DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) visible. CNA L said he/she is not sure why staff did not place the resident’s catheter in a dignity bag. During an interview on 4/26/18 at 11:16 A.M., LPN M said staff are expected to place residents’ catheter bags in a dignity bag so the urine is not visible. LPN M said he/she is not sure why staff did not place the resident’s catheter bag in a dignity bag. During an interview on 4/26/18 at 11:52 A.M., CNA D said residents’ catheter bags should be kept covered in a dignity bag so the urine is not visible to others. During an interview on 4/2618 at 6:56 P.M., the Director of Nursing (DON) said staff should keep residents’ catheter bags covered in a dignity bag so the urine is not visible to others. The DON said he/she is not sure why staff did not place the resident’s catheter bag in a dignity bag. 3. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted on [DATE]. Review of the resident’s care plan, dated 11/21/17, showed staff are directed to provide assistance with dressing. Review of the resident’s inventory sheet, dated 12/01/17, showed the resident entered the facility with two coats. Review of the residents’ MDS, a federally mandated assessment instrument, dated 12/04/17, showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s MDS, a federally mandated assessment tool, dated 02/15/18, showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene; -Antidepressant medication seven days a week. Observation on 04/25/18 at 9:11 A.M., showed the resident sat alone on the couch at the end of the hall. Observation on 04/25/18 at 10:54 A.M., showed the resident sat alone on the couch at the end of the hall. Observation on 04/25/18 at 3:18 P.M., showed the resident sat alone on the couch at the end of the hall. Observation on 04/26/18 at 10:00 A.M., showed the resident awake in bed. During an interview on 04/24/18 at 10:10 A.M., the resident said he/she is not wearing underpants today because he/she does not have any clean. He/She said he/she only has one pair and they are in laundry. He/She said not wearing underpants makes him/her feel uncivilized. During an interview on 04/26/18 at 10:00 A.M., the resident said the Social Services brought him/her one pair of underpants yesterday but they are dirty and stained. He/She said he/she had to wear them last night because he/she has to wear something at night but he/she did not want to because they were gross. During an interview on 04/25/18 at 4:25 P.M., Social Services said the resident asked for undergarments the other day and staff provided him/her with more. He/She said the facility provides clothing to all needy residents and staff are expected to list those clothing |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) items on the inventory sheet. During an interview on 04/26/18 at 3:24 P.M., the Administrator said they provide clothing to all indigent residents. He/She said they have a lot of donated clothes they keep in the Orphan Room. He/She said they have sizes to fit just about anybody. He/She said if they need to, they also buy clothes for residents. He/She said they buy undergarments new. He/She said the Activities Director and the Housekeeping Supervisor are responsible for making sure residents have all the clothes they need. He/She said all a resident has to do is tell a staff member and it will be discussed in the morning meeting. He/She said he/she was not aware of any resident being without undergarments. He/She said staff should never provide residents with used undergarments. During an interview on 04/26/18 at 3:37 P.M., the Housekeeping Supervisor said he/she tries to make sure the residents have what they need. He/She provided the resident with about five outfits when he/she arrived. He/She is unsure about the undergarments. He/She said he/she will check on the resident. He/She said if the resident reported needing undergarments to any staff member (CNA/Laundry) he/she expects the staff to report it to him/her. During an interview on 04/26/18 at 6:59 P.M., the DON said all staff are responsible to ensure a resident has clothing and if not, staff should report it to him/her so he/she can take care of it. He/She said they do have a lot of nice clothing. He/She said the housekeeping supervisor checks to make sure residents have what they need upon admission. He/She said he/she had no idea Resident #44 did not have undergarments and no one ever reported it to him/her. 4. Review of Resident #48’s significant change MDS, dated [DATE], showed staff assessed the resident with moderate cognitive impairment, and required limited assistance of one person with eating. Review of the resident’s care plan last updated (YEAR), showed staff are directed to assist with meals, and offer finger foods. Observation on 4/23/18 at 1:15 P.M., showed CNA G served the resident his/her meal, stood next to the resident and assisted with the meal. Observation on 4/23/18 at 1:18 P.M., showed the CNA G continued to stand next to the resident and assisted him/her to eat. Observation on 4/23/18 at 1:22 P.M., showed the CNA G continued to stand next to resident and assisted him/her to eat. 5. Review of Resident #81’s quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, required limited assist of one with eating, no behaviors or rejection of care. Review of the resident’s care plan for ADLs last updated (YEAR), showed staff are directed to assist with meals. Observation on 4/23/18 at 1:00 P.M., showed the resident sat in his/her wheelchair at the dining table. Observation showed the resident used his/her right hand to raise his/her shirt to his/her cheek, and exposed his/her abdomen. Further observation showed five other residents (2 females, 3 males) sat at the table in line of sight, and staff present in the dining room did not offer redirection to assist the resident maintain his/her dignity. Observation on 4/23/18 at 1:33 P.M., showed CNA K stood next to the resident at the dining table and fed him/her a few bites of turkey. The CNA did not assist the resident to eat his/her meal in a dignified manner. Observation on 4/23/18 at 1:35 P.M., showed the resident continued to use his/her right hand to raise his/her shirt to his/her cheek, and exposed his/her abdomen. Further observation showed five other residents sat at the table in line of sight, and CNA N or |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0550 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) other staff present in the dining room did not offer any redirection to the resident. Observation on 4/23/18 at 1:49 P.M., showed the resident continued to use his/her right hand to raise his/her shirt to his/her cheek, and exposed his/her abdomen. Further observation showed five other residents sat at the table in line of sight, and CNA N or other staff present in the dining room did not offer any redirection to the resident. Observation on 4/24/18 at 1:43 P.M., showed CNA N sat next to the resident and assisted him/her to eat. The CNA did not communicate with the resident as he/she assisted the resident to eat his/her meal. During an interview on 04/26/18 at 5:50 P.M., CNA I said if staff see a resident in a public area with exposed skin they should cover them up and notify the nurse to see if they need to be taken back to their room. 6. Review of Resident #195’s Quarterly MDS, a federally mandated assessment tool, dated 03/01/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Independent with transfers and eating. Review of the resident’s care plan, dated 04/02/18, showed staff are directed to assist with tray setup, encourage the resident to complete meals, and assist the resident with meals. Observation on 04/23/18 at 12:43 P.M., showed CNA G stood beside the resident while he/she fed him/her. Further observation showed CNA G did not communicate with the resident during the meal. The CNA did not assist the resident to eat his/her meal in a dignified manner. During an interview on 04/25/18 at 3:54 P.M., CNA H said they sit the feeders at the first table and staff are expected to sit down at the table and assist them. During an interview on 04/26/18 at 9:18 A.M., CNA D said all residents on the special care unit need some help with meals. He/She said some just need cueing and supervision but others need help to eat their meals. The CNA said he/she was trained to sit down and speak to residents when assisting them with meals but said he/she has noticed some staff stand while they feed residents. During an interview on 04/26/18 at 9:48 A.M., LPN F said staff should sit down beside residents and explain what they are eating when assisting them with meals. He/She said he/she has not attended any in-services on assisting residents with meals. During an interview on 4/26/18 at 5:51 P.M., LPN B said staff are expected to sit at eye level and converse with the resident when they assist with feeding. Staff are also expected to ensure the resident’s skin is covered (whether male or female), and offer redirection to protect privacy and dignity. During an interview on 4/26/18 06:19 PM CNA C said there should always be at least one staff in the dining room when residents are eating, and staff are expected to sit next to the resident while they assist the resident to eat to provide a dignified dining environment. During an interview on 04/26/18 at 6:59 P.M., the DON said he/she expects staff to sit next to the resident (not across the table, or stand), when they assist the resident to eat. Staff should also cover the resident’s skin if exposed, whether male or female. | |
F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Reasonably accommodate the needs and preferences of each resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) Based on observation, interview, and record review, facility staff failed to provide reasonable accommodations of individual needs and preferences by failing to ensure call lights were left in reach for two residents (Resident #10 and #38) and by failing to clean wheelchairs for two residents (Residents#10 and #81). The census was 99. 1. Review of Resident #10’s quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Rarely or never understood; -Physical and verbal behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of urine and occasionally incontinent of bowel. Review of the resident’s care plan, dated 12/19/17, showed staff are directed to keep the call light within reach, answer the call light promptly, ensure clean appearance at all times, and ensure assistive devices are appropriate. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment, dated 03/08/18, showed staff assessed the resident as follows: -Rarely or never understood; -Physical and verbal behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of urine and occasionally incontinent of bowel. Observation on 04/23/18 at 11:51 A.M., showed the resident in bed with a soiled brief around his/her knees. There was a strong odor of feces and urine in the room. Further observation showed the resident’s call light coiled on the floor under the bedside table outside the reach of the resident. Additional observation showed the seat of the resident’s wheelchair soiled with brown debris with an odor of feces. Observation on 04/23/18 at 12:10 P.M., showed the resident in bed naked. There was a strong odor of feces and urine in the room. Further observation showed the resident’s call light coiled on the floor under the bedside table outside the reach of the resident. Observation on 04/23/18 at 1:10 P.M., showed the resident in his/her wheelchair in the dining room. There was a strong odor of feces near the resident. Observation on 04/23/18 at 3:04 P.M., showed the resident in his/her wheelchair in the TV room. There was a strong odor of feces and urine. Observation on 04/24/18 at 3:26 P.M., showed the resident lie in bed in a brief. There was a strong odor of feces in the room. Further observation showed the resident’s call light coiled on the floor under the bedside table outside the reach of the resident. Additional observation showed the seat of the resident’s wheelchair with brown debris with an odor of feces. Observation on 04/24/18 at 3:41 P.M., showed staff entered the resident’s room, provided care, and left the resident’s room. Further observation showed the resident’s call light remained coiled on the floor under the bedside table outside the reach of the resident. Staff did not place the call light within the resident’s reach. Observation on 04/25/18 at 2:50 P.M., showed the resident in bed. Further observation showed the resident’s call light coiled on the floor under the bedside table outside the reach of the resident. 2. Review of Resident #38’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of bladder and bowel. Review of the resident’s care plan, dated 07/21/16, showed staff are directed to keep the call light within reach and answer the call light promptly. Observation on 04/25/18 at 2:14 P.M., showed the resident in his/her wheelchair at the foot of his/her bed near the door. He/She was alone in the room with no television or radio. Further observation showed the call light under the blanket near the head of the bed outside the resident’s reach. Observation on 04/26/18 at 9:44 A.M., showed the resident in his/her wheelchair at the foot of his/her bed near the door. He/She was alone in the room with no television or radio. Further observation showed the call light near the head of the bed outside the resident’s reach. During an interview on 04/25/18 at 3:54 P.M., Certified Nursing Assistant (CNA) H said he/she makes sure the resident doesn’t have any additional needs before he/she leaves the room. He/She said the call light should be left within reach before staff leave a resident’s room. 3. Review of Resident #81’s quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, did not ambulate, and used a wheelchair. Observation on 4/23/18 at 12:20 P.M., showed the resident in his/her broda chair (an adjustable tilt and recline wheelchair) in the dining room with multiple colored dried debris to both sides of the chair. Observation on 4/24/18 at 1:06 P.M., showed the resident in his/her broda chair in the dining room with multiple colored dried debris to both sides of the chair. Observation on 4/26/18 at 6:15 P.M., showed the resident in his/her broda chair in the dining room with multiple colored dried debris to both sides of the chair. 4. During an interview on 4/26/18 at 5:51 P.M., Licensed Practical Nurse (LPN) B said staff are expected to place call lights near the bed, and within the resident’s reach at all times. Residents’ wheelchairs are cleaned by the night shift staff or as needed by any other staff if obviously dirty, but he/she was not sure if staff had a specific schedule for cleaning the wheelchairs. During an interview on 04/26/18 at 5:50 P.M., CNA I said staff should attend to the resident’s needs and let them know to call if they need anything before they leave a room. He/She said the resident’s call light light should be left within reach. He/She said if they are in bed he/she makes sure the call light is close to them and if they are in their wheelchair he/she hands it to them. He/She said he/she would clean and sanitize a resident’s wheelchair and check their cushion before he/she transferred the resident into the wheelchair. During an interview on 04/26/18 at 5:57 P.M., LPN J said staff should make sure the call light and water is in reach and any positioning devices are in place before they leave a resident’s room. He/She said if they are up in a chair staff often pin the call light to them so they can reach it. He/She said he/she would clean off any noticeable debris before he/she transferred a resident into their wheelchair. During an interview on 04/26/18 at 6:59 P.M., the DON said when a resident is in their room, their call light should be left within reach. He/She said a call light should not ever be coiled under the bed or under the bedside table. He/She said some residents may not be physically or mentally able to use their call light but staff checks on them when they make their rounds. He/She said whether or not a resident may be able to use a call light it should still be within reach. He/She said night shift CNAs clean wheelchairs |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0558 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) monthly. He/She said the housekeeping supervisor goes around and checks wheelchairs and cleans them in the shower room. He/She said staff should clean any noticeable debris from wheelchairs immediately. | |
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, facility staff failed to ensure residents have | |
F 0570 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assure the security of all personal funds of residents deposited with the facility. Based on interview and record review, facility staff failed to purchase a surety bond in |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0570 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) -The Operations Manager must be notified anytime the Trust Fund balance (multiplied by 1 1/2) exceeds the surety bond liability limit. 2. Review of the resident trust fund account for (MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of $ 44,375.55, which requires a surety bond of $66,000.00. The current ledger amount is $ 37,601.00. 3. Review of the Department of Health and Senior Services (DHSS) database, showed the facility has an approved non-cancelable Escrow Agreement Account in the amount of $60,000.00. 4. During an interview on 4/24/18 at 09:30 A.M., The Business Office Manager said the administrator is responsible to ensure the bond amount is sufficient. During an interview on 04/26/18 at 6:30 P.M., the Administrator said the corporate office is responsible to ensure the bond is sufficient. He/She said the corporate office advised them they were over their bond about a week ago and told them to spend it down. | |
F 0576 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure residents have reasonable access to and privacy in their use of communication methods. Based on observation, interview and record review the facility failed to ensure fifteen |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0576 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) phone at the nurse’s station. During an interview on 04/26/18 at 9:18 A.M., CNA D said the phone on the 200 hall was down for a week or two. He/She said all the residents are allowed to use the phone. During an interview on 04/26/18 at 6:30 P.M., the Administrator said a resident ripped the phone out of the wall and maintenance staff tried to fix it but could not. He/She said he/she called the phone provider but they were unable to fix it so it was down about a month. During an interview on 04/26/18 at 6:59 P.M., the DON said the phone was down for a week because residents are always breaking the phone. He/She said no resident is restricted from using the phone. He/She said the residents usually break the phone but this time the resident pulled out the line and it took them a while to get it fixed. | |
F 0583 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Keep residents’ personal and medical records private and confidential. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0583 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/18, showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s medical records showed a large stack of personal correspondence from the resident to the president was included with the resident’s stored medical record. Staff did not store the resident’s private correspondence appropriately to protect the resident’s right to privacy. During an interview on 04/24/18 at 10:10 A.M., the resident said he/she wants to go somewhere else. He/She said he/she tried to talk to Social Services but he/she is just too busy. He/She said he/she feels like he/she is in prison. He/She said no one here likes him/her because of the letters to the president. He/She said he/she wrote letters to the president and the staff have them in his/her chart. During an interview 04/26/18 at 3:00 P.M., the Administrator said the resident was placed at the facility on an emergency basis by the state. He/She said he/she found the letters from the resident to the president in his/her chart in medical records storage. He/She said the letters came over with the resident from the hospital. He/She said he/she does not know if the letters were ever in the resident’s chart or not. He/She said he/she does not know why the letters were not given back to the resident. He/She said he/she thought the state wanted staff to keep the letters to help with the guardianship case. During an interview on 04/26/18 at 6:59 P.M., the DON said he/she does not think the resident is lucid. He/She said the resident seems ok at times but if you read the letters he/she wrote to the president you would know otherwise. | |
F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 10) 04/19/18. Review of the facility’s MDS software showed an annual assessment due on 02/09/18, the assessment was not validated, finalized, transmitted, or completed. 2. Review of the CMS MDS database showed Resident #8’s last submitted quarterly assessment with an ARD of 02/16/18. Review of the CMS MDS database showed the resident’s previous submitted quarterly assessment with an ARD of 11/17/17. Review of the CMS MDS database showed the resident’s previous submitted quarterly assessment with an ARD of 05/11/17. Review of the CMS MDS database showed the resident’s previous submitted quarterly assessment with an ARD of 02/11/17. Review of the CMS MDS database showed the resident’s previous submitted quarterly assessment with an ARD of 11/11/16. Review of the facility’s MDS software showed a quarterly assessment due on 05/19/18. Review of the facility’s MDS software showed a comprehensive (admission, annual, or significant change) assessment has not been a validated, finalized, transmitted, or completed from 11/11/16 to 2/16/18. 3. Review of the CMS MDS database showed Resident #11’s last submitted quarterly assessment with an ARD of 12/11/17. Review of the facility’s MDS software showed an annual assessment due 03/13/18, the assessment was not validated, finalized, transmitted, or completed. 4. Review of the facility’s MDS software showed Resident #22’s quarterly assessment with an ARD of 04/06/18 transmitted with the completion date on Section Z0500B as 04/06/18. Review of the CMS MDS database showed the resident’s last submitted quarterly assessment with an ARD of 01/03/18. Review of the CMS MDS database showed the resident’s previous quarterly assessment with an ARD of 10/02/17. Review of the CMS MDS database showed the resident’s submitted entry-tracking assessment with an ARD of 09/22/17. Review of the CMS MDS database showed the resident’s submitted discharge with return anticipated assessment with an ARD of 09/21/17. Review of the CMS MDS database showed the resident’s submitted entry-tracking assessment with an ARD of 08/04/17. Review of the CMS MDS database showed the resident’s submitted discharge with return anticipated assessment with an ARD of 08/03/17. Review of the CMS MDS database showed the resident’s submitted entry-tracking assessment with an ARD of 07/20/17. Review of the CMS MDS database showed the resident’s submitted discharge with return anticipated assessment with an ARD of 07/19/17. Review of the CMS MDS database showed the resident’s previous quarterly assessment with an ARD of 07/15/17. Review of the CMS MDS database showed the resident’s previous quarterly assessment with an ARD of 01/15/17. Review of the facility’s MDS software showed a comprehensive (admission, annual, or significant change) assessment has not been a validated, finalized, transmitted, or completed from 1/15/17 to 4/6/18. 5 Review of the CAA summary section of the Resident Assessment Instrument (RAI) Manual showed the following: -Check section A (Care Area Triggered) if Care area is triggered; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 11) -For each triggered care area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem(s) identified in your assessment of the care area. The care plan decision column must be completed within seven days of completing the RAI (MDS and CAA’s). Check column B (Care Planning Decision) if the triggered area is addressed in the care plan; -Indicate in the location and date of CAA Documentation column where information related to the CAA can be found. CAA documentation should include information on the complicating factors, risks, and any referrals for this resident for this care area; -Signature of Registered Nurse (RN) Coordinator for CAA process and date signed; -Signature of Person completing care plan decision and date signed. 6 Review of Resident #10’s MDS, dated [DATE], showed staff documented the following information in Section V of the Care Area Assessment: – The areas which triggered in Care Area A are [MEDICAL CONDITION], Cognitive Loss/Dementia, Visual Function, Communication, ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Behavioral Symptoms, Activities, Falls, Nutritional Status, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 7.Review of Resident #13’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Visual Function, Activities of Daily Living (ADL) functional/rehabilitation potential; urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 8. Review of Resident #26’s MDS, dated [DATE], showed staff documented the following information in Section V of the Care Area Assessment: -The areas which triggered in Care Area A are Cognitive Loss/Dementia, ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Falls, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 9. Review of Resident #31’s MDS, dated [DATE], showed staff documented the following information in Section V of the Care Area Assessment: -The areas which triggered in Care Area A are Cognitive Loss/Dementia, Psychosocial Well-Being, Behavioral Symptoms, Falls, Nutritional Status, and [MEDICAL CONDITION] Drug Use; -No section triggered as care planning decisions in section B; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 12) -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 10. Review of Resident #38’s MDS, dated [DATE], showed staff documented the following information in Section V of the Care Area Assessment: -The areas which triggered in Care Area A are [MEDICAL CONDITION], Cognitive Loss/Dementia, Visual Function, Communication, ADL Functional/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Behavioral Symptoms, Activities, Falls, Nutritional Status, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 11. Review of Resident #44’s MDS, dated [DATE], showed staff documented the following information in Section V of the Care Area Assessment: -The areas which triggered in Care Area A are [MEDICAL CONDITION], Cognitive Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Falls, Nutritional Status, and [MEDICAL CONDITION] Drug Use; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 12. Review of Resident #48’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive Loss/Dementia, Communication, Urinary Incontinence and Indwelling Catheter, Psychosocial well-being, Behavioral Symptoms, Activities, Falls, Nutritional Status, Dehydration/fluid maintenance, Pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 13. Review of Resident #52’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive Loss/Dementia, ADL functional/rehabilitation potential, Psychosocial well-being, Falls, Nutritional Status, Dehydration/fluid maintenance, Pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 14. Review of Resident #53’s MDS, dated [DATE], showed staff documented the following |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 13) information in the CAA: -Cognitive loss/dementia, visual function, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 15. Review of Resident #63’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, and pressure ulcer triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 16. Review of Resident #68’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive loss/dementia, urinary incontinence and indwelling catheter, psychosocial well-being, mood state, activities, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 17. Review of Resident #76’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive loss/dementia, ADL functional/rehabilitation potential, falls, feeding tube, dehydration/fluid maintenance, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 18. Review of Resident #83’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive Loss/Dementia, Communication, ADL functional/rehabilitation potential, Psychosocial well-being, Mood state, Activities, Falls, Dehydration/fluid maintenance, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 14) -No signature of person completing care plan decision and date signed. 19. Review of Resident #191’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive Loss/Dementia, ADL functional/rehabilitation potential, Behavioral Symptoms, Falls, Nutritional Status, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 20. Review of Resident #199’s MDS, dated [DATE], showed staff documented the following information in the CAA: -Cognitive loss//dementia, urinary incontinence and indwelling catheter, psychosocial well being, behavioral symptoms, falls, nutritional status, pressure ulcer, and [MEDICAL CONDITION] drug use triggered as care areas in section A; -No section triggered as care planning decisions in section B; -Nothing documented in the location and date of CAA documentation on where information could be found; -No signature of the RN Coordinator for CAA process and date signed; -No signature of person completing care plan decision and date signed. 21. During an interview on 4/26/18 at 6:30 P.M., the Program Manager said he/she and the Administrator are both responsible to complete the MDS assessments and expects them to be completed per the RAI guidelines. He/She said she was not aware that they had to complete section V on the comprehensive MDSs. 22. During an interview on 4/26/18 at 6:30 P.M., the Administrator said she and the Program Manager are responsible to complete the MDS. The Administrator said she expects them to be completed per the RAI guideline. The Administrator said she was told they did not have to complete section V if they did a hand written manual’ care plan. | |
F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assess the resident when there is a significant change in condition **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) -Significant Change in Status Assessment; -Significant Correction to Prior Comprehensive Assessment. -The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident’s status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -Impacts more than one area of the resident’s health status; and -Requires interdisciplinary review and/or revision of the care plan. -A Significant Change in Status MDS is required when: -A resident enrolls in a hospice program; or -A resident changes hospice providers and remains in the facility; or -A resident receiving hospice services discontinues those services; or -A resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident’s current status to the most recent CMS-required MDS). -A Significant Change in Status MDS is considered timely when the RN Assessment Coordinator signs the MDS as complete at section Z0500B & V0200B2 by the 14th calendar day after the determination that a significant change has occurred (determination date + 14 calendar days). -Assessment Completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete. -For required Comprehensive assessments, assessment completion is defined as completion of the CAA process in addition to the MDS items, meaning that the registered nurse (RN) assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item V0200B) completion attestations. Since a Comprehensive assessment includes completion of both the MDS and the CAA process, the assessment timing requirements for a comprehensive assessment apply to both the completion of the MDS and the CAA process. The facility did not have a written policy for completing Significant Change MDS assessments. 2. Review of Resident #26’s Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/22/17, showed staff assessed the resident as follows: -Moderate cognitive impairment; -No behaviors; -Hallucinations and delusions; -Limited assistance of one or more staff with bed mobility, dressing, eating, toileting, and hygiene; -No assistive devices; -No pressure ulcers or risk of pressure; -Antipsychotic 7 days a week. Review of the resident’s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) -No behaviors; -Hallucinations and delusions; -Limited assistance of one or more staff with bed mobility, dressing, eating, toileting, and hygiene; -No assistive devices; -No pressure ulcers or risk of pressure; -No antipsychotic medications. Review of the resident’s physician’s orders [REDACTED]. The resident was ordered the antipsychotic after the Quarterly MDS. Review of the resident’s nurse’s note, dated 03/30/18, showed the resident yelled at staff and accused them of trying to kill him/her. The resident displayed verbal behaviors after the Quarterly MDS. Review of the resident’s Physical Therapy notes, dated 03/27/18, showed the resident was issued a walker on 03/27/18 to assist with mobility. The resident used the assistive device after the Quarterly MDS. Review of the resident’s POS, dated 04/13/18, showed the resident was diagnosed with [REDACTED]. The resident developed a pressure ulcer after the Quarterly MDS. Observation on 04/25/18 at 11:12 A.M., showed the resident sit on the couch at the end of the hall with his/her walker next to him/her. During an interview on 04/25/18 at 10:34 A.M., Licensed Piratical Nurse (LPN) F said the resident just received his/her walker from therapy recently. He/She said the resident could walk on his/her own prior to getting the walker. Staff did not complete a significant change MDS, as directed by the RAI manual, after the resident declined in areas of antipsychotic medications, behaviors, pressure ulcers, and assistive devices. 3. Review of Resident #32’s quarterly MDS, dated [DATE], showed staff assessed the resident with [DIAGNOSES REDACTED]. -Moderate cognitive impairment; -Delusions; -Verbal behaviors towards others; -Wandering behaviors, and rejection of care. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as: -discharged to acute hospital; -Moderate cognitive impairment; -Displayed hallucinations and delusions; -Physical and verbal behaviors towards other; -Wandering behaviors, and rejection of care. Review of the resident’s medical records showed he/she had significant changes in at least two behavioral areas, was discharged to an inpatient Psychiatric hospital on [DATE] for treatment, and returned to the facility on [DATE]. Further review of the records on 4/26/18, showed staff did not complete a significant change MDS assessment, within 14 days as directed by the RAI manual, after staff identified a significant change in his/her mental health condition. 4. Review of Resident #81’s quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and received Hospice Care. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment, and did not receive Hospice Care. Further review of the records showed staff did not complete a timely significant change MDS assessment within 14 days after the resident was discharged from Hospice services, as |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) directed by the RAI manual. During an interview on 4/23/18 at 11:30 A.M., Certified Nursing Assistant (CNA) O said staff had provided hospice care to the resident, but not at the moment. During an interview on 4/24/18 at 10:47 A.M., the Assistant Director of Nursing (ADON) said staff discharged the resident from Hospice services on 1/5/18. During an interview on 4/24/18 at 3:31 P.M., the Program Manager said he/she was new to completing MDS assessments and did not know that he/she needed to complete a significant change MDS when a resident is discharged from Hospice services. He/She said Resident #81 was discharged from Hospice on 1/5/18, and he/she found out on 3/6/18 that he/she should complete a significant change MDS. 5. During an interview on 04/26/18 at 6:30 P.M., the Program Manager said he/she and the Administrator are responsible to complete the MDS assessments. He/She said staff should complete the MDS assessments according to RAI guidelines. He/She said he/she knows significant change MDS assessments should be done whenever a resident goes on and off hospice or has changes in three or more areas. During an interview on 04/26/18 at 6:30 P.M., the Administrator said they complete the MDS assessments according to RAI guidelines. He/She said staff should complete a significant change MDS assessment with every significant change. He/She said a significant change is either improvement or decline in three or more areas. | |
F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Based on interview and record review, facility staff failed to transmit required Minimum |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 18) Review of the facility’s MDS software showed an annual assessment due on 02/02/18, not finalized, not transmitted, and not completed. 4. Review of the CMS MDS database showed Resident #3’s last submitted quarterly assessment with an ARD of 11/09/17. Review of the CMS MDS data base showed Resident #3’s last submitted discharge with no return anticipated assessment with an ARD of 01/09/18. Review of the CMS MDS database showed Resident #3’s last submitted entry tracking record with an ARD of 02/13/18. Review of the facility’s MDS software showed an annual assessment with an ARD of 02/14/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B is 02/14/18. Review of the facility’s MDS software showed an entry assessment due on 02/26/18, not validated, not finalized, not transmitted, and not completed. 5. Review of the CMS MDS database showed Resident #4’s last submitted quarterly assessment with an ARD of 11/09/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 02/13/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B is 02/13/18. 6. Review of the CMS MDS database showed Resident #6’s last submitted quarterly assessment with an ARD of 11/16/17. Review of the CMS MDS data base showed Resident #6’s last submitted discharge return anticipated assessment with an ARD of 12/08/17. Review of the CMS MDS database showed Resident #6’s last submitted entry tracking assessment with an ARD of 12/18/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 02/15/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 02/15/18. 7. Review of the CMS MDS database showed Resident #9’s last submitted quarterly assessment with an ARD of 12/08/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 03/09/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/09/18. 8. Review of the CMS MDS database showed Resident #10’s last submitted quarterly assessment with an ARD of 12/08/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 03/08/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/08/18. 9. Review of the CMS MDS database showed Resident #12’s last submitted quarterly assessment with an ARD of 12/11/17. Review of the facility’s MDS software shows an annual assessment with an ARD of 03/13/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/13/18. 10. Review of the CMS MDS database showed Resident #13’s last submitted quarterly assessment with an ARD of 12/11/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 03/09/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/09/18. 11. Review of the CMS MDS database showed Resident #14’s last submitted quarterly assessment with an ARD of 12/11/17. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 19) Review of the facility’s MDS software showed an annual assessment with an ARD of 03/12/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/12/18. 12. Review of the CMS MDS database showed Resident #15’s last submitted quarterly assessment with an ARD of 12/13/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 03/14/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/14/18. 13. Review of the CMS MDS database showed Resident #16’s last submitted quarterly assessment with an ARD of 12/14/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 03/16/18 not properly validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/16/18. 14. Review of the CMS MDS database showed Resident #17’s last submitted quarterly assessment with an ARD of 12/15/17. Review of the facility’s MDS software shows an annual assessment with an ARD of 03/16/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/16/18. 15. Review of the CMS MDS database showed Resident #18’s last submitted quarterly assessment with an ARD of 12/15/17. Review of the facility’s MDS software showed an annual assessment with an ARD of 03/23/18 validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/23/18. 16. Review of the CMS MDS database showed Resident #19’s last submitted quarterly assessment with an ARD of 12/18/17. Review of the facility’s MDS software shows an annual assessment with an ARD of 03/23/18 not properly validated, not finalized, not transmitted, and the completion date on Section Z0500B 03/23/18. 17. During an interview on 4/24/18 at 3:31 P.M., the Program Manager said he/she does not know when the MDS assessments are transmitted because the Administrator is responsible to submit the MDS assessments. During an interview on 04/26/18 at 10:56 A.M., the Administrator said the staff did not complete the Section V on the comprehensive MDS assessments so they were initially validated but not finalized or accepted. | |
F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure each resident receives an accurate assessment. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) staff assessed the resident as follows: -Unable to complete cognitive assessment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -No assistive devices; -Hospice care. Review of the resident’s medical record showed hospice staff provided the resident a walker on 09/28/17. Observation on 04/24/18 at 4:03 P.M., showed the resident in the dining room in his/her wheelchair at a table. Observation on 04/25/18 at 10:52 A.M., showed the resident in his/her wheel chair and watch television (TV) in the TV in room. Staff did not accurately code the resident’s walker use, wheelchair use or hospice care. 2. Review of Resident #44’s Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/18, showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited one-person assist with transfers, dressing, toileting, and hygiene; -No Psychiatric/Mood Disorder diagnosis; -No injections; -No antipsychotic medication; -Antidepressant medication seven days a week. Review of the resident’s POS, dated 02/07/18, showed staff were directed to inject a 20mg antipsychotic into the resident daily PRN (as needed) for aggressive behavior for 90 days. Staff did not accurately code the resident’s antipsychotic medication. 3. Review of Resident #48’s quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Extensive assist of one person with ambulation, locomotion on and off unit; -Did not use any mobility devices. Review of the resident’s care plan for fall intervention, last updated 6/15/17, showed staff documented the resident has impaired ambulation, and directed staff the resident needs assistance, uses a wheelchair for mobility as a result of Dementia, and uses a high back wheelchair with two foot rests. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Extensive assist of one person with ambulation, locomotion on and off unit; -Did not use any mobility devices. Review of the resident’s comprehensive MDS dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Extensive assistance of one person with ambulation, locomotion on and off unit; -Did not use any mobility devices. Observation on 4/23/18 at 1:15 P.M., showed the resident sat in a high back wheelchair at the dining table. Observation on 4/23/18 at 3:55 P.M., showed the resident sat in a high back wheelchair at |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) the dining table. Observation on 4/26/18 at 10:45 A.M., showed Certified Nursing Assistant (CNA) E Patricia propelled the resident in his/her high back wheelchair from the dining room to his/her room. Observation on 4/26/18 at 10:54 A.M., showed CNA D and CNA E transferred the resident from the high back wheelchair to the bed, provided perineal care, and transferred the resident back to the wheelchair. CNA D said staff are expected to push the resident in his/her wheelchair with the foot pedals. Staff did not accurately code the resident’s use of a wheelchair for mobility, as required on section G0600 of the MDS. 4. Review of Resident #83’s admission MDS showed staff documented the resident was admitted on [DATE], and assessed the resident with: -[DIAGNOSES REDACTED]. -Brief Interview for Mental Status (BIMS-test for cognitive impairment) score of seven, indicates severe cognitive impairment; -Independent with bed mobility, transfer, ambulation and locomotion on unit. Review of the resident’s Baseline Care Plan, undated, showed staff documented the resident had no skin issues, and had intact skin. Further review of the Comprehensive Care Plan, dated 3/12/18, showed staff are directed: -[DIAGNOSES REDACTED]. -Orient resident to surroundings and routine activities; -Needs assist of all ADLs; -Ambulatory fall risk. Review of the nurses’ notes, dated 3/22/18 at 9:00 P.M., showed staff documented the resident fell in the hall on the way to answer the phone. The resident said he/she got dizzy. Staff cleansed a skin tear to the back of the resident’s head, applied dressing, and administered Tylenol for comfort. Review of the nurses’ notes, dated 3/23/18 showed staff documented the resident stumbled and was lowered to the floor. The resident said he/she felt dizzy since the day before. The physician and resident representative were notified. Resident was transferred to the emergency room for evaluation. Review of the resident’s discharge return anticipated MDS dated [DATE], showed staff documented the resident was admitted on [DATE], and assessed the resident with: -Modified independence-some difficulty in new situations only; -No falls since admission or the prior assessment (prior assessment date 3/12/18). Review showed staff did not document the resident’s fall with injury on 3/22/18 as required on section J1800 and J1900 of the MDS. Review of the nurses’ notes, dated 3/29/18 showed staff documented the resident returned from the hospital via ambulance from a fall related to dizziness. Observation and interview on 4/23/18 at 2:04 P.M., showed the resident in a wheelchair in his/her room, with scabs to his/her left elbow, and a small hematoma (swelling) to his/her right forehead. The resident said he/she fell due to dizzy spells, and staff sent him/her to the hospital for treatment. During an interview on 4/24/18 at 11:04 A.M., Certified Medication Technician (CMT) A said the resident fell about a month or so ago, and thinks he/she was sent to the emergency room for treatment. 5. Review of Resident #191’s PASRR Level II screening review, dated 2/2/18, showed facility staff are directed: -The Department of Mental Health (DMH) has determined the applicant has met the federal |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0641 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) definition of Serious Mental Illness (SMI) but does not require specialized services; -It has been determined that this client meets facility admission requirements; -This information must be reflected on the resident’s current MDS. Review of the resident’s admission MDS, dated [DATE], and electronically signed as completed on 2/26/18, showed staff assessed the resident as follows: -admitted [DATE] with a [DIAGNOSES REDACTED]. -BIMS score of 12, indicates moderate cognitive impairment; -Is not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition; -Received Antipsychotic and Antidepressant for seven days during the seven-day review period; -Did not receive antipsychotic medications since admission/entry/re-entry or prior assessment. Staff did not accurately complete sections A1500 (PASRR) and N0450 (Antipsychotic medication review) as required on the MDS. 6. During an interview on 4/26/18 at 6:30 P.M., the Administrator said he/she and the Program Manager completes the MDS assessments. He/She expects the MDS to be completed per the RAI guidelines. He/She said if a resident’s PASSR screening was completed, he/she expects that information to be reflected on the MDS, and did not know why Resident #191’s MDS was not accurate. The Administrator also said Resident #83’s fall with injury should have been documented on the MDS, it was just missed. | |
F 0644 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0644 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) Review of the resident’s POS, dated 11/21/17, showed staff are directed to administer a 25mg [MEDICATION NAME] (antidepressant) to the resident daily for depression. Review of the resident’s POS, dated 02/07/18, showed staff are directed to administer by injection a 20mg [MEDICATION NAME] (antipsychotic) to the resident daily PRN (as needed) for aggressive behavior for 90 days. Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by injection a 1mg [MEDICATION NAME] (antipsychotic) to the resident daily in the morning. Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by injection a 2.5mg [MEDICATION NAME] (antipsychotic) to the resident daily at bedtime. Review of the resident’s Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/18, showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited one-person assist with transfers, dressing, toileting, and hygiene; -No Psychiatric/Mood Disorder diagnosis; -No injections; -No antipsychotic medication; -Antidepressant medication seven days a week. During an interview on 04/25/18 at 4:25 P.M., the Social Services Director said nursing staff completes the PASRRs and he/she just submits them. He/She said PASRRs do not ever need to be updated or resubmitted as far as he/she knows. He/She said he/she is unsure if Resident #44 has a mental illness but he/she said the resident does not have any signs or symptoms of mental illness. He/She said the state is referring the resident for Guardianship due to him/her not being able to make responsible life decisions on his/her own. The Social Services Director also said he/she has not received any training on completing PASSR assessments. During an interview on 04/26/18 at 6:59 P.M., the DON said Level I and Level II PASRR screenings should be completed accurately prior to admission. He/she said the resident displays signs symptoms of mental illness and has a [DIAGNOSES REDACTED]. | |
F 0646 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0646 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) a nursing facility to ensure the client does not trigger a Level II screening. A level II screening refers to clients with the [DIAGNOSES REDACTED]. -A client that requires a Level II screening cannot be admitted to the nursing facility prior to the determination of the Level II; -The triggers for the level II screening are: -the client has had inpatient psychiatric treatment in the past two years; -the client was suicidal or homicidal (includes Dementia clients); -the client has very aggressive behavior (includes Dementia clients); -the client has a [DIAGNOSES REDACTED]. -If the resident has a [DIAGNOSES REDACTED]. -If a verbal consent is obtained, the guardian’s name must appear on the line and be witnessed by two people; -Section F: must include the physician’s discipline and license number, and the date of the physician’s signature. -A significant change in status is defined as a change in two or more areas on the Minimum Data Set (MDS) 3.0 (a federally mandated assessment), regarding a client’s needs. It can be either physical or mental changes; -Changes in Status are completed by the nursing home in which the resident is residing. It is not completed by the hospital. A change in status will be completed in conjunction with the MDS. It is the responsibility of the nursing facility to identify the change in status for a mentally ill or intellectually impaired client. The MDS coordinator and the person who completes the DA 124 forms should work closely together to ensure they are completed; -A DA-124 A/B and a DA-124 C form must be completed and submitted to COMRU for a change in status. The nursing facility should indicate Change in Status on the client’s DA 124 application. If not indicated the application will be processed as a Pre-admission Level II screening and payment could be affected. The facility should attach a short summary indicating the reason. -Example: The initial application does not indicate a client as a Level II, however after nursing facility admission the client has now admitted to inpatient psychiatric treatment and/or a Level II was never completed when one should have been completed. The trigger for a Level II MI screening is inpatient psychiatric treatment in the past 2 years. The client has now triggered the need for a Level II screening. The DA-124 application must be completed and submitted to COMRU. 2. Review of Resident #32’s medical records showed his/her first admission to the facility was 7/28/08. Additional review showed he/she had at least two inpatient Psychiatric treatments in (YEAR). Review of the resident’s Level I PASSR screen for Mental Illness/Mental [MEDICAL CONDITION] or Related Condition, undated, showed staff documented: -The resident showed signs and symptoms of major mental disorder; -The person has been diagnosed as having major mental disorder; -The person has had serious problems in levels of functioning in the last six months; -The person has received intensive psychiatric treatment in the past two years. Further review of the form showed the resident representative did not sign or date section E of the form, and the physician signed section F, but did not date the form. The Level II referral was not completed/submitted as directed by the COMRU instructional guide. Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident with [DIAGNOSES REDACTED]. -Not evaluated by Level II PASRR and determined to have a serious mental illness and/or mental [MEDICAL CONDITION] or a related condition; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0646 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 25) -Brief Interview for Mental Status (BIMS-test for cognitive impairment) score of 12: indicates moderate cognitive impairment; -No signs and symptoms of [MEDICAL CONDITION]; -Delusions; -Verbal behaviors towards others; -No wandering behaviors; -Rejection of care; -Change in behaviors, not assessed. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident with [DIAGNOSES REDACTED]. -BIMS score of 9: indicates moderate cognitive impairment; -No signs and symptoms of [MEDICAL CONDITION]; -Delusions; -Verbal behaviors towards others; -Wandering behaviors, and rejection of care; -Change in behaviors, not assessed. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as: -discharged to acute hospital; -Moderate cognitive impairment; -No signs and symptoms of [MEDICAL CONDITION]; -Displayed hallucinations and delusions; -Physical and verbal behaviors towards other; -Wandering behaviors, and rejection of care; -Change in behaviors, not assessed. Review of the resident’s medical records showed the resident was discharged to an inpatient Psychiatric hospital on [DATE], and returned to the facility on [DATE]. Further review of the records showed staff did not notify the appropriate state mental health authority of the increased behavioral and psychiatric symptoms in a resident previously diagnosed with [REDACTED]. During an interview on 4/25/18 at 4:26 P.M., the Social Services Director (SSD) said he/she started working at the facility about two years ago, and is responsible to submit PASRR referrals to COMRU. The SSD said the resident’s level I PASRR screen was undated, so he/she was unsure when it was completed. The SSD said he/she did not receive any training from COMRU, and was not instructed by the corporate office to review or submit PASRR screens/referrals any other time except on admission of a resident. The SSD said if a resident has a mental illness diagnosis, that is an indicator for a Level II PASSR screen/referral. He/She said facility staff does not normally re-submit PASRR screens for Level II referrals once a prior Level I was submitted. The SSD said since Resident #32 was admitted with a [DIAGNOSES REDACTED]. During an interview on 4/25/18 at 4:40 P.M., the SSD said the resident receives psychological therapy at the facility from a Licensed Psychologist several times a week. During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said he/she expects PASRR screens to be completed correctly and prior to a resident’s admission to the facility. The DON said a Level II screen should have been completed. | |
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. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0656 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, facility staff failed to develop and implement measurable goals and interventions for comprehensive care plans for four sampled residents (Residents #10, #22, #44, and #195) related to eating assistance, fall preventions, and individualized non pharmacological behavior interventions. The facility census was 99. 1. Review of Resident #10’s annual Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Rarely or never understood; -Physical and verbal behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of urine and occasionally incontinent of bowel. Review of the resident’s care plan, dated 05/19/16, showed staff are directed to: -Set up the resident’s tray and assist him/her during meals; -Offer the resident alternatives for known food dislikes if he/she is not eating well; -Report any refusals to eat to the charge nurse and document the refusal in the consumption book. Review of the resident’s care plan, dated 08/07/16, showed staff are directed to attempt to address the resident’s dementia related behaviors with non pharmacological interventions prior to utilizing any PRN medications. Staff did not specify what individualized non pharmacological interventions to use for the resident. Observation on 04/24/18 at 1:10 P.M., showed staff did not assist or encourage the resident at lunch. Observation on 04/24/18 at 1:28 P.M., showed the resident left the dining room and did not eat any of his/her meal. 2. Review of Resident #22’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -No assistive devices. Review of the resident’s medical record showed hospice gave the resident a walker on 09/28/17. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Unable to complete cognitive assessment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -No assistive devices; -Hospice. Review of the resident’s care plan, dated 08/07/16, showed staff are directed to attempt to address the resident’s dementia related behaviors with non pharmacological interventions prior to utilizing any PRN medications. Staff did not specify what individualized non pharmacological interventions to use for the resident. 3. Review of Resident #38’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of bladder and bowel. Review of the resident’s care plan, dated 07/21/16, showed staff are directed to keep the call light within reach and answer the call light promptly. Review of the resident’s care plan, dated 02/23/17, showed staff are directed to assist the resident with meals as needed. Staff did not specify what level or type of assistance the resident may need. Observation on 04/24/18 at 1:06 P.M., showed staff did not assist the resident at lunch. Observation on 04/25/18 at 2:14 P.M., showed the resident in his/her wheelchair at the foot of his/her bed near the door. He/She was alone in the room with no television or radio. Further observation showed the call light under the blanket near the head of the bed out of the resident’s reach. Observation on 04/26/18 at 9:44 A.M., showed the resident in his/her wheelchair at the foot of his/her bed near the door. He/She was alone in the room with no television or radio. Further observation showed the call light near the head of the bed out of the resident’s reach. 4. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted on [DATE]. Review of the resident’s care plan, dated 11/21/17, showed staff did not address the resident’s [MEDICAL CONDITION] medication. Review of the residents’ Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/04/17, showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/18, showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene; -Antidepressant medication seven days a week. 5. Review of Resident #195’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Verbal behaviors; -Independent with transfers, dressing, eating, and toileting; -Antipsychotic medication seven days a week and antianxiety medication one day a week. Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory but a fall risk and staff are directed to: -Administer medication as ordered; -Pharmacist and physician to review medications monthly and PRN; -Monitor gait and transfer and alert nurse with changes; -Supervise resident outdoors; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 28) -Observe for effects of medication such as: drowsiness, restlessness, nervousness, abnormal movements, [DIAGNOSES REDACTED] (persistent or intermittent muscle contractions), muscle cramps, increase in falls, and change in mood or behavior; -Complete labs as ordered and report to Medical Director. Staff did not incorporate appropriate interventions for the resident who has a history of multiple falls with injury. 6. During an interview on 04/26/18 at 5:50 P.M., CNA I said a care plan has something to do with the resident’s needs and should be individualized because needs differ from person to person. He/She said a resident’s fall risk should be listed on the care plan. During an interview on 04/26/18 at 5:57 P.M., LPN J said care plans have to be individualized because residents all have different needs. He/She said he/she has noticed the care plans are generic. During an interview on 04/26/18 at 6:30 P.M., the Administrator said the DON is responsible to update the care plans to meet the resident’s need. He/She said they have a cheat sheet with standard interventions to add if a resident falls or develops a pressure sore. He/She said all staff can update the care plans. He/She said MDSs and care plans should adequately reflect the resident and the care plan should be updated with the MDS. During an interview on 04/26/18 at 6:59 P.M., the DON said he/she and the Administrator update care plans. He/She said the care plans are updated with falls, wounds, and with any individualized changes to the resident. He/She said the facility’s care plans are pretty general and could be more specific. He/she said staff get care directions from the care plan so they should be individualized and updated so staff will know how to appropriately care for residents. MO 773 | |
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** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 29) wheelchair at a table. Observation on 4/25/18 at 10:52 A.M., showed the resident in his/her wheelchair in the TV in room. 3. Review of Resident #26’s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -No mood; -No behaviors; -Hallucinations and delusions; -Limited assistance of one or more staff with bed mobility, dressing, eating, toileting, and hygiene; -No assistive devices; -No pressure or risk of pressure; -No antipsychotic medications. Review of the resident’s care plan, dated 1/05/18, showed staff did not update the care plan when the resident could no longer ambulate on his/her own and began to use a walker. Observation on 4/25/18 at 11:12 A.M., showed the resident sat on the couch at the end of the hall with his/her walker. 4. Review of Resident #32’s medical records showed staff documented the resident re-admitted to the facility on [DATE]. Review of the resident’s care plan for [MEDICAL CONDITION] and Behavior Management, last updated 5/4/17, showed staff are directed: -Resident has [DIAGNOSES REDACTED]. -Staff will document behaviors as they occur, and document noted behaviors in chart as needed; -The consultant pharmacist and physician will evaluate and document continued use of medications and taper medications at least monthly as indicated; -Staff will attempt to address behaviors with non-pharmacological interventions prior to utilizing any PRN meds; -Staff will monitor for any side effects or Extrapyramidal Symptoms (EPS) (drug-induced movement disorders/side effects); -Resident begs staff for soda, if staff refuse, he/she yells out and says he hit me, please re-direct resident. Review of the resident’s comprehensive annual MDS, dated [DATE], showed staff assessed the resident with [DIAGNOSES REDACTED]. -Not evaluated by Level II PASRR screening; -Brief Interview for Mental Status (BIMS-test for cognitive impairment) score of 12: indicates moderate cognitive impairment; -No signs and symptoms of [MEDICAL CONDITION]; -Delusions; -Verbal behaviors towards others; -No wandering behaviors; -Rejection of care; -Change in behaviors, not assessed. Staff did not update the care plan within seven days after completion of the comprehensive annual MDS assessment dated [DATE]. Review of the Social Services Director (SSD) notes, dated 1/10/18, showed he/she documented the resident did not have any significant changes in his/her behavior, but needed re-direction for behavioral outburst. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 30) Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident with [DIAGNOSES REDACTED]. -BIMS score of 9: indicates moderate cognitive impairment; -No signs and symptoms of [MEDICAL CONDITION]; -Delusions; -Verbal behaviors towards others; -Wandering behaviors, and rejection of care; -Change in behaviors, not assessed. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -discharged to acute hospital; -Moderate cognitive impairment; -No signs and symptoms of [MEDICAL CONDITION]; -Displayed hallucinations and delusions; -Physical and verbal behaviors towards others; -Wandering behaviors, and rejection of care; -Change in behaviors, not assessed. Further review of the records showed the resident was discharged to an inpatient Psychiatric hospital on [DATE], and returned to the facility on [DATE]. Staff did not document any updates to the resident’s care plan after he/she had changes in behaviors to include hallucinations, wandering, physical behaviors towards others, and had at least one inpatient psychiatric stay. Further review showed staff did not update the comprehensive care plan after 5/4/17. 5. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted on [DATE]. Review of the resident’s care plan, dated 11/21/17, showed staff did not update the care plan to direct staff to provide individualized interventions in response to resident behaviors or monitor for side effects of [MEDICAL CONDITION] medications. Further review showed staff did not update the care plan within seven days after completion of the comprehensive admission MDS assessment, dated 12/04/17. Review of the resident’s POS, dated 11/21/17, showed staff are directed to administer a 25mg [MEDICATION NAME] (antidepressant) to the resident daily for depression. Review of the resident’s POS, dated 02/07/18, showed staff are directed to administer by injection a 20mg [MEDICATION NAME] (antipsychotic) to the resident daily PRN (as needed) for aggressive behavior for 90 days. Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by injection a 1mg [MEDICATION NAME] (antipsychotic) to the resident daily in the morning. Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer by injection a 2.5mg [MEDICATION NAME] (antipsychotic) to the resident daily at bedtime. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 31) -Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene; -Antidepressant medication seven days a week. 6. Review of Resident #48’s medical records, showed staff documented the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the resident’s care plan for [MEDICAL CONDITION], last updated 8/8/16, showed staff documented the resident had [DIAGNOSES REDACTED]. -Administer [MEDICATION NAME] (medication to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder), [MEDICATION NAME] (medication to treat depression), and [MEDICATION NAME] (medication to treat [MEDICAL CONDITIONS] disorder, and depression); -Document behaviors as they occur; -Abnormal Involuntary Movement Scale (AIMS) assessment on admission, quarterly and with signficant changes; -Pharmacist and Physician will evaluate and document continued use of meds, and taper meds monthly as indicated. Review of the resident’s comprehensive significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Daily wandering and rejection of care; -Behaviors improved since prior assessment (prior assessment date 2/27/18); -[DIAGNOSES REDACTED]. -Received Antipsychotics and Antidepressant medications daily during the seven-day review period; -Received Antipsychotics on a routine basis only, with last attempted GDR 2/6/18. Review of the resident’s POS, dated 3/1/18 through 4/26/18, showed staff did not document an order for [REDACTED].>Staff did not update the care plan within seven days after completion of the comprehensive significant change MDS assessment dated [DATE]. Further review showed staff did not make any updates to the resident’s comprehensive care plan after 6/15/17. 7. Review of Resident #52’s medical records showed the resident was admitted [DATE], and re-entered the facility on 3/1/17 after an acute hospital stay. Review of the resident’s care plan, last updated 4/11/17, showed staff assessed the resident at risk for falls, required assistance with ADL’s as needed, and directed staff to encourage the resident to do as much for himself/herself as possible. Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -[DIAGNOSES REDACTED]. -Very important to have books, newspapers and mazazines to read, listen to music, and keep up with the news; -Required supervision with eating, toilet use, personal hygiene, and bathing; -Uses a walker; -Received antidepressant and diuretic medications for seven days during the seven-day review period. Staff did not update the care plan within seven days after completion of the comprehensive annual MDS assessment dated [DATE]. Additional review showed staff did not document any updates to the resident’s comprehensive care plan after 4/11/17. During an interview on 4/23/18 at 3:09 P.M., the resident said he/she has gotten weaker and needs assistance with bathing. He/She said staff used to send a letter out for care plan meetings, but they haven’t in a long time, so if they are still having the meetings, |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 32) he/she does not know about it. 8. Review of Resident #81’s medical records showed staff documented the resident re-admitted to the facility on [DATE]. Review of the resident’s care plan, for Behavior management, [MEDICAL CONDITION], and [MEDICAL CONDITION], last updated 8/8/16, showed staff documented [DIAGNOSES REDACTED]. -If the resident exhibits behaviors, staff will attempt to assess the cause for behaviors and address cause promptly; -If behaviors are not caused by medical factors, staff will attempt to manage behaviors with non pharmacological interventions first; -Resident starting Hospice care, begin 7/15/16; -[MEDICAL CONDITION] medication due to the following conditions: Dementia, [MEDICAL CONDITIONS], Anxiety, and combativeness; -Following medications per physician’s orders [REDACTED]. -Staff will document behaviors as they occur, and all noted behaviors and interventions; -The consultant pharmacist and physician will evaluate and document continued use of medications and taper medications at least monthly as indicated -Staff will attempt to address behaviors with non-pharmacological interventions prior to utilizing any PRN meds; -Staff will monitor for any side effects or EPS. Review of the resident’s significant change MDS, dated [DATE] on paper, and electronically signed as completed on 3/6/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -No behaviors, or rejection of care, with improved behaviors; -Received antipsychotic, antidepressant, and hypnotic medications for seven days during the seven day review period; -Last attempted GDR on 10/6/17. Staff did not update the care plan within seven days after completion of the comprehensive significant change MDS assessment completed 3/6/18. Review of the resident’s POS, dated 4/1/18 through 4/30/18, showed staff did not document an order for [REDACTED].>Further review showed staff did not make any updates to the resident’s comprehensive care plan after the physician discontinued several [MEDICAL CONDITION] medications. 9. Review of Resident #191’s admission MDS, dated [DATE], and electronically signed as complete 2/26/18, showed staff assessed the resident as follows: -admitted [DATE] with a [DIAGNOSES REDACTED]. -BIMS score of 12, indicates moderate cognitive impairment; -Feeling down, depressed, or hopeless (nearly every day); -No physical, verbal, or other behavioral symptoms directed towards others; -Daily wandering that did not impact others; -Received antipsychotic and antidepressant medications for seven days during the seven-day review period; -Did not receive antipsychotic medications since admission/entry/re-entry or prior assessment. Review of the resident’s care plan, dated 2/6/18, showed staff are directed: -Has history of [MEDICAL CONDITION], delusions, paranoia, disheveled, disorganized, social withdrawal; -Remind resident of scheduled activity that involve memory challenge; -Encourage to walk with reliable buddy to dining room, chapel, etc., -Place resident on locked unit; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 33) -Resident wanders to smoking area with intent to smoke; -Resident is very withdrawn and quiet to self at times. Other times resident is aggressive and anxious with unstable mood. Review of the resident’s records showed the resident was involved in a physical altercation with another resident on 2/11/18. Further review showed the resident was sent to the hospital on [DATE] for medical and psychiatric evaluation related to behaviors. Staff did not update the resident’s care plan after his/her involvement in a physical altercation with another resident on 2/11/18. During an interview on 4/25/18 at 4:40 P.M., the Social Services Director (SSD) said there is a Licensed Psychologist that sees residents at the facility, but he/she does not think the Psychologist sees the resident. The SSD said he/she does one-on-one visits with the resident. The SSD said he/she normally gives recommendations to the Administrator to update care plans, but had not given/offer any specific psychological services to the resident. 10. Review of Resident #195’s Quarterly MDS, a federally mandated assessment tool, dated 03/01/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Verbal behaviors; -Independent with transfers, dressing, eating, and toileting; -Antipsychotic medication seven days a week and antianxiety medication one day a week. Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory but a fall risk and staff are directed to: -Administer medication as ordered; -Pharmacist and physician to review medications monthly and PRN; -Monitor gait and transfer and alert nurse with changes; -Supervise resident outdoors; -Observe for effects of medication such as: -drowsiness, restlessness, nervousness, abnormal movements, [DIAGNOSES REDACTED], muscle cramps, increase in falls, and change in mood or behavior; -Complete labs as ordered and report to Medical Director. Review of the resident’s incident report, dated 04/10/18, showed housekeeping staff found the resident on the floor. Further review showed the resident had no bleeding or swelling. Additional review showed the resident said his/her leg gave way. Review of the resident’s Post Incident report, dated 04/10/18, showed staff assessed the resident’s skin clear with no bruises on day, evening, and night shifts. Review of the resident’s Post Incident report, dated 04/11/18, showed staff assessed the resident’s skin clear with no bruises on day, evening, and night shifts. Review of the resident’s Post Incident report, dated 04/12/18, showed staff assessed the resident’s skin clear with no bruises on day, evening, and night shifts. Staff did not update the care plan after the resident fell on [DATE]. 11. During an interview on 04/26/18 at 5:50 P.M., CNA I said a care plan has something to do with the resident’s needs and should be individualized because needs differ from person to person. He/She said the nurses update the care plans so he/she notifies the nurse. He/She said a resident’s fall risk should be listed on the care plan. During an interview on 04/26/18 at 5:57 P.M., LPN J said care plans have to be individualized because residents all have different needs. He/She said he/she has noticed the care plans here are generic. He/She said the Program Manager usually updates the care plans but nurses can update them after falls or incidents. He/She said new interventions should be listed on a resident’s care plan after a fall. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 34) During an interview on 04/26/18 at 6:30 P.M., the Administrator said the DON is responsible to update the care plans to meet the resident’s needs. He/She said they have a cheat sheet with standard interventions to add if a resident falls or develops a pressure sore. He/She said all staff can update the care plans. He/She said MDS assessments and care plans should adequately reflect the resident and the care plan should be updated with the MDS. During an interview on 04/26/18 at 6:59 P.M., the DON said he/she and the Administrator update care plans. He/She said the care plans are updated with falls, wounds, behaviors, and with any individualized changes to the resident. He/She said the facility’s care plans are pretty general and could be more specific. He/she said staff get care directions from the care plan so they should be individualized and updated so staff will know how to appropriately care for residents. He/She said Resident #191’s care plan should have been updated after the physical altercation occurred, particularly since the resident did not have a history of physical behaviors towards others. | |
F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure services provided by the nursing facility meet professional standards of quality. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 35) resident had his/her oxygen on and set at six liters per nasal cannula. Observation on 4/25/18 at 2:48 P.M. showed the resident in his/her room in bed. The resident had his/her oxygen on and set at six liters per nasal cannula. During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) AL said the nurse lets us know how much oxygen a resident should be on. CNA AL said the nurse is the only person to change the level the oxygen is on. CNA AL said he/she is not sure how many liters the resident’s oxygen should be set on. During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said staff should follow the physician’s orders regarding oxygen administration levels. LPN M said he/she is not sure what level the resident’s oxygen should be set at. LPN M said if staff notice the oxygen is not being administered per the physician’s orders the nurse should change it to the ordered rate. During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said said staff should follow the physician’s orders regarding oxygen administration levels. The DON said he/she is not sure what level the resident’s oxygen should be set at. The DON said if staff notice the oxygen is not being administered per the physician’s orders the nurse should change it to the physician’s ordered rate. The DON said he/she does not know why the resident’s oxygen was not set per the physicians orders. The DON said the charge nurse is expected to monitor oxygen setting for accuracy every shift. 3. Review of Resident #195’s Quarterly MDS, a federally mandated assessment tool, dated 03/01/18, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Verbal behaviors; -Independent with transfers, dressing, eating, and toileting; -Antipsychotic medication seven days a week and antianxiety medication one day a week. Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory but a fall risk and staff are directed to: -Administer medication as ordered; -Pharmacist and physician to review medications monthly and PRN; -Monitor gait and transfer and alert nurse with changes; -Supervise resident outdoors; -Observe for effects of medication such as: drowsiness, restlessness, nervousness, abnormal movements, [DIAGNOSES REDACTED], muscle cramps, increase in falls, and change in mood or behavior; -Complete labs as ordered and report to Medical Director. Additional review showed staff did not implement fall prevention measures appropriate for a resident with a history of falls with injury and did not review or update the care plan after the resident fell on [DATE]. Review of the resident’s nurse’s notes, dated 04/02/18, showed staff documented the resident arrived at the facility very confused with a soft cast on his/her left arm for a fracture from a fall. Review of the resident’s POS, dated 04/10/18, showed staff are directed to administer 650mg of Tylenol every six hours PRN (as needed). Review of an incident report, dated 04/10/18, showed staff found the resident on the floor and the resident said his/her legs gave way. Review of the resident’s POS, dated 04/19/18, showed staff obtained an order for [REDACTED]. Review of the resident’s nurse’s notes, dated 04/21/18, showed staff documented they found a large greenish bruise on the resident’s right arm, a greenish bruise on the resident’s |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 36) right shoulder, and a dark greenish bruise on the resident’s right ankle. Further review showed staff documented they notified the physician and an x-ray was ordered and completed. Review of the resident’s nurse’s notes, dated 04/24/18, showed staff contacted the x-ray agency for results. Further review showed the x-ray results showed the resident had a right humeral head and neck (upper arm bone) fracture. Additional review of the resident’s medical record showed five days passed between the date of the ordered x-ray and the date staff obtained the x-ray results. Review of the medication administration report (MAR), dated 04/01/18-04/30/18 showed staff did not document the resident’s PRN pain medication. During an interview on 04/25/18 at 10:23 A.M., the ADON said he/she noticed a bruise on the resident’s right hand on 04/19/18 that he/she thought was from a blood draw. He/She said the Nurse Practitioner (NP) assessed the resident and ordered an x-ray which came back negative for breaks or fractures. He/She said the NP did not see any other bruises. He/She said he/she did not know how the resident fractured his/her arm. During an interview on 04/25/18 at 10:25 A.M., LPN F said the resident fell sometime this month. He/She said when a resident falls staff complete an incident report and they are kept in the DON’s office until completed and then returned to the resident’s chart. He/She said the resident had x-ray results come back yesterday that showed the resident had an arm fracture. During an interview on 04/25/18 at 11:09 A.M., the DON said the resident’s arm fracture was due to a fall on 04/10/18 and the incident report should have been back in the resident’s chart. During an interview on 04/25/18 at 3:08 P.M., LPN F said the resident’s PRN Tylenol should be on the MAR and he/she does not know why it is not listed on there. He/She said they do not do routine pain assessments only admission, quarterly, and post incident for 72 hours unless the physician wants them to do it longer. He/She said the resident only complained of pain once on his/her shift on Friday 04/20/18 when the resident’s sister came out and told the LPN he/she was hurting. He/She said he/she asked the medication technician to give the resident his/her Tylenol. During an interview on 04/26/18 at 6:59 P.M., the DON said there are no interventions on the resident’s care plan because he/she had not triggered yet. He/She said a resident triggers for the fall prevention program after two falls. He/She said the resident had a history of [REDACTED]. He/She said the resident’s care plan should have had more detailed fall interventions due to his/her history of falls at their sister facility. The DON also said the resident’s care plan should have been updated after he/she fell on [DATE] and all medications should be listed on the MAR. | |
F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide activities to meet all resident’s needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 37) with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident is maintained. 2. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the following: -Saturday, 1/6/18: family visits, movies available; -Sunday, 1/7/18: family visits, movies available; -Saturday, 1/13/18: family visits, movies available; -Sunday, 1/14/18: family visits, movies available; -Saturday, 1/20/18: family visits, movies available; -Sunday, 1/21/18: family visits, movies available; -Saturday, 1/27/18: family visits, movies available; -Sunday, 1/28/18: 2 P.M. family visits, movies available. Staff did not plan weekend activities other than church (not listed on calendar), family visits, and movies available. 3. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the following: -Saturday, 2/3/18: family visits, movies available; -Sunday, 2/4/18: family visits, movies available; -Saturday, 2/10/18: family visits, movies available; -Sunday, 2/11/18: family visits, movies available; -Saturday, 2/17/18: family visits, movies available; -Sunday, 2/18/18: family visits, movies available; -Saturday, 2/24/18: family visits, movies available; -Sunday, 2/25/18: 2 P.M. family visits, movies available. Staff did not plan weekend activities other than church (not listed on calendar), family visits, and movies available. 4. Review of the Activity Calendar for the facility, dated (MONTH) (YEAR), showed the following: -Saturday, 3/3/18: family visits, movies available; -Sunday, 3/4/18: family visits, movies available; -Saturday, 3/10/18: family visits, movies available; -Sunday, 3/11/18: family visits, movies available; -Saturday, 3/17/18: family visits, movies available; -Sunday, 3/18/18: family visits, movies available; -Saturday, 3/24/18: family visits, movies available; -Sunday, 3/25/18: P.M. family visits, movies available; -Saturday, 3/31/18: family visits, movies available. Staff did not plan weekend activities other than church (not listed on calendar), family visits, and movies available. 5. Review of Resident #10’s annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/08/18, showed staff assessed the resident as follows: -Rarely or never understood; -Physical and verbal behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of urine and occasionally incontinent of bowel. Review of the resident’s care plan, dated 03/08/16, showed staff are directed to: -Orient the resident to surroundings, routine, and environment; -One on One interaction with the Activities Director; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 38) -Offer activities in the resident’s interest; -Encourage attendance in activities. Review of the resident’s medical record showed no Individual Resident Daily Activities sheet for (MONTH) (YEAR). Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th, 10th, 11th, 12th, 14th, 15th, 17th, 18th, 20th, 22nd, 24th, 25th, 26th, 28th, 29th, 30th, and 31st. Further review showed these dates were the weekend and the resident did not attend activities on the weekends. Additional review showed the only resident activities staff marked for the month were 11 room visits. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th, 8th, 10th, 11th, 12th, 14th, 15th, 17th, 18th, 20th, 22nd, 24th, 25th, 26th, 28th, 29th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekends. Observation on 04/23/18 at 11:51 A.M., showed the resident in bed. Staff did not engage the resident in any activities. Observation on 04/23/18 at 12:10 P.M., showed the resident in bed. Staff did not engage the resident in any activities. Observation on 04/23/18 at 1:10 P.M., showed the resident in his/her wheelchair in the dining room. Staff did not engage the resident in any activities. Observation on 04/23/18 at 3:04 P.M., showed the resident in his/her wheelchair in the TV room. Staff did not engage the resident in any activities. Observation on 04/24/18 at 3:26 P.M., showed the resident in bed. Staff did not engage the resident in any activities. Observation on 04/25/18 at 2:50 P.M., showed the resident in bed. Staff did not engage the resident in any activities. 6. Review of Resident #13’s MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two or more staff for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. Review of the resident’s care plan, undated, showed staff are directed to do the following: -Encourage to attend activities for socialization; -Explain to me about activities and make sure I understand; -Continue to ask what he/she would like to do; -Resident loves to participate and be included. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 6th, 7th, 13th, 14th, 20th, 21st, 27th, and 28th. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 4th, 10th, 11th, 17th 18th, 24th, 25th. Further review showed these dates were the weekend and the resident did not attend activities on the weekends. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd 4th, 10th, 11th, 17th, 18th, 24th, 25th, and 31st. Further review showed these dates were the weekend and |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 39) the resident did not attend activities on the weekends. Review of the resident’s MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Very important to go outside; -Somewhat important to participate in reading, music, be around animals, keep up with news, do things with groups of people, and do his/her favorite activities; -Required extensive assistance of two or more staff for bed mobility; -Required total assistance of one staff for locomotion and dressing; -Required total assistance of two or more staff for transfer, toilet use, and personal hygiene. During an interview on 4/24/18 at 8:48 A.M., the resident said there is noting to do on the weekends and he/she wished there was something for him/her to do on the weekends. The resident said he/she would like bingo or something like that. The resident said he/she gets bored on the weekends especially if no family comes to visit him/her. 7. Review of Resident #22’s quarterly change Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -No assistive devices. Review of the resident’s care plan, dated 10/24/16, showed staff are directed: -Encourage to attend all activities; -Explain activities and make sure he/she understands; -Continue to ask him/her what activities he/she enjoys. Review of the resident’s quarterly change MDS, dated [DATE], showed staff assessed the resident as follows: -Unable to complete cognitive assessment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -Hospice care. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 1st, 2nd, 4th, 6th, 7th, 8th, 10th, 13th, 16th, 17th, 19th, 20th, 21st, 24th, 27th, 28th, and 30th. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th, 10th, 11th, 13th, 15th, 17th, 18th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Additional review showed the only resident activities marked for the month were 13 room visits and one family visit. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th, 8th, 10th, 11th, 12th, 14th, 15th, 17th, 18th, 20th, 21st, 22nd, 24th, 25th, 26th, 28th, 29th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Additional review showed the only resident activities marked for the month were eight room visits and one family visit. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 40) Observation on 04/24/18 at 4:03 P.M., showed the resident in the dining room in his/her wheelchair at a table. Staff did not engage the resident in any activities. Observation on 04/26/18 at 9:47 A.M., showed the resident in bed. Staff did not engage the resident in any activities. 8. Review of Resident #26’s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -No mood; -No behaviors; -Hallucinations and delusions; -Limited assistance of one or more staff with bed mobility, dressing, eating, toileting, and hygiene; -No assistive devices; -No antipsychotic medications. Review of the resident’s care plan, dated 01/05/18, showed staff were directed to: -Encourage to attend all activities; -Explain activities and make sure he/she understands; -Continue to ask him/her what activities he/she enjoys. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th, 7th, 9th, 12th, 13th, 14th, 16th, 17th, 19th, 20th, 21st, 23nd, 25th, 27th, 30th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 1st, 3rd, 4th, 6th, 7th, 9th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 6th, 8th, 10th, 11th, 14th, 15th, 16th, 17th, 18th, 21tst, 23rd, 24th, 25th, 28th, 29th, 30th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Observation on 04/25/18 at 11:12 A.M., showed the resident sat on the couch at the end of the hall with his/her walker. Staff did not engage the resident in any activities. Observation on 04/26/18 at 9:48 A.M., showed the resident lay on his/her bed. Staff did not engage the resident in any activities. 9. Review of Resident #38’s quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Frequently incontinent of bladder and bowel. Review of the resident’s care plan, dated 07/21/16, showed staff did not provide any direction or interventions to address or encourage activities. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 41) -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of bladder and bowel. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 1st, 2nd, 4th, 6th, 7th, 10th, 12th, 13th, 16th, 17th, 19th, 20th, 21st, 22nd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th, 10th, 11th, 13th, 14th, 15th, 18th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 6th, 8th, 10th, 11th, 12th, 15th, 17th, 20th, 22tst, 23rd, 24th, 25th, 26th, 28th, 29th, 30th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Observation on 04/25/18 at 2:14 P.M., showed the resident in his/her wheelchair near his/her room door. Further observation showed the resident alone and the TV off. Staff did not engage the resident in any activities. Observation on 04/26/18 at 9:44 A.M., showed the resident sit in his/her wheelchair near his/her room door. Further observation showed the resident alone and the TV off. Staff did not engage the resident in any activities. 10. Review of Resident #44’s face sheet, dated 11/21/17, showed the resident was admitted on [DATE]. Review of the resident’s care plan, dated 11/21/17, showed staff are directed to: -Encourage to attend all activities; -Explain activities and make sure he/she understands; -Continue to ask him/her what activities he/she enjoys. Review of the resident’s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited one-person assist with transfers, dressing, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 2nd, 4th, 6th, 7th, 9th, 11th, 12th, 14th, 16th, 17th, 19th, 20th, 21st, 23th, 25th, 27th, 28th, and 30th. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 4th, 6th, 8th, 10th, 11th, 13th, 15th, 17th,18th, 20th, 22nd, 24th, 25th, 27th, 29th, 30th, and 31st. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 42) Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 2nd, 3rd, 4th, 6th, 7th, 9th, 11th, 13th, 15th, 16th,17th,18th 20th, 21st, 23rd, 24th, 25th, 27th, 28th, 29th, 30th, and 31st . Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Observation on 04/25/18 at 9:11 A.M., showed the resident sat alone on the couch at the end of the hall. Staff did not engage the resident in any activities. Observation on 04/25/18 at 10:54 A.M., showed the resident sat alone on the couch at the end of the hall. Staff did not engage the resident in any activities. Observation on 04/25/18 at 3:18 P.M., showed the resident sat alone on the couch at the end of the hall. Staff did not engage the resident in any activities. Observation on 04/26/18 at 10:00 A.M., showed the resident in bed. Staff did not engage the resident in any activities. 11. Review of Resident #48’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED].>-Severe cognitive impairment; -Rarely or never understood; -Trouble concentrating on things, such as reading newspaper or watching TV (nearly everyday); -Extensive assistance of one person with transfers, ambulation, and locomotion on/off unit. Review of the resident’s care plan, last updated 6/15/17, showed staff did not document any specific interventions for activities. Review of the resident’s significant change MDS, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Severe cognitive impairment; -Unclear speech (slurred or mumbled words); -Rarely or never understood; -Trouble concentrating on things, such as reading newspaper or watching TV (nearly everyday); -Extensive assistance of one person with transfers, ambulation, and locomotion on/off unit; -Resident prefers snacks between meals. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document any weekend activities on the 3rd, 4th, 10th, 11th, 17th, 18th, 24th, and the 25th. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document any weekend activities on the 3rd, 4th, 10th, 11th, 17th, 18th, 24th, 25th, and the 31st. Observation on 4/23/18 at 3:55 P.M., showed the resident sat in his/her wheelchair at the dining table, mumbling words to him/herself and moved his/her hands back and forth across the table. Staff did not engage the resident in any activities. During an interview on 4/26/18 at 10:54 A.M., CNA D said the resident does not attend any activities on the first floor. He/She said staff sometimes give the resident towels to fold to keep his/her hands busy, but he/she cannot really participate in scheduled activities. 12. Review of Resident #63’s MDS, dated [DATE], showed staff assessed the resident as follows: |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 43) -Moderate cognitive impairment; -Somewhat important to read, listen to music, keep up with the news, participate in his/her favorite activities, and go outside; -Required extensive assistance of two or mores staff for bed mobility, transfers, locomotion, dressing and personal hygiene. Review of the residents care plan, undated, showed staff are directed to do the following: -Encourage to attend all activities; -Explain activities and make sure he/she understands; -Continue to ask him/her what activities he/she enjoys. Review of the residents (MONTH) (YEAR), Individual Resident Daily Activities sheet, showed staff did not document the resident attended activities on the 6th, 7th, 13th, 14th, 20th, 21st, 27th, and 28th. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. During an interview on 4/24/18 at 9:15 A.M., the resident said there is not much to do on the weekends and it gets boring. 13. Review of Resident #68’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Somewhat important to read, listen to music, keep up with the news, and participate in religious services; -Required limited assistance of one staff for transfers, toileting, and personal hygiene. Review of the resident’s care plan, undated, showed staff were directed to do the following: -Encourage to attend all activities; -Explain activities and make sure he/she understands; -Ask what activities he/she would enjoy; -Encourage resident to participate as much as possible; Review of the resident’s Annual Activity Progress notes, dated (MONTH) (YEAR), showed the resident usually enjoys bingo, socializing, television/radio, movies, pet visits, unit activities, entertainment, trivia/current, and music. Review of the residents (MONTH) (YEAR), Individual Resident Daily Activities sheet, showed staff did not document the resident attended activities on the 6th, 7th, 13th, 14th, 20th, 21st, 27th, and 28th. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd, 4th, 10th, 11th, 17th 18th, 24th, 25th. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document the resident attended activities on the 3rd 4th, 10th, 11th, 17th, 18th, 24th, 25th, and 31st. Further review showed these dates were the weekend and the resident did not attend activities on the weekend. 14. Review of Resident #83’s admission MDS, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Modified independence-some difficulty in new situations only; -No behaviors or rejection of care; -Somewhat important to have books, newspapers, and magazines to read, and listen to music; -Independent with all ADL’s; |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 44) -Requires supervision of one person with locomotion off unit. Review of the resident’s care plan, dated 3/12/18, showed staff are directed: -Remind resident of scheduled activity that involve memory challenge; -Orient to surroundings, routine activities; -Resident cannot care for himself/herself, confused, depressed, suicidal, tearful and [MEDICAL CONDITION]; -Needs assist of all ADLs; -Encourage to attend all activities; -Continue to ask what activities the resident would enjoy; -Isolative to room, please try to get him/her to join in. Review of the resident’s Individual Resident Daily Activities, dated (MONTH) (YEAR), showed staff did not document any weekend activities on the 17th, 18th, and the 31st. During an interview on 4/23/18 at 2:10 P.M., the resident said he/she has been at the facility for about three weeks now, and there is not much to do around here. Observation and interview on 4/23/18 at 3:54 P.M., showed the resident sat in his/her wheelchair at the dining table. The resident said he/she is an outdoors person, so anything outside would be great for him/her to enjoy, even just the courtyard. 15. During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) L said on the weekends there is church in the activity rooms and television. CNA L said CNAs help set up the activities, but they do not document activities are provided on the weekends. During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said he/she believes there are activities on the weekend but he/she is not sure if staff document them. During an interview on 4/26/18 at 11:30 A.M., LPN F said there are activities on the weekends and it depends on the activity as to if the CNAs are responsible or the nurses. He/She said they are not sure if they document that activities are done but he/she does not document on the activity part in the chart. During an interview on 4/26/18 at 11:52 A.M., CNA D said staff do not provide activities on the weekends. He/She said sometimes the CNAs put on the TV for the resident but he/she is not sure if they document activities anywhere. During an interview on 4/26/18 at 6:06 P.M., LPN B said he/she has worked every other weekend for the past year, and has never seen any weekend activities held for the residents on the second floor. During an interview on 4/26/18 at 6:19 P.M., CNA C said there are no scheduled activities on the weekends, but staff does stuff with the residents because they need something to do. He/She said the AD is only at the facility Monday through Friday. During an interview on 04/26/18 at 6:26 P.M., the AD said the Restorative Aide conducts activities on the second floor. The AD said there are no staff-led activities on the weekends, but the nurses and CNAs help with activities, and provide coloring materials, cards, and movies for residents to watch. The AD said he/she leaves lots of games out on the weekends, but does not know if the residents play them. The AD said all residents are allowed downstairs for activities if they want to participate. Church services are held on Sundays, and the volunteers document on paper which residents attended. During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said he/she expects staff to document activities on the activity documentation form. |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 46) 3. Observation on 4/24/18 at 10:09 A.M., showed the Director of Nursing (DON) propelled an unidentified resident down the 100 hallway without foot pedals. Observation showed the resident’s feet slid on the floor. 4. Review of Resident #29’s quarterly Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Resident is rarely/never understood; -No behaviors; -Limited assistance of one or more staff for transfers, dressing, eating, toileting, and hygiene; -Always incontinent of bladder and bowel. Observation on 4/24/18 at 12:47 P.M., showed CNA D propelled Resident #29 down the 200 hallway without foot pedals. Observation showed the residents feet slid on the floor. 5. During an interview on 4/25/18 at 3:54 P.M., CNA H said staff have been trained to make sure the wheelchair is locked before they propel residents in wheelchairs but that is it. He/She said if he/she was pushing a resident and his/her feet dragged the floor he/she would stop and get foot pedals because if not the residents feet could get caught. During an interview on 4/26/18 at 9:18 A.M., CNA D said staff should make sure the wheelchair is locked when a resident sits down and unlocked before staff starts pushing. He/She said you should not push a resident without foot pedals. He/She said staff has not had any training about pushing residents without foot pedals. He/She said he/she has pushed residents without foot pedals because he/she wants to help them and was never told not to do it. During an interview on 4/26/18 at 9:48 A.M., LPN F said staff should not propel a resident in a wheelchair without foot pedals because their feet could get caught and they could fall out. He/She said all staff was in-serviced on the dangers of pushing a resident without foot pedals. During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said residents should have foot pedals on when staff propel them. 6. Review of the facility’s records showed the facility did not have a policy on resident transfers via mechanical lifts (hoyer or sit-to-stand). 7. Review of Resident #81’s quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Independent with bed mobility; -Limited assistance of one person with transfers, and toilet use; -Uses wheelchair. Review of the resident’s care plan for fall interventions, last updated 4/2018, showed staff are directed: -Resident is on the falling star program (usually implemented after a resident falls twice); -Requires hoyer lift (mechanical sling style lift) with two-person assistance; -Resident uses geri/Broda chair (an adjustable tilt and recline wheelchair); -Geri/Broda chair reclined when resident is up; -Resident takes [MEDICAL CONDITION] medications; -Fall mat at bedside; -Wear non-skid footwear. Observation and interview on 4/25/18 at 9:03 A.M., showed CNA D and CNA O transferred the resident from his/her Broda chair with a sit-to-stand mechanical lift. Observation showed the resident did not hold on to the lift during transfer, and pulled both his/her legs |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 47) upwards behind him/her. Observation showed the resident’s torso (chest, upper abdomen, and back) hung from the sling on the lift, while the CNAs instructed him/her to help them and stand. The CNAs said the resident requires assistance of two staff for quite some time now, due to a decline in his/her activities of daily living (ADLs). The CNAs did not properly transfer the resident as directed by the care plan to prevent accident hazards. During an interview on 4/25/18 at 10:30 A.M., Licensed Practical Nurse (LPN) F said the resident has not been able to ambulate since he/she started working at the facility back in 2/2017. Observation on 4/26/18 at 10:32 A.M., showed the resident lay on his/her right side on the floor in his/her room next to the Broda chair, with his/her feet under the bed. Observation showed the Broda chair in the upright position. During an interview on 4/26/18 at 10:38 A.M., CNA O said staff had left the resident sitting upright in his/her Broda chair inside the room unattended. During an interview on 4/26/18 at 5:51 P.M., LPN B said the CNAs have a booklet that instructs them on the care and level of assistance residents need. The LPN said staff are expected to transfer the resident with a hoyer lift and two staff because he/she cannot stand. The LPN said staff should not use a sit-to-stand lift to transfer the resident. During an interview on 4/26/18 at 6:19 P.M., CNA C said staff should transfer the resident with two staff and a gaitbelt because he/she stands with transfers. During an interview on 4/26/18 at 7:00 P.M., the DON said staff are expected to use two people to transfer the resident with a gaitbelt, but he/she can be transferred with a hoyer lift because he/she does not always bear weight. The DON said if the care plan directs staff to use a hoyer, then he/she expects staff to use a hoyer lift. 8. Review of Resident #195’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Verbal behaviors; -Independent with transfers, dressing, eating, and toileting; -Antipsychotic medication seven days a week and antianxiety medication one day a week. Review of the resident’s nurse’s notes, dated 04/02/18, showed the resident arrived at the facility very confused with a soft cast on his/her left arm for a fracture from a fall. Review of the resident’s care plan, dated 04/02/18, identified the resident as ambulatory but a fall risk and staff are directed to: -Administer medication as ordered; -Pharmacist and physician to review medications monthly and PRN; -Monitor gait and transfer and alert nurse with changes; -Supervise resident outdoors; -Observe for effects of medication such as: drowsiness, restlessness, nervousness, abnormal movements, [DIAGNOSES REDACTED], muscle cramps, increase in falls, and change in mood or behavior; -Complete laboratory tests as ordered and report to Medical Director. Additional review of the care plan showed staff did not implement fall prevention measures appropriate for a resident with a history of falls with injury or update the care plan after the resident fell on [DATE]. Review of an incident report, dated 04/10/18, showed staff documented they found the resident on the floor and he/she said his/her legs gave way. Review of the resident’s POS, dated 04/19/18, showed staff obtained an order for [REDACTED].>Review of the resident’s nurse’s notes, dated 04/21/18, showed staff found a large greenish bruise on the resident’s right arm, a greenish bruise on the resident’s |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 48) right shoulder, and a dark greenish bruise on the resident’s right ankle. Further review showed the physician was notified and an x-ray was ordered and completed. Review of the resident’s nurse’s notes, dated 04/24/18, showed staff contacted the x-ray agency for results. Further review showed the x-ray results showed the resident had a humeral head and neck fracture (upper arm fracture). During an interview on 04/25/18 at 10:25 A.M., LPN F said the resident fell sometime this month. He/She said when a resident falls, staff complete an incident report and they are kept in the Director of Nursing (DON’s) office until completed and then returned to the resident’s chart. He/She said the resident did report pain in his/her arm to him/her on 04/19/18 and he/she told the medication technician to check on him/her. He/She said staff received an x-ray report yesterday (4/24/18) that showed the resident had an arm fracture. During an interview on 04/26/18 at 6:59 P.M., the DON said there are no interventions on the resident’s care plan because he/she had not triggered yet. He/She said a resident triggers for the fall prevention program after two falls. He/She said the resident had a history of [REDACTED]. He/She said the resident’s care plan should have had more detailed fall interventions due to his/her history of falls at their sister facility. He/She said the resident’s care plan should have been updated after he/she fell on [DATE]. 9. Review of the facility’s Director of Housekeeping and Laundry Services job discription, undated, showed the director of housekeeping and laundry services is directed to do the following: -To make daily rounds to assure that facility is maintained in a clean and safe manner; -Assure that housekeeping and laundry personnel follow established safety regulations in used of equipment and supplies at all times. 10. Observation on 4/23/18 at 12:05 P.M., showed the room across from resident room [ROOM NUMBER] unlocked and unattended. Further observation showed the room contained one gallon of floor polishing solution, spray bottles of floor cleaner, spray bottles of floor finish restoring solution, three one gallon jugs of multisurface cleaner, one unlabeled chemical spray bottle with clear liquid, one unlabeled chemical spray bottle with blue liquid, one unlabeled chemical spray bottle with green liquid, three spray bottles of spray floor buff solution, one bottle of cleaner and disinfectant. Further observation showed all labeled bottles with a warning to keep out of reach of children. Observation showed residents walked past the room. Observation on 4/24/18 at 11:38 A.M., showed the room continued to be unlocked and unattended. Further observation showed the room continued to contain the same chemicals and residents walked by the room. Observation on 4/24/18 at 4:25 P.M., showed the room continued to be unlocked and unattended. Further observation showed the room continued to contain the same chemicals and residents walked by the room. Observation on 4/25/18 at 2:50 P.M., showed the room continued to be unlocked and unattended. Further observation showed the room continued to contain the same chemicals and residents walked by the room. Observation on 4/26/18 at 9:25 A.M., showed the room continued to be unlocked and unattended. Further observation showed the room continued to contain the same chemicals and residents walked by the room. 11. Observation on 04/23/18 at 3:25 P.M., showed the shower room on the 200 hall unlocked and unattended. Further observation showed the cabinet was unlocked and the sharps container overflowed with used razors. Additional observation showed residents in their rooms with their doors open across the hall. 12. During an interview on 04/25/18 at 3:54 P.M., CNA H said sharps and chemicals should |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 49) be stored in the dirty utility room and sharps container. He/She said the dirty utility room is left locked up. During an interview on 4/26/18 at 11:10 A.M., CNA L said chemicals and sharps should be stored behind locked doors inaccessible to residents. CNA L said he/she was not sure why the chemicals were not locked up. During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said chemicals and sharps should be stored behind locked doors inaccessible to residents. LPN M said he/she was not sure why the chemicals were not locked up. During an interview on 4/26/18 at 11:30 A.M. LPN F said sharps and chemicals are to be stored behind locked doors. During an interview on 4/26/18 at 11:52 A.M. CNA D said sharps and chemicals should be kept in the dirty utility room and locked. During an interview on 4/26/18 at 6:56 P.M., the Director of Nursing (DON) said sharps and chemicals should be kept in the housekeeping closets and behind a locked door. | |
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** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 50) hygiene. Review of the resident’s side rail screening, dated 3/9/18, showed staff documented the resident will have two side rails to be used as an enabler to promote independence and the resident has expressed a desire to have the side rails raised while in bed. Review of the resident’s Physician order [REDACTED]. Review of the resident’s medical record showed it did not contain an entrapment assessment or an informed consent for the use of side rails. Review of the resident’s nurse’s notes, dated (MONTH) (YEAR) through (MONTH) (YEAR), showed staff did not document information related to the resident’s use of side rails or wish for side rails. Observation on 4/24/18 at 8:57 A.M., showed the resident in bed with two full side rails raised. Observation on 4/25/18 at 9:22 A.M., showed the resident in bed with two full side rails raised. Observation on 4/26/18 at 9:18 A.M., showed the resident in bed with two full side rails raised. 3. Review of the Resident #63’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, locomotion, dressing, and personal hygiene. Review of the resident’s side rail screen, dated 4/24/18, showed staff documented the resident will have one side rail to assist the resident in reposition and transfer. Review of the resident’s POS, dated (MONTH) (YEAR), showed an order to have one side rail to promote independence as an enabler with an order date of 4/24/18. Further review showed the order for side rails did not contain a [DIAGNOSES REDACTED]. Review of the resident’s medical record showed it did not contain an entrapment assessment or an informed consent for the use of side rails. Review of the resident’s nurses notes, dated (MONTH) (YEAR) through (MONTH) (YEAR), showed staff did not document information related to the resident’s use of side rails or wish for side rails. Observation on 4/23/18 at 2:27 P.M., showed the resident in bed with two quarter side rails raised, one on each side of the head of bed. Observation on 4/25/18 at 2:51 P.M., showed the resident in bed with two quarter side rails raised, one on each side of the head of bed. Observation on 4/26/18 at 9:24 A.M., showed the resident in bed with two quarter side rails raised, one on each side of the head of bed. 4. Review of Resident #68’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility; -Required total assistance of two or more staff for transfers. Review of the resident’s side rail screen, dated 3/16/18, showed staff documented the resident will have one side rail to assist the resident in reposition and transfer and resident expressed a desire to have side rails raised while in bed. Review of the resident’s POS, dated (MONTH) (YEAR), showed an order to have left side side rail for an enabler with an order date of 4/24/18. Further review showed the order for side rails did not contain a [DIAGNOSES REDACTED]. Review of the resident’s medical record showed it did not contain an entrapment assessment |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0700 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 51) or an informed consent for the use of side rails. Review of the resident’s nurses notes, dated (MONTH) (YEAR) through (MONTH) (YEAR), showed staff did not document information related to the resident’s use of side rails or wish for side rails. Observation on 4/25/18 at 9:46 A.M., showed the resident in bed with one half side rail up on the resident’s left side of the bed. Observation on 4/25/18 at 2:48 P.M., showed the resident in bed with one half side rail up on the resident’s left side of the bed. 5. During an interview on 4/26/18 at 11:10 A.M., Certified Nurse Assistant (CNA) L said if the resident’s bed has siderails attached to them they should have the side rails raised while in bed. During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said residents with physician orders [REDACTED]. LPN M said staff complete side rail assessments but he/she is not sure if they complete entrapment assessments or obtain informed consents. LPN M said residents with side rails should have a physician’s orders [REDACTED]. During an interview on 4/26/18 at 11:30 A.M., LPN F said residents who need side rails should have a physician order [REDACTED]. LPN F said he/she is not sure if a informed consent should be obtained. He/She said entrapment assessments are done by the Director of Nursing (DON). During an interview on 4/26/18 at 1:48 P.M., the Quality Assurance Nurse said facility staff is in the process of developing a policy for entrapment assessments, and does not currently have any entrapment assessments documented. During an interview on 4/26/18 at 12:55 P.M., the Assistant Director of Nursing (ADON) said they do not have side rail consents for the use of side rails. During an interview on 4/26/18 at 6:56 P.M., the DON said if the resident used siderails, staff should obtain an informed consent, a physician’s orders [REDACTED]. The DON said staff should have removed Resident #63’s side rails because he/she doesn’t use side rails. | |
F 0727 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, facility staff failed to provide the services of a |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0727 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 52) dates: -Saturday 4/7/18, 0 hours; -Sunday 4/8/18, 0 hours; -Tuesday 4/10/18, 7.50 hours; -Thursday 4/12/18, 7.25 hours; -Saturday 4/14/18, 0 hours; -Sunday 4/15/18, 0 hours; -Saturday 4/21/18, 0 hours; -Sunday 4/22/18, 0 hours. During an interview 4/26/18 8:28 A.M., the Administrator said the PM is the full time RN who works Monday through Friday. The DON serves as the RN on weekends, but sometimes he/she is only in the building for a couple hours at a time. The PM said he/she does not work on the weekends. During an interview on 4/26/18 at 9:05 A.M., Certified Medication Technician (CMT) A said he/she does staffing and other than the DON, the only RN on staff is the PM, who works Monday through Friday. The DON is not scheduled/staffed to work on the weekends. The CMT said the facility does not have an RN scheduled/staffed to work Saturdays and Sundays. During an interview on 4/26/18 at 11:10 A.M., the DON said he/she sometimes enter the facility on the weekends for about two to three hours, but not eight hours. He/She said the facility did not have an RN scheduled to work the weekends at this time. | |
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** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 53) -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Received Antipsychotics and Antidepressant medications daily during the seven-day review period; -Received Antipsychotics on a routine basis, with last attempted gradual dose reduction (GDR) 10/16/17. Review of the MRR dated 12/7/17, showed the Consultant Pharmacist documented: -[MEDICATION NAME] 15 milligrams (mg) by mouth (PO) at bedtime (QHS) for unintentional weight loss (since 4/7/17); -Even though this medication is being used for unintentional weight loss, CMS regulations require that all antidepressants be reviewed for a gradual dose reduction twice during the 1st year, then yearly thereafter in an attempt to find the lowest effective dose. With this in mind: -Please consider a dose reduction to [MEDICATION NAME] 7.5mg PO QHS (or consider discontinuation using a titration). Review of the MRR dated 1/9/18 showed the Consultant Pharmacist documented no irregularities found. Review of the resident’s physician’s orders [REDACTED]. Review of the MRR dated 2/5/18, showed the Consultant Pharmacist again documented: -[MEDICATION NAME] 15mg PO QHS for unintentional weight loss (since 4/7/17); -Even though this medication is being used for unintentional weight loss, CMS regulations require that all antidepressants be reviewed for a gradual dose reduction twice during the 1st year, then yearly thereafter in an attempt to find the lowest effective dose. With this in mind: -Please consider a dose reduction to [MEDICATION NAME] 7.5mg PO QHS (or consider discontinuation using a titration). Review of the resident’s POS, dated 2/1/18 through 2/28/18, showed on 2/6/18, the physician ordered a dose reduction for [MEDICATION NAME] to 7.5mg PO QHS. Staff did not document a physician’s response until two months after the Consultant Pharmacist’s recommendation. Review of the MRR, dated 3/13/18, showed the Consultant Pharmacist documented please consider checking the following labs (laboratory blood tests) : -CMP (Complete Metabolic Panel- blood test to assess the status of a person’s metabolism), CBC (Complete Blood Count- blood test to assess the cells that make up your blood), every 6 months; -FLP (Fasting Lipid Panel-measures the level of specific cholesterol in the blood), Vitamin D, TSH (a blood test that measures the [MEDICAL CONDITION] hormone levels), and HbA1C (measures how well diabetes is controlled) yearly. Review of the MRR, dated 4/5/18, showed the Consultant Pharmacist documented: -Quetiapine 50mg PO every morning (QAM) and 150mg PO at bedtime (QHS) since 10/16/17; -CMS regulations require that antipsychotics be reviewed for a gradual dose reduction in an attempt to find the lowest effective dose; -With this in mind: Please consider a dose reduction to Quetiapine 50mg QAM and 100mg PO QHS. Review of the resident’s POS, dated 4/1/18 through 4/26/18, showed the following orders: -Quetiapine 100mg (take with 50mg=150mg) at bedtime for [MEDICAL CONDITION]; -Quetiapine 50mg tab every morning and at bedtime for [MEDICAL CONDITION]; -CMP, CBC, FLP, Vitamin D, TSH, and HbA1C ordered 4/18/18. Staff did not document a physician’s response to the recommended laboratory tests until 30 |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 54) days later, and did not document a response to the dose reduction of [MEDICATION NAME] as recommended by the Pharmacist on 4/5/18 (three weeks prior). During an interview on 4/26/18 at 1:29 P.M., the Assistant Director of Nursing (ADON) said the Psychiatrist is scheduled to be at the facility the following week, but he/she was unsure exactly which day. The ADON said the MRR form was faxed to the Psychiatrist’s office for review. 3. Review of Resident #68’s medical record showed staff documented the resident was admitted on [DATE], and has [DIAGNOSES REDACTED]. Review of the resident’s MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -diagnosed with [REDACTED]. -No behaviors; -Did not receive antianxiety medications during the assessment period. Review of the MRR, dated 2/1/18, showed the Consultant Pharmacist documented: -[MEDICATION NAME] (anxiety medication) 2 mg/ml (0.25mL) by mouth every four as needed for anxiety; -The patient has not received this medication thus far. The resident has an as needed (PRN) order for [MEDICATION NAME] dated 9/1/17. CMS regulation states as needed [MEDICAL CONDITION] orders must be limited to 14 days unless the prescribing practitioner believes it is appropriate for the as needed order to extend beyond the 14 days and documents the rationale in a progress note and indicates the duration for the order. -Please discontinue this medication at this time: -A progress note was created and new prescription written that includes quantity and duration. Further review of the MRR dated 2/1/18, showed the physician marked disagree and signed the paper. The Physician did not document a rationale for declining the recommendation. Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 4/26/18 at 12:55 P.M., the ADON said he/she is not sure why there was not a rationale for the declination of the pharmacy recommendation. 4. During an interview on 4/26/18 at 11:16 A.M., Licensed Practical Nurse (LPN) M said he/she is not sure what the pharmacy review process is. During an interview on 4/26/18 at 11:30 A.M., LPN F said he/she is not sure about the pharmacy review process. He/She said the pharmacist completes them and then sends the ADON notes, who forwards them to the physician. During an interview on 4/26/18 at 12:55 P.M., the ADON said the pharmacist comes once a month and reviews the resident’s medications. Then the consultant pharmacist prints the MRR and the ADON faxes them to the physician. The ADON said if he/she gets an order from the physician regarding the MRR then he/she or the nurse whom he/she delegates will note it in the resident’s chart. The ADON said if he/she does not hear back from the physician, staff will call and try to get telephone orders and have the physician sign the form when he/she comes back in the facility. The ADON said he/she tries to get the physician to sign the sheet or write a rational if they disagree. He/She said he/she knew that the physician was supposed to sign and write a rationale, but he/she tries to encourage them to sign and write an rationale. The ADON said he/she is responsible to ensure this is done. | |
F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 55) contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 56) -Severe cognitive impairment; -No behaviors; -Limited assistance of one or more staff for bed mobility, transfers, dressing, eating, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s nurses notes, dated 01/16/18, showed staff called the physician after the resident became upset about his/her pets and his/her trial date and threw a medical chart at the nurse. The staff were ordered to administered a one time dose of 20mg of [MEDICATION NAME] intravenously (by injection). Review of the resident’s nurse’s notes, dated 02/07/18, showed the resident was upset about his/her new roommate and he/she yelled and banged his/her hands on the nurse’s station. Review of the resident’s POS, dated 02/07/18, showed staff are directed to administer by injection 20mg of [MEDICATION NAME] (antipsychotic) to the resident daily PRN for aggressive behavior for 90 days. Review of the National Institute of Health’s U.S. National Library of Medicine showed, [MEDICATION NAME] (Ziprasidone), is used to treat the symptoms of [MEDICAL CONDITION] (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). It is also used to treat episodes [MEDICAL CONDITION](frenzied, abnormally excited or irritated mood) or mixed episodes (symptoms [MEDICAL CONDITION] depression that happen together) in patients with [MEDICAL CONDITION] disorder (manic [MEDICAL CONDITION]; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Ziprasidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. Further review of the resident’s medical record showed staff did not document a [DIAGNOSES REDACTED]. Review of the resident’s Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Mood feeling tired/moving slow several days a week; -No behaviors; -Limited assistance of one or more staff with transfers, dressing, toileting, and hygiene; -Antidepressant medication seven days a week. Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer a 2.5mg tablet of [MEDICATION NAME] (antipsychotic) to the resident at bedtime. Further review showed staff did not document a corresponding medical diagnosis. Review of the resident’s POS, dated 03/28/18, showed staff are directed to administer a 1mg tablet of [MEDICATION NAME] to the resident every morning. Further observation showed staff did not document a corresponding medical diagnosis. Review of the National Institute of Health’s U.S. National Library of Medicine showed [MEDICATION NAME] is used to treat the symptoms of [MEDICAL CONDITION] (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes [MEDICAL CONDITION](frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms [MEDICAL CONDITION] depression that happen together) in adults and in teenagers and children [AGE] years of age and older with [MEDICAL CONDITION] disorder (manic [MEDICAL CONDITION]; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). [MEDICATION NAME] is also used to treat |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 57) behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). [MEDICATION NAME] is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. Review of the resident’s nurse’s notes, dated 04/12/18, showed the resident was not himself/herself. His/Her speech is slow and he/she has an unsteady gait. Further review of the resident’s medical record showed staff did not document a [DIAGNOSES REDACTED]. During an interview on 04/25/18 at 4:25 P.M., the Social Services Director said he/she is unsure if the resident has a mental illness but he/she said the resident does not have any signs or symptoms of mental illness. He/She said the state is referring the resident for Guardianship due to the resident not being able to make responsible life decisions on his/her own. During an interview on 04/26/18 at 10:19 A.M., Physician P said [MEDICATION NAME] should only be administered to [MEDICAL CONDITION] residents with psychotic episodes but it gets misused for behaviors. He/She said his/her practice does not like to use antipsychotics at all. He/She said they should only be used for residents who are psychotic or out of control. He/She said a resident should not receive a [MEDICATION NAME] injection without a proper diagnosis. He/She said [MEDICATION NAME] should not be used for behaviors related to a response to a stressful situation. He/She said [MEDICATION NAME] causes the most metabolic disruption in comparison to other antipsychotics. During an interview on 04/26/18 at 1:52 P.M., the resident said he/she does not need some of the medication the facility gives to him/her. He/She said he/she thinks the medication is what made his/her legs have muscle spasms. He/She said the Assistant Director of Nursing (ADON) told him/her he/she could not see a different physician. During an interview on 04/26/28 at 5:57 P.M., LPN J said all medication, especially [MEDICAL CONDITION] medications, should include a corresponding [DIAGNOSES REDACTED]. He/She said PRN [MEDICAL CONDITION] medication orders should include a stop date within 14 days. During an interview on 04/26/18 at 6:59 P.M., the DON said Resident #44 displays signs symptoms of mental illness and has a [DIAGNOSES REDACTED]. He/She expects staff would have documented the state of the resident’s improvement. He/She does not think the resident is lucid. He/She said the resident was on a PRN antipsychotic for aggressive behaviors. He/She is not sure if any lesser drugs were used prior to the [MEDICATION NAME]. He/She said the [MEDICATION NAME] is usually used for [MEDICAL CONDITION] but he/she does not think the resident has that diagnosis. He/She said he/she expects staff to use other interventions prior to using medication. He/She said the resident was upset about calling the pound to check on his/her dogs and became more upset after finding out he/she had lost his/her dogs, as he/she should in that situation. The DON said he/she thinks the resident was upset about the situation. He/She said nursing staff should make sure all [MEDICAL CONDITION] medications list a [DIAGNOSES REDACTED]. | |
F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | 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: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 58) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to dispose of outdated and discontinued medications for five residents (Residents #68, #201, #202, #203, and #204). Facility staff also failed to dispose of four outdated stock medications. The facility census was 99. 1. Review of the facility’s policy on Storage of Medications, dated 6/12/2003, showed staff are directed: -Outdated, contaminated or deteriorated medications and those in containers which are cracked, soiled, or without secure closures are immediately removed from stock and disposed of according to procedures for medication destruction in Policy F-23 (Disposition and Return of Medication), and reordered from the pharmacy if a current order exists; -Medication storage areas are kept clean, well lit, and free of clutter. 2. Review of the facility’s policy on Disposition and Return of Medication, dated 6/12/2003, showed staff are directed: -Carded non-controlled substances and sealed unit of use containers may be returned to the pharmacy within 30 days of discontinuation/discharge; -All medications not in use or discontinued should be destroyed or returned within 30 days. 3. Review of the facility’s records showed: -Resident #68 was re-admitted to the facility on [DATE] without a physicians order for [MEDICATION NAME] 150 mg (heartburn medication) or [MEDICATION NAME] (blood pressure medication) 100 mg; -Resident #201 was a current resident of the facility; -Resident #202 had been discharged from, the facility on 7/27/17; -Resident #203 had expired in the facility on 2/6/18; and -Resident #204 was re-admitted to the facility on [DATE] without a physicians order for [MEDICATION NAME] 10mg (muscle relaxer). 4. Observation on 4/23/18 at 10:44 A.M., showed a bin full of medications that had been discontinued by the physician or from residents who had been discharged /expired from the facility. Further observation showed the bin included: -For Resident #68: a bubble card of [MEDICATION NAME] 150 mg with a date of 7/19/17, and [MEDICATION NAME] with a date of 3/08/18; -For Resident #203: a bubble card of [MEDICATION NAME] 125 mcg ([MEDICAL CONDITION] medication) with a date of 1/31/18; and -For Resident #204: a bubble card of [MEDICATION NAME] 10 mg 1/2 tabs with a date of 8/08/17. 5. Observation of the medication cart on 4/23/18 at 1:27 P.M., showed the following: -For Resident #201: a box of Sodium Chloride 0.9% (normal saline) with a date of 4/24/16; -For Resident #202: a box of [MEDICATION NAME] 2.5mg/3ml (breathing treatment) with a date of 12/20/16; -A bottle of Chlorexidine [MEDICATION NAME] 4% Liquid (medicated mouthwash) stock medication with a date of 4/19/17; -Cranberry 450 mg tablets with a date of 1/18/18; and -Gericare wax removal ear drops with a date of 9/17/17. 6. During an interview on 4/23/18 at 1120, Licensed Practical Nurse (LPN) K said the nurses are responsible to give any expired or discontinued medications to the Director of Nursing (DON) or Assistant Director of Nursing (ADON) as soon as possible so they can be destroyed. He/She said the nurses and Certified Medication Technicians (CMT) are to check the carts and medication rooms monthly, and the pharmacy is also responsible for checking |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 59) them monthly. During an interview on 4/23/18 at 3:31 P.M., CMT P said all CMT’s are expected to check the medication carts daily during their shift and if any expired medications are found they should report it to their nurse who is then responsible to take care of them. During an interview on 4/26/18 at 8:04 P.M., the DON said the CMT’s and the nurses are expected to check the med carts for expired meds, and the ADON also checks the carts once a month. The DON said he/she destroys meds from the med room once a month. | |
F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review facility staff failed to store food and |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 60) dated with the open date and expiration date. He/She said chemicals should never be stored with food. During an interview on 05/02/18 at 2:12 P.M., dietary staff R said staff should clean up any messes as soon as they see it. He/She said open food should be wrapped and dated with a sharpie. He/She said staff should put the open and use by date. He/She said chemicals should never be stored with food. He/She said all dietary staff are in-serviced During an interview on 05/02/18 at 2:15 P.M., the Dietary Manager said staff should clean up any spilled food or drink in the kitchen immediately. He/She said open food should be labeled and dated and stored appropriately. He/She said all dietary staff are trained to seal, label, and date all food items and he/she is not sure why some food was open and undated. He/She said chemicals should never be stored with food. He/She said the chemicals were delivered on Friday, 04/20/18, and they should have been put away over the weekend. He/She said chemicals are stored with rags and mops in the utility room near the kitchen. | |
F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide and implement an infection prevention and control program. Based on observation, interview, and record review, facility staff failed to appropriately |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 61) drawer of the medication cart, did not don gloves, checked Resident #205’s blood glucose level, and laid the unsanitized multi-use glucometer on top of the medication cart. The CMT did not sanitize the multi-use glucometer before or after use. 6. Observation on 4/23/18 at 3:55 P.M., showed CMT U removed the unsanitized glucometer from the top of the medication cart, did not don gloves, and checked Resident #237’s blood glucose level. He/She placed the unsanitized multi-use glucometer on top of the medication cart. The CMT did not sanitize the multi-use glucometer before or after use. 7. During an interview on 4/26/18 at 9:03 A.M., CMT A said staff are expected to clean the multi-use glucometers with bleach wipes or alcohol pad after use with each resident, but staff did not have any bleach wipes available for use at the moment. During an interview on 4/26/18 at 5:51 P.M., Licensed Practical Nurse (LPN) B said staff are expected to clean the glucometers between residents and daily, for infection control. During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said staff are expected to use bleach wipes to clean the multi-use glucometers after each use on a resident, and leave wet for about a minute. Glucometers should also be cleaned weekly. The DON said it is absolutely not okay to use alcohol pads to clean the glucometers. 8. Observation on 04/23/18 at 12:46 P.M., showed Licensed Practical Nurse (LPN) F used his/her bare hands to pick up glasses of water and Kool-Aid by the rims and served multiple residents. The LPN did not wear gloves to directly touch the rim of the glass to prevent the spread of infection. 9. Observation on 04/23/18 at 12:56 P.M., showed the Assistant Director of Nursing (ADON) used his/her bare hands to pick up glasses of water and Kool-Aid by the rim and served Resident #26. The CNA did not wear gloves to directly touch the rim of the glass to prevent the spread of infection. 10. Observation on 4/23/18 at 1:15 P.M., showed Certified Nursing Assistant (CNA) G served Resident #48 his/her meal in the dining room. The CNA held the glass of kool aid by the rim, pulled the spout with his/her bare hands to open a carton of strawberry shake, and poured the shake into a cup. The CNA did not wear gloves to directly touch the rim of the glass and the carton spout to prevent the spread of infection. 11. Observation on 04/24/18 at 12:52 P.M., showed CNA N used his/her bare hands to pick up a glass of water by the rim and served Resident #29. The CNA did not wear gloves to directly touch the rim of the glass to prevent the spread of infection. 12. Observation on 04/24/18 at 1:00 P.M., showed CNA N used his/her bare hands to pick up glasses of water and juice by the rim and served Resident #44. The CNA did not wear gloves to directly touch the rim of the glass to prevent the spread of infection. 13. Observation on 4/24/18 at 1:19 P.M., showed CNA N used his/her bare hands to pick up a glass of water by the rim and served Resident #188. The CNA did not wear gloves to directly touch the rim of the glass to prevent the spread of infection. 14. Observation on 4/24/18 at 1:21 P.M., showed CNA G used his/her bare hands to pick up two glasses of liquids by the rim and served Resident #79. The CNA did not wear gloves to directly touch the rim of the glass to prevent the spread of infection. 15. During an interview on 04/26/18 at 5:50 P.M., CNA I said staff should wash their hands and sanitize before serving food to residents. He/She said staff should hold the base of the glass and not the top so they do not make anyone sick. During an interview on 4/26/18 at 5:51 P.M., Licensed Practical Nurse (LPN) B said when staff serve resident’s meals, they are expected to hold the glass towards the bottom and not by the rim, particularly if staff did not wear gloves. During an interview on 4/26/18 at 7:00 P.M., the Director of Nursing (DON) said he/she expects staff to hold glasses towards the bottom and hold plates on the side, without |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 62) touching the food, when they serve meals to residents. | |
F 0909 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0909 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 63) Observation on [DATE] at 9:18 A.M., showed the resident in bed with two full side rails raised. 5. Review of the Resident #63’s MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, locomotion, dressing, and personal hygiene. Review of the resident’s side rail screen, dated [DATE], showed staff documented the resident will have one side rail to assist the resident to reposition and transfer. Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED]. Review of the resident’s medical record showed it did not contain a maintenance inspection to include an entrapment assessment for the use of siderails. Observation on [DATE] at 2:27 P.M., showed the resident in bed with two quarter side rails raised, one on each side of the head of bed. Observation on [DATE] at 2:51 P.M., showed the resident in bed with two quarter side rails raised, one on each side of the head of bed. Observation on [DATE] at 9:24 A.M., showed the resident in bed with two quarter side rails raised, one on each side of the head of bed. 6. Review of Resident #68’s MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff for bed mobility; -Required total assistance of two or more staff for transfers. Review of the resident’s side rail screen, dated [DATE], showed staff documented the resident will have one side rail to assist the resident to reposition and transfer and the resident expressed a desire to have side rails raised while in bed. Review of the resident’s POS, dated (MONTH) (YEAR), showed an order to have the left side rail for an enabler with an order date of [DATE]. Further review showed the order for side rails did not contain a [DIAGNOSES REDACTED]. Review of the resident’s medical record showed it did not contain a maintenance inspection to include an entrapment assessment for the use of siderails. Observation on [DATE] at 9:46 A.M., showed the resident in bed with one half side rail up on the resident’s left side of the bed. Observation on [DATE] at 2:48 P.M., showed the resident in bed with one half side rail up on the resident’s left side of the bed. 7. During an interview on [DATE] at 10:10 A.M., the Maintenance supervisor said he/she is expected to complete the measurements for entrapment assessments for residents with side rails, but he/she does not document them. During an interview on [DATE] at 11:10 A.M., Certified Nurse Assistant (CNA) L said if the resident’s bed has siderails attached to them, staff should raise the side rails while the resident is in bed. During an interview on [DATE] at 11:16 A.M., Licensed Practical Nurse (LPN) M said he/she is not sure if anyone measures the residents’ mattress/bed frames, and side rails for the zones of entrapment. During an interview on [DATE] at 11:30 A.M., LPN F said entrapment assessments with measurements are done by the Director of Nursing (DON). During an interview on [DATE] at 12:55 P.M., the Assistant Director of Nursing (ADON) said staff do not have side rail consents for the use of side rails. During an interview on [DATE] at 6:56 P.M., the DON said if the resident used siderails, |
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 7/16/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265720 |
| (X3) DATE SURVEY COMPLETED 04/26/2018 | |||||||
NAME OF PROVIDER OF SUPPLIER CREVE COEUR MANOR | STREET ADDRESS, CITY, STATE, ZIP 1127 TIMBER RUN DRIVE | |||||||||
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) | |
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F 0909 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 64) staff should be completing entrapment assessments. The DON said facility staff did not measure the zones for entrapment. | |