of infection, pain, and bleeding daily and as
needed;
-Communicate with [MEDICAL TREATMENT] center regarding medication, diet and lab results.
Coordinate the resident’s care in collaboration with [MEDICAL TREATMENT] center;
-Consult with the dietician for nutritional support related to [MEDICAL CONDITION];
-Ensure that food and fluids offered during activities comply with diet restrictions;
-Monitor shunt site by palpating for thrill and auscultating for bruit every shift. Notify
physician of absence of thrill or bruit.
Review of the resident’s medical record showed staff documented the resident received
[MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at an offsite [MEDICAL TREATMENT]
clinic.
Observation on 9/4/18 at 3:15 P. M., showed staff returned from [MEDICAL TREATMENT] with
the resident. Unknown staff assisted the resident back to the nurse’s station. Staff did
not immediately assess the resident’s access site or call the [MEDICAL TREATMENT] clinic
for a report.
Review of the nurse’s notes on 9/5/18 at 2.00 P. M., showed that staff did not document
assessment of the resident’s access site for [MEDICAL TREATMENT] immediately upon return
from the offsite [MEDICAL TREATMENT] clinic on 9/4/18 at 3:15 P.M. Further record review
showed staff did not document communication with the [MEDICAL TREATMENT] clinic after the
resident returned from [MEDICAL TREATMENT].
5. During an interview on 9/5/18 at 11:05 A.M., Licensed Practical Nurse (LPN) F said they
do not send any communication to [MEDICAL TREATMENT]. He/She said the charge nurse is
responsible for communicating with the [MEDICAL TREATMENT] clinic. He/She said the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 49)
[MEDICAL TREATMENT] center notifies the facility when there is a problem.
During an interview on 9/5/18 at 6:45 P.M., LPN V said staff do not call or communicate
with the [MEDICAL TREATMENT] clinic unless there is a problem. LPN V said after the
resident returns from [MEDICAL TREATMENT] the nurse will assess the access site, but only
document in the nurse’s notes if there is a problem.
During an interview on 9/5/18 at 2:21 P.M., the DON said that the RD calls [MEDICAL
TREATMENT] weekly and gets updates on resident status. She said [MEDICAL TREATMENT] does
not send any information to the facility.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess and
obtain a consent for the use of side rails for six residents (Residents #11, #52, #60,
#19,#23, and #278). The facility census was 80.
Record review of the facility Safe and Effective Use of Bed Rails policy statement, dated
11/2017, showed the facility must attempt to use alternatives prior to installing a side
or bed rail. If a side or bed rail is used, the facility must ensure correct installation,
use and maintenance of bed rails, including but not limited to to the following:
-Assess the resident for risk of entrapment from bed rails prior to installation;
-Review the risk and benefits of bed rails with the resident or resident representative
and obtain informed consent prior to installation;
-Ensure that the bed’s dimensions are appropriate for the resident’s size and weight.
Procedures:
1. Resident will be assessed upon admission, readmission, quarterly, and change in
condition utilizing the Evaluation for Use of Bed Rails Form;
2. If a bed rail will be utilized, the risks and benefits of bed rail usage will be
reviewed with the resident and/or resident representative and a consent will be obtained
prior to installation;
3. The facility will document any alternatives to the use of a bed rail and how these
alternatives did not meet the resident’s assessed needs;
4. A person centered care plan will be developed within 48 hours of admissions.
Review of the form titled Evaluation for Use of Bed Rails, undated, showed the following:
-Resident Status: Were appropriate alternatives attempted prior to considering bed rails;
-Why is the use of bed rail(s) being considered: Medical Diagnosis, Resident request,
Family Request, For safety, security, other and explain;
-Identify all that contribute to the resident’s need to use bed rails: Weakness,
Orthostatic hypertension, balance deficit, pain, unable to support trunk in upright
position, knees buckle, leans right, left, forward and other. Cognitive: Requested rails
(states it provides a sense of security), other. Security: History of rolling out of bed,
fear of rolling out of bed, history of sliding to floor, other;
-Will the bed rails assist the resident in: Bed Mobility, Transfer and Other;
-Additional Considerations and Risk Factors: Restraints (waist, leg or arm): Used and/or
Not used. Bladder Continence, Bowel Continence, Toileting;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 50)
-Recommendations and recommended type;
-Benefits: Based on the resident’s individual need(s), bed rails may be beneficial for:
-Security: Can provide resident with a sense of security if the resident has a fear of
falling, his/her movement is compromised or he/she is accustomed to sleeping in a larger
bed;
-Mobility Aide: Can enable resident to reposition self, or assist in repositioning self
either side to side or upward/downward. Can assist resident in safety entering or exiting
bed;
-Safety: Can act as safety measure by preventing slipping or rolling onto floor for
resident with, but not limited to, [MEDICAL CONDITION], neurological or movement
disorders;
-Potential Risks and Negative Outcomes: The use of bed rail(s) may involve risks such as:
getting caught in the rails, getting caught between the rail and mattress, strangulation,
suffocation, hitting against the rails causing bruising and/or skin tears, and crawling
over the top of the rail risking a fall from a higher level with a risk for greater injury
or death. Bed rails can present a hazard to certain individuals, particularly those
residents with physical limitations or altered mental status, such as dementia or [MEDICAL
CONDITION]. Other negative outcomes may include, but are not limited to: reduce physical
mobility and muscle functioning, skin integrity issues, feelings of isolation and
increased agitation and anxiety.
-I have been informed that I have a medical need that would be addressed by the use of bed
rails. I have been advised of the benefits and potential risks and negative outcomes of
bed rail use, and the health care professionals’ evaluation/recommendations: I do
voluntary consent to use of bed rails recommended above; I do not consent to the use of
bed rails recommended above and understand related liabilities;
-Resident signature, Resident Representative or Durable Power of Attorney for Healthcare
signature, and Facility Representative signature/title.
1. Review of Resident #11’s quarterly Minimum Data Set (MDS), federally mandated
assessment tool, dated 5/26/18, showed the facility staff assessed the resident as
follows:
-BIMS 10 (moderate cognitive impairment);
-Required extensive assistance from staff with bed mobility, transfers, dressing and
toileting;
-[DIAGNOSES REDACTED].
Review of the resident’s comprehensive care plan, dated 3/19/18, directed staff to use 1/2
side rails as an enabler on the resident’s bed.
Review of the resident’s medical record showed staff did not complete a bed rail
assessment for the resident’s bed and use of side rails and did not receive consent from
the responsible party.
Observation on 8/29/18 at 12:30 P.M., showed the resident lay resting in bed with eyes
closed. Further observation showed the bed had 1/2 side rails pulled up on both sides of
the bed.
Observation on 8/30/18 at 3:30 A.M., showed the resident lay resting in bed with eyes
closed. Further observation showed the bed had 1/2 side rails pulled up on both sides of
the bed.
Observation on 8/31/18 at 10:30 A.M., showed the resident lay resting in bed with eyes
closed. Further observation showed the bed had 1/2 side rails pulled up on both sides of
the bed.
2. Record review of Resident #52’s face sheet showed he/she was admitted to the facility
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 51)
on [DATE] [DIAGNOSES REDACTED].>-Fracture left femur (thigh bone);
-[MEDICAL CONDITION] (the narrowing of arteries due to plaque buildup on the artery walls.
Arteries carry blood from the heart to the rest of the body).
Record review of the resident’s physician’s orders [REDACTED].
-Skilled physical therapy (PT) and occupational therapy (OT) five times a week for twelve
weeks.
Record review of the resident’s Care Plan, dated 8/8/18, showed the resident:
-Had a 1/2 side bed rail as an enabler on the right side of the resident’s bed;
-Had a recent fall which resulted in a left femur fracture;
-Required assistance with all Activities of Daily Living (ADL’s).
Observation on 8/27/18 at 1:00 P.M., showed the resident had a 1/2 bed rail attached to
the right side of his/her bed.
During an interview on 8/31/18 at 11:00 A.M , the resident said:
-He/she used the bed rail to pull him/herself up to sit in an erect position;
-He/she needed the bed to help him/herself move from the bed to his/her wheelchair;
-Has to contact the nurse if there are problems with the bed rails and then the nurse
notifies maintenance if bed rails did not work properly.
Record review of the resident’s Medical Record on 8/31/18, showed the staff did not
complete a bed rail assessment, and there was no consent form that was completed and
signed by the resident and/or his/her responsible party found in the resident’s medical
record.
3. Record review of Resident #60’s face sheet showed the resident was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].>-Mild Cognitive Impairment;
-Dysphasia (language disorder marked by deficiency in the generation of speech or due to
brain disease or damage);
-Type II Diabetes.
Record review of the resident’s Care Plan, dated 8/8/18, showed the resident:
-Had right sided weakness and required assistance with all his/her ADL’s and transfer
needs;
-Needed maximum assistance from staff for all transfer needs, bed mobility, dressing,
personal hygiene and toilet use;
-Had a 1/2 side rail as an enabler on the right side of the resident’s bed.
Record review of the physician’s orders [REDACTED].
During an interview on 8/29/18 at 9:30 A.M., the resident said he/she used the bed rail to
move from the bed to the wheelchair.
Record review of the resident’s Medical Record on 8/31/18 showed a bed rail assessment was
completed for the resident on 8/10/18, but there was no signed consent form by the
resident or the resident’s representative in the resident’s medical record.
4. Review of Resident #278’s MDS, dated [DATE], showed the facility staff assessed the
resident as follows:
-Short and long term memory loss;
-Required extensive assistance with bed mobility, eating, toilet use and personal hygiene;
-Uses wheelchair for mobility;
-Falls prior to admission to the facility.
Review of the resident’s comprehensive care plan, dated 3/15/18, directed staff on the
following interventions:
-Report changes in activities of daily living performance to nurse;
-One-half side rails as an enabler;
-Provide PT and OT as ordered;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 52)
-Provide the amount of assistance and supervision that is needed;
-5/6/18-Resident fell with new interventions added to provide assistance with transfers,
remind to lock wheelchair, call light within reach and frequent monitoring required to
maintain safe environment.
Observation on 8/27/18 at 1:55 P.M., showed the resident lay in bed on his/her back with
his/her knees bent and feet pressed against the foot board. Low air loss mattress inflated
and 1/2 side rails on both sides of the bed.
Observation on 8/28/18 at 9:07 A.M., showed the resident sat up in bed eating breakfast,
air mattress, and 1/2 bed rails with a 2-3 inch opening between the mattress and bed rail,
on each side.
Observation on 8/28/18 at 3:58 P.M., showed the resident rested in bed with 1/2 bed rails
on both sides and the mattress about 2-3 inches from the siderails on both of the sides.
Observation on 8/29/18 at 10:24 A.M., showed the resident lay on his/her right side near
the edge of the bed, kicking his/her legs off the side of the bed. Siderails on both sides
continue to have a 2-3 inch gap between the mattress and the bed rail and low air loss
mattress set at a level three.
Observation on 8/29/18 at 12:33 P.M., showed the resident with his/her head of the bed
elevated and feeding him/herself lunch with both 1/2 side rails up with mattress 2-3
inches away from the bed rails on each side.
Observation on 8/29/18 at 12:27 P.M., showed the resident lay in bed with both legs off
the side of the bed with both 1/2 side rails up and mattress 2-3 inches away from the bed
rails on each side.
Observation on 8/30/18 at 2:39 A.M., showed the resident lay on his/her left side with one
leg off the left side of the bed and both 1/2 side rails up with about four inches between
the mattress and bed rail on the resident’s left side of the bed.
Observation on 8/30/18 at 4:07 A.M., showed the resident’s legs toward the edge of the bed
on the right side and 1/2 side rail and mattress remained about 4 inches from each other
on the resident’s left side.
Observation on 8/30/18 at 4:30 A.M., showed the mattress had slid to the right side of the
frame causing a four inch gap between the bed rails and the mattress on the left side of
the bed.
Observation on 8/30/18 at 5:12 A.M., showed the resident lay on his/her right side toward
the edge of the mattress holding onto the side rail.
Record review of the resident’s medical record showed the facility staff did not complete
a side rail assessment to determine the need for side rails, and did not have the resident
or responsible party sign a consent for use of the side rails. Further review showed staff
initiated a side rail assessment dated [DATE], but did not fill it out.
5. Review of Resident #19’s MDS, dated [DATE], showed facility staff assessed the resident
as follows:
-Severe cognitive impairment;
-Required extensive assistance with bed mobility, transfers, dressing, toilet use;
-[DIAGNOSES REDACTED].
-One fall with no injury since most recent admission.
Review of the resident’s comprehensive care plan, dated 3/20/18, directed staff on the
following interventions:
-Report changes in activities of daily living performance to nurse;
-One-half side rails as an enabler;
-Provide PT and OT as ordered;
-Provide the amount of assistance and supervision that is needed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 53)
Observation on 8/27/18 at 1:57 P.M., showed the resident lay in bed on his/her back, bed
in lowest position and 1/2 side rails on both sides of the bed.
Observation on 8/28/18 at 4:00 P.M., showed the resident rested in bed with 1/2 side rails
on both sides.
Observation on 8/29/18 at 9:19 A.M., showed the resident lay on his/her right side with a
wedge behind his/her back and 1/2 side rails up on both sides of the bed.
Observation on 8/30/18 at 03:26 A.M., showed the resident lay in bed with 1/2 side rails
on both sides of his/her bed and bed in the lowest position.
Record review of the resident’s medical record showed the facility staff did not complete
a side rail assessment to determine the need for side rails, and did not have the resident
or responsible party sign a consent for use of the side rails. Further review showed staff
initiated a side rail assessment dated [DATE], but did not obtain a consent with a
signature from the resident or responsible party.
6. Review of Resident #23’s MDS, dated [DATE], showed staff assessed the resident as
follows:
-Mild cognitive impairment;
-Required extensive assistance bed mobility, transfers, dressing, toilet use and personal
hygiene;
-[DIAGNOSES REDACTED].>-No falls since last admission or assessment.
Review of the resident’s comprehensive care plan, dated 12/29/17, directed staff on the
following interventions:
-Report changes in activities of daily living performance to nurse;
-One-half side rails as an enabler;
-Provide PT and OT as ordered;
-Provide the amount of assistance and supervision that is needed;
-On 7/27/18 staff documented to encourage the resident to use the call light for
assistance.
Observation on 8/30/18 at 2:45 A.M., showed the resident lay in his/her bed on the right
side. Further observation showed the resident had 1/2 side rails up on both sides of the
bed.
Review of the resident’s medical record showed the facility staff did not complete a side
rail assessment to determine the need for side rails, and did not have the resident or
responsible party sign a consent for use of the side rails.
7. During an interview on 9/5/18 at 6:51 P.M., Licensed Practical Nurse (LPN) P said side
rails are suppose to have a consent signed to be used. Side rails can be used if the
resident is able to use them to assist with sitting up. If the resident is not able to use
them for positioning, then they would be a restraint. If a resident is alert and oriented
times one, maximum assistance with care, and can’t move themselves, then side rails should
not be used. He/she would have to look at the form to verify if the side rails are per
family request.
During an interview on 9/5/18 at 6:58 P.M., the Director of Nursing (DON) said side rail
assessments should be done on admission. If a resident is able to use the side rail to
assist with mobility the device is not considered a restraint.

F 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Provide enough nursing staff every day to meet the needs of every resident; and have a
licensed nurse in charge on each shift.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility staff failed to provide
sufficient staff to meet the needs of the residents. The facility failed to complete
restorative nursing services for four residents (Resident #13, #14, #18, #36), and failed
to provide wound treatments to eight residents (Resident #11, #14, #18, #19, #26, #53,
#435, and #436) as ordered when the facility pulled the treatment nurse to the floor or
he/she was not working. Additionally, the facility failed to provide timely assistance and
repositioning for five residents (Resident #11, #13, #23, #436 and #437), failed to put
interventions in place and provide frequent monitoring for one resident at risk for falls
(Resident #278), failed to identify and complete a significant change in status Minimum
Data Set (MDS) assessment on three residents (Resident #19, #23, and #278) and failed to
complete 48 hour baseline care plans for eight residents (Resident #23, #60, #77, #178,
#278, #431,#433, and #436). Further, the the group interview resulted in concerns that
staff failed to answer the call lights in a timely manner, assist to reposition residents,
provide bedtime snacks and provide meals timely. The facility census was 80.
1. Review of the daily staffing sheets, dated 8/11/18 through 8/16/18, showed no
restorative certified nursing aide (CNA) scheduled. Further review showed the following:
-8/11/18 three registered nurses (RN), eight licensed practical nurses (LPN) (three worked
16 hour shifts), no treatment LPN, 17 CNA’s, and one CNA on orientation.
-8/12/18 three RN’s (one RN worked a 16 hour shift), six LPN’s (one is the LPN treatment
nurse and one worked 7:00 P.M. – 7:00 A.M.) and 15 CNA’s (one worked a 12 hour shift, one
worked a three hour shift, and one worked a four hour shift), and two CNA orientees;
-8/13/18 four RN’s, five LPN’s, no restorative CNA or treatment nurse, 14 CNA’s (one
worked worked a three hour shift), and one CNA on orientation on evening shift;
-8/14/18 seven RN’s, two LPN’s, one treatment LPN, and 15 CNA’s (one left early), and one
CNA on orientation on evening shift;
-8/15/18 four RN’s, six LPN’s (one worked a four hour shift), one treatment LPN, and 17
CNAs;
-8/16/18 five RN’s, four LPN’s, one LPN treatment nurse, and 17 CNA’s.
Review of the daily staffing sheets, 8/24/18 through 9/5/18, showed no restorative CNA
scheduled. Further review showed the following:
-8/24/18 four RN’s, five LPN’s (one is the LPN treatment nurse), and 20 CNA’s on days
(written to outside of CNA’s is 6 on days, 7 on evenings, and 5 on nights);
-08/25/18 four RN’s, seven LPN’s, two nurse orientees, no treatment nurse, and 19 CNA’s
(written to the outside of the CNA’s is 6 on days, 5 on evenings, and 3 on nights);
-8/26/18 one RN, seven LPN’s (one is the MDS Coordinator and one worked 7:00 P.M. to 6:00
A.M.), one LPN orientee and one RN orientee, one certified medication technician (CMT),
LPN treatment nurse, and 16 CNA’s (one CNA worked 7 P.M. to 11 P.M.);
-8/27/18 four RN’s (one RN worked a 16 hour shift), five LPN’s (one is LPN treatment
nurse), and 16 CNA’s (two CNA’s worked 16 hours shifts);
-8/28/18 four RN’s (one RN worked a 16 hour shift and one RN worked 7:00 P.M.-11:00 P.M.),
one RN orientee, five LPN’s (one is MDS coordinator), one LPN treatment nurse, and 17
CNA’s;
-8/29/19 two RN’s, one RN orientee, eight LPN’s (one from a different facility), one LPN
treatment nurse, and 18 CNA’s;
-8/30/18 three RN’s (one worked a 12 hour shift and one worked 16 hours), five LPN’s (one
worked a 12 hour shift and one worked a 16 hour shift), one LPN treatment nurse, and 17
CNA’s (one with weight written next to name, two with late and a line through their names,
and one worked a 16 hour shift);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 55)
-8/31/18 three RN’s, seven LPN’s (one worked a 16 hour shift), one LPN treatment nurse,
and 16 CNA’s (one CNA worked 12 hours and two CNAs worked a 16 hour shift);
-9/1/18 four RN’s (one worked a 16 hour shift and one from a different facility), five
LPN’s (one worked a 16 hour shift), no LPN treatment nurse, and 15 CNA’s (two worked 12
hour shifts, two worked 16 hour shifts, and one marked orientation on days and scheduled
by him/herself on evening shift);
-9/2/18 four RN’s (one from a different facility), seven LPN’s (one worked a 16 hour
shift), no LPN treatment nurse, and 14 CNA’s (one worked a 12 hour shift and four worked
16 hour shifts);
-9/3/18 three RN’s, six LPN’s (one is LPN treatment nurse and one worked a 16 hour shift),
and 14 CNA’s (one worked a 12 hour shift and one worked a 16 hour shift);
-9/4/18 four RN’s (one worked a 12 hour shift), six LPN’s (one worked a 12 hour shift and
two worked a 16 hour shift), no LPN treatment nurse, and 17 CNA’s (one worked a 16 hour
shift and one is the staffing coordinator); and
-9/5/18 four RN’s (documented on the staffing sheet as one RN with CMT but no CMT’s were
scheduled), six LPN’s (three from a different facility, and one is the facility’s hospital
liaison), LPN treatment nurse, and 17 CNA’s (one worked a 12 hour shift).
Further review of the daily staffing sheets, dated 8/11/18 through 8/16/18 and 8/24/18
through 9/5/18, showed the LPN treatment nurse was pulled to work as a unit floor nurse
four times and did not work six days.
2. Review of the facility assessment tool staffing plan, last updated 8/14/18, showed the
facility staff documented the total number of staff needed as the following:
-Licensed nurses providing direct care: 11;
-Nurse Aides: 18; and
-Other nursing personnel (e.g., those with administrative duties): 5.
3. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment tool, dated 6/16/18, showed staff assessed the resident as follows:
-Short and long term memory loss;
-Required extensive assistance of staff with bed mobility, dressing, and toileting;
-Dependent upon staff for assistance with eating and personal hygiene;
-[DIAGNOSES REDACTED].
-Did not receive Restorative Nursing in the last seven days for range of motion.
Review of the resident’s comprehensive care plan, dated 3/19/18, showed staff documented
the resident is at risk for contractures due to the history of a [MEDICAL CONDITION]. The
resident’s comprehensive care plan directed staff on the following interventions:
-Provide the assistance of one for transfers and activities of daily living;
-Please get me up at least three times a week;
-Please transfer me to my wheelchair with a hoyer lift;
-Provide restorative nursing as ordered.
Observation on 8/29/18 at 12:33 P.M., showed the resident remained positioned on his/her
back since 8:45 A.M. in the bed with the head of bed up approximately 45 degrees.
Observations on 9/4/18 from 1:00 P.M. to 6:00 P.M., showed the resident remained in the
same position in his/her geri-chair, in a reclined position with his/her feet propped up
on pillows. Staff did not reposition the resident during this time.
4. Review of Resident #14’s quarterly MDS, dated [DATE], showed staff assessed the
resident as follows:
-Required extensive assistance with bed mobility, transfers, dressing, eating, toileting
and personal hygiene;
-[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 56)
-Did not receive restorative nursing services for range of motion in the last 7 days.
Review of the resident’s comprehensive care plan, dated 6/6/18, showed the resident
problems listed as having contractures, weakness and spasms with inability to achieve full
functional range of motion. The resident’s comprehensive care plan directed the
restorative aid on the following interventions:
-Assist to move, through tolerated range, supporting joints about and below extremity;
-Refer to therapy as needed;
-Report or document any decline;
-Reposition for comfort at end of session;
-Dowel exercises three times a week.
Review of the resident’s physician’s orders [REDACTED]. Further, the physician ordered the
resident to wear the right upper extremity splint five times a week for 4-8 hours and
directed nursing to check to see if skin issues or redness noted.
Observation on 8/30/18 at 9:45 A.M., showed the resident positioned in his/her wheelchair
with the left arm contracted at the elbow as his/her elbow lay against his/her chest area.
During the time of this observation the resident did not extend his/her left arm.
Observation on 9/5/18 at 10:00 A.M., showed the resident positioned in his/her wheelchair
with the left arm contracted at the elbow as his/her elbow lay against his/her chest area.
During the time of this observation the resident did not extend his/her left arm.
5. Review of the Restorative Nursing log showed the following residents listed to receive
restorative nursing services:
-Resident #18-Occupational therapy (OT) recommended right shoulder self range of motion by
grasping hands lifting up/down in/out from chest 20 repetitions (reps), the resident is to
complete bicep curls and wrist rotation 20 reps using a one pound dumbbell. Further review
showed the Restorative Aid (RA) did not document that the restorative exercises that were
recommended by (OT) were provided in (MONTH) (YEAR) and (MONTH) (YEAR);
-Resident #36-OT recommended RA on 7/26/18 for three times a week passive range of motion
exercises to both lower extremities and passive range of motion to both upper extremities
three times a week. Further review showed the RA did not document that the restorative
exercises that were recommended by (OT) were provided in (MONTH) (YEAR) and (MONTH)
(YEAR).
6. During an interview on 8/31/18 at 12:20 P.M., the Therapy Coordinator said the
therapist gives the Director of Nursing (DON) the referrals for RA and then nursing sets
up the resident for restorative exercises with the restorative aide.
7. During an interview on 08/31/18 at 10:56 A.M., CNA AA said she/he is the restorative
aide, but has not been able to provide restorative nursing for the residents since (MONTH)
(YEAR) because she/he continually is pulled from her/his duties to provide direct resident
care.
8. Review of the Resident Council Meeting Minutes, dated 5/7/18, showed 21 residents in
attendance shared the following concerns:
– Some of the nurses don’t come;
– Nurses don’t want to check anything if you ask, he/she avoids;
– Nurses also do not explain what pills they are giving you;
– The nurses and aides don’t know what is going on if they come from the other side/hall.
Review of the Resident Council Meeting minutes, dated 6/4/18, showed 16 residents in
attendance shared the following concerns:
– The 11:00 P.M. to 7:00 A.M. shift aides do not do every two hour rounds;
– Aides do not help in the main dining room;
– One resident said he/she was left in the bathroom for over an hour;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 57)
– Resident beds are not being made;
– Resident asked for towels and did not receive any.
Review of the Resident Council Meeting minutes, dated 7/2/18, showed 19 residents in
attendance shared the following concerns:
– Staff were late getting residents up every morning for breakfast.
9. During the Resident Council interview on 8/28/18 at 1:30 P.M., nine residents attended
and shared the following concerns related to sufficient/competent nurse staffing:
-Medication not available from pharmacy have to wait for it to be delivered or staff have
to get it re-filled. One resident said he/she ran out of eye drops used to treat his/her
[MEDICAL CONDITION] (a condition of increased pressure within the eyeball, causing gradual
loss of sight);
– Resident said one time staff shut his/her door and oxygen tank ran out. He/She turned on
the call light and waited 45 minutes;
-Six residents said they have to wait one to two hours for staff to answer call lights.
Sometimes staff come in, turn off call light and say they will be back;
-Seven of the residents said they do not feel there was sufficient staff to take care of
everyone and staff will tell you they are short staffed. Nights and weekends are worst for
staffing;
-Staff do not always wear name tags and when residents ask their name staff respond with
why you want to know?;
-Staff call in on weekends and night shift;
-Residents say facility tries to hire more staff but the staff usually don’t stay;
-Staff place call light out of reach of residents;
-Staffing issues have been brought up in resident council meetings before;
-Seven residents said snacks are brought out to nurses stations during evening shift but
are not offered to residents. Residents have to go up to the nurses station or ask staff
for a snack. The residents would like to have snacks offered to them before bedtime.
10. Observation on 8/30/18 at 03:57 A.M., showed Resident #437 yelling Could I have a
little help in here please the resident sat up on the side of the bed with his/her legs
hanging off the bed wearing an incontinence brief and t-shirt. CNA F went into the room
and told the resident to lay down. The resident said he/she needed to go to the bathroom.
CNA F brought the resident a urinal.
During an interview on 8/30/18 at 3:57 A.M., CNA F said he/she had 20 patients to care for
and has been trying to get the resident to stay in bed all night. CNA F said he/she was
working on the north and south halls.
11. During an interview on 8/29/18 at 9:28 A.M., Resident #436 said staff woke him/her up
at 3:30 AM to pre-dress him/her in bed. The resident said that was very unusual. He/She
said the staff did not know how to get his/her brace on and had to find the therapy aide
to assist them. He/she said sometimes he/she has to wait two hours to be changed. As a
result, he/she has had accidents and gotten urine all over the floor. This happened a few
times. Having to wait long periods for assistance is consistent throughout all shifts.
12. Review of Resident #23’s medical record showed the resident:
-Required extensive assistance for his/her ADL’s;
-Always incontinent of bladder and frequently incontinent of bowel;
-At risk for pressure ulcer development.
Observations during the survey showed staff did not consistently assist the resident to
determine his/her care needs and provide assistance in a timely manner when he/she
hollered out and cried.
13. Observation on 8/30/18 at 2:45 A.M., showed staff did not provide timely incontinence
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0725

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 58)
care for Resident #11 when staff found the resident with a saturated incontinence brief
and pad beneath the resident. Observation showed the soiled linens leaked through the
plastic bag in which they were discarded and left a wet spot on the bedside table. The CNA
said he/she was the only CNA on that hall during the shift.
14. Review of Resident #13’s medical record showed the resident:
-Required extensive assistance from staff for his/her ADL’s;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-At risk for pressure ulcers.
Observations during the survey showed staff did not assist the resident to reposition or
provide incontinent care for an extended period of time.
15. Review of Resident #278’s medical record showed the resident:
-Required assistance from staff for his/her ADL’s;
-Incontinent of bowel and bladder;
-Had multiple falls;
Observation during the survey showed staff did not initiate appropriate interventions and
more frequent monitoring for the resident to keep the resident safe from sliding out of
bed and falling.
16. Review of Residents #19, #18, #14, #11, #53, #435, and #436 showed the residents had
pressure ulcers with physician ordered treatments. Further review showed staff did not
consistently document application of the wound treatments as ordered by the residents’
physicians.
17. Observations and record review during the survey showed Resident #26 had abrasions on
his/her left and right forearms, with physician ordered treatments. Observations showed
the resident’s abrasions were not consistently covered, and record review showed staff did
not document a treatment dressing change on 9/2/18.
18. During an interview on 8/31/18 at 9:45 A.M., LPN G said she/he is the wound nurse and
provides all of the treatments during the week and weekly wound assessments but has been
pulled from her/his position to perform charge nurse duties. LPN G said she/he was pulled
from her/his wound treatments to perform charge nurse duties three times in the last seven
days.
19. Review of Residents #23, #60, #77, #178, #278, #431, #433, #436’s 48 hour baseline
care plans showed staff did not accurately complete the form and did not ensure the form
was reviewed and signed by the resident or his/her representative.
20. Review of Residents #19, #23, and #278’s medical records, including MDS assessments,
showed staff did not complete a significant change MDS assessment as directed by the
Resident Assessment Instrument manual for the resident’s changes.
21. During an interview on 9/5/18 at 6:58 P.M., the Director of Nursing (DON) said the
facility determines that they have enough staff by taking into account the acuity of the
residents and the facility’s corporate has a ppd (allotted nursing hours per resident per
day) set at the corporate level. The facility also has a staffing scheduler.

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure that nurses and nurse aides have the appropriate competencies to care for every
resident in a way that maximizes each resident’s well being.

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 59)
staff had the appropriate competencies and skill sets to provide nursing and related
services and that nurse aides are able to demonstrate competency in skills and techniques
necessary to care for residents’ needs. Staff failed to demonstrate safe transfer
techniques for two residents (Resident #4 and #278), failed to maintain the low air loss
mattress setting for one resident (Resident #278), failed to prevent medication errors for
three residents (Resident #19, # 228, and #433), failed to check placement prior to
administering medications for one resident (Resident #19), failed to provide appropriate
incontinent care for four residents (Resident #3, #19, #77, and #278) and did not
reposition or provide toileting assistance for two residents (Resident #13 and #23).
Additionally, facility staff failed to provide competent nursing staff when caring for
five residents (Resident #3, #4, #9,#23 and #429) and one anonymous resident in a
dignified manner. The facility census was 80.
1. During observations on [DATE] and [DATE], showed the following:
-[DATE] at 4:00 P.M., Certified Nurse Aide (CNA) D applied the gait belt around Resident
#4’s upper chest. CNA D and CNA E then grasped the gait belt and lifted the resident from
the bed to the wheelchair. The resident’s knees were bent during the transfer and he/she
was unable to bear weight;
-[DATE] at 2:06 P.M., CNA H and CNA I attached the sit to stand lift sling around Resident
#278 and to the sit to stand lift. CNA I lifted the resident with the lift. The resident
remained in a sitting position with his/her knees bent and arms extended above his/her
head. The sling around the resident was bunched up under his/her arms. The resident was
unable to bear weight. CNA H turned the lift toward the wheelchair, while CNA I pushed on
the resident’s bottom, then lowered to the wheelchair. The CNA’s said the resident needs
to be a hoyer lift (mechanical lift) transfer;
-[DATE] at 2:38 P.M., CNA H and certified occupational therapy assistant (COTA) transfer
Resident #278 back to bed with the sit to stand lift. The CNA and COTA applied a sling and
gait belt around the resident. The resident remained in a sitting position during the
transfer with his/her knees bent, arms above his/her head, the sling bunched up under the
resident’s arms, and the resident was unable to bear weight.
During an interview on [DATE] at 10:07 A.M., the Director of Nursing (DON) said they
already started educating staff on the sit to stand lift transfer yesterday. If a CNA
notices a change in the residents transfer status or a decline, they need to report it to
the nurse. The nurse should assess the resident to see if the transfer status changed.
2. Observations from [DATE] at 1:00 P.M. to [DATE] at 2:06 P.M. showed Resident #278’s low
air loss mattress setting at a level 3 firmness. Further observations from [DATE] at 2:38
P.M. to [DATE] at 5:25 A.M., showed the resident lay on a low air loss mattress, fully
inflated to a level 5 firmness. The resident had a fall during the change of shift for
evenings and nights on [DATE] and at 3:28 A.M. on [DATE]. Interviews with CNA’s, Licensed
Practical Nurses (LPN’s), Registered Nurses (RN’s), and the DON showed staff did not know
what the setting of the resident’s low air loss mattresses was supposed to be set on or
who was responsible for monitoring the settings.
3. Observations and record review showed staff did not administer the following
medications in a manner to prevent medication errors. Observations, record review, and
interviews showed the following:
-Resident #433 reported the nurse on the evening of [DATE] tried to administer the
resident’s [MEDICATION NAME] (blood thinner) when the medication was on hold related to
the resident’s International Normalized Ration (INR) of 4.1 (High);
-Resident #19’s [MEDICATION NAME] (anticonvulsant) order showed do not crush. Registered
nurse (RN) R crushed the medication and administered through the [DEVICE] ([DEVICE]) and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 60)
did not check placement of the [DEVICE] prior to administration of medications;
-LPN D attempted to administer [MEDICATION NAME] (treats high blood pressure) 50 milligram
(mg) and [MEDICATION NAME] (acid reducer) 40 mg to Resident #228. The resident questioned
the medications and when the LPN looked at the Medication Administration Record,
[REDACTED].
During an interview on [DATE] at 6:45 A.M., LPN D said staff are expected to check the
five rights (right resident, medication, dose, time and right route) before administering
medications to a resident.
4. Observations from [DATE] to [DATE], showed staff did not provide thorough and proper
pericare to Resident #3, #19, #77, and #278 during incontinent care. Staff did not ensure
that they cleansed all areas covered with urine or stool. Additionally, the staff did not
cleanse from front to back while providing care.
During an interview on [DATE] at 6:40 P.M., CNA L said staff are expected to remove their
gloves and wash their hands after providing incontinent care.
5. Observations showed staff did not provide repositioning or incontinent assistance for
the following:
-Resident #13 remained reclined in his/her geri-chair from 1:00 P. M. to 6:00 P.M. without
staff repositioning or providing incontinent assistance; and
-Resident #23 remained in his/her wheelchair without repositioning or incontinent
assistance from 8:45 A.M. to 1:00 P.M. and 2:00 P.M. to 4:07 P.M. The resident reported
he/she had not been changed all day.
6. Observations from [DATE] to [DATE], showed staff speaking to residents in an
undignified manner. Observations showed the following:
-Resident #23 crying and hollering out frequently without staff acknowledging or
addressing the resident’s needs. On [DATE], observation showed CNA H say to the resident,
You are really going to have to quit that crying. There is nothing wrong with you. The
resident began to crying louder and harder;
-CNA H told Resident #3 in an abrupt manner to lift his/her legs and after his/her pants
and brief were around the resident’s ankles the CNA pushed down on the resident’s legs
while abruptly saying put your legs down;
-Resident #4 repetitively asked the CNA to not to hurt him/her as he/she has been through
a lot. The CNA said in a harsh tone, What have you been through?;
-Resident #29 reached out for a salt shaker in the dining room and the activity director
said harshly, Don’t you get into that! I will get you!;
-An alert and orient anonymous resident said he/she would like to go back to his/her room
but staff take it out on him/her when he/she asks. The staff are hateful, mean.
During an interview on [DATE] at 2:55 P.M., Resident #429 said over the weekend he/she had
been up in his/her geri-chair since early morning and was not put to bed until 12:00 A.M.
The resident said he/she asked the staff to please put him/her to bed as his/her leg and
bottom were hurting. He/she said staff never got the nurse to assess for pain medication.
He/she said the two staff took him/her to his/her room and said they were going to put
others to bed and be back to help him/her. The resident said staff just left me in the
room and I was hurting so bad. When staff returned to assist the resident to bed they
wouldn’t listen to him/her before trying to transfer him/her. The resident said he/she
told the staff to get his/her chair closer to the bed. The staff picked him/her up without
using a gait belt, one staff grasped his/her arms and the other staff grasped his/her
legs. The resident said one staff complained about his/her back hurting. The resident said
staff never notified the nurse of his/her pain and he/she did not receive any pain
medication.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 61)
7. Review of the Facility Assessment, dated [DATE], showed the following information for
staff training, education and competencies:
-We have a full-time staff development coordinator who is responsible for orientation,
nursing education, and CNA certification hours, We hold all staff meetings and nursing
meetings monthly to go over education and topics about the facility. We provide CPR
(cardiopulmonary resuscitation) classes. We also have safety fairs and Life Care
University topics to complete for new processes and procedures;
-Staff are expected to provide the care to meet the resident’s needs.
Further review showed the Facility Assessment did not include specific training needs with
competencies to assess the knowledge of the staff to include transfers, infection control,
medication administration and dignity.
During an interview on [DATE] at 6:58 P.M., the DON said they determine if staff are
competent in their jobs by completing random observations of staff interactions with
residents, observing pericare and medication administration, by completing rounds on
different shifts. The facility also just hired a new staff development coordinator that
will be doing all of the mandatory inservices, completing staff training, making
observations, and providing education when he/she observes care not being completed
correctly and staff will be held accountable.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to administer
medications with an error rate of less than five percent. Facility staff administered
medications with an error rate of 10 percent of the 30 medications observed. Facility
staff attempted to administer medication to Resident #433 that was ordered to held by the
resident’s physician, attempted to administer to Resident #228 the wrong resident’s
medication, crushed a medication that was contraindicated and failed to check placement of
a feeding tube before administering medications for Resident #19. The facility census was
80.
1. Review of the facility Administering Medications policy, dated 6/21/06, showed the
following:
Medications are to be administered as soon as possible after doses are prepared and are
to be administered by the same person who prepared the dose. Each medication administered
at the time of administration must be promptly recorded in the resident’s individual
medication record per initial of the licensed nurse who must sign his or her first and
last name and position on the medication administration record;
-Medications prescribed for one resident must not be administered to any other resident.
2. Observation on 8/30/18 at 6:00 A.M., showed Licensed Practical Nurse (LPN) D
administered medications to the residents on the 100 Hall. LPN D was outside room [ROOM
NUMBER] preparing the following medications: [REDACTED]
-[MEDICATION NAME] (treats high blood pressure) 50 milligram (mg) one tablet; and
-[MEDICATION NAME] (acid reducer) 40 mg one tablet.
Further observation showed LPN D entered room [ROOM NUMBER] to administer the morning
medications. Resident #228 lay in bed and LPN D reached out to hand her/him the
medications, but the resident asked what they were because this was the first time
medications were given to him/her this early in the morning. LPN D tried to explain what

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 62)
the purpose of the medications were and instructed the resident these were the medications
the physician ordered. The resident remained very concerned why she/he was receiving them
and insisted on the nurse checking the order. LPN D then explained to the resident she/he
would go back to the medication orders and check. LPN D looked at the Medication
Administration Record (MAR), but did not realize she/he was looking at the wrong resident
until the surveyor pointed it out to him/her on the MAR. LPN D did not ask the resident
his/her name, or medication, dose and time of medications that she/he takes everyday.
During an interview on 8/30/18 at 6:45 A.M., LPN D said she/he usually works night shift
and did get the residents mixed up. Further, LPN D said staff are expected to check the
five rights (right resident, medication, dose, time and right route) before administering
medications to a resident.
3. Review of Resident #433’s medical record showed the resident admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Review of telephone physician orders [REDACTED]. Give [MEDICATION NAME] 5 mg 8/29, 8/30,
9/1 and 9/2/18. [MEDICATION NAME] 10 mg on 8/31/18. PT/INR (blood test that checks
bleeding time) at [MEDICATION NAME] Clinic 8/31/18.
During an interview on 8/29/18 at 8:19 A.M., the resident said he/she goes to a
[MEDICATION NAME] clinic. He/She said they checked his/her INR and it was over 4.1. The
resident said the nurse on the evening shift on 8/27/18 tried to administer his/her
[MEDICATION NAME], but the resident caught it and told the nurse that his/her [MEDICATION
NAME] was on hold for two days.
4. Review of Resident #19’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, dated 6/18/18, showed staff assessed the resident as:
-Severe cognitive impairment;
-Minimal depression;
-No behaviors or rejection of care;
-Received 51% or more of daily nutrition and 501 cubic centimeters (cc) or more of daily
fluids through tube feeding.
Review of the resident’s care plan, dated 6/19/18, showed staff assessed the resident as
at risk for his/her needs not being met related to memory impairment and relying on staff
for most decision-making. Staff are directed to anticipate and provide daily care as
indicated, administer fluids per [DEVICE] ([DEVICE]) as ordered, administer tube feeding
formula and flushes as ordered, check the [DEVICE] placement by draw back aspiration and
auscultation prior to administering any bolus enteral feeding, keep head of bed up at
least 30 degrees, observe for [MEDICAL CONDITION] activity and report to the resident’s
physician, observe for side effects of anticonvulsant medications, observe lab values for
therapeutic level, observe status after [MEDICAL CONDITION], and report any changes in
cognition or behavior to resident’s physician.
Review of the resident’s physician orders, dated (MONTH) (YEAR), showed the physician
ordered the following:
-Check and verify placement of the [DEVICE] prior to enteral feedings, water flushes, and
medication administrations;
-Flush [DEVICE] with 10 milliners (ml) of water between each medication during
administration;
-[MEDICATION NAME] ([MEDICAL CONDITION] medication) 500 mg table by mouth two times daily
*administer by mouth*; and
-[MEDICATION NAME] ([MEDICAL CONDITION]) 5 mg tablet by mouth daily *administer by mouth*
Review of the resident’s pharmacy consultation, dated 6/1-26/18, showed the pharmacist
recommended the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 63)
-[MEDICATION NAME], please administer by mouth-can be hazardous to employee crushing
medication;
-Levetiracetam ([MEDICATION NAME]), please administer by mouth.
Further review showed the physician accepted the recommendations on 7/2/18.
Review of the resident’s telephone order sheet (TOS), dated 7/2/18, showed staff
documented an order from the physician for the [MEDICATION NAME] and [MEDICATION NAME] to
be administered by mouth and do not crush.
Observation on 8/29/18 at 8:36 A.M., showed Registered Nurse (RN) R placed the resident’s
[MEDICATION NAME] 500 mg 1 tab and [MEDICATION NAME] sprinkle 125 mg 3 caps into a
medicine cup after crushing the [MEDICATION NAME]. The RN popped the resident’s Losartan
100 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10 mg, and [MEDICATION NAME] 25 mg,
crushed the medication and placed in a medication cup, then crushed [MEDICATION NAME] 5 mg
and [MEDICATION NAME] 10 mg and placed them into a third medication cup. The RN added
about 10 cc water to each cup and and mixed the medication into the water. The RN entered
the resident’s room, placed the syringe into the resident’s [DEVICE]. Observation showed
the RN poured 30 cc water into the syringe without checking placement with auscultation
and/or aspiration. The RN poured the resident’s blood pressure medications into the
syringe, followed by the crushed [MEDICATION NAME] and [MEDICATION NAME] and last the
crushed [MEDICATION NAME] and [MEDICATION NAME] sprinkles. The RN did not flush with any
water between the medications. The RN flushed with 30 cc of water and reconnected the
resident.
During an interview on 9/5/18 at 6:58 P.M., the director of nursing (DON) said the nurse
is expected to make sure medications match the orders on the MAR, ensure the correct dose
by comparing the card to the MAR and sanitize hands prior to administration and between
residents. The nurse needs to tell the resident what the medications are. If the nurse is
unaware of what the medication is for, he/she should not give the medication until he/she
looks it up. If a medication is put on hold, the nurse that takes the order needs to
document hold on the MAR or TAR for the days that it is on hold. If a resident has a
[DEVICE] he/she prefers that the pharmacy sends liquid medications, but if they have a
pill and it is not supposed to be crushed, the nurse should administer the medication by
mouth unless the resident is not able. If the resident can not take the oral form, the
nurse needs to notify the physician.

F 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to conduct and document a
thorough facility-wide assessment to determine what resources are necessary to care for
residents during both day-to-day operations and emergencies. The facility census was 80.
Review of the facility assessment, last updated [DATE], showed staff documented a list of
medical [DIAGNOSES REDACTED]. Staff did not document the acuity levels of the facility
residents to determine the intensity of care and services needed and the staff
competencies necessary to provide the care needed to address these [DIAGNOSES REDACTED].
Review of the resources section of the facility assessment tool, showed the facility

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0838

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 64)
documented staffing plan as follows:
-Licensed nurses providing direct care: 11;
-Nurse Aides: 18;
-Other nursing personnel (e.g., those with administrative duties): 5;
-Other staff needed for behavioral healthcare and services: 0;
-Licensed dietician or other clinically qualified nutrition professional: 2;
-Food and nutrition service staff: 7;
-Respiratory care services staff: 0.
Additional review showed staff did not specify staffing per shift, or based on any
variances in acuity or specific, individualized care needs. Documentation showed facility
staff stated they have a full time nursing staff coordinator who does nursing scheduling
day to day. The resident preferred rise times, bath days, preferred nap/bed times,
activities, meal times, total care patients, [MEDICAL TREATMENT], wound treatments, and
therapy are taken into account with staffing and resources needs. Staff training/education
and competencies that are necessary are provided by a full time staff development
coordinator who is responsible for orientation, nursing education and CNA certification
hours. They hold all staff meetings and nursing meetings monthly to go over education and
topics about the facility. The facility provides CPR (cardiopulmonary resuscitation)
classes and also has safety fairs, and Life Care University topics to complete for new
processes and procedures.
Additional review showed staff documented: the facility has a mix of white and African
American residents. The majority are Catholic and Christian with a few Protestant and
Lutheran religions.
Further review of the facility assessment showed staff documented they have contracts with
all 3rd party vendors, but did not list who their contracts are with, memorandums of
understanding, or other agreements with third parties to provide services or equipment to
the facility. Staff did not document their pharmacy, rehabilitation therapy provider, or
other contracted staff. Staff did not list or provide a source for inventory of physical
resources needed, such as numbers and types of medical supplies and equipment needed to
provide care for the facility’s residents according to the facility assessment.
During an interview on [DATE] at 2:40 P.M., the administrator said he/she did not have
further information for the facility assessment. He/She was unaware that the facility
assessment needed to be more detailed.

F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Arrange for the provision of hospice services or assist the resident in transferring to
a facility that will arrange for the provision of hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish the hospice plan of
care in coordination with the facility’s plan of care for two residents (Resident #21 and
#80) on hospice services. Further, the facility staff could not identify the facility
designated hospice liaison. The facility census was 80.
1. Review of Resident #80’s Significant change Minimum Data Set (MDS), a federally
mandated assessment tool, dated 11/21/17 showed the facility assessed the resident as
follows:
-Short and long term memory loss;
-Required extensive assistance from staff with bed mobility, transfers, dressing,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 65)
toileting and personal hygiene;
-Frequently incontinent of urine;
-Always incontinent of bowel;
-At risk for the development of a pressure ulcer;
-Received hospice services.
Further review of the medical record showed the resident’s hospice plan of care was not
accessible to staff until requested from the Director of Nurses (DON).
Review of the Hospice Interdisciplinary Comprehensive Care Plan dated 10/31/17 directed
hospice services on the following interventions:
-Nursing to evaluate systems;
-Nursing to assist with pain management;
-Nursing to teach medication management;
-Provide emotional support;
-Evaluate socialfinancial needs;
-Aide assisted with personal care and Activities of Daily Living;
-Bereavement risk;
-Hospice will teach medication and treatment, safety issues, advanced directives, symptom
control, patients rights, hospice notification of changes and hospice philosophy.
Review of the resident’s comprehensive care plan, dated 5/30/18, directed staff on the
following interventions for Hospice care:
-Administer pain medication per physician’s orders [REDACTED].>-Put interventions in
place to keep the resident comfortable;
-Will choose hospice and notify changes in condition;
-Encourage time with family and friends.
-Further review showed the resident’s coordinated plan of care with hospice services,
dated 5/30/18, did not include the following information:
– Diagnoses;
– A common problem list;
– Palliative interventions;
– Palliative goals/objectives;
– Responsible discipline(s);
– Responsible provider(s); and
– Resident/designated representative choices regarding care and goals.
2. Review of Resident #21’s admission MDS, dated [DATE], showed the facility staff
assessed the resident as follows:
-Short and long term memory;
-Required extensive assistance with bed mobility, transfers, dressing, eating, toileting
and personal hygiene;
-Frequently incontinent of urine;
-Always incontinent of bowel;
-[DIAGNOSES REDACTED].
-At risk for the development of pressure ulcer;
-Stage IV pressure ulcer;
-Application of dressing other than to feet;
-Application of ointments other than to feet;
-Hospice is not marked.
Review of the resident’s comprehensive care plan, dated 4/20/18, directed staff on the
following interventions for hospice services:
-Arrange for clergy of choice to visit;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 66)
-Assist in learning stress management/relaxation;
-Assure resident that symptoms of grieving are normal and will improve with time;
-Determine resident’s expectations;
-Discuss coping strategies;
-Discuss the resident concerns of being unwanted or feeling useless;
-Discuss with resident feelings, reminiscence, issues;
-Encourage family/friends to remain involved;
-Give positive reinforcement as involvement improves to solve conflicts;
-Invite and encourage to activities;
-Observe need for psychological services;
-Provide resident or responsible party with education as needed in the following areas.
Review of the resident’s closed medical record showed only one Hospice Coordinated Task
Plan of Care note, dated 4/11/18. Further review showed the Hospice Coordinated Plan of
Care showed the schedule for nurse visits and aide visits, social worker frequency and
Chaplin frequency.
Further review showed the resident’s coordinated plan of care with hospice services, dated
4/20/18, did not include the following information:
– Diagnoses;
– A common problem list;
– Palliative interventions;
– Palliative goals/objectives;
– Responsible discipline(s);
– Responsible provider(s); and
– Resident/designated representative choices regarding care and goals
During an interview on 9/5/18 at 7:10 P.M., Licensed Practical Nurse (LPN) V said for
residents receiving Hospice, a verbal report is given to the charge nurse after the clinic
visit. LPN V said a hospice note is in the hospice book for each company, but there is not
a care plan from hospice included and is unsure where the hospice care plan is located.
Further, LPN V does not know who or what the hospice liaison is for the facility.
During an interview on 9/5/18 at 2:40 P.M., the Director of Nurses (DON) said the hospice
liaison is the social worker, who communicates between the hospice and the facility. At
this time, the DON said she will have to find the location of the hospice care plans in
the facility.

F 0867

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Set up an ongoing quality assessment and assurance group to review quality deficiencies
and develop corrective plans of action.

Based on record review and interview, the facility failed to implement an effective
quality assurance (QA)/quality assurance performance improvement (QAPI) program when they
did not implement appropriate interventions to correct on-going, systemic issues. The
facility census was 80.
Review of the facility Performance Improvement Committee policy, dated 6/26/09, showed the
following:
– This policy is to establish and maintain a performance improvement committee, which
identifies and addresses quality concerns and implements corrective action.
-Goal:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 0867

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 67)
– To monitor and evaluate the appropriateness and quality of care provided within the
framework of the Performance Improvement Plan;
– To provide a means whereby negative outcomes relative to resident care are identified
and resolved through an interdisciplinary approach, and positive outcomes can be
reinforced through education and monitoring;
-Committee Authority: The Performance Improvement Committee functions as an advisory
committee to the Executive Director to implement the Performance Improvement Program,
including, but not limited to, the following tasks:
– Identify negative and positive outcomes on direct or indirect resident care;
– Establish criteria and standards of practice of professional organizations, health care
regulations, and federal and state requirements, as applicable to the facility;
– Meeting with the regional or divisional team to discuss any problem areas encountered if
necessary;
– Set thresholds on areas not already set by corporate.
Review of the facility’s annual statement of deficiencies (SOD) for the past three years,
showed the facility was cited for F281, a citation for failing to provide services that
meet professional standards; and for the past two years, showed the facility was cited for
F441, a citation for failing to care for residents utilizing acceptable infection control
procedures to prevent the spread of infection. The current SOD, dated 9/6/18, cited a
deficiency at F658, failure to provide services that meet professional standards, and
F880, failure to provide care in accordance with acceptable infection control procedures.
Based on multiple deficiencies cited in resident rights, admission, transfer, and
discharge practices, resident assessment and care plans, quality of care, nursing
services, pharmacy services, administration, and infection control procedures, the
facility does not have an effective quality assessment and assurance program to ensure
staff identify issues and develop and implement appropriate plans of action to correct
identified quality deficiencies that affect the residents’ health, safety and quality of
life.
During an interview on 9/5/18 at 08:14 PM, the administrator said the QA meetings consist
of the medical director, all clinical management, social services, the wound nurse,
therapy, and dietary manager. We try to include all levels of staff in the building in our
QAPI. The QAPI binder is discussed monthly. This is used to help set policies, protocols,
and see what needs to be fixed. We will complete and review audits, look at reductions,
and investigations. The top area trends that we review in our QA includes wounds,
infection control, bounce backs, dietary, falls, and weight loss. If the QA team notices
issues are still occurring, they look to see if it is a specific person that is not
implementing the interventions and if it is not a person then they go back and look at how
we are going to resolve the issue.

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 follow
acceptable infection control precautions for seven residents (Residents #11, #19, #23,
#53, #77, #278, and #435) out of 23 sampled residents and five additional residents
(Residents #3, #4, #9, #18, and #429). Staff failed to wash hands and change gloves during
wound and incontinence care and placed wash cloths directly into sink basins. The facility

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 68)
census was 80.
Review of the facility Hand Hygiene policy, dated 4/01/15, showed the following:
-Purpose: To decrease risk of transmission of infection by appropriate hand hygiene;
-Handwashing: When hands are visibly dirty, contaminated, or soiled, wash with
non-anti-microbial or anti-microbial soap and water;
-Note: Because alcohol based hand rubs do not kill spore-forming organisms, they should
not be used by staff when caring for residents with infections caused by spore-forming
organisms. Examples are [MEDICAL CONDITION] and bacillus anthracis. Staff will use
antimicrobial soap and water or non-antimicrobial soap and water for hand washing when
caring for residents with infections caused by spore-forming organisms;
-If hands are not visibly soiled, use an alcohol based hand rub for routinely
decontaminating hands in all clinical situations other than those listed under Handwashing
above.
1. Observation on 8/28/18 at 10:00 A.M., showed Certified Nursing Aide (CNA) J cleaned
liquid stool off of Resident #3’s wheelchair with Clorox wipes in the resident’s room. CNA
J removed his/her gloves, without washing or sanitizing his/her hands, put on a new pair
of gloves. CNA J placed wash cloths directly into the sink basin with water running over
them. Observation showed CNA H in the resident’s bathroom while the resident sat on the
toilet. The CNA removed the resident’s liquid stool covered pull-up from the resident’s
ankles. Observation showed CNA H assisted the resident off the toilet with the same soiled
gloves. CNA J handed CNA H two wash cloths from the sink basin and CNA H cleansed the
resident’s buttocks and perineal folds with the same wash cloth, then with the same gloves
used a dry towel to dry off the resident. Without washing their hands or changing gloves,
CNA H and CNA J assisted the resident to his/her wheelchair directly on the wheelchair
cushion. CNA H placed the resident’s brief, pants, socks and shoes on his/her lower
extremities, told the resident to stand up and pulled up the resident’s pull-up and pants,
with the same soiled gloves. CNA J removed his/her gloves, grabbed the Clorox wipe
container and left the resident’s room. CNA H placed the soiled linens in a plastic bag
and left the resident’s room with the same soiled gloves on. Observation showed CNA H and
CNA J did not wash their hands prior to leaving the resident’s room.
2. Observation on 9/04/18 at 6:25 P.M., showed Registered Nurse (RN) M and CNA L entered
Resident #4’s room and applied gloves without washing their hands. The RN and CNA removed
the resident’s sweater and t-shirt and placed a gown on the resident. The RN assisted
turning the resident to his/her right side and pulled down the resident’s pants and
removed the resident’s pull-up. Observation showed a strong urine odor and the resident’s
pull-up very wet. CNA cleansed the resident’s buttock, removed his/her gloves, without
washing his/her hands, opened the drawer on the bedside table, grabbed the resident’s
barrier cream and handed it to the RN. The RN applied the barrier cream to the resident’s
buttocks then removed his/her gloves. The CNA and RN positioned a brief under the resident
and placed a pillow under his/her right arm and legs. Further observation showed the CNA
and RN did not wash their hands upon entering the resident’s room and between dirty to
clean tasks. Additionally, the CNA touched the resident’s personal care items without
washing his/her hands after performing pericare.
3. Observation on 8/30/18 at 3:01 A.M., showed CNA K enter resident #9’s room to provide
incontinent care. He/she placed towels in the sink and turned and on the water. CNA K
removed a wet towel from the sink and began to provide pericare on the resident. He/she
changed gloves without washing his/her hands, rolled the resident to his/her right side,
placed soiled items in a plastic bag and placed the bag in a chair with a bedspread. The
CNA changed his/her gloves without washing his/her hands and elevated the resident’s feet
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 69)
on two pillows. He/she removed gloves and carried the bag of soiled towels into the
hallway. He she re-entered the room and put on gloves without washing his/her hands, then
emptied the resident’s catheter and disposed of the urine in toilet. He/she removed
his/her gloves and washed his/her hands then exited the room. Further observation showed a
brown bean shaped object left in sink.
4. Observation on 8/30/18 at 2:45 A.M., showed CNA A entered Resident #11’s room and
applied gloves without washing his/her hands. Observation showed the resident’s pants
pulled down to his/her ankles under the covers. The CNA cleansed the resident’s abdominal
fold and front perineal area with a wipe. The CNA removed his/her gloves and without
washing his/her her hands, applied gloves. Observation showed the CNA turned the resident
to his/her right side, removed the saturated brief from the back side and cleansed the
resident’s buttocks. Observation showed the resident’s brief leaked through to the
incontinence cloth pad under the resident. The CNA changed his/her gloves, without washing
his/her hands, positioned a dry pad and brief under the resident, and applied barrier
cream to the resident’s buttocks. The CNA removed his/her gloves and without washing
his/her hands, applied gloves and turned the resident to his/her left side and positioned
the brief, pulled down the resident’s shirt, positioned his/her feet on a pillow, placed
soiled linens in bag on bedside table, handed the resident his/her call light and left the
room with gloves on and bagged linens. Observation showed the CNA left the resident’s room
with soiled gloves and did not wash his/her hands with glove changes. Further observation
showed the soiled linens leaked through the plastic bag and left a wet spot on the bedside
table, which CNA A did not clean.
5. Observation on 8/29/18 at 3:07 P.M., showed Licensed Practical Nurse (LPN) G removed
Resident #18’s soiled dressing from the resident’s coccyx, changed gloves without washing
his/her hands, cleansed the wound with normal saline, and changed his/her gloves without
washing his/her hands. The LPN applied the ordered treatment to the wound bed, and covered
it with an abdominal pad and adhesive tape. Observation showed the LPN did not wash
his/her hands after removing gloves and going from dirty to clean tasks.
6. Observation 8/30/18 at 3:56 A.M., showed CNA C entered Resident #19’s room, placed
washcloths in the sink basin with water running over them, and put on a pair of gloves.
The CNA pulled down the resident’s blanket and removed his/her brief from the front, then
cleansed the resident’s front perineal and turned the resident his/her left side.
Observation showed the resident had a small stool. The CNA cleansed the resident’s gluteal
crease, tucked a brief under the resident, turned the resident to his/her other side, and
fastened the resident brief. The CNA pulled up the resident’s sheet and used his/her
controller to raise the head of the bed. Observation showed the CNA did not wash his/her
hands when he/she entered the resident’s room, changed gloves, or wash his/her hands when
going from dirty to clean tasks, and before touching the resident’s personal care items.
The CNA removed his/her gloves and left the resident’s room with the bagged soil linens
without washing his/her hands.
7. Observation on 8/29/18 at 4:45 P.M., showed CNA T entered Resident #23’s room to
provide incontinent care. CNA T applied clean gloves then assisted the resident into bed
and removed his/her pants and soiled brief. CNA T assisted the resident onto his/her side
then cleansed the buttocks, groin and back area. CNA T then continued to wear the same
soiled gloves while she/he touched the resident, the bedside table and the clean brief.
Staff did not remove soiled gloves and wash hands after providing incontinent care.
8. Observation on 8/29/18 at 11:04 A.M., showed Resident #53 up in his/her wheelchair with
his/her feet directly on the foot pedal and heel lift boot boots on the floor. Observation
showed LPN G washed his/her hands, cut the resident’s soiled dressing off of the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 70)
resident’s left foot/ankle. LPN G removed his/her gloves and without washing or sanitizing
his/her hands, put on a new pair of gloves. The LPN cleansed the wound, removed his/her
gloves, without washing or sanitizing his/her hands, put on clean gloves. Observation
showed the LPN applied the resident’s ordered treatment to his/her wound, put on the
resident’s socks and heel lift boots. Further observation showed the LPN did not wash or
sanitize his/her hands between dirty to clean tasks and with glove changes.
9. Observation 8/30/18 at 3:13 A.M., showed CNA K put on gloves without washing his/her
hands and placed two disposable incontinence pads under Resident #77. The CNA wet a towel
in the sink and started providing incontinence care to the resident. CNA K told the
resident he/she had a small bowel movement. The CNA cleaned the resident’s bottom with
cleansing wipes then changed gloves without washing his/her hands. The CNA applied barrier
cream to the resident’s bottom. He/she changed gloves without washing his her hands and
rolled the resident to his/her left side. The CNA placed the soiled items in a plastic
bag, removed his/her gloves, and wrapped the resident’s leg stumps with a disposable
incontinence pad. The CNA disposed the bag of soiled items in a container located in the
hall. He/she removed the gloves and walked toward the nurses’ station without washing
his/her hands.
Observation on 8/30/18 at 10:00 A.M., showed LPN G and CNA Z entered the room to provide a
treatment for [REDACTED]. The resident lay in bed with a brief on and was incontinent of
urine and stool. CNA Z applied gloves and removed the resident’s soiled brief. CNA Z and
LPN G assisted the resident to his/her side, and CNA Z applied gloves and cleansed the
resident’s back, buttocks and groin areas. CNA Z then, with the same soiled gloves, turned
the resident back over onto his/her back and placed the clean brief up through the
resident’s legs and fastened the brief. Staff did not remove soiled gloves and wash hands
after providing incontinent care.
10. Observation on 8/30/18 at 5:47 A.M., showed CNA C applied gloves without first washing
his/her hands, and unfastened Resident #278’s brief. Observation showed dried brown stool
to the resident’s buttocks and groin. The CNA cleansed the crease of the buttocks, applied
a clean brief while turning the resident side to side. Further observation showed the CNA
did not change gloves or wash hands when going from dirty to clean tasks during the
provision of care.
11. Observation on 9/4/18 at 3:20 P.M., showed CNA BB entered Resident #429’s room to
provide incontinent care. The resident lay in bed incontinent of urine. CNA BB applied
gloves and assisted the resident onto his/her side then removed the soiled brief. CNA BB
then cleansed the resident’s front peri area and buttocks, groin and folds. CNA BB
continued to wear the same soiled gloves and touch the resident, clean linen and bedside
drawer. CNA BB then applied a cream to the resident’s skin as she/he continued to wear the
same soiled gloves. Staff did not remove soiled gloves and wash hands after providing
incontinent care.
12. Observation on 8/29/18 at 4:57 P.M., showed CNA W and LPN G wore gowns and gloves and
entered Resident #435’s room. The resident had liquid feces on his/her buttocks. LPN G
cleansed the resident’s buttock and changed his/her gloves, without washing his/her hands,
applied gloves and removed the resident’s old dressing from his/her coccyx. Observation
showed a large amount of blood tinged drainage on the old dressing. LPN G cleansed the
wound, remove his/her gloves, and without washing his/her hands, applied new gloves.
Observation showed the resident continued to have liquid stool. LPN G cleansed the stool
and changed gloves without washing his/her hands, and applied the resident’s ordered
treatment to the wound. The LPN cleansed liquid stool from the resident’s bottom, removed
gloves, did not wash his/her hands, and applied the dry dressing over the wound.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265345

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF BRIDGETON

STREET ADDRESS, CITY, STATE, ZIP

12145 BRIDGETON SQUARE DR
BRIDGETON, MO 63044

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 71)
Observation showed the LPN applied barrier cream to the buttocks and groin without
changing gloves or washing his/her hands. Further observation showed the LPN changed
his/her gloves without washing his/her hands, removed the resident’s right heel lift boot,
and cut off the dressing to the right foot. Observation showed scant (small) amount of
serosangineous drainage on the soiled dressing and a moon shaped black eschar wound to the
resident’s outer heel and a dime size circle black eschar area to the lateral right foot.
The LPN cleansed both areas, changed gloves without washing hands or sanitizing, applied
the ordered treatment and wrapped the foot with kerlix gauze.
13. During an interview on 9/05/18 at 6:40 P.M., CNA L said staff are expected to wash
hands after pericare, after changing gloves and when providing any care.
During an interview on 9/05/18 at 7:10 P.M., LPN V said staff are expected to wash hands
after providing any care, and are expected to remove gloves after incontinent care and
wash hands.
During an interview on 9/5/18 at 6:58 P.M., the Director of Nursing (DON) said staff are
expected to wash their hands before putting on gloves, after removing soiled items, before
putting on on clean gloves, after the care is completed, and before they exit the room.
Staff can use sanitizer if their hands/gloves are not visibly soiled. Staff should wet
wash cloths by holding them in their hands or using a wash basin. Staff should not place
wash cloths directly into the sink basin. When staff are doing wound care, staff are
expected to wash their hands prior to putting on gloves, take off dirty dressings and
place them in a plastic bag on bed, wash their hands, reglove, apply the treatment as
order, take gloves off, wash hands, and tie the bag with soiled items. Staff are expected
to sanitize or wash their hands any time that they remove gloves.