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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 provide a
dignified dining experience by delaying request for a drink, failing to provide proper
eating utensils and allowing a resident to eat from another resident’s plate, by not
honoring a resident’s desire and request when to get out of bed, and posting signs
regarding resident’s care visible from the hallway. This deficient practice affected five
sampled residents. (Residents #71, #74, #44, #6 and #60). The census was 77.
1. Review of Resident #71’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/4/18, showed the following:
-Cognitively intact;
-Able to make needs known;
-Extensive staff assistance needed with eating;
-Consumed mechanically altered (food processed to make it easier to chew) diet;
-[DIAGNOSES REDACTED].
Observation on 9/17/18 of the main dining room lunch service, showed:
-At 12:23 P.M., the resident sat at his/her table and no fluids available to him/her. One
dietary aide used a beverage cart and passed drinks one table at a time to the residents
in the dining room;
-At 12:27 P.M., the resident requested a drink from Dietary Aide B when he/she took the
resident’s food order. He/she said another staff member provided the drinks and that staff
member would get the resident his/her drink. Dietary aide B did not get the resident
his/her requested drink;
-At 12:41 P.M., the resident continued to have no drinks served to him/her. One dietary
staff member continued to pass drinks from a beverage cart to dining room tables. No
additional staff provided assistance for beverage service;
-At 12:51 PM., staff served the resident two beverages. He/she immediately began to drink.
Two nurse aides sat at tables with residents;
-At 1:05 P.M., the resident served his/her lunch plate with no utensils available with the
meal and the resident requested utensils from the dietary aide. The dietary aide said
he/she would bring some utensils from the kitchen;
-At 1:13 P.M., staff provided no utensils. The resident used the teaspoon from his/her
coffee cup to eat his/her meal.
During an interview on 9/17/18 at 2:30 P.M., the resident said he/she liked to sit at the
back of the dining room but often he/she had to wait a long time for any drinks to be
served. He/she used the teaspoon from his/her coffee because that is all he/she had to use
to eat the meal. The staff did not bring a fork, knife or a clean spoon to use.
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing (DON) said multiple
aides are scheduled to assist in the dining room to pass out meal plates and serve
beverages. When a resident asks for a drink or utensils the staff member should get the
requested items for the resident right away. Any staff person can get utensils or
beverages.
2. Review of Resident #74’s admission MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Required extensive assistance from staff for most activities of living (ADL’s, daily self
care);
-Frequently incontinent of bowel and bladder;

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-[DIAGNOSES REDACTED].
-Special treatments: [MEDICAL TREATMENT] (Process for removal of waste and excess water
from the blood due to kidney failure).
Review of Resident #44’s admission MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Limited assistance required for most ADL’s, with supervision of one person required for
eating;
-[DIAGNOSES REDACTED].
Observation of the dining room on 9/17/18, showed the following:
-At 12:52 P.M., Residents #74 and #44 shared a table at the front of the dining room
during the lunch meal. Resident #74 finished everything on his/her lunch plate and pushed
it to his/her right. Resident #44 placed his/her partially eaten plate of food on top of,
and then over, Resident #74’s empty plate. Resident #74 pulled the plate in front of
him/herself and began to eat from Resident #44’s plate;
-At 1:18 P.M., Resident #74 no longer sat at the table and Resident #44’s finished plate
sat on table in his/her place. Resident #44 consumed all the food from Resident #74’s
plate except for a few beans, ate dessert and said lunch was good.
During an interview on 9/21/18 at 10:20 A.M., the corporate nurse said the resident’s were
good friends and sometimes did that.
4. Review of Resident #6’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Extensive assistance needed for all personal hygiene and mobility;
-Unable to ambulate;
-Always incontinent of urine;
-[DIAGNOSES REDACTED].
Observation on 9/19/18 at 5:45 A.M., showed the resident sat in his/her room in the
wheelchair. He/she dozed and said that he/she had been in the chair since 5:00 A.M. and
did not like it. He/she said he/she had informed the staff many times that he/she does not
like being up so early but they do not allow him/her a choice.
Observation on 9/19/18 at 10:17 A.M., showed the resident sat in the wheelchair in his/her
room with his/her eyes closed and a plate of food on the over bed table in front of
him/her. The resident said that staff get him/her up every day at 5:00 A.M. and he/she
does not like to get up at that hour. He/she informed the staff that he/she would like to
get up later however staff continue to get him/her up at 5:00 A.M.
Observation on 9/21/18 at 7:10 A.M., showed the resident sat in the TV room in the
wheelchair and his/her head rested on his/her hand. He/she said staff got him/her out of
bed again this morning at 5:00 AM. and he/she wanted to stay in bed.
Review of division 200’s available morning get up lists, showed Resident #6’s name on the
list dated 7/11/18, 7/29/18 and another undated list.
During an interview on 9/21/18 at 7:20 A.M., Licensed Practical Nurse (LPN) A said that a
certified nurse aide (CNA) told him/her that the get up lists are good for a couple of
weeks.
During an interview on 9/21/18 at 10:30 A.M. the DON said resident’s should be allowed to
get up when they want to and not when they are told to.
5. Review of Resident #60’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Sometimes able to understand others;
-Total dependence on staff for hygiene, dressing, toileting and bed mobility;
-[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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-Nutrition approaches included tube feeding (a tube surgically inserted through the
abdomen into the stomach to provide hydration, nutrition and medications).
Review of the resident’s care plan, last revised on 9/5/18, and in use during the survey,
showed the following:
-At risk for issues with nutrition, dehydration and constipation;
-Staff stated the resident was at risk for each issue and included it was due to the
resident being a tube feeder.
Observations of the resident’s room on 9/17/18 at 2:19 P.M., 9/18/18 at 10:46 A.M.,
9/19/18 at 1:12 P.M., 9/20/18 at 7:07 A.M., and 9/21/18 at 8:00 A.M., showed the
following:
-An orange piece of paper taped to the wall to the right of the resident’s bed and visible
from the hallway;
-At the top of the paper in large letter Safe Swallowing/Feeding Guidelines, and then
continued on to show what the resident and staff should and should not do during meals.
During an interview on 9/21/18 at 10:20 A.M., the administrator said staff could have used
a different term than tube feeder to reference how the resident received nutrition. It was
not a dignified term. Any sign visible from the hall is not private.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to keep resident’s accounts from
being overdrawn, for two of 45 resident whose accounts were managed by the facility (
Residents #326 and #327). The census was 77.
1. Review of the facility’s account ledger for the resident trust fund dated (MONTH)
(YEAR), showed:
-Resident #327 account balance of negative $399.95;
-Resident #326 account balance of negative $959.00.
2. Review of the facility’s account ledger for the resident trust fund dated (MONTH)
(YEAR), showed:
-Resident #327 account balance of negative $399.95;
-Resident #326 account balance of negative $959.00.
3. Review of the facility’s account ledger for the resident trust fund dated (MONTH)
(YEAR), showed:
-Resident #327 account balance of negative $399.95;
-Resident #326 account balance of negative $959.00.
4. During an interview on 9/20/18 at approximately 11:00 A.M., the assistant business
office manager said a resident’s account should never have a negative balance.
5. During an interview on 09/21/18 at 10:20 A.M., the administrator said a resident’s
account should never have a negative balance. She has been made aware of the situation and
was working with the business office.

F 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

Based on observation, interview and record review, the facility failed to post the results
of the most recent survey of the facility in a place readily accessible to residents,
family members and legal representatives of residents. The census was 77.
Observation on 9/17/18 at approximately 11:33 A.M., showed a sign posted at the entrance
of the facility indicating that the survey binder was located in the library.
Observation on 9/17/18 at approximately 11:33 A.M., 9/18/18 at approximately 9:00 A.M.,
9/20/18 at approximately 9:50 A.M. and 9/21/18 at approximately 9:00 A.M., showed no
survey binder in the facility library.
Observation on 9/19/18 at approximately 6:30 A.M., 9/20/18 at approximately 9:50 A.M. and
9/21/18 at approximately 9:43 A.M., showed a survey binder located at nurses station on
100 hall, under another binder.
During a group meeting on 9/18/18 at approximately 11:22 A.M., all of the residents said
they were not aware of the survey binder nor where it was kept.
During an interview on 9/24/18 at approximately 8:30 A.M., the administrator said she
expects residents and visitors to have access to view the survey binder. She was unable to
locate the survey binder during survey, and will see that the survey binder is moved to
the library and residents are aware of its location.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility’s abuse and neglect policies,
procedures and protocols, failed to identify when, how, and by whom determinations of
capacity to consent to a sexual contact will be made and where this documentation will be
recorded. The census was 77.
Review of the facility’s Protection of Residents: Reducing the Threat of Abuse and
Neglect, last revised (MONTH) (YEAR), showed:
-Sexual abuse is non-consensual sexual contact of any kind with a resident. Includes, but
is not limited to, sexual harassment, sexual coercion or sexual assault;
-No requirement specified for the facility to identify when, how, and by whom
determinations of capacity to consent to sexual contact will be made and where this
documentation will be recorded.
During an interview on 9/17/18 at 10:29 A.M., the administrator said she was not sure if
the facility had a policy that addressed a resident’s capacity to consent to sexual
activity.
During an interview on 9/21/18 at 10:20 A.M., the administrator said she thought their
policy covered capacity to consent to sexual activity. After reviewing the policy with the
administrator, she acknowledged the required information was not included in the current
policy.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

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

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
plans were reviewed, updated and/or revised to include a resident’s preference to sleep in
a chair, refusal to change out of soiled, dirty clothing, and one resident’s order to have
nothing by mouth for two of 18 sampled residents (Residents #28 and #21). The census was
77.
1. Review of Resident #28’s annual Minimum data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/6/18, showed:
-[DIAGNOSES REDACTED].
-Moderate cognitive impairment.
Observation of the resident on 9/17/18 at approximately 10:33 A.M., 9/18/18 at
approximately 7:30 A.M., 9/19/18 at approximately 5:53 A.M., and 9/20/18 at approximately
12:30 P.M., showed he/she wore the same grey soiled, dirty shirt.
Review of the residents shower sheets on 9/20/18 at approximately 1:09 P.M., showed:
-The resident scheduled to receive a shower every Monday and Thursday;
-On Monday 9/10/18, the resident received a shower;
-On Thursday 9/13/18, the resident refused a shower;
-On Monday 9/17/18, the resident refused a shower;
-On Thursday 9/20/18, the resident received a shower, and was the observed to be wearing
the same grey soiled, dirty shirt.
During an interview on 9/19/18 at approximately 6:36 A.M., the resident said he/she sleeps
in the chair because he/she has to get up a lot at night to use the bathroom.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Assistance required with dressing, bathing, toileting, and mobility. Often
refuses showers;
-Approaches: Encourage self-performance and call his/her famiy member if refuse to shower.
Place side rails up so I can use them to assist myself in bed;
-The care plan did not address what alternatives to offer if he/she refuses a shower;
-The care plan did not address the resident’s preference to sleep in a chair in his/her
room and not the bed;
-The care plan did not address the resident’s refusal to change out of soiled, dirty
clothing;
-The care plan did not address how staff should approach him/her when refusing to change
his/her clothing.
Further record review, showed no documentation of staff attempting to contact the
resident’s mother.
During an interview on 9/20/18 at approximately 12:30 P.M., certified nurses aide (CNA) J
said the resident took a shower that day and refused to change into clean clothes.
2. Review of Resident #21’s annual MDS dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Extensive assistance needed for bed mobility;
-No ability to speak;
-Received tube feeding for nutrition.
Review of the resident’s physician orders, showed resident is to have no food or drink by
mouth.
Review of the resident’s care plan dated 7/16/18 and in use at the time of the survey,
showed:
-Problem: The resident has impaired vision;
-Approaches: identify type and location of food on his/her plate;
-The care plan did not address the order to have no food or drink by mouth;
3. During an interview on 9/21/18 at approximately 10:20 A.M., the Director of 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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
said a resident’s care plan should be reviewed and updated to reflect the resident’s
current needs. Resident #28’s care plan should include his/her preference of sleeping in a
chair and his/her refusal to change his/her clothing. Resident #21’s care plan should
include his/her order for no food or drink by mouth.

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, the facility failed to follow
acceptable nusing practice and physican orders regarding indications for as needed
medications (PRN), administering medications, obtaining an order for [REDACTED].#128,
#228, #50, #53, #65, #231, #60, #27 and #75). The census was 77.
1. Review of Resident #128’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 9/14/18, showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Limited assistance to dependent on staff for personal care and mobility;
-[DIAGNOSES REDACTED].
Review of the physician’s orders [REDACTED].
-An order, dated 9/7/18, to administer [MEDICATION NAME] (a medication that opens the
airways in the lungs) nebulizer (converts medication to a mist to be inhaled) every four
hours PRN. No indication for use provided with the order;
-An order, dated 9/7/18, to administer [MEDICATION NAME] (stool softener) 100 milligrams
(mg)/10 milliliters (ml) twice a day per [DEVICE] (a tube small tube surgically inserted
in to the stomach to administer nourishment and medication) PRN. No indication for use
provided with the order;
-An order, dated 9/7/18, to administer [MEDICATION NAME] (used to treat anxiety and
[MEDICAL CONDITION]) 5-10 mg intramuscularly (IM) every 5-10 minutes, not to exceed 30 mg.
No indication for use provided with the order;
-An order, dated 9/7/18, to administer Senna (stool softener) 8.6 mg per [DEVICE] twice a
day PRN. No indication for use provided with the order.
Review of the medication administration record (MAR), dated 9/7 through 9/30/18, showed
the following:
-[MEDICATION NAME] nebulizer every four hours PRN. The medication had no indication for
use;
-[MEDICATION NAME] 100 mg twice a day PRN. The medication had no indication for use;
-[MEDICATION NAME] 5-10 mg every 5-10 minutes, not to exceed 30 mg. The medication had no
indication for use;
-Senna 8.6 mg twice a day PRN. The medication had no indication for use.
2. Review of Resident #228’s admission MDS dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Dependent on staff for personal care and mobility;
-[DIAGNOSES REDACTED].
Review of the POS, dated 9/12/18, showed the following:
-An order, dated 9/12/18 to administer [MEDICATION NAME] (opioid [MEDICATION NAME]) 20

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 6)
mg/ml, 5 mg sublingual (SL, under the tongue) every two hours PRN. No indication for use
provided with the order;
-An order, dated 9/12/18 to administer [MEDICATION NAME] ([MEDICATION NAME], liquid
anti-anxiety) 20 mg/ml, 5 mg SL every two hours PRN. The medication had no indication for
use.
Review of the undated MAR in use, showed the following:
-[MEDICATION NAME] 20 mg/1 ml. Administer 5 mg SL every two hours PRN. The medication had
no indication for use;
-[MEDICATION NAME] 20 mg/1 ml. Administer 5 mg SL every two hours PRN. The medication had
no indication for use.
During an interview on 9/21/18 at 10:30 A.M., the Director of Nursing (DON) and the
corporate nurse said all PRN medications should have an indication for use.
3. Review of Resident #50’s quarterly MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-An admission date of [DATE].
Review of the resident’s medical record, showed:
-Re-admitted to the facility on [DATE] from a hospital stay;
-An order dated 9/10/18 for [MEDICATION NAME] injections (blood thinner that prevents the
formation of blood clots) 5000 unit/ml, inject 1ml subcutaneously (beneath the skin) every
eight hours for 7 days.
Review of the resident’s MAR dated 9/2018, showed the following:
-[MEDICATION NAME] injections 5000 unit/ml, inject 1ml subcutaneously give at 6:00 A.M.,
2:00 P.M., and 10:00 P.M. on 9/12/18 through 9/18/18;
-Blank spaces on the MAR for dates and times of 9/12/18 at 6:00 A.M., 9/13/18 at 6:00
A.M., 9/15/18 at 2:00 P.M., 9/16/18 at 6:00 A.M. and 2:00 P.M., and 9/18/18 at 6:00 A.M.
-No notes listed on back of the MAR in show why the medication was not given.
During an interview on 9/19/19 at approximately 8:00 A.M., LPN R said if the MAR shows
empty spots with no initials there is no way to verify if the medication was given. Nurses
should initial the MAR when administering a medication and should initial and circle their
initials when a medication was not administrated and write on the back of the MAR the
reason.
During an interview on 9/21/18 at approximately 10:15 A.M., the DON said if a medication
was not given the nurse should initial the MAR, circle the initials and make note on the
back of the MAR. Blood work should be drawn as ordered. She expects staff to follow
physician orders, contact the doctor and the DON immediately once they are aware an order
was not followed for any reason and to make a nurses note regarding this event.
4. Review of Resident #53’s admission MDS, dated [DATE], showed the following:
-An admission date of [DATE];
-Cognitively intact;
-Required extensive assistance with most ADL’s;
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) (YEAR) POS, showed an order dated 6/9/18, for [MEDICATION
NAME] (nerve pain medication) 75 mg to be given twice a day.
Review of the resident’s 6/2018 MAR, showed the following:
-Staff circled their initials for the A.M. dose on 6/10/18, 6/11/18, 6/12/18, 6/13/18;
-Staff wrote the medication was not available from the pharmacy for the A.M. doses on the
back of the MAR;
-Staff left a P.M. dose blank on 6/11/18 and circled their initials for the P.M. dose on
6/13/18;
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 7)
-Staff did not document anything on the back of the MAR for the blank and circled P.M.
doses;
-Staff left the A.M. and P.M. dose blank for 6/14/18 and did not document any information
regarding the missing doses on the back of the MAR.
During an interview on 9/21/18 at 7:54 A.M., LPN H said he/she only follows the telephone
orders in the chart. He/She doesn’t go by the orders on the POS because they aren’t
updated often enough. Staff are supposed to put the new orders in the MAR/TAR, call
pharmacy and also write a nurse’s note for new orders.
During an interview on 9/21/18 at 10:20 A.M., the DON said if orders are given to the
pharmacy by noon, the medications will be delivered in the afternoon of the same day. If
they are given to the pharmacy after noon, they will be delivered on the first delivery
the next day. Staff should have called the pharmacy. If there is a hole in the MAR it
means the medication was not given. She would expect staff to administer medications as
ordered.
5. Review of Resident #65’s admission MDS, dated [DATE], showed the following:
-Extensive assistance required for bed mobility, dressing, eating, toilet use and personal
hygiene;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-[DIAGNOSES REDACTED].
Review of the resident’s face sheet, dated 8/22/18, showed additional [DIAGNOSES
REDACTED].
Review of the resident’s POS, dated 9/1/18 through 9/30/18, showed an order dated 8/22/18,
for [MEDICATION NAME] (anticoagulant) 30 mg/0.3 ml, subcutaneously inject 0.3 ml every day
at bedtime.
Review of the resident’s MAR, dated 9/1/18 through 9/30/18, showed the following:
-[MEDICATION NAME] 30 mg/0.3 ml, subcutaneously inject 0.3 ml every day at bedtime, blank
9/3 thorugh 9/5/18 with no documentation on the back of the MAR, initialed and circled
9/17 through 9/19/18, with documentation of not available, not given, on the back of the
MAR.
During an interview on 9/21/18 at 10:20 A.M., the corporate nurse said if a medication is
not administered due to resident refusal or it is not available, the nurse or certified
medication technician (CMT) should inform the DON within 24 hours. The physician should be
informed within 48 hours. The DON said she was not made aware [MEDICATION NAME] was not
administered to the resident as ordered. If medications are ordered from the pharmacy
before noon, they are received the same day. If they are ordered after noon, the
medication would be on the medication delivery the next morning. She did not think
[MEDICATION NAME] was contained in the emergency kit.
Review of the listing of medication contained in the emergency kit, showed [MEDICATION
NAME] 30mg/0.3 ml syringe included.
6. Review of Resident #231’s face sheet, showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, dated 9/15/18, showed the following:
-Activity of daily living (ADL) assistance and therapy services needed to maintain or
attain prior level of function;
-Used oxgen.
Review of the resident’s POS, dated 9/15/18 through 9/30/18, showed the following:
-An order, dated 9/15/18 to change oxygen tubing weekly;
-No order for the use of oxygen, rate of administration, or whether continuous or as
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 8)
needed;
-An order, dated 9/15/18, for [MEDICATION NAME]-[MEDICATION NAME] (medication used to
improve lung function) FHA 160 micrograms (mcg)-4.5 mcg/actuation aerosol inhaler, inhale
two puffs twice daily;
-An order, dated 9/15/18 for [MEDICATION NAME]-sulfate (used to treat shortness of breath)
90 mcg/actuation breath activated powder inhaler, two puffs every 4 hours as needed;
-No order to self administer medications.
Observation of the resident, showed the following:
-On 9/19/18 at 12:50 P.M., the resident sat in a wheelchair in the dining room and wore
oxygen via nasal cannula (NC-Device used to deliver oxygen with two small tubes that fit
into the nostrils) at 2 liters (L);
-On 9/19/18 at 1:03 P.M., the [MEDICATION NAME]-sulfate inhaler sat in a plastic bag on
the resident’s beside cabinet;
On 9/20/18 at 10:11 A.M., the [MEDICATION NAME]-sulfate inhaler sat in a plastic bag on
the resident’s beside cabinet;
-On 9/20/18 at 10:14 A.M., the resident sat in a wheelchair in the therapy room and wore
oxygen via NC at 2L;
-On 9/21/18 at 8:38A.M., the resident sat in a wheelchair in the dining room and wore
oxygen via NC at 2L.
During an interview on 9/21/18 at 10:20 A.M., the DON said there should be physician’s
orders [REDACTED]. The nurse who clarified the admission orders [REDACTED].
During an interview on 9/21/18 at 8:26 A.M., CMT P opened a drawer on the medication cart
to look for the resident’s [MEDICATION NAME]-[MEDICATION NAME] inhaler, and said the
[MEDICATION NAME]-sulfate inhaler must be at the resident’s bedside because it was not in
the medication cart. When resident’s self-administered a medication, he/she would ask them
if it had been done and then go back and document on the MAR. There should be an order to
say the resident may keep the medication at the bedside and self-administer it.
During an interview, the DON said there must be a physician’s orders [REDACTED]. A nurse
should watch the resident administer the medication, and then document the MAR.
7. Review of Resident #60’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Total dependence on staff for hygiene, dressing, toileting and bed mobility;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-At risk for pressure ulcers. Three unstageable pressure ulcers (Slough (dead tissue) is
present, the actual base and condition of the ulcer cannot be determined).
Review of the resident’s 9/2018 POS, showed the following:
-An order, dated 6/18/18,, for Eliquis (anticoagulant) take one tablets per [DEVICE]
([DEVICE], a tube surgically inserted through the abdomen into the stomach to provide
hydration, nutrition and medications), twice a day;
-An order, dated 6/18/18 for Aspirin, 325 mg, per [DEVICE] daily for heart health;
-An order, dated 9/18/18, to hold Eliquis 5mg and Aspirin 325 mg for surgery on 9/20/18.
Resume on 9/21/18.
Review of the resident’s 9/2018 MAR, showed staff wrote Hold on 9/19/18 and 9/20/18 for
the twice daily dosages of Eliquis and the once daily dose of Aspirin.
During an interview on 9/21/18 at 10:20 A.M., the DON said staff should have only held the
medication on 9/20/18.
Further reivew of the resident’s 9/2018 POS, showed the following:
-An order, dated 7/22/18, to cleanse right inner thigh with normal saline (solution used
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 9)
to clean wounds). Apply Santyl (ointment used to heal skin ulcers). Cover with dressing
daily;
-An order, dated 7/23/18, to cleanse chin with normal saline. Apply gauze. Change daily
and as needed (PRN).
Review of the resident’s 9/2018 treatment administration record (TAR), showed staff wrote
Healed on the treatment orders for the right inner thigh and chin. Staff did not include a
date the areas were healed.
During an interview on 9/21/18 at 10:20 A.M., the DON said she would expect staff to get
an order discontinued and removed from the POS and TAR if an area is healed. Staff should
also include the date the area was healed.
Further review of the resident’s record, showed a telephone order, dated 9/5/18, for
[MEDICATION NAME] (antibiotic) 100 mg cap to be given every 12 hours. Staff did not
include the reason why it was ordered.
During an interview on 9/21/18 at 10:20 A.M., the DON said there should be a corresponding
[DIAGNOSES REDACTED]. She would expect staff to clarify orders.
8. Review of Resident #27’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance with most ADL’s including hygiene, bed mobility, toileting
and dressing;
-[DIAGNOSES REDACTED].
Review of the resident’s 9/2018 POS, showed an order, dated 4/11/18, for [MEDICATION NAME]
(medication used to treat high blood pressure) 5 milligrams mg take one tablet daily. Hold
if systolic blood pressure (SBP, the top number or highest blood pressure when the heart
is squeezing and pushing the blood round the body) is below 100.
Review of the resident’s medical record, showed the following:
-On the 7/2018 MAR, staff documented the resident’s SBP 9 out of 31 opportunities. Staff
documented administering the medication 31 times;
-On the 8/2018 MAR, staff documented the resident’s SBP 0 out of 31 opportunities. Staff
documented administering the medication 31 times;
-On the 9/2018 MAR, staff documented the resident’s SBP 0 out of 21 opportunities. Staff
documented administering the medication 21 times;
-Review of the back of the MAR’s, showed no information to explain why the SBP was not
documented.
During an interview on 9/21/18 at 10:20 A.M., the DON said if an order has a parameter for
administration, it should be followed. If an area on the MAR is blank, it means the
medication or treatment wasn’t given. There should be information on the back. Their new
process is to notify the DON in 24 hours and the medical director in 48 hours if a
medication or treatment is missed. She was not aware the resident’s SBP had not been
recorded.
9. Review resident #75’s admission MDS, dated [DATE], showed the following:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-A physicians order dated 9/7/18 for lab work of complete blood count (determines general
health status and screens for and monitors for a variety of disorders) and basic metabolic
panel (blood test that measures sugar level, electrolyte and fluid balance and kidney
function) to be drawn on 9/10/18;
-No lab results for 9/10/18.
During an interview on 9/19/18 at approximately 12:50 A.M., LPN R said the resident’s lab
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 10)
work was not drawn, the order must have been missed, because it was never entered in the
lab computer system.

F 0676

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure residents do not lose the ability to perform activities of daily living unless
there is a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
restorative therapy for one resident reviewed with orders for restorative therapy.
(Resident #277). The sample size was 18. The census was 77.
Review of Resident #277’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/13/18, showed:
-Total staff assistance needed for dressing, eating, hygiene and transfers;
-Experienced functional limitations to both upper and lower extremities;
-[DIAGNOSES REDACTED].
-Received no restorative therapy services.
Review of the resident’s 9/2018 physician order [REDACTED].
Review of restorative therapy (RT) binder, showed:
-No documentation for the months of 2/2018, 3/2018 and 4/2018 that RT services had been
provided;
-Restorative therapy documented as provided for 6 out of 31 days for 5/2018;
-Restorative therapy documented as provided for 5 out of 31 days for 6/2018;
-No documentation available that restorative therapy was provided for 7/2018 and 8/2018;
-Restorative therapy documented as provided for 5 out of 21 days for 9/2018.
During an interview on 9/21/18 at 7:39 A.M., Restorative Therapy Aide (RTA) E said he/she
is the only staff member that performs RT services in the building. He/she often gets
pulled to the floor to work as a nurse aide and when that occurrs RT services does not get
done for that day. He/she does not document how a resident had tolerated RT services.
He/she has a monthly meeting with management to discuss resident participation. The RT
orders do not have specific exercises for individual resident needs or how long the
exercises should be done.
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing said the RT aide
should not be pulled from RT duties and placed on the floor to work as a nurses aide
often. All nursing staff are able to provide RT services to residents. She did not expect
the order to contain exercises specific to the resident’s needs or the minutes of exercise
length.

F 0686

Level of harm – Actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide treatment
to existing pressure ulcers (pressure injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or friction) and failed to prevent the
development of new pressure ulcers. The facility identified nine residents as having

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 11)
pressure ulcers, six were included in the sample and issues were identified with four
(Resident #60, #48, #231 and #74). The census was 77.
Review of the facility’s Pressure Ulcer/Injury Prevention Policy, dated 11/2017, showed
the following:
-A comprehensive skin assessment on admission and re-admission to the center may identify
pre-existing signs of possible deep tissue damage already present. These signs include
purple or very dark areas surrounded by [MEDICAL CONDITION] (swelling), profound redness
or induration (a hardened mass or formation), bogginess (an abnormal texture of tissues
characterized by a feeling of sponginess, usually because of high fluid content) and/or
drainage;
-A risk assessment tool that determines the resident’s risk for pressure ulcer
development. The score is documented in the resident’s chart;
-A resident’s risk may increase due to an acute illness or condition change and may
require additional evaluation;
-A skin assessment should be performed weekly;
-Measures to maintain and improve the resident’s tissue tolerance to pressure are
implemented in the plan of care and include:
-Skin inspections with particular attention to bony prominences;
-Skin cleansing with appropriate cleanser at the time of soiling and at routine
intervals;
-Treat skin with moisturizers;
-Minimize skin exposure to incontinence using devices such as briefs and skin barriers;
-Minimize injury due to shear (pressure against the skin) and friction (rubbing two
surfaces against one another) through proper positioning, transfers and turning schedules;
-Encourage fluid intake;
-Improve resident’s mobility and activity;
-Measures to protect the resident against pressure friction and shear are implemented in
the plan of care:
-Reposition at least every two to four hours;
-Utilize positioning devices to keep bony prominences from direct contact;
-Heel protectors/suspension should be implemented when the resident is in bed;
-Use lift devices to move residents in bed;
-Use pressure reduction devices when the resident is in a wheelchair;
-A pressure reduction mattress is placed under the resident;
-Resident and significant others are educated regarding the preventative skin care plan;
-When skin breakdown occurs, it requires attention and a change in the plan of care.
Review of the facility’s Wound Assessment policy, dated 2/25/15, showed:
-Guidelines:
-It is the responsibility of the licensed nurse to complete the wound assessment and to
document the findings on the treatment record – wound assessment;
-Assessment and documentation are completed at admission, re-admission, weekly and as
needed (PRN);
-The wound type is identified;
-Pressure ulcers are staged based upon the Minimum Data Set (MDS) guidelines (a federally
mandated assessment instrument completed by facility staff). All other wounds do not
require staging;
-Response to treatment based on the goal for the resident’s wound is noted, additional
documentation may be needed when a wound is not responding to treatment;
-Documentation of the wound should include description including physical
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 12)
characteristics, in the medical record to avoid miscommunication or misinterpretation and
should include wound location, stage, size, tissue type, exudate (drainage),
undermining/tunneling (unidirectional depth of the wound into broader and deeper tissue
areas), wound bed presentation, odor and any pain and wound type.
1. Review of Resident #60’s significant change MDS, dated [DATE], showed:
-Severely impaired cognition;
-Required total assistance with bed mobility, transfers, hygiene, dressing and toileting;
-Frequently incontinent;
-At risk for pressure ulcers;
-Number of unhealed pressure ulcers: Zero;
-Number of pressure ulcers present at last assessment: Zero;
-Skin and pressure ulcer treatments: Pressure reducing device for chair and bed, and
ointments.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Total dependence on staff for hygiene, dressing, toileting and bed mobility;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Number of pressure ulcers upon last assessment: Zero;
-At risk for pressure ulcers;
-Number of unstageable pressure ulcers (slough (moist dead tissue) or eschar (dry dead
tissue) is present, the actual base and condition of the ulcer cannot be determined)
developed since last assessment: 3;
-Dimensions of unhealed stage III (full thickness tissue loss. Subcutaneous fat may be
visible but bone, tendon or muscle is not exposed. Slough may be present but does not
obscure the depth of tissue loss. (MONTH) include undermining or tunneling) or stage IV
(full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often includes undermining or tunneling): 4.4
centimeters (cm) by 2.3 cm by 0.0 cm;
-Skin and ulcer treatments: Pressure reducing devices for chair and bed, pressure ulcer
care, nutrition/hydration and surgical wound care.
Review of the resident’s significant change MDS, dated [DATE], showed the following:
-Required extensive assistance with mobility, transfers, toileting and hygiene;
-Frequently incontinent of bladder and bowel;
-At risk for pressure ulcers;
-Current number of unhealed pressure ulcers at each stage: One at stage IV;
-Dimensions of unhealed pressure ulcer: 5.5 cm by 11.0 cm by 7.0 cm;
-Skin and ulcer treatments: Pressure reducing devices for chair and bed,
turning/repositioning and pressure ulcer care.
Review of the resident’s care plan, last revised on 9/5/18, and in use during the survey,
showed:
Problem: Resident has a stage IV pressure ulcer on the coccyx (tailbone) and diabetic
ulcers to bilateral (both) of the lower extremities. Resident has right lower leg
immobility, incontinence and poor nutritional status;
Goal: Resident will not develop any new areas of skin breakdown through next review;
Approaches included: Staff will assist as needed to reposition/shift weight to relieve
pressure. Avoid skin/skin contact. Assessment completed quarterly and as needed, weekly
skin check, consult/make referral for screen as needed, encourage side rails and/or
trapeze to assist in turning and float heels. Minimize pressure over bony prominences,
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 13)
notify nurse of any new areas of skin breakdown/redness/blisters/bruises/discoloration.
Observe effectiveness/response to treatments as ordered. Low air loss mattress (LAL,
special mattress used to relieve pressure) and cushion. Resident attends a hospital based
wound care center. Resident has wound surgery scheduled for 9/20/18.
Review of the facility’s wound report, provided on 9/17/18, showed the following for the
resident:
-For the week of 5/21 through 5/25/18: Wound bed of all 5 open areas are stage III with
red/pink and has excoriation (skin irritation) around coccyx. (Staff included
indecipherable measurements);
-No further wound reports provided for (MONTH) (YEAR);
-No wound reports provided for (MONTH) (YEAR);
-For the week of 7/8 through 7/13/18:
-Left buttocks stage II, measured 1.6 cm by 2.3 cm by 0.2 cm with red excoriated areas,
no defined edges with scant (small amount) drainage;
-Right buttocks stage II, measured 1.9 cm by 2.8 cm with red excoriation and blanchable.
Second right buttocks area healed;
-Coccyx, not staged, measured 0.8 cm by 1.0 cm with red excoriation;
-Second left buttocks area, not staged, measured 2.2 cm by 1.2 cm by 0.1 cm with red
excoriation and scant drainage;
-For the week of 7/16 through 7/20/18:
-Left buttocks, stage II, measured 1.6 cm by 2.8 cm, pink and blanchable;
-Right buttocks, stage II, measured 1.9 by 2.8 cm with pink, blanchable defined edges;
-Left ankle, stage IV, measured 2.0 cm by 3.0 cm by 0.2 cm with 75% slough and red
defined edges and scant drainage;
-Right chin, stage IV, measured 3.2 cm by 1.9 cm by 0.1 cm with 50% slough and red
defined edges and scant drainage;
-Coccyx, not staged, measured 0.8 cm by 1.0 cm with 50% slough and red defined edges;
-Second left buttocks, not staged, area measured 2.2 cm by 1.2 cm by 0.1 cm with 50%
slough and red defined edges and scant drainage;
-No further wound reports provided for (MONTH) (YEAR);
-For the week of 8/13 through 8/17/18:
-Right inner thigh, stage II, measured 10.0 by 2.6 with 10% slough and blanchable defined
edges;
-Left ankle, unstageable, measured 1.9 cm by 2.8 cm by 0.2 cm with 50% slough and red
defined edges and scant drainage;
-Right buttocks, not staged, measured 2.4 cm by 2.8 cm, pink and red with macerated edges
(caused by excessive amounts of fluid remaining in contact with the skin or the surface of
a wound for extended periods) and dark wound bed with defined edges;
-Coccyx, not staged, measured 0.8 by 1.0 with excoriated, pink and non-defined edges;
-No further wound reports provided for (MONTH) (YEAR);
-For the week of 9/10 through 9/14/18:
-Right inner thigh, stage II and stage IV, measured 9.0 cm by 0.2 cm with 10% slough and
blanchable defined edges and moderate drainage;
-Left ankle, unstageable, measured 2.0 cm by 3.0 cm by 0.2 cm with 75% slough, red
defined edges and scant drainage;
-Coccyx, not staged, measured 0.8 cm by 0.1 cm with excoriated pink area and non-defined
edges with scant drainage;
-Right chin, unstageable, measured 2.5 cm by 1.8 cm by 0.1 cm with 50% slough and red
with defined edges and scant edges;
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 14)
-No further would reports provided for (MONTH) (YEAR).
Review of the resident’s (MONTH) (YEAR) electronic physician order [REDACTED].
-An order dated 6/18/18, to apply [MEDICATION NAME] (skin barrier ointment) to buttocks
topically every shift and PRN for skin integrity;
-An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam (dressing specifically
designed to manage chronic or acute draining wounds) every three days;
-An order dated 7/22/18, to cleanse buttocks and coccyx with normal saline. Apply Duoderm
(protective dressing). Change every three days;
-An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl
(ointment used to help break up and remove dead skin and tissue). Cover with Island
dressing (an absorbent pad) daily;
-An order dated 7/22/18, to cleanse left ankle with normal saline. Apply small Allevyn.
Skin prep (protective wipe) to all affected areas daily;
-An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change
daily and PRN.
Review of the resident’s (MONTH) (YEAR) telephone orders, showed the following:
-An order dated 8/23/18, for Santyl ointment. Cleanse coccyx with normal saline. Pat dry.
Apply nickel size Santyl to area on coccyx then cover with Allevyn foam every day and PRN;
-An order dated 8/29/18, to send out to wound clinic.
Review of the resident’s (MONTH) (YEAR) treatment administration record (TAR), showed the
following:
-An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam every three days. Staff
documented a slash marks through the order and wrote d/c (discontinued). Staff did not
document administering this treatment for [REDACTED].
-An order dated 7/22/18, to cleanse buttocks and coccyx with normal saline. Apply Duoderm.
Change every three days. Staff did not document the application of this treatment on 8/4,
8/5, 8/7, 8/8, 8/10, 8/11, 8/13, 8/14 and 8/16 through 8/24, (YEAR). After the 8/25/18
application, staff wrote d/c and N.O. (new order) and did not document the application of
any further treatments;
-An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl.
Cover with Island foam dressing daily. Staff documented applying the treatment 22 out of
28 opportunities. On 8/29/18, staff wrote healed;
-An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change
daily and PRN. Staff documented applying the treatment 28 out of 31 opportunities;
-An order dated 6/18/18, to apply [MEDICATION NAME] to buttocks topically every shift and
as needed. Staff documented applying the treatment 20 times out of 31 opportunities for
the A.M. treatment. Staff documented applying the treatment 27 times out 31 opportunities
for the afternoon treatment. Staff documented applying the treatment 30 out of 31 times
for the night treatment;
-An undated, handwritten order to cleanse coccyx with normal saline. Apply Santyl to area.
Apply Duoderm every 48 hours on the night shift. Staff did not document applying this
treatment on the TAR;
-An undated, handwritten order to cleanse coccyx with normal saline, pat dry. Apply
Santyl, nickel thick to coccyx. Cover with Allevyn foam every day on the evening shift.
Staff did not document applying this treatment on the TAR;
-Review of the back of the TAR’s, showed staff did not document why treatments were not
completed as ordered.
Review of the resident’s (MONTH) progress notes, showed no documentation of wound
assessments, measurements, descriptions or treatment of [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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 15)
Review of the resident’s (MONTH) (YEAR), electronic POS, showed the following orders:
-An order dated 6/18/18, to apply [MEDICATION NAME] to buttocks topically every shift and
PRN for skin integrity;
-An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam every three days;
-An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl.
Cover with Island dressing daily;
-An order dated 7/22/18, to cleanse left ankle with normal saline. Apply small Allevyn.
Skin prep to all affected areas daily;
-An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change
daily and PRN;
-An order dated 8/23/18, to cleanse coccyx with normal saline. Pat dry. Apply nickel size
Santyl ointment to area on coccyx. Cover with Allevyn foam. Change daily and PRN.
Review of the resident’s (MONTH) (YEAR) telephone orders, showed the following:
-An order dated 9/5/18, for [MEDICATION NAME] (antibiotic used to treat infections) 100
milligram (mg) to be given every 12 hours. Staff did not include a [DIAGNOSES REDACTED].
-An order dated 9/10/18, to cleanse the coccyx with mild soap and rinse thoroughly. Pat
wound area dry using gauze sponges. Apply nickel thick Santyl to the wound bed and pack,
with wet to dry dressing, cover with 4 by 4 gauze, Abdominal pad (ABD pad, used for large
wounds or for wounds requiring high absorbency) and tape. Change twice a day every 12
hours.
Review of the resident’s (MONTH) (YEAR) TAR, showed:
-An order dated 6/18/18, to cleanse open areas. Apply Allevyn foam every three days. Staff
crossed off this order and did not document applying this treatment for [REDACTED].
-An order dated 7/22/18, to cleanse right inner thigh with normal saline. Apply Santyl.
Cover with Island dressing every day. Staff crossed off this order and did not document
applying this treatment for [REDACTED].
-An order dated 7/23/18, to cleanse chin with normal saline. Apply 4 by 4 gauze. Change
daily and PRN. Staff crossed off this order and did not document applying this treatment
for [REDACTED].
-an order for [REDACTED]. Apply nickel size Santyl ointment to area on coccyx. Cover with
Allevyn foam. Change daily and PRN. Staff failed to document the application of the
treatment on 9/1, 9/2, 9/7, 9/8 and 9/9/18. Staff then wrote changed 9/10/18. Staff
crossed off this order and did not document applying this treatment for [REDACTED].
-An order dated 6/18/18, to apply [MEDICATION NAME] to buttocks topically every shift and
as needed. Staff documented applying the morning treatment for 15 of 20 opportunities.
Staff documented applying the afternoon treatment for 16 of 19 opportunities. Staff
documented applying the night treatment 16 of 19 opportunities;
-A handwritten order dated 9/10/18, to cleanse the coccyx with mild soap and rinse
thoroughly. Pat wound area dry with gauze sponges. Apply nickel thick Santyl to wound bed
and pack with wet to dry dressing. Cover with 4 by 4 gauze, ABD pad and tape. Change twice
a day every 12 hours. Staff documented starting the morning treatment on 9/11/18 and
provided the treatment 9 out of 10 opportunities. Staff documented starting the evening
treatment on 9/11/18 and provided the treatment 7 out of 10 opportunities.
Review of the resident’s (MONTH) (YEAR) progress notes, showed the following:
-A nurse’s note, dated 9/5/18 at 3:46 P.M., Resident lying in bed, turned on right side
facing window. Dressing on coccyx dry and intact. No signs or symptoms of distress noted.
Educated staff of importance of resident staying dry and being rotated every two hours.
New orders given from wound clinic;
-A nurse’s note, dated 9/6/18 at 2:25 P.M., Nurse made rounds to ensure resident was dry
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 16)
before shift change. Dressing on coccyx was changed by this nurse and Director of Nursing
(DON). Call placed to wound clinic to set up closed pulse irrigation (CPI, hydro-wound
debridement). Appointment for 9/10/18 is a follow up wound care appointment and to get a
second opinion from the surgeon;
-A nurse’s note, dated 9/12/18 at 3:20 P.M., Resident has appointment scheduled for
surgery to get a [DEVICE] (a device used to vacuum drainage from the wound);
-A nurse’s note, dated 9/20/18 at 6:20 A.M., Coccyx wound cleaned and dressing changed. At
4:45 A.M., resident was taken by ambulance to hospital for wound treatment;
-The progress notes, showed no further documentation of wound assessments, measurements,
descriptions or treatment of [REDACTED].
Observations of the resident during the survey process, showed the following:
-On 9/17/18 at 2:18 P.M., resident rested on his/her back on a low air loss mattress with
the head of bed raised. The resident asked to be turned;
-On 9/18/18 at 10:46 A.M., the resident rested on his/her back, awake, with his/her head
of bed raised;
-On 9/18/18 at 12:45 P.M., the resident rested on his/her back, awake, with his/her head
of bed raised;
-On 9/18/18 at 2:28 P.M., the resident rested on his/her left side, awake, with his/her
head of bed raised;
-On 9/19/18 at 10:35 A.M., the resident rested on his/her right side, awake, with his/her
head of bed raised;
-On 9/19/18 at 1:41 P.M., the resident rested on his/her left side with his/her head of
bed raised. The resident said his/her butt hurt earlier, but staff moved him/her and
he/she is starting to feel better.
During an interview on 9/21/18 at 10:20 A.M., with the DON and corporate nurse, the DON
said the resident is being treated at a wound clinic for his/her coccyx. The area was
debrided (surgical removal of tissue) so that a [DEVICE] could be applied. The charge
nurse is responsible for providing the ordered treatments and should take measurements.
The facility wound nurse was terminated in the middle of (MONTH) (YEAR). They suspect the
disgruntled employee took wound reports. certified nurse aides (CNAs) also monitor the
resident’s skin before showers are given and are to make the nurse aware if any changes
are noted. If an area on the TAR is blank, it means the treatment was not completed. An
antibiotic should have a corresponding diagnosis. The corporate nurse said the resident
has a history of infections in his/her wounds.
During an interview on 9/26/18 at 12:45 P.M., the wound clinic nurse said the wound clinic
had seen the resident for two visits. The first visit had been on 9/5/18 and the coccyx
wound had been a stage IV at that time, had a foul odor and large amounts of drainage with
dead tissue. The wound had so much slough that the only option was surgical debridement.
The wound physician performed an in office debridement and placed the resident on
[MEDICATION NAME] 100 mg twice a day for ten days for an obvious infection to the wound.
The physician wanted to apply a [DEVICE] at the time; however, due to the extensiveness of
the infection and tissue death, the physician scheduled a surgical wound debridement for
9/20/18 and for a [DEVICE] to be placed at the time of surgery. The wound increased in
length and width between the first appointment on 9/5/18 and the second clinic appointment
of 9/10/18. The wound physician completed a wound culture on 9/5/18 and the results showed
positive for bacterial growth, the surgical debridement was scheduled. At the first
appointment, the facility had told the clinic the resident had the coccyx wound since
(MONTH) (YEAR). The resident had the scheduled wound debridement on 9/20/18 and remained
at the hospital for a 23 hour post-surgical observation and discharged back to 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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 17)
facility with a [DEVICE] to the coccyx and a scheduled post-surgical follow up appointment
for 9/24/18. The resident did not show up for the scheduled appointment on 9/24/18 because
the facility failed to transport the resident, citing issues with transportation. The
post-surgical visit was rescheduled to 10/1/18. He/she had concerns with the facility
completing wound treatments as ordered because on the 9/10/18 appointment, the resident
arrived to the appointment with no dressing or treatment to the stage IV coccyx wound. The
facility does not send treatment records or nurse notes to the wound clinic appointments.
It is vital that wound treatments are completed as ordered so the wounds heal correctly
and the risk of infection is reduced.
Review of the resident’s wound clinic documentation, provided on 9/27/18, showed the
following:
-Resident’s visits:
-9/5/18, resident made appointment;
-9/10/18, resident made appointment. Surgical consult;
-9/24/18, resident missed appointment. No call, no show;
-10/1/18, pending appointment.
Review of resident’s wound clinic 9/5/18 progress notes, showed the following:
-Resident’s history of present illness (HPI): 9/5/18: Resident comes to wound center due
to having a large stage IV pressure ulcer involving the sacrum (triangular bone located
above the coccyx). Examination showed an ulcer measured 5.5 cm by 11.0 cm by 7.0 cm. The
ulcer showed a significant amount of tunneling and necrotic material. Resident was
hosptalized on [DATE]. At the time of discharge from the hospital the resident was noted
to have a pressure ulcer involving the back and buttocks noted to be a stage III;
-Wound history: Resident presents with three open areas which have been present for
approximately three months. Laboratory tests have not been completed in the last month.
The resident had not tested positive for an antibiotic resistant organism. The resident
has not tested positive for osteo[DIAGNOSES REDACTED] (inflammation of bone caused by
infection);
-Assessment: Large pressure ulcer of the buttocks. Wound #3 is open. Original cause of
wound was it gradually appeared. The wound is currently classified as a stage IV wound
with etiology of pressure ulcer and is located on the coccyx. The wound measures 5.5 cm by
11 cm by 7 cm. There is muscle and fat layer exposed and fascia (a thin sheath of fibrous
tissue enclosing a muscle or other organ) exposed. There is no tunneling noted, however
there is undermining. There is a medium amount of Serosanguineous (containing or relating
to both blood and the liquid part of blood) drainage noted. Foul odor after cleansing
noted. There is medium red granulation within the wound bed. There is a medium amount of
necrotic tissue within the wound bed including adherent slough;
-Wound treatment: Change two times a day with Santyl ointment. Apply nickel thick into
wound then pack with wet to dry dressing over Santyl today only at wound center wet to dry
dressing. Turn every 2 hours. Resident should be off his/her bottom as much as possible.
Air loss mattress on bed, cushion when up in chair;
-Procedure: Pre-procedure [DIAGNOSES REDACTED]. There was a skin/subcutaneous
tissue/muscle debridement. Debridement with total area of 60.5 square cm performed. A
minimal amount of bleeding was controlled with pressure. The procedure was tolerated well.
Post debridement measurements: 5.5 cm by 11 cm by 7 cm. Post procedure [DIAGNOSES
REDACTED].
-Laboratory test ordered: Tissue culture with sensitivity of the coccyx;
-Medication ordered: [MEDICATION NAME] 100 mg to be given twice a day for 10 days starting
on 9/5/18;
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 18)
-Return appointment in one week.
Review of the resident’s wound clinic progress notes on 9/10/18, showed the following:
-Assessment: Wound #3 status is open. Original cause of wound was it gradually appeared.
The wound is currently classified as a stage IV wound with etiology of pressure ulcer and
is located on the coccyx. The wound measure 7 cm by 13 cm by 7 cm. There is muscle, fat
layer exposed and fascia exposed. There is undermining starting at 12:00 (location
representative of a clock face) and ending at 2:00 with a maximum distance of 3.5 cm.
There is a medium amount of serosanguineous drainage noted. Foul odor noted after
cleaning. There is a medium red granulation within the wound bed. There is a medium amount
of necrotic tissue within the wound bed including adherent slough and necrosis of muscle;
-Stage IV decubitus ulcer (pressure ulcer), would benefit from surgical debridement and
negative pressure therapy;
-Plan:
-Follow up appointments: Return in one week, 9/17/18 to plan surgery in the next week
with [DEVICE] application. Resident will need [DEVICE] at facility following surgery;
-Dressing change frequency: Two times a day, every 12 hours;
-Dressing/Treatment: cleanse the coccyx with mild soap and rinse thoroughly. Pat wound
area dry with gauze sponges. Apply nickel thick Santyl to wound bed and pack with wet to
dry dressing. Cover with 4 by 4 gauze, ABD pad and tape. Change twice a day every 12
hours;
-Negative wound therapy: [DEVICE] to wound continuously at 125 pressure. Santyl to wound
first, then start [DEVICE] with it after surgery is done;
-Follow-up appointment: Will schedule for wound debridement, [DEVICE] will be placed as
outpatient.
2. Review of Resident #48’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Extensive staff assistance needed for toileting, hygiene, bed mobility and dressing;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-admitted to facility with one stage IV pressure ulcer (wound extends to the bone, often
exposed tendon and muscle present);
-No other pressure ulcers present upon admission;
-At risk to develop additional pressure ulcers;
-Received wound care, pressure ulcer prevention and turning and repositioning services.
Review of the resident’s care plan, updated on 8/11/18 and in use at the time of the
survey, showed:
-Problem: Stage IV pressure ulcer to coccyx;
-Goal: Pressure ulcer will show signs of healing by decrease in size, improved appearance
and free from infection;
-Approaches: Staff assist PRN to reposition and shift weight to relieve pressure, complete
weekly skin checks, float heels in bed, minimize pressure over bony prominence, notify the
nurse immediately of any new areas of skin breakdown, redness, blisters, bruises
discoloration noted during bathing or daily care, notify resident and responsible party of
any new areas of skin breakdown, observe effectiveness of response to treatment as
ordered, observe for pain and medicate PRN, provide incontinence care after each episode
and apply barrier cream, provide air mattress, report changes in skin to the physician and
wound care as ordered.
Review of the resident’s weekly skin integrity data collection form, showed:
-On 5/10/18 admission skin assessment: bruises and redness to the coccyx and both heels;
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

(continued… from page 19)
-On 5/17/18: Necrotic (dead) coccyx ulcer and boggy areas to both heels;
-On 5/24/18: Necrotic coccyx ulcer and open areas to both heels;
-No additional skin assessments located from 5/24/18 to 6/5/18.
Review of the resident’s pressure ulcer status record, showed:
-On 6/5/18: Coccyx wound unstageable. Measured 6.1 cm by 6.5 cm small amount of drainage,
no odor and has white edges, eschar and slough;
-On 6/11/18: Unidentified wound measured 7.8 cm x 6.6 cm copious (large amounts) of
drainage, no odors, tissue is yellow, green and macerated (moist tissue damage), wound is
improved. Physician notified on 6/11/18;
-On 9/11/18: Coccyx wound unstageable, measured 2 cm x 3 cm x 1.5 cm deep, moderate
drainage, no odor, wound is beefy red, no tunneling.
-No documentation found for the scheduled assessment dates of 6/20, 6/25, 7/2, 7/18, 8/13
and 8/28/18 for the coccyx pressure wound.
Review of the resident’s wound clinic discharge note, showed:
-On 8/27/18 the resident seen outpatient at the wound clinic and received the following
orders for the coccyx wound: Apply Santly nickel thick to the wound bed, apply [DEVICE],
pack tunneling area lightly at 7 o’clock, Duoderm around the wound for protection.
[DEVICE] to wound continuously at 125 millimeters of mercury (mm/hg) pressure. Resident
should be turned or repositioned every two hours, use pillows for positioning;
-Wound clinic discharge note, showed follow up appointment scheduled for 9/10/18;
-On 9/17/18 the resident seen at the wound care clinic and received the following orders
for the coccyx wound: Clean area with normal saline, apply Santyl nickel thick to coccyx
wound bed, apply [DEVICE]. Apply Duoderm around wound edges;
-Apply moisturizing lotion to feet and legs daily;
-Date acquired: 5/11/18;
-Measurements: 1.9 cm long x 2 cm wide x 2.5 cm deep;
-Ulcer type: Stage IV
-Exudate type and color: Serosangeous and red, brown, small amount of necrotic tissue;
-Exposed tissues: fat and muscle layers;
-Peri-wound (wound edge): Excoriation and maceration present.
Review of the resident’s (MONTH) (YEAR), physician order [REDACTED].>-An order dated
8/11/18 to clean coccyx wound with normal saline, apply Santyl ointment to the wound bed,
soak gauze with normal saline, squeeze out excess and pack into wound bed, pack with gauze
and cover with Allevyn, change daily. The order had a hand drawn line through the order
that showed the order changed, no date found when order changed and no new order
documented;
-No order located on the POS for the use of [DEVICE] and treatment to the coccyx wound.
Review of the resident’s (MONTH) (YEAR) TAR, showed:
-An undated order for [DEVICE] 125 mm/hg pressure. Apply Santly first to coccyx, then
wound vac. Change three times weekly:
-The dressing scheduled to be completed on 9/19/18;
-An order dated 9/17/18 to apply moisturizing lotion to feet and legs daily, scheduled for
11:00 P.M. to 7:00 A.M., showed no staff initials the treatment had been provided.
Observation on 9/19/18 at 5:58 A.M., showed CNA F and G talked in the hallway. CNA G told
CNA F that he/she had not been responsible to care for the resident during the night
shift. CNA F threw both his/her hands in the air and said he/she thought the CNA G was
responsible to care for the resident, so he/she guessed he/she will care for him/her now.
He/she gathered supplies and entered the resident’s room. He/she unfastened the urine
saturated brief and provided personal care 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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 – Few

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

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

Based on observation, interview and record review, the facility failed to have sufficient
supplies for catheters, obtain an appointment with a urologist, obtain orders for size,
catheter care and reason for a urinary catheter, and failed to maintain proper placement
for catheters. The facility identified five residents with urinary catheters. Of those
five, three were reviewed and problems were identified with all three. (Resident’s #53,
#65 and #128). The sample size was 18. The facility census was 77.
Review of the facility’s Urinary Incontinence and Indwelling Urinary Catheters policy,
dated 9/26/17, showed
the following:
-Intent:
-That a resident who is admitted to the facility without an indwelling urinary catheter
(a small rubber tube placed in the urethra (urine passageway) to the outside of the body
to drain urine) shall not be catheterized unless there is valid medical justification.
Examples of criteria for placement of an indwelling catheter per evidenced based
guidelines include acute [MEDICAL CONDITION] (inability to urinate), bladder outlet
obstruction (a blockage at the neck of the bladder), an open wound to the sacrum
(triangular bone in the lower back) or perineum (genital area), end of life care and
[MEDICAL CONDITION] bladder (flaccid or spastic bladder causing pain and difficulty
urinating);
-A resident who is admitted to the facility with an indwelling catheter in place without
medical justification shall have it discontinued as soon as is clinically warranted;
-Procedures:
-Monitor the catheter daily and assess for complications resulting from the use of an
indwelling urinary catheter such as symptoms of blockage with associated bypassing of
urine, catheter associated urinary tract infection (CAUTI), expulsion of the catheter,
pain, discomfort and bleeding. Also assess the potential for catheter removal;
-Develop an individualized care plan based on assessment findings and revise as needed.
For the resident with an indwelling urinary catheter, include a component to inform the
resident and representative about the risks and benefits of catheter use and identify
approaches to minimize the risk of infection by addressing personal hygiene measures,
catheter/tubing care and educating the resident and representative regarding signs and
symptoms of a urinary tract infection UTI).
1. Review of Resident #53’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/16/18, showed the following:
-Resident admitted on [DATE];
-Cognitively intact;
-Required extensive assistance with activities of daily living (ADL’s, daily self care)
including bed mobility, transferring, dressing and toileting;
-No catheter in place;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/22/18, and in use during the survey, showed

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
the following:
-Problem: Resident experiences incontinent episodes of bowel and bladder. Resident has
history of urinary tract infections [MEDICAL CONDITION];
-Goal: Resident’s dignity will be maintained as evidenced by being kept clean, dry and
free from odors;
-Approaches: Provide prompt perineal care (peri-care, washing the front and back of the
hips, genitals, anal area and buttocks) as needed for incontinent episodes, check and
change every two hours and as needed, use adult brief for dignity.
Review of the resident’s medical record, showed a Catheter Justification sheet, dated
8/17/18, which showed the following:
-Catheter size 16 and balloon size not documented;
-Indwelling: yes;
-Urethral blockage: yes, ureter (the duct by which urine passes from the kidney to the
bladder);
-Additional reviewer notes: suprapubic (S/P, a small opening in the lower abdominal wall
to place a catheter (small rubber tube) in to the bladder to drain urine) catheter;
-Primary reason continued use of indwelling catheter is unavoidable at the time of this
review: [MEDICAL CONDITION] (unable to urinate).
Review of the resident’s electronic physician order [REDACTED].
Review of the resident’s nurse’s notes, dated 9/10/18, showed the nurse attempted to
change the S/P drain sponge (dressing at the S/P insertion site) and noted the resident’s
SP catheter had become dislodged. He/she had been unable to locate the correct size of S/P
catheter at the facility. The resident used a S/P sized 12 with a 10 cubic centimeter (cc)
balloon. The resident’s bladder presented as slightly distended (enlarged or swollen with
urine). The nurse called the physician’s nurse practitioner (NP) and the NP gave a new
order to place an indwelling urinary catheter. This nurse will have the day shift nurse
call the resident’s urologist to see if an appointment can be made for today, 9/10/18.
This nurse placed a size 14 catheter with a 5 cc balloon via the resident’s urethra. The
catheter drained yellow urine.
Further review of the resident’s nurse’s notes, showed staff documented on 9/11/18, staff
placed a call to the resident’s urologist two times to schedule a new appointment. No
response given that day.
Review of the resident’s telephone orders, showed the following:
-An order, dated 9/10/18 for staff to:
-Notify urology to see if S/P catheter should be replaced;
-Order correct size for S/P catheter, and replace if urology says ok;
-Obtain urinanalysis to rule out UTI;
-The order did not include what the correct size was for the S/P catheter or when to
change it;
-An undated order, showed:
-Late entry for 9/10/18 at 6:40 A.M.;
-Urinary catheter via urethra;
-Have morning nurse call to urologist to see if resident can get appointment today;
-Staff did not include the proper size of the catheter or when to change it.
Further review of the resident’s medical record, showed no further documentation regarding
the resident’s urologist appointment, orders for correct size and frequency of change for
an indwelling catheter or if staff monitored the stoma (abdominal opening for the S/P
catheter) site or for signs or symptoms of adverse effects due to the S/P catheter being
removed.
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
During an interview on 9/19/18 at 10:26 A.M., the resident said he/she has a catheter.
He/she has not seen a urologist since his/her S/P catheter came out. He/she changes and
cleans the catheter him/herself.
During an interview on 9/20/18 at 1:01 P.M., LPN I said the resident was admitted without
a catheter and then had retention issues. A S/P catheter was placed, but has since come
out. An indwelling catheter was then placed instead. Staff should obtain an order for
[REDACTED].
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing (DON) said catheter
supplies are kept in the facility. Central Supply is responsible for ensuring sufficient
supplies are available to staff. Nursing staff should know how to insert a S/P catheter.
There should be orders now. The corporate nurse said she did not think placing an
indwelling catheter instead of a S/P catheter should be considered an unnecessary
procedure. The care plan should be updated to reflect the resident’s current condition and
needs.
2. Review of Resident #65’s admission MDS, dated [DATE], showed the following:
-Extensive assistance required for bed mobility, dressing, eating, toilet use and personal
hygiene;
-Indwelling catheter;
-[DIAGNOSES REDACTED].
Review of the initial data collection tool, dated 8/22/18, showed the resident had an
indwelling urinary catheter inserted in the hospital on [DATE].
Review of the resident’s care plan, dated 9/4/18, showed the following:
-Has a urinary catheter related to [DIAGNOSES REDACTED].
-Handwritten note dated 9/11/18, Foley-possibly [MEDICAL CONDITION] bladder related to
C3-C4 spinal injury, awaiting urology (physician who specializes in disorders of the
urinary tract) appointment and spinal surgery on (MONTH) 2;
-Approaches included change catheter per policy, change drainage bag per policy, keep
catheter tubing free of kinks, deep drainage bag below level of bladder, provide catheter
care per policy and review for possible removal of catheter.
Review of the POS [REDACTED].
During an observation and interview on 9/18/18 at 1:20 P.M., showed the resident sat in a
wheelchair in his/her room, wore a neck brace and a privacy bag contained a urinary
catheter drainage bag with the tubing underneath the wheelchair. He/she said he/she was
supposed to have a urology consult tomorrow but got a call from the physician’s office
saying he/she could not be seen. The catheter was placed in the hospital and had not been
changed at the facility.
Observation of the resident, showed the following:
-On 9/20/18 at 10:28 A.M., he/she sat up in a wheelchair in the therapy room with the
catheter tubing outside the catheter bag, looped in a circle, approximately 8 inches in
diameter, with urine collected in the tubing unable to drain;
-On 9/21/18 at 7:26 A.M., the resident sat on the bed and talked on the telephone. The
urinary catheter drainage bag, not contained in a privacy bag, hung on a walker next to
the bed, with the urine filled tubing stretched over the resident’s left leg, unable to
drain into the drainage bag.
During an observation and interview on 9/21/18 at 9:51 A.M., showed the resident sat on
the bed, with the catheter tubing stretched over his/her left leg and extended to the
catheter drainage bag, hung on a walker next to the bed. The tubing contained 6 to 8
inches of urine unable to drain into the drainage bag. The drainage bag was approximately
half full of dark orange-yellow urine. The resident said the urology consult was 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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
determine if he/she still needed the catheter. The nurses at the facility had called
his/her physician’s office several times but did not get called back. He/she was
frustrated.
Review of the resident’s progress notes, showed no documentation of contact with the
physician’s office to inquire about setting up a urology consult.
During an interview on 9/21/18 at 10:20 A.M., the DON said there should be orders for the
use of a urinary catheter, including the size. The corporate nurse said it depends on the
physician how often a catheter is changed. The DON said staff should document in the
progress notes any communication with a physician’s office.
During an interview on 9/21/18 at 3:00 P.M., the Corporate Vice President said the
catheter drainage bag should be positioned below the bladder and the catheter tubing
should be positioned to allow urine to drain into the collection bag. It would not be
appropriate for the tubing to be looped.
3. Review of Resident #128’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Limited assistance to dependent on staff for personal care and mobility;
-[DIAGNOSES REDACTED].
Review or the POS, dated 9/10/18, showed an order to place an indwelling catheter.
The order did not address the size of the catheter, the size of the balloon, the reason
for placement of the catheter or catheter care (cleansing of and around the catheter
insertion site).
Review of the 48 hour admission care plan, showed a urinary catheter inserted on 910/18.
Review of the nurse’s notes, showed a new urinary catheter inserted on 9/16/18. The note
did not include the size of the catheter but did note the bulb size as 10 cc’s. The note
did not have a reason for the indwelling urinary catheter.
Observation on 9/18/18 at 12:42 P.M., 9/19/18 at 5:37 A.M., 8:42 A.M. and 11:28 A.M.,
9/20/18 at 6:46 A.M. and 2:01 P.M. and 9/21/18 at 7:09 A.M., showed the resident lay in
bed on his/her back and the urinary catheter bag hung on the bedframe on the opposite side
of the bed towards the door to the room.
During an interview on 9/21/18 at 10:20 A.M., the DON said the catheter should always be
noted on the POS and include the size, frequency of change, reason for the catheter and
catheter care.

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 ensure residents
who required [MEDICAL TREATMENT] received such services, consistent with professional
standards of practice, by failing to follow physician’s orders [REDACTED]. The facility
identified eight residents who received [MEDICAL TREATMENT]. Two were chosen for review
and problems were identified with both (Residents #74 and #52.
1. Review of Resident #74’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/29/18, showed the following:
-admission date of [DATE];
-Required extensive assistance from staff for most captivities of living (ADL’s, daily
self care) including bed mobility, transfers, dressing and hygiene;

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 24)
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Special treatments received while a resident: [MEDICAL TREATMENT] (process for removal of
waste and excess water from the blood due to kidney failure).
Review of the resident’s care plan, last revised on 9/17/18 and in use during the survey,
showed the following:
-Problem: Resident is on [MEDICAL TREATMENT], CP updated 7/2/18, showed resident is on
[MEDICAL TREATMENT] due to [MEDICAL CONDITION];
-Approaches included: Check shunt site (a connection between a vein and an artery, usually
in the forearm or upper arm) for signs and symptoms of infection, pain or bleeding daily
and as needed. Communicate with [MEDICAL TREATMENT] center regarding medications, diet and
laboratory results. Make transportation arrangements for [MEDICAL TREATMENT] for Mondays,
Wednesdays and Fridays at 5:15 A.M.
Review of the resident’s 9/2018 physician order [REDACTED].
-Resident readmitted to facility on 9/10/18 (a Monday);
-An order, dated 9/10/18 to check blood pressure before and after [MEDICAL TREATMENT]
three days a week;
-An order, dated 9/10/18, to assess shunt site daily;
-An order, dated 9/10/18, to check the bruit (an audible vascular sound associated with
turbulent blood flow) and thrill (a vibratory sensation felt on the skin overlying an area
of turbulence) upon return after [MEDICAL TREATMENT] three times a week.
Review of the resident’s 9/2018 treatment administration record (TAR), showed the
following:
-Check shunt site post [MEDICAL TREATMENT] for bruit and thrill. Out of four
opportunities, staff documented checking the site three times. Staff also documented
checking the site five times on days the resident did not have [MEDICAL TREATMENT];
-Check blood pressure post [MEDICAL TREATMENT]. Staff documented checking blood pressure
one time out of four opportunities;
-Check blood pressure before [MEDICAL TREATMENT]. Staff documented checking blood pressure
three times out of four opportunities.
2. Review of Resident #52’s significant change MDS, dated [DATE], showed the following:
-Extensive assistance required for bed mobility, dressing, toilet use and bathing;
-Received [MEDICAL TREATMENT];
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated 9/1/18 through 9/30/18, showed the following:
-An order, dated 8/9/18, [MEDICAL TREATMENT] three days a week on Tuesday, Thursday and
Saturday;
-An order, dated 8/9/18, to check blood pressure before and after [MEDICAL TREATMENT],
three days weekly;
-An order, dated 8/9/18, to check for bruit and thrill upon return after [MEDICAL
TREATMENT], three days weekly;
-An order, dated 8/9/18, to check shunt or permament catheter site daily for signs of
infection.
Review of the resident’s TAR, dated 9/1/18 through 9/30/18, showed the following:
-Check blood pressure before [MEDICAL TREATMENT], three days weekly, blank 9/1/18 through
9/11/18; check blood pressure after [MEDICAL TREATMENT], three days weekly, blank 9/1/18
through 9/14/18, with no documentation on the back of the TAR;
-Check for bruit and thrill upon return, after [MEDICAL TREATMENT], three days weekly,
blank 9/1/18 through 9/9/18, with no documentation on the back of the TAR;
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 25)
-Check shunt or permanent catheter site daily for signs of infection, blank 9/1/18 through
9/10/18, with no documentation on the back of the TAR.
During an interview on 9/17/18 at 2:22 P.M., the resident said the facility did not do
anything with her dailysis access site. All of that was done when he/she was at [MEDICAL
TREATMENT].
3. During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing said she expected
staff to follow orders and to check the bruit and thrill for [MEDICAL TREATMENT]
residents. Staff should also check and document a resident’s blood pressure before and
after [MEDICAL TREATMENT] if there is an order. If an area is blank on the TAR it means
the treatment was not completed. Staff should only document performing a treatment on the
ordered days.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview, the facility failed to have a system in place to ensure certified
nurse aides (CNAs) received the required annual 12 hours of in-service training based on
performance reviews for CNAs who worked in the facility more than one year for five of
five employees reviewed. The census was 77.
On 9/18/18 at 9:52 A.M., five CNA employee files were requested to review the twelve hour
CNA training.
On 9/19/18 at 8:00 A.M., the administrator said he/she could not locate the training or
the in- service binder. He/she suspected former employees had removed the training binders
from the facility. He/she recalled multiple days of in-services had been done, but was not
able to produce documentation for the training that had been done with staff.
During an interview on 9/19/18 at 9:42 AM the corporate nurse manager said the facility
does not have the training hours for the five of five requested CNA employee annual
training hours. He/she said that several staff have been terminated and those staff may
have taken the training binders when they left.
During an interview on 9/21/18 at 10:20 A.M., the administrator and the corporate nurse
manager said no documentation had been located for continued training or in-servicing for
the requested CNA training hours.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure monthly medication
reviews (MMR) recommendations were completed as recommended and failed to ensure reviews
were completed and documented by the consultant pharmacist. This affected five of 18
residents reviewed (Residents #27, #60, #8, #48 and #52). The facility census was 77.
1. Review of Resident #27’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/16/18, showed the following:
-Cognitively intact;

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-Required extensive assistance with most activities of daily living (ADL’s, daily self
care activities) including hygiene, bed mobility, toileting and dressing;
-[DIAGNOSES REDACTED].
Review of the resident’s 5/2018 MRR, showed the following:
-Resident receives Xarelto 20 milligrams (used to prevent blood clots) and is also
receiving [MEDICATION NAME] 100 mg (used to prevent [MEDICAL CONDITION]). Concomitant
(accompanying) use of the two medications may result in decreased efficacy of Xarelto. The
manufacturer recommends avoiding concomitant use;
-Recommendation:
-Please re-evaluate continued use of this combination as it increases the risk of
clotting events;
-If this therapy is to continue at this dose, it is recommended that A) the prescriber
document an assessment of risk versus benefit, indicating that it continues to be a valid
therapeutic intervention for this individual; and B) the facility interdisciplinary team
(ITD) ensure ongoing monitoring for effectiveness and potential adverse consequences;
-Physician’s response: I accept the recommendation(s) above, please implement as written.
Review of the resident’s medical record, showed the following:
-The physician did not document an assessment of the risks versus benefits of the
continued medication regime;
-Staff did not clarify with the physician when and if an risk/benefit assessment would be
completed;
-The resident’s 9/2018 physican order sheet (POS), showed the resident continued to
receive the same doses of Xeralto 5mg and [MEDICATION NAME] 100 mg as in (MONTH) (YEAR).
2. Review of Resident #60’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Total dependence on staff for hygiene, dressing, toileting and bed mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-On 12/6/17, a MRR indicated the resident received Eliquis (anticoagulant) and Aspirin 325
mg daily;
-Recommendation:
-Please re-evaluate continued use of this combination as it increases the risk of
bleeding. Please consider the discontinuation of Aspirin;
-If this therapy is to continue, it is recommended that A) the prescriber document an
assessment of risk versus benefit, indicating that it continues to be a valid therapeutic
intervention for this individual; and B) the facility ITD ensure ongoing monitoring for
effectiveness and potential adverse consequences;
-Physician’s response: I accept the recommendation(s) above, please implement as written.
Further review of the residents medical record, showed the following:
-No documentation by the physician to show an assessment of the risks versus benefits for
continued use of Eliquis and aspirin;
-A 9/2018 POS, showed the following orders:
-An order, dated 6/18/18, for Eliquis 5 mg, take one tablet twice a day;
-An order, dated 6/18/18 for Aspirin 325 mg take daily;
-Staff did not follow up with the MMR to discontinue the use of Aspirin.
Further review of the resident’s MMR’s, showed the following:
-The consultant pharmacist signed the MMR log for 12/6/17, but did not indicate if any
irregularities were found;
-The consultant pharmacist signed the MMR log for 2/5/18, but did not indicate if any
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
irregularities were found;
-Staff did not follow up with the consultant pharmacist to determine if any irregularities
were found.
3. Review of Resident #8’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Received an antidepressant seven of seven days;
-Received an anticoagulant (blood thinner) seven of seven days;
-Received a diuretic (water pill) seven of seven days;
-Received an opioid (narcotic [MEDICATION NAME]) seven of seven days.
Review of the pharmacy’s MRR, showed no drug irregularities for 3/18, 4/18, 6/18, 7/18 and
8/18. The review for 5/18 showed to see the report.
Further review of the medical record, showed no information regarding the MRR
irregularity, dated 5/18.
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing (DON) said the
consultant pharmacist should either select No Irregularities or See Report, they should
not be left blank. The nurse who is caring for the resident should follow up with the
resident’s physician to seek clarification on MMR recommendations. Staff should not call
the pharmacist for clarification. If a physician makes a recommendation, it should be
followed. The facility has recently obtained a new consultant pharmacist because they were
having issues with the old one who was in place when these recommendations were given.
4. Review of Resident #48’s 9/2018 physician order [REDACTED].>-An order dated 5/10/18
for finastride (used to treat [MEDICAL CONDITION]) 5 milligrams (mg), take one tablet
daily for [MEDICAL CONDITION].
Review of the pharmacy consultation report, dated 8/21/18, showed the resident received
[MEDICATION NAME] daily for [MEDICAL CONDITION]. The consultation showed the resident was
to follow up on the [MEDICAL CONDITION] with a urologist. The pharmacy consultant had been
unable to locate the urology consult in the medical record. The resident’s physician
signed on 8/23/18, and noted that he/she accepted the recommendation and did not address
the urology consult. No documentation showed staff had followed up on the pharmacist
recommendation or the urology consult.
During an interview on 9/21/18 at 10:20 A.M., the DON said after the pharmacist makes a
recommendation, the charge nurse is responsible to make the resident’s physician aware of
the recommendations. If the physician agreed with the recommendations, the nurse would
fill out a telephone order sheet and make the needed changes in the resident’s record.
When a consult is recommended the nurse is responsible to make the appointment and if the
resident needed transportation, to notify social services.
5. Review of Resident #52’s significant change MDS, dated [DATE], showed the following:
-Extensive assistance required for bed mobility, dressing, toilet use and bathing;
-Received [MEDICAL TREATMENT];
-[DIAGNOSES REDACTED].
Review of the resident’s monthly medication regimen review check sheets, showed no
indication of reviews done for (MONTH) and (MONTH) (YEAR).
During an interview on 9/21/18 at 10:20 A.M., the corporate nurse said they had problems
with their conultant pharmacist not communicating with the facility and requested that
person not come back. She thought he/she was removed in May. A pharmacy supervisor did the
reviews in (MONTH) and July, and now they have another one.

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of 5% or less. Out of 26 opportunities, four errors occurred
resulting in a 15.38% medication error rate (Residents #176, #22 and #41). The census was
77.
1. Review of Resident #176’s physician order [REDACTED].
-An order dated 9/6/18 for [MEDICATION NAME] (used to treat high blood pressure) 25
milligram (mg) tablet. Take 75 mg once daily.
Observation on 9/19/18 at 8:31 A.M., showed Certified Medication Technician (CMT) U
administered one 25 mg of [MEDICATION NAME] to the resident. The resident’s Medication
Administration Record [REDACTED].
During an interview on 9/19/18 at 9:30 A.M., CMT U said he/she missed the additional two
tablets. He/she did not normally pass the medications to the residents on the hallway the
resident lived on. He/she had been pulled from a different area of the building to assist
in passing medications.
2. Review of Resident #22’s 9/2018 POS, showed:
-An order dated 5/11/18 for [MEDICATION NAME] 4 percent (%) topical patch to apply one
patch to the neck for neck pain;
-An order dated 6/11/18 for [MEDICATION NAME] 0.05% eye drops. Administer one drop into
each eye twice a day for dry eyes.
Observation on 9/19/18 at 8:05 A.M., showed CMT V administered one 5% [MEDICATION NAME] to
back of the resident’s neck. CMT V removed his/her gloves, washed his/her hands and
reapplied gloves. He/she obtained a tissue and asked the resident to tilt his/her head
back. CMT V administered three [MEDICATION NAME] 0.05 % eye drops into each of the
resident’s eyes. He/she applied pressure to the inner eye canthus for 30 seconds, not for
the recommended one minute for each eye.
3. Review of Resident #41’s 9/2018 POS, showed:
-An order dated 8/22/18 for [MEDICATION NAME]100 units per (/) milliliter (ml). Administer
per sliding scale guidelines three times a day.
During an observation on 9/18/18 at 7:46 A.M., Licensed Practical Nurse (LPN) K washed
his/her hands, explained the procedure to the resident and gloved his/her hands. He/she
verified the insulin order in the resident’s Medication Administration Record [REDACTED].
He/she applied the needle to the insulin pen and administered the insulin to the
resident’s left abdomen. He/she did not prime the needle before he/she administered the
ordered insulin to the resident. He/she did not know he/she should have primed the insulin
pen needle before administering the ordered dose of insulin. He/she had not had any
training or in-servicing on insulin pen priming.
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing said insulin pen
needles should be primed. If the needle is not primed that could effect the amount of
insulin the resident received. Physician orders [REDACTED]. indicated [REDACTED].

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to date insulin
flex pens (prefilled insulin pens) and vials of insulin once opened, failed to discard
outdated and not dated insulin pens and vials and did not ensure each insulin flex pen and
vial had a resident’s name on three of three medication carts for five of 32 insulin pens
and vials observed. The census was 77
Review of the facility’s Insulin Storage Recommendations, last revised (MONTH) 31, (YEAR),
showed the following:
-Discard [MEDICATION NAME] (long acting) insulin 28 days after opened;
-Discard Humalog (fast acting) insulin 28 days after opened;
-Discard [MEDICATION NAME] (fast acting) insulin 28 days after opened.
1. Observation on [DATE] at 10:26 A.M., of the medication cart on the 200 hall, showed the
following:
-One vial of [MEDICATION NAME]with no name and date opened as [DATE];
-One opened vial of Humalog insulin with no date opened or date expired;
-One opened Humalog flex-pen with no date opened or date expired;
-One opened Humalog flex-pen with no resident name;
-One opened [MEDICATION NAME] flex pen with no resident name.
During an interview on [DATE] at 10:35 A.M., Licensed Practical Nurse (LPN) C, said all
insulin vials and flex pens are good for 28 days. They are to be dated when opened and
have the resident’s name on the label. If the nurse sees the insulin does not have a
resident’s name, does not have a date opened or it is out of date, the insulin should be
thrown away.
During an interview on [DATE] at 10:45 A.M., LPN D said that all insulin vials and flex
pens are good for 30 days after opening.
During an interview on [DATE] at 10:20 A.M., the Director of Nursing and the corporate
nurse said the length of time the insulin is good for, is determined by the type of
insulin and all flex pens and vials should have the resident’s name on the container.

F 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide sufficient support personnel to safely and effectively carry out the functions
of the food and nutrition service.

Based on observation and interview, the facility failed to ensure staffing was sufficient
to serve meals to residents in a timely manner. This deficient practice had the potential
to affect all residents who ate in the main dining room. The census was 77.
During an interview on 9/17/18, the Dietary Manager (DM) said breakfast was served at 7:30
A.M., lunch at 12:00 P.M. and dinner at 5:00 P.M.
Observation of the main dining room on 9/17/18, showed the following:
-At 12:22 P.M., a resident sat at a bedside table at the back of the dining room near the
door and a dietary slip and utensils lay on the table;
-At 12:22 P.M., one dietary aide (DA) stood at a cart and served drinks one table at a
time to approximately 48 residents seated in the dining room;
-At 12:27 P.M., a resident seated at the back of the dining room gave his/her food order
and requested drinks from DA U, who told the resident the other DA would get his/her
drink;
-At 12:32 P.M., less than one-half of the residents seated in the dining room had drinks

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 0802

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
as the DA continued to serve from the cart;
-At 12:33 P.M., DA Q carried two covered plates from the kitchen and served two residents;
DA Q and DA U, continued to carry covered plates two at a time from the kitchen and serve
residents;
-At 12:42 P.M., four tables at the back of the room still had no drinks. At one of those
tables, sat a certified nurse aide (CNA) and two residents who required assistance. At
another table, sat one CNA and one resident who required assistance;
-At 12:51 P.M., the resident seated at the back of the dining room was served coffee and
soda and immediately began to drink;
-At 1:01 P.M., one resident at one of the assist tables received food and the CNA fed the
resident;
-At 1:05 P.M., the resident seated at the back of the dining room was served lunch, said
he/she did not receive salisbury steak and requested a soup spoon and a fork;
-At 1:07 P.M., the resident at the other assist table received food and the CNA fed the
resident;
-At 1:11 P.M., the DA served the requested salsbury steak, cut it up, left the resident’s
table and did not provide utensils. The resident took a teaspoon from his/her coffee cup
and began to eat the meal. The resident did not receive a soup spoon or fork during the
meal service;
-At 1:13 P.M., the resident seated at the bedside table, had no drink or meal, and said
his/her order had not been taken yet;
-At 1:19 P.M., a nurse took the resident at the bedside table’s dietary slip to the
kitchen; at 1:23 P.M., he/she was served a drink and meal, while other residents received
dessert;
-During the meal service, no CNA’s assisted with the delivery of food to the residents.
During an interview on 9/20/18 at 12:00 P.M., the DM said there are two DA’s who worked
during breakfast and lunch to serve drinks and the meal. It is a lot for those two to
handle. Sometimes nursing helped out but most of the time, just dietary staff. He did not
think the CNA’s considered helping in the dining room part of their job.
During an interview on 9/21/18 at 10:20 A.M., the corporate nurse said the CNA’s have a
rotation list and also help serve in the dining room. The Director of Nursing said the
aides that sit with residents who require assistance eating are not expected to serve
meals. They are assigned to help residents on a daily basis, and not part of the rotation
schedule.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, the facility failed to ensure food was served under
sanitary conditons by not using serving utensils. The census was 77.
Observation of the kitchen on 9/20/18 at 12:05 P.M., showed the following:
-Cook V stood at the steamtable and wore gloves. Cook V plated roasted pork, mashed
potatoes, gravy and vegetables on four plates, placed both gloved hands, palms down, on
the counter, picked up dietary slips and placed them under four plates, reached into the
open oven, grabbed a dinner roll with his/her gloved hand and placed it on a plate. Cook V
filled four more plates, reached into the open oven, grabbed four dinner rolls in his/her

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
gloved hand and placed them on the plates. Cook V then picked up a section of sliced sweet
potato from a cutting board on the stove with his/her gloved hand and placed it on one of
the plates. Cook V continued to lay out dietary slips, placed both gloved hands, palms
down, on the counter, pick up stacked plates from a rack with the fingers of his/her left
hand placed in the midde of the plate and serve rolls using gloved hands. There were no
utensils in place for cook V to serve the rolls or the sweet potatoes.
During an interview on 9/21/18 at 3:00 P.M. the Dietary Manager said utensils should be
used to serve all food and gloved hands that have been contaminated should not touch any
food or dishware.

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain complete and
accurate records for two sampled residents and failed to maintain complete records for
their wound tracking and prevention program (Residents #8 and #66). The sample was 18. The
census was 77.
1. Review of Resident #8’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/9/18, showed the following:
-No cognitive impairment;
-Required extensive assistance to total dependence on staff for personal care and
mobility;
-[DIAGNOSES REDACTED].
Review of the care plan, last reviewed on 9/18/18 and in use during the survey, showed the
following:
-Problem: Chronic pain as evidenced by complaints of pain relatied to left hand swelling,
arthritis and immobility;
-Goal: Pain will be minimized with medication and positioning;
-Approaches included:
-Administer routine and as needed (PRN) pain medication and observe for possible side
effects;
-Educate resident/family about pain management measures and request pain medication early
before pain is out of control;
-Notify physician if resident does not demonstrate/state relief or reduction of pain;
-Observe and report to nurse any signs/symptoms of pain, i.e , crying, resist moving,
resistance of care, grimaces;
-Report changes in pain location, type, frequency or intensity to the physician.
Review of the physician’s orders [REDACTED].
-An order, dated 3/9/18, to administer [MEDICATION NAME] (used to treat mild to moderate
pain) 50 milligrams (mg) every eight hours;
-An order, dated 7/13/18, to administer [MEDICATION NAME] (opioid [MEDICATION NAME]) 5/325
mg every eight hours.
Review of the medication administration record (MAR), dated 8/1 through 8/31/18, showed
the following:
-[MEDICATION NAME] 50 mg not recorded as administered at 6:00 A.M. on 8/4 or 8/9/18 and no
explanation provided for the missed doses;

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
-[MEDICATION NAME] 50 mg not recorded as administered at 2:00 P.M. on 8/5, 8/14, 8/16,
8/17, 8/23 and 8/30/18 and no explanation provided for the missed doses;
-[MEDICATION NAME] 50 mg not recorded as administered at 10:00 P.M. on 8/8, 8/17, 8/19,
8/20 or 8/30/18 and nurse’s initials circled on 8/3, 8/16 and 8/18/18. No explanation
provided for the missed doses;
-[MEDICATION NAME] 5/325 mg not recorded as administered at 8:00 A.M. on 8/4, 8/5, 8/17 or
8/30/18 and no explanation provided for the missed doses;
-[MEDICATION NAME] 5/325 mg not recorded as administered at 4:00 P.M. on 8/17, 8/18, 8/19
or 8/20/18 and no explanation provided for the missed doses;
-[MEDICATION NAME] 5/325 mg not recorded as administered at 12:00 A.M. on 8/2, 8/4, 8/9,
8/10, 8/12, 8/13, 8/14, 8/15, 8/16, 8/18, 8/20, 8/21, 8/22, 8/26, 8/27, 8/29, 8/30 or
8/31/18 and the nurse’s initials circled on 8/3/18. No explanation provided for any of the
missed doses.
Review of the pharmacy controlled substances proof of use form, dated 8/1 through 8/31/18,
showed the following:
-[MEDICATION NAME] 50 mg signed out as administered at 2:00 P.M. on 8/14, 8/17 and
8/30/18;
-[MEDICATION NAME] 50 mg signed at as administered at 10:00 P.M. on 8/17, 8/19, 8/20 and
8/30/18;
-[MEDICATION NAME] 5/325 mg signed out as administered at 8:00 A.M. on 8/4, 8/5, 8/17 and
8/30/18;
-[MEDICATION NAME] 5/325 mg signed out as administered at 4:00 P.M. on 8/17, 8/19 and
8/20/18;
-[MEDICATION NAME] 5/325 mg signed out as administered at 12:00 A.M. on 8/10, 8/12 and
8/18/18
Review of the MAR, dated 9/1 through 9/19/18, showed the following:
-[MEDICATION NAME] 50 mg not recorded as administered at 6:00 A.M. on 9/1/18 and no
explanation provided for the missed dose;
-[MEDICATION NAME] 50 mg not recorded as administered at 2:00 P.M. on 9/5 and 9/6/18 and
no explanation provided for the missed doses;
-[MEDICATION NAME] 50 mg not recorded as administered at 10:00 P.M. on 9/1, 9/7 or 9/13/18
and no explanation provided for the missed doses;
-[MEDICATION NAME] 5/325 mg not recorded as administered at 8:00 A.M. on 9/4/18 and no
explanation provided for the missed dose;
-[MEDICATION NAME] 5/325 mg not recorded as administered at 4:00 P.M. on 9/17/18 and no
explanation provided for the missed dose;
-[MEDICATION NAME] 5/325 mg not recorded as administered at 12:00 A.M. on 9/1 or 9/2/18
and no explanation provided for the missed doses.
Review of the pharmacy controlled substances proof of use form, dated 9/1 through 9/19/18,
showed the following:
-[MEDICATION NAME] 50 mg signed out as administered at 6:00 A.M. on 9/1/18;
-[MEDICATION NAME] 50 mg signed out as administered at 2:00 P.M. on 9/5 and 9/6/18;
-[MEDICATION NAME] 50 mg signed out as administered at 10:00 P.M. on 9/1, 9/7 and 9/13/18;
-[MEDICATION NAME] 5/325 mg signed out as administered at 12:00 A.M. on 9/2/18.
During an interview on 9/21/18 at 10:30 A.M., the Director of Nursing (DON) said a blank
on the MAR or circled initials means the medication was not given and the reason should be
documented on the back of the MAR.
During an interview on 9/25/18 at 12:55 P.M., the DON said if a medication is signed out
on the pharmacy substance sheet she would expect it to be recorded on the resident’s MAR
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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
and if it is not, the nurse just forgot to record it. Sometimes the nurse may drop the
pill or the resident may refuse the medication, but then it should be recorded as wasted.
A waste is recorded on the same controlled substance form and it has to be witnessed by
two nurses. It is definitely something that needs to be looked in to.
2. Review of Resident #66’s admission MDS, dated [DATE], showed:
-Cognitively intact;
-[DIAGNOSES REDACTED].
-Received intravenous (IV) antibiotic medication daily.
Review of the resident’s treatment administration record (TAR), dated 8/9/18 through
8/31/18, showed the following:
-An order dated, 8/9/18 to change the resident’s IV/PICC (peripherally inserted central
catheter inserted into a central vein) line dressing once a week. Scheduled dates of
8/16/18 and 8/23/18 for the IV/PICC line dressing to be changed. No staff initials
documented on the scheduled dates. No documentation found to the back of the TAR for the
missed dressing changes;
-An undated order [MEDICATION NAME](used to treat bacterial infections) 2 grams IV,
administer every eight hours. Staff did not initial the ordered 6:00 A.M. administration
as completed on 8/25, 8/29 and 8/30/18. Staff did not initial the 2:00 P.M.,
administration as completed on 8/27 and 8/28/18. Staff did not initial the 10:00 P.M.,
administration time as completed on 8/24, 8/29 and 8/30/18;
-The back of the resident’s TAR contained no documentation to address the missed doses of
the ordered antibiotic therapy medication.
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing said administration
of IV/PICC line medications and IV/PICC line dressing changes are the responsibility of
the resident’s charge nurse. Physician orders [REDACTED].
3. During the survey entrance conference on 9/17/18 at 10:30 A.M., the facility was asked
to provide their pressure sore/wound report for the last three months.
Review of the facility’s Weekly Non-pressure Ulcer Tracking Report, provided by the
facility on 9/17/18, showed the following:
-Tracking information for the weeks of 5/21/18, 6/18/18, 7/2/18, 7/8/18, 7/16/18, 8/13/18
and 9/10/18;
-Staff failed to retain wound tracking reports for 8 out of 14 weeks requested.
During an interview on 9/17/18 at approximately 2:00 P.M., the corporate nurse said a
former employee took wound report information for residents when he/she was terminated in
mid (MONTH) (YEAR).

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

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

Based on observation, interview and record review the facility failed to ensure
appropriate hand hygiene practices while providing personal hygiene and failed to ensure
resident admission [MEDICAL CONDITION] testing had been completed. This effected two of 18
sampled residents (Resident #48 and Resident #228). The census was 77.
Review of the facility’s hand hygiene policy, revised 4/1/15, showed:
-Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene;

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:

265838

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

NAME OF PROVIDER OF SUPPLIER

LIFE CARE CENTER OF FLORISSANT

STREET ADDRESS, CITY, STATE, ZIP

1201 GARDEN PLAZA DRIVE
FLORISSANT, MO 63033

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 34)
-Policy: Handwashing is the most important procedure for preventing infections;
-Handwashing: Staff should wash hands when hands are visibly dirty, contaminated or
soiled.
1. Review of Resident #48’s quarterly MDS, Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/11/18, showed:
-Cognitively intact;
-Extensive staff assistance needed for toileting, hygiene, bed mobility and dressing;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation and interview on 9/19/18 at 5:58 A.M., showed Certified Nurse Aide (CNA) F and
G stood in the hallway outside of the resident’s room. The resident’s door remained
closed. CNA F said he/she had not been assigned to care for the resident during the night
shift. CNA G said to CNA F that he/she did not have the resident on his/her assignment and
the resident had been the responsibility of CNA F for the night shift. CNA F threw his/her
hands in the air and said Well I thought the resident was yours, so I guess I will take
care of the resident now. CNA F gathered the care supplies and entered the resident’s
room. He/she filled a bath basin with warm soapy water, applied gloves to his/her hands
and placed the bath basin on the resident’s bed side table. He/she placed several wash
cloths in the basin. CNA F unfastened the resident’s urine saturated brief and tucked the
brief between the resident’s legs. He/she used the same gloved hands and obtained another
wash cloth from the bath basin and provided care to the front of his/her thighs. He/she
placed the used wash cloth back into the soapy bath basin. He/she used the same gloved
hands and assisted the resident to turn onto his/her side. CNA F used the same gloved
hands, obtained a wash cloth from the bath basin and cleaned the resident’s buttocks.
He/she placed the used wash cloth back into the bath basin. CNA F used the same gloved
hands and applied a clean brief under the resident and secured the brief into place. CNA F
said he/she forgot to wash his/her hands after he/she entered the resident’s room. He/she
forgot to wash hands and change his/her gloves when he/she applied the clean brief under
the resident. Used wash cloths should not get placed back into a clean bath basin.
During an interview on 9/21/18 at 10:20 A.M., the Director of Nursing (DON) said staff
should wash their hands before providing any care. Gloves and hand washing should occur
when staff complete a dirty task and before touching any clean items. Hand washing helps
to prevent the spread of infection. Used wash cloths should not be placed into clean bath
basins used for that resident’s care.
2. Review of Resident #228’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Dependent on staff for personal care and mobility;
-[DIAGNOSES REDACTED].
Review of the medical record, showed no documentation the resident received a purified
protein derivative (PPD) (a skin test that determines [MEDICAL CONDITION] (TB), an
infection, usually of the lungs) test.
During an interview on 9/21/18 at 10:30 A.M., the DON said she would provide information
that the two step PPD was completed, however, the information was not provided.