Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265733

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

NAME OF PROVIDER OF SUPPLIER

ST JOHNS PLACE

STREET ADDRESS, CITY, STATE, ZIP

3333 BROWN ROAD
SAINT LOUIS, MO 63114

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 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain the surety bond (a
purchased bond for security of residents’ personal funds) amount for at least one and one
half times the average monthly balance of the residents’ personal funds for the last 12
consecutive months from (MONTH) (YEAR) through (MONTH) 2019. The facility’s census was 60.
Record review on 2/20/19 of the residents’ personal funds account for the last 12
consecutive months from (MONTH) (YEAR) through (MONTH) 2019 showed:
– The facility’s approved bond amount equaled $40,000.00;
– The average monthly balance for the residents’ personal funds equaled $31,389.50;
– An average monthly balance of $31,389.50 rounded to the nearest thousand equaled
$31,000.00, at one and one half times will equal the required bond amount of at least
$46,500.00.
During an interview on 2/21/19 at 9:46 A.M., the Administrator in Training (AIT) said the
Labor Day holiday fell early and put them over double in the month of (MONTH) which in
turn put them over the required bond amount.
Record review of the facility’s policy, titled Nursing Home Surety Bond, dated (MONTH)
2009, showed:
– A surety bond must be issued by an insurance company licensed for [MEDICATION NAME] with
the State of Missouri;
– A surety bond must be at least $1,000.00;
– Did not address the required bond amount to equal one and one half times the average
monthly balance of the residents’ person funds.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility failed to issue a Skilled Nursing
Facility Advanced Beneficiary Notice (SNF ABN), a Centers for Medicare and Medicaid
Services (CMS) Form (a required notice to beneficiaries of covered skilled services
ending) when benefits were not exhausted and the resident remained in the facility for two
residents (Resident #20 and #35) out of three sampled residents. The facility’s census was
60.
1. Record review of Resident #20’s medical record showed:
– The resident’s Medicare Part A skilled services start date of 11/16/18 and end date of
12/9/18;
– The facility initiated a discharge on 12/7/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was not a SNF ABN Form issued.
2. Record review of Resident #35’s medical record showed:
– The resident’s Medicare Part A skilled services start date of 12/21/18 and end date of
1/13/19;
– The facility initiated a discharge on 1/11/19 from Medicare Part A Services when benefit
days were not exhausted;
– There was not a SNF ABN Form issued.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265733

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

NAME OF PROVIDER OF SUPPLIER

ST JOHNS PLACE

STREET ADDRESS, CITY, STATE, ZIP

3333 BROWN ROAD
SAINT LOUIS, MO 63114

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 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
3. During an interview on 2/21/19 at 9:52 A.M., the Administrator in Training (AIT) said
he wasn’t aware that they were supposed to be using both forms but will use the correct
forms in the future.
4. Record review of the facility’s policy, titled ABN Quick Glance Guide, dated 9/4/12,
did not address use of SNF ABN Form .

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan (plan for immediate needs) within 48 hours of admission which included
the minimum healthcare information necessary to properly care for the immediate needs of
one resident (Resident #65) out of two closed records. The facility’s census was 60.
Record review of Resident #65’s physician’s orders [REDACTED].
– Resident admitted on [DATE];
– [DIAGNOSES REDACTED]. or stomach), [MEDICAL CONDITION] disorder, constipation,
hypertension (high blood pressure), and chronic pai[DIAGNOSES REDACTED].
Record review of the resident’s care plan, dated 12/4/18, showed:
– Maintain current functional status;
– Social Services will assist with discharge plans and arranging home health;
– Did not address mood, behaviors, activities, activities of daily living (ADLs), pain,
nutrition, dental, medications, or [MEDICAL CONDITION].
During an interview on 2/21/19 at 12:23 P.M., the Director of Nursing (DON) said the
resident wasn’t at the facility very long and that was his/her baseline care plan.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

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

Based on interview and record review, the facility failed to develop and implement a
comprehensive care plan with specific interventions for four residents, (Residents #21,
#25, #26, and #61) out of 15 sampled residents. The facility’s census was 60.
1. Record review of Resident #21’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– An order, dated 10/18/18, for [MEDICATION NAME] (an anti-psychotic medication used to
treat certain mental/mood conditions) one milligram (mg) twice daily.
Record review of the resident’s comprehensive care plan, dated 3/18/18, showed no care
plan for [MEDICAL CONDITION] medications.
During an interview on 2/20/19 at 11:05 A.M., the Director of Nursing (DON) said the
[MEDICATION NAME] should be care planned.
2. Record review of Resident #25’s POS, dated 2/1/19 through 2/28/19, showed the resident

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265733

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

NAME OF PROVIDER OF SUPPLIER

ST JOHNS PLACE

STREET ADDRESS, CITY, STATE, ZIP

3333 BROWN ROAD
SAINT LOUIS, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
had a [DIAGNOSES REDACTED].
Record review of the resident’s care plan, dated 3/18/18, showed staff identified the
resident received [MEDICAL TREATMENT] three times per week. Staff did not include goals or
approaches to address the [MEDICAL TREATMENT] in the care plan.
During an interview on 2/20/19 at 1:45 P.M., the DON said staff normally would have
developed a care plan for residents who received [MEDICAL TREATMENT]. The DON did not know
why staff had not developed a care plan to address [MEDICAL TREATMENT].
3. Record review of Resident #26’s POS, dated 2/1/19 through 2/28/19, showed the resident
had a [DIAGNOSES REDACTED]. On 4/24/17, the physician ordered the use of one-half side
rails on both sides for mobility and self care.
Record review of the resident’s care plan, updated 12/17/18, showed staff had not
developed a care plan to address the use of side rails. On 11/7/16, staff identified the
resident as at risk for falls. Staff listed approaches to address fall risks to include
the use of raising one-half side rails on both sides.
During an interview on 2/20/19 at 1:45 P.M., the DON said the resident used side rails to
keep him/her from falling despite not having had any recent falls. The DON also said staff
should have developed a care plan to specifically address the use of side rails.
4. Record review of Resident #61’s POS, dated 2/1/19 – 2/28/19, showed:
– [DIAGNOSES REDACTED].
– An order, dated 4/27/18, for [MEDICATION NAME] (an antidepressant medication used to
treat depression and anxiety) 60 mg once daily;
– An order, dated 10/18/18, for [MEDICATION NAME] (an anti-psychotic medication used to
treat certain mental/mood conditions) 25 mg 1/2 tab twice daily.
Record review of the resident’s comprehensive care plan, dated 1/31/19, showed no care
plan for [MEDICAL CONDITION] medications.
During an interview on 2/20/19 at 11:05 A.M., the DON said the [MEDICATION NAME] and the
[MEDICATION NAME] should be care planned.
5. Record review of the facility’s care plan policy, dated (MONTH) (YEAR), showed:
– The interdisciplinary team in conjunction with the resident and his/her family or legal
representative, develops and implements a comprehensive, person-centered care plan for
each resident;
– The care plan interventions are derived from a thorough analysis of the information
gathered as part of the comprehensive assessment.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to assess three
residents (Residents #26, #37 and #58) out of a sample of 15 residents for the use of bed
bed rails prior to installation and review the risks and benefits of bed rails with the
resident or resident representative. The facility’s census was 60.
1. Record review of Resident #26’s physician’s orders [REDACTED]. On 4/24/17, the
physician ordered the use of one-half side rails on both sides for mobility and self care.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265733

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

NAME OF PROVIDER OF SUPPLIER

ST JOHNS PLACE

STREET ADDRESS, CITY, STATE, ZIP

3333 BROWN ROAD
SAINT LOUIS, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Review of the resident’s care plan, updated 12/17/18, showed staff had not developed a
care plan to address the use of side rails. On 11/7/16, staff identified the resident as
at risk for falls. Staff listed approaches to address fall risks to include the use of
raising one-half side rails on both sides.
Review of the resident’s quarterly Minimum Data Set (MDS) (a federally mandated assessment
instrument required to be completed by facility staff), dated 12/19/18, showed:
– The resident rarely or never understood; therefore, staff did not complete a Brief
Interview for Mental Status (BIMS).
– The resident required total assistance of bed mobility and transfers.
– The resident had not experienced a fall.
– Staff utilized physical restraints of elevated bed rails on both sides of the bed daily.

During an interview on 2/20/19 at 1:45 P.M., the Director of Nursing (DON) said Resident
#26 used side rails to keep him/her from falling despite not having had any recent falls.
The DON said the resident wiggled around but did not turn and reposition him/herself. The
DON said staff did not raise the side rails as a restraint.
2. Record review of Resident #37’s quarterly MDS dated [DATE], showed:
– BIMS not conducted due to resident rarely/never understood;
– Total dependence of one to two persons for transfer;
– Physical restraints of bed rails X 2 used daily.
Record review of the resident’s POS, dated (MONTH) 2019, showed no orders for bed rails.
Observation on 2/19/19 at 9:05 A.M. of the resident showed half rails X 2 used on the bed.
Observation on 2/20/19 at 3:30 P.M. of the resident showed half rails X 2 used on the bed.
3. Record review of Resident 58’s quarterly MDS, dated [DATE], showed:
– BIMS score of 6 out of a possible 15;
– Extensive to total dependence of two or more persons physical assist for transfers;
– Physical restraints of bed rails X 2 used daily.
Record review of the resident’s POS, dated (MONTH) 2019, showed no orders for bed rails.
Observation on 2/19/19 at 10:12 A.M. of the resident showed half rails X 2 used on the
bed.
Observation on 2/21/19 at 8:30 A.M. of the resident showed half rails X 2 used on the bed.
4. During an interview on 2/21/19 at 10:12 A.M., the DON said the facility had not
implemented a formal assessment instrument to determine a resident’s safety when using bed
rails. He/she was not aware that a physician’s orders [REDACTED].
5. Record review of the facility’s policy on bed rails, dated (MONTH) (YEAR), showed:
– Side rails are only permissible if they are used to treat a resident’s medical symptoms
or to assist with mobility and transfer of residents;
– An assessment will be made to determine the resident’s symptoms, risk of entrapment, and
reason for using side rails;
– When used for mobility or transfer, an assessment will include a review of the
resident’s bed mobility, ability to change positions, transfer to and from bed or chair,
and to and from toilet;
– Risk of entrapment from the use of side rails:
– The bed’s dimensions are appropriate for the resident’s size and weight;
– Consent for using restrictive devices will be obtained from the resident or legal
representative;
– The risks and benefits of side rails will be considered for each resident.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265733

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

NAME OF PROVIDER OF SUPPLIER

ST JOHNS PLACE

STREET ADDRESS, CITY, STATE, ZIP

3333 BROWN ROAD
SAINT LOUIS, MO 63114

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to store all drugs
and biological’s in a safe and effective manner by monitoring refrigerator temperatures
and keeping with accepted professional standards for infection control in the medication
refrigerator. The facility’s census was 60.
Observation of the medication refrigerator on 2/21/19 at 9:31 A.M. showed:
– No temperature logs;
– Freezer at top of refrigerator had ice buildup of two inches on the left side to six
inches on the right side;
– Refrigerator section contained three unlabeled covered containers of food, one container
of sour cream, one bag of shredded cheese, one can of soda, one bottle of water, and five
cartons of Orange Flavored Med Pass 2.0;
– Dried brown sticky substance on the floor of the bottom drawer;
– Drawer contained 10 unopened labeled pens of [MEDICATION NAME] (a medication used to
control blood sugar in people with diabetes, a disease that occurs when the pancreas is no
longer. able to make insulin), 26 unopened labeled pens of Novalog (a medication used to
control blood sugar in people with diabetes), and three unopened labeled pens of Humolog
(a medication used to control blood sugar in people with diabetes);
– Dried brown sticky substance on the bottom floor of refrigerator.
During an interview on 02/21/19 at 9:10 A.M., Certified Medication Technician (CMT) A and
Registered Nurse (RN) B said they do not keep a temperature log. The food belongs to staff
and is normally kept there.
During an interview on 2/21/19 at 1:49 P.M., the Director of Nurses (DON) said the
refrigerator temperature should be monitored daily, the CMT is responsible for that task
and has admitted it has not been done. She would not expect there to be ice buildup or
sticky substances on the refrigerator surfaces. Staff food should not be kept in the
medication refrigerator.
Record review of the facility’s policy, titled Storage of Medications, dated (MONTH) 2007,
showed:
– The facility shall store all drugs and biological’s in a safe, secure, and orderly
manner;
– The nursing staff shall be responsible for maintaining medication storage and
preparation areas in a clean, safe, and sanitary manner;
– Medication requiring refrigeration must be stored in a refrigerator located in the drug
room at the nurses’ station or other secured location. Medications must be stored
separately from food and must be labeled accordingly.

F 0865

Level of harm – Potential for minimal harm

Residents Affected – Many

Have a plan that describes the process for conducting QAPI and QAA activities.

Based on interview and record review, the facility failed to develop a Quality Assurance

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265733

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

NAME OF PROVIDER OF SUPPLIER

ST JOHNS PLACE

STREET ADDRESS, CITY, STATE, ZIP

3333 BROWN ROAD
SAINT LOUIS, MO 63114

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 0865

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 5)
and Performance Improvement Plan (QAPI). The facility’s census was 60.
Record review showed the facility does not have a QAPI plan which contains the necessary
policies and protocols describing how they will identify and correct their quality
deficiencies, track and measure performance, and establish goals and thresholds for
performance measurement.
During an interview on 2/21/19 at 9:05 A.M., the Administrator said the facility had
quarterly meetings with the department heads and the medical director but had not
developed a QAPI plan.