| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0567 Level of harm – Potential for minimal harm Residents Affected – Many | Honor the resident’s right to manage his or her financial affairs. Based on interview and record review, the facility failed to ensure resident requests for | |
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) -A signed code status sheet, dated 10/12/17, for DNR; -A physician order [REDACTED]. -A POS, dated 1/3 through 1/31, 2/1 through 2/28 and 3/1 through 3/31/19, with an order for [REDACTED]. Review of the resident’s care plan, dated 1/3/19, and in use during the survey, showed: -Problem: Psychosocial wellbeing – Resident has chosen to be a DNR; -Goal: Resident’s wishes will be filled; -Interventions: Evaluate yearly. In the event the resident’s heart stops, no life sustaining measures will be given. During an interview on 3/14/19 at 9:12 A.M., the Assistant Director of Nurses (ADON) looked at the resident’s medical record, verified the resident had signed a DNR code status sheet and that the POSs showed a full code status since 1/3/19. She would expect the signed code status sheet and the POS to both show the resident’s code status as a DNR. During an interview on 3/14/19 at 9:18 A.M., the Social Service Designee (SSD) verified the resident’s code status as a DNR. | |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0583 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 2) in a private area and should never be administered in the hallway for other residents, staff and visitors to observe due to privacy issues. 2. Review of Resident #23’s medical record, reviewed on 3/13/19 at 1:02 P.M., showed: -[DIAGNOSES REDACTED]. -Review of a Monthly Summary, dated 2/17/19, showed: -Wheelchair most of the day; -Independent with positioning and transfers. Observation on 3/13/19 at 7:49 A.M., showed Registered Nurse (RN) E administered an insulin injection to the resident in his/her room: -RN E entered the room with insulin supplies; -RN E did not pull the privacy curtain nor shut the door to the resident’s room; -The resident sat in his/her wheelchair, with his/her shirt pulled up, exposing his/her left abdomen; -RN E cleansed the resident’s abdomen with an alcohol pad, inserted the syringe into the resident’s abdomen, counted to two and withdrew the syringe, then cleansed the insertion site with an alcohol pad; -The resident sat in full view of the hallway from the open door during the entire procedure; -Other staff and residents were observed in view, in the hall, in front of the resident’s open doorway during the resident’s insulin administration. During an interview on 3/15/19 at 8:52 A.M., the DON said it is not appropriate for staff to administer insulin in open areas. Nurses are expected to administer insulin in private areas to protect resident’s privacy. | |
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Respond appropriately to all alleged violations. **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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 3) -Once the resident is cared for and initial reporting has occurred, an investigation should be conducted, Components of the investigation may include: -Interview the involved resident, if possible, and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses; -Interview all witnesses separately, Include roommates, residents in adjoining rooms, staff members in the area and any noted visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement; -Document the entire investigation chronologically; -The facility must report the result of all investigation to the administrator or his or her designated representative and other officials in accordance with state law, including to the state survey agency within 5 working days of the incident, and if alleged violation is verified appropriate corrective action must be taken. Review of facility’s Sexual Intimacy policy, dated 12/2018, showed: -Policy: It is the responsibility of The facility to balance a resident’s rights and provide protection related to sexual contact while an individual is residing in our facility, through obtaining sexual intimacy history, present activity level, assessing ability to provide consent, conducting interviews, utilization of information obtained through observation, analysis of assessment data, safe sex education, and implementation of interventions; -Sexual intimacy history: As part of the admission process, the social service worker will interview the resident or their responsible party to obtain information about a resident’s past sexual intimacy history. Information obtained by the social service interview will be documented on the psychosocial history; -Present sexual activity level: When an observation occurs that a relationship is developing between residents, a resident is expressing a desire to pursue a relationship, or witnessed sexual contact between two residents, staff should report this to the charge nurse, supervisor or administrator. Social service worker, Director of Nursing, nursing supervisor, charge nurse or administrator will be assigned to interview the resident and/or residents involved in any of the scenarios; -Assessment of ability to Consent: Resident’s chart will be reviewed to identify if a resident or an appointed responsible party is making decisions related to the resident’s healthcare. Resident’s cognitive assessments will be reviewed to determine the resident’s level of orientation. Residents will be interviewed separately in a private location using yes/no and open ended questions, by an appointed staff member to determine the following: -Understands the distinctively sexual nature of the conduct; -Understands that their body is private and they have the right to refuse; -Understands that there may be health risks associated with the sexual act; -Understands that there may be negative social response to the conduct; -Analysis of the information: The interdisciplinary team will review the information obtained through the cognitive assessment to determine the resident’s ability to understand their actions and if able to give consent for a sexual relationship. The analysis of information will be documented in the Social Service or Nurses Notes. Review of Resident #63’s quarterly Minimal Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 2/1/19, showed: -Brief interview for mental status (BIMS) score of 14 out of a possible score of 15, which showed the resident as cognitively intact; -Has delusions (misconceptions or beliefs that are firmly held, contrary to reality); |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) -Received antipsychotic medications; -No set up/physical help from staff needed for walking in room and corridor, transfers, bed mobility or dressing; -Wheelchair used for mobility; -[DIAGNOSES REDACTED]. -Resident’s guardian or legally authorized representative participated in assessment. Review of the resident’s medical record, showed: -The resident had a legal guardian; -No documentation that the resident: -Understands the distinctively sexual nature of the conduct; -Understands that their body is private and they have the right to refuse; -Understands that there may be health risks associated with the sexual act; -Understands that there may be negative social response to the conduct; -No documentation of the interdisciplinary teams determination of the resident’s ability to understand their actions and if able to give consent for a sexual relationship. Review of the resident’s care plan, dated 12/3/18, showed: -Problem: The resident has a history of disclosing his/her personal information such as diagnoses, health concerns, etc.; -Goal: The Resident will only discuss concerns with social services or nursing through the next review; -Interventions: Social services to educate resident on appropriate behavior; -The care plan failed to identify sexual behaviors as a problem, history of allegedly providing sexual favors and/or documentation the resident had been deemed competent to consent to sexual activity. Review of the resident’s Social Services progress notes, dated 2/15/19, showed the social worker made aware resident giving sexual favors. Resident educated on safe sex and importance of being aware of partners’ conditions before engaging in these activities. Guardian made aware. Social worker will continue to support and monitor. Observation of the resident on 3/14/19 at 9:04 A.M., showed the resident sat in a wheelchair in his/her room. The resident said he/she wanted a private room but there were no private rooms available. During an interview on 3/14/19 at 10:12 A.M., the facility’s social worker said: -On 2/15/19, the resident stated he/she gave another resident sexual favors but would not identify the sexual partner; -The social worker conducted a one on one counseling session with the resident to remind him/her of safe sex practices and the importance of choosing a partner who is able to give sexual consent; -The social worker only documents encounters with residents in their medical records, she does not document one on one conversations with residents; -He/she believed the resident was cognitively able to make sexual choices; -Staff communicates daily and during interdisciplinary team (IDT) meetings on Fridays to discuss who is sexually active; -The nursing staff did not know the resident’s sexual partner; -The social worker asked one resident if they were Resident #63’s sexual partner and he/she denied it. The social worker does not have documentation of this conversation; -The social worker did not identify the resident’s sexual partner; -The social worker did not notify the Administrator as she felt the resident was protecting his/her privacy by not identifying the sexual partner. During an interview 3/14/19 at 1:20 P.M., the administrator and the Director of Nursing |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0610 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) (DON) stated: -Protocol for identifying residents who are cognitively able to make choices for sexual intimacy include: Reviewing BIMS score, cognitive assessments, personal interviews and feedback from the resident clarifying they understand what occurs with sexual relationships, how to make safe choices and how to ask for consent from partners; -There are residents in the facility that are not able to give sexual consent due to cognitive impairment; -If staff suspects sexual relationships are occurring between residents, the administration is to be notified. The administrator will investigate the claim to make sure the acts are consensual and not abuse; -When informed a resident has had sexual relations with an unidentified resident in the facility, the administrator would investigate by interviewing the resident who made the claim to see if they would identify their partner. If no name is given, then the administrator and social worker would interview other residents and staff to see if they could discover who might be the other partner; -Documentation of the investigation would include the claim of sexual relations, who was interviewed and when; -If the facility is unable to identify the second partner, the social worker would focus on sex education during resident group; -The social worker will conduct one on one sessions with the resident who would not identify their partner to make sure the resident understands what a sexual relationship involves and to insure the resident asks their partner for consent; -The facility did not investigate the resident’s allegation on 2/15/19, that he/she was giving sexual favors to an unidentified resident. After the social worker asked one resident if he/she had sexual relations with Resident #63, which he/she denied, the facility did not interview any other residents. | |
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) 3. Review of Resident #32’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice upon the emergency transfer. 4. Review of Resident #66’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -No documentation the resident and/or the representative received written notice upon the emergency transfers. During an interview on 3/12/19 at 1:21 P.M., the resident said he/she had recently been sent to the hospital and did not receive any transfer notice from the facility. 5. Review of Resident #64’s medical record, showed: -Transferred to the hospital on [DATE]; -No documentation the resident and/or the representative received written notice upon the emergency transfer. 6. Review of Resident #54’s medical record, showed: -Transferred to the hospital on [DATE]; -No documentation the resident and/or the representative received written notice upon the emergency transfer. 7. Review of Resident #56’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE]; -No documentation the resident and/or the representative received written notice upon the emergency transfer. 8. During an interview on 3/14/19 at 9:00 A.M., Nurse A said staff send a copy of the resident’s face sheet, physician order [REDACTED]. He/she thinks the social service designee (SSD) sends the responsible party a notice. 9. During an interview on 3/14/19 at 9:19 A.M., the SSD said he does call the responsible party whenever a resident is discharged to the hospital just to let them know the resident went to the hospital and will call them again when the resident returns to the facility. He does not send any paper work with the resident or send any paperwork to the responsible party if the resident is going to return from the hospital. The only time a resident would be sent to the hospital with a discharge notice is when they go out and the facility will not readmit him/her. 10. During an interview on 3/14/19 at 2:30 P.M., both the administrator and the Director of Nurses (DON) said they were not aware they needed to be issuing an emergency discharge notice to the resident or their responsible party whenever the resident had an emergency transfer to the hospital with a return anticipated and had not been issuing any notices. | |
| F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0625 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 interview and record review, the facility failed to provide written notice to the residents or their legal representatives of the facility bed hold policy at the time of transfer to the hospital, for seven of 18 sampled residents, who were recently transferred to the hospital for various medical reasons (Residents #3, #63, #32, #66, #64, #54 and #56). The census was 72. 1. Review of Resident #3’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfer. 2. Review of Resident #63’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfer. 3. Review of Resident #32’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfer. 4. Review of Resident #66’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfers. During an interview on 3/12/19 at 1:21 P.M., the resident said he/she had recently been sent to the hospital and did not receive any written bed hold notice from the facility at the time of his/her transfer. 5. Review of Resident #64’s medical record, showed: -Transferred to the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfers. 6. Review of Resident #54’s medical record, showed: -Transferred to the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfers. 7. Review of Resident #56’s medical record, showed: -Transferred to the hospital on [DATE] and returned to the facility from the hospital on [DATE]; -Transferred to the hospital on [DATE]; -No documentation the resident or the resident’s representative received written notice of the facility’s bed hold policy at the time of transfers. 8. During an interview on 3/14/19 at 9:00 A.M., Nurse A said staff send a copy of the resident’s face sheet, physician order [REDACTED]. He/she thinks the social service designee (SSD) sends the responsible party a bed hold notice whenever the resident is sent to the hospital. 9. During an interview on 3/14/19 at 9:19 A.M., the SSD said he does call the responsible |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 8) party whenever a resident is discharged to the hospital just to let them know the resident went to the hospital and will call them again when the resident returns to the facility. He does not send any paper work with the resident or provide it to the responsible party if the resident is going to return from the hospital. The bed hold policy is in the admission packet. 10. During an interview on 3/14/19 at 2:30 P.M., both the administrator and the Director of Nurses (DON) said they were not aware they needed to be issuing a written bed hold policy to the resident or their representative whenever the resident had an emergency discharge to the hospital with a return anticipated and had not been issuing any notices. | |
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) (DON) stated care plans should address sexual intimacy for residents who are sexually active. Review of facility’s Sexual Intimacy policy, dated 12/2018, showed: -Policy: It is the responsibility of the facility to balance a resident’s rights and provide protection related to sexual contact while an individual is residing in our facility, through obtaining sexual intimacy history, present activity level, assessing ability to provide consent, conducting interviews, utilization of information obtained through observation, analysis of assessment data, safe sex education, and implementation of interventions; -As part of the admission process, the social service worker will interview the resident or their responsible party to obtain information about a resident’s past sexual intimacy history; -Information obtained by the social service interview will be documented on the psychosocial history; -The interdisciplinary team (IDT) will review information obtained through the cognitive assessment, observations, and the interview to determine the resident’s ability to understand their actions and if able to give consent for a sexual relationship. The analysis of information will be documented in the social service or nurses notes; -If a resident is able to consent: -The relationship will be monitored and observed for any changes; -Safe sex practice education will be provided and safe sex practices encouraged; -If the resident is unable to consent: -If the resident has an assigned decision-maker, the staff will report the resident’s sexual relationship status and the result of the analysis of information. If needed, a family meeting to include the resident will be held to determine how to respect the resident’s right and provide protection, if needed. This will be documented in the social service note. 2. Review of Resident #56’s face sheet, showed [DIAGNOSES REDACTED]. Review of the resident’s quarterly MDS, dated [DATE], showed: -BIMS score of 12 out of 15; -A BIMS score of 8-12, showed the resident had moderately impaired cognition; -[DIAGNOSES REDACTED]. -Has delusions; -Received antipsychotic medications. Review of the resident’s behavior/intervention monthly flow record, dated 1/1/19 through 2/28/19, showed: -Agitation: 2/22/19; -Hallucination/delusion/paranoid: 2/22/19. Review of the resident’s care plan, updated 3/3/19, showed: Problem: At risk for falling, is up as desired and uses a wheelchair at times. He/she has decreased safety awareness/poor judgement, receives daily antianxiety and diuretic drug therapies due to a history of [MEDICAL CONDITIONS] and an anxiety disorder; Approaches: -Assure the floor is free of glare, liquids and foreign objects; -Encourage resident to walk on sidewalk during inclement weather; -Encourage resident to assume standing position slowly; -Keep personal items and frequently used items within reach; -Provide proper, well maintained footwear; -Provide resident an environment free of clutter; |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0656 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) -Remind to lock wheelchair brakes prior to any transfer; -The care plan failed to identify agitation and hallucinations/delusions/paranoia as problems with goal and interventions. 3. Review of Resident #1’s quarterly MDS, dated [DATE], showed: -Cognitively impaired; -One staff person assist for all activities of daily living (ADLs); -Nutrition, feeding tube; -Unclear speech; -Rarely makes self-understood/understands; -No behaviors; -[DIAGNOSES REDACTED]. Review of the resident’s physician order [REDACTED]. -Diet: Nothing by mouth (NPO); -Elevate head of bed 30 degrees at all times. Review of the resident’s care plan, in use during the survey, showed the following: -Problem: Resident is non-compliant with his/her NPO status. He/she continues to go in the dining room and drink plain coffee, or water; -Approach: Explain dietary requirements and consequences of dietary non-compliance; -Problem: At risk for weight loss/gain due to all hydration and nutrition via a gastrostomy tube ([DEVICE], a tube inserted through the abdomen that delivers nutrition directly to the stomach), due to dysphagia (difficulty swallowing) from a prior stroke and is dependent on staff for nutritional needs. He/she may have pleasure feedings of puree consistency with honey thickened liquids. Observation and interview on 3/12/19 at 11:59 A.M., showed the resident lay on his/her bed and appeared asleep while additional residents were observed in the dining room eating lunch. Nurse A stated the resident’s next tube feeding would be at 2:00 P.M. During an interview on 3/14/19 at 8:33 A.M., the administrator said the resident is NPO, but known to buy chips out of the snack machine. On 3/15/19 at 9:23 A.M., the administrator said the resident was NPO and did not have and order for pleasure feeding or honey thickened liquids. She was not aware his/her care plan contained pleasure feeding or honey thickened liquids. 4. During an interview on 3/15/19 at 9:30 A.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the care plans are updated weekly and quarterly. | |
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide appropriate treatment and care according to orders, resident’s preferences and goals. **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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) for one resident (Resident #40). The census was 72. 1. Review of Resident #33’s face sheet, showed a [DIAGNOSES REDACTED]. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/18, showed: -Brief interview for mental status (BIMS) score of 14 out of 15, showed the resident was cognitively intact; -[DIAGNOSES REDACTED]. -Has delusions; -Antipsychotic medications administered in the last seven days; -Antipsychotic medications received on a routine basis. Review of the resident’s judgement for involuntary electroconvulsive therapy form, dated 11/8/17, showed: -Upon clear and convincing evidence the Court finds that the respondent is receiving outpatient treatment at a private mental health facility; -The respondent is unable, by reason of a mental illness, to evaluate information in order to make an informed choice as to the proper medical treatment of [REDACTED]. -The respondent has been treated in the past with electroconvulsive therapy which resulted in significant improvement in the respondent’s mental disorder for substantial period of time; -The electroconvulsive therapy is necessary because there is a strong likelihood that the therapy will significantly improve the respondent’s mental disorder for a substantial period of time without causing respondent any serious functional harm, and electroconvulsive therapy is the most effective and least invasive form of therapy which can result in substantial improvement in the respondent’s condition. Review of the resident’s care plan, dated 3/20/18, showed: -Problem: Receives ECT treatments related to history of [MEDICAL CONDITION]; -Approach: Appointments as ordered. Monitor for adverse effects: headaches, dizziness, jaw pain, muscle aches, amnesia, fatigue, nausea and vomiting. Review of the resident’s physician orders sheet (POS), dated 3/1/19 through 3/31/19, showed: -[DIAGNOSES REDACTED]. -Further review, showed no physician orders for ECT and/or monitoring and assessing for adverse effects of the treatment. Review of the resident’s progress notes, showed: -On 5/23/18 at 12:00 P.M., resident returned from ECT at hospital. No acute signs or symptoms of any distress noted. Next ECT date 5/30/18; -No documentation if the resident attended ECT on 5/30/18; -On 10/31/18 at 1:30 P.M., resident returned from ECT follow up. ECT for 11/14/18; -No documentation if the resident attended ECT on 11/14/18; -On 1/17/19 at 6:30 A.M., spoke to resident’s family member who was made aware of resident’s desire to not attend ECT session today; -No further documentation of the resident’s ECT treatments or monitoring and assessing for adverse effects of ECT. Observation on 3/12/19 at 10:51 A.M., showed the resident sat in his/her room and said he/she received ECT treatments for several years. He/she enjoyed reading, but it had become more difficult because he/she started to have double vision as a result of the ECT. On 3/13/19 at 1:31 P.M., the resident said he/she has ECT treatments every other Wednesday. During an interview on 3/15/19 at 8:32 A.M., the administrator and the Director of Nursing |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) (DON) said the resident received ECT treatments every other week. There are no physician’s orders for the ECT treatments because they are court ordered. They would expect staff to assess the resident for any physical side effects when he/she returned from ECT treatments and document them in the progress notes. They were not aware of the resident’s complaints of double vision or when the resident last had an eye exam and would expect there to be physician orders for the ECT. 2. Review of the facility’s policy for Neuro Checks, reviewed on 12/1/18, showed the following: -Assess the resident for changes in level of consciousness, which is a cardinal sign of untoward pathology. Assess the resident immediately after the fall, then frequently throughout the shift. Assessment should continue for a minimum of 72 hours; -Notify the physician immediately after the fall, follow the physician’s orders related to the fall; -Observe the resident for obvious injuries to the scalp, including lacerations, bruises, or contusions. Observe for confusion, memory loss, difficulty speaking, gait or balance problems, pupils of unequal size or reactions, headache, vomiting, visual disturbances, or periods of coherence alternating with periods of confusion or lethargy. Monitoring must continue for a minimum of 72 hours (or until the resident is asymptomatic for a specified period of time); -Perform frequent neurologic assessments every; -15 minutes for one hour; -30 minutes for two hours; -60 minutes for four hours; -Eight hours for 16 hours; -Eight hours until at least 72 hours have elapsed and the resident is stable; -Neurological assessments include (at a minimum) pulse, respiration and blood pressure measurements, pupil size and reactivity, equality of hand grip strength. Completing the post fall neuro check form to help keep findings objective. Review of Resident #40’s annual MDS, dated [DATE], showed: -Cognitively impaired; -One staff person assist for bed mobility, dressing, toilet use, dressing and personal hygiene; -Two staff person assist for transfers; -Upper/lower extremity impairment on one side; -Wheelchair for mobility; -[DIAGNOSES REDACTED]. Review of the resident’s care plan, in use during the survey, showed the following: -Problem: Falls, on 1/9/19, the resident rolled out of bed. The bed was in lowest position, he/she fell on to the fall mat, without injury; -Approach: Encourage not to transfer him/herself and ask for assistance with transfers. Continue to use floor mat and ensure bolster mattress is in place and in good condition. Review of the facility accident/incident log, dated (MONTH) 2019 through (MONTH) 2019, showed no documented incident/fall for the resident. Review of the resident’s nurse’s notes, showed on 1/9/19, while seated at the desk, this nurse was notified the resident was on the floor, beside his/her bed, on the floor mat. No open or bruised areas noted, the resident stated he/she just laid down to relax. Fall unwitnessed, neuro checks initiated. Further review of the resident’s medical record, showed no documented neuro checks for the fall on 1/9/19. |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0684 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 13) During an interview on 3/14/18 at 11:32 A.M., Nurse A said once neuro checks are completed, the documentation is turned over to the DON. During an interview on 3/15/18 at 8:38 A.M., the DON and the administrator said neuro checks had not been completed after the resident’s fall on 1/9/19. Neuro checks would be expected after an unwitnessed fall, and the resident’s neuro checks should have been completed. | |
| F 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, and record review the facility failed to establishes a system of |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0755 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 14) 3. Review on 3/12/19 at 1:09 P.M., of the facility’s controlled substance shift change count check sheet, dated (MONTH) 2019, for the 200 hall CMT cart, showed: -11 out of 34 shifts: Count with one nurse documented; -5 out of 34 shifts without count of narcotics. Review on 3/12/19 at 1:09 P.M., of the facility’s controlled substance shift change count check sheet, dated (MONTH) 2019, for the 200 hall CMT cart, showed: -9 out of 83 shifts: Count with one nurse documented; -3 out of 83 shifts without count of narcotics. 4. During an interview with the Administrator, DON, Assistant Director of Nursing (ADON) and Director of Clinical Operations on 3/15/19 at 8:32 A.M., the following statements were made: -The DON is responsible for checking if the narcotic shift change reports are filled out correctly and conduct a monthly audit of the facility’s narcotics and narcotic shift change reports; -The pharmacy conducts a quarterly audit of the facility’s narcotics; -Staff will notify the DON if the narcotic shift change count is off; -The DON would investigate the missing narcotic by examining the physical narcotic cards and verifying the number of narcotics listed on the narcotic shift change report; -Given the examples of missing documentation on the narcotic shift change reports, they are not sufficient to obtain accurate reconciliation of narcotics. | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) opened them and wiped his/her eyes with a clean tissue. At 7:06 A.M., CMT B handed the resident the Incruse Ellipta inhaler. The resident took the inhaler and administered 1 puff. CMT B took the inhaler back, handed the resident a plastic cup of water and told him/her to rinse his/her mouth. The resident took the cup of water and drank the water. CMT B did not attempt to have the resident spit the water out into the cup or further educate the resident on proper rinse procedure. Review of WebMD instructions for Simbrinza eye drops, showed to apply gentle pressure on the inner canthus (eye duct) for 1 to 2 minutes before opening the eyes after administration. During an interview on 3/14/19 at 8:28 A.M., the Director of Nurses (DON) said the facility policy is to hold the inner canthus or have the resident keep their eyes closed for 1 minute after administration of eye drops to prevent the medication from being absorbed into the blood stream. The facility policy is to wait 1 minute between puffs of the same inhaler. Both the [MEDICATION NAME] and the Incruse Ellipta inhalers are steroid medications. Staff should have residents rinse their mouth with water after administration of the inhalers and not swallow the water to help prevent a thrush (yeast) infection of the mouth or stomach. She would expect staff to observe the resident as they administer the inhalers to ensure they are administering them correctly and not turn away from the resident to continue to gather medications. 2. Review of Resident #1’s quarterly Minimal Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/5/18, showed: -Short term memory problem; -Some difficulty making decisions regarding tasks of daily living; -Total dependence for eating; -[DIAGNOSES REDACTED]. Review of the resident’s POS, dated (MONTH) 2019, showed: -Flush resident’s [DEVICE] with 70 milliliters (ml) of water before and after each feeding; -May crush/open/dissolve appropriate medications; -An order to administer aspirin 81 milligram (mg) via [DEVICE]; -An order to administer carvedilol (a medication used to treat high blood pressure) through the [DEVICE]. Observation of medication administration thru the resident’s [DEVICE] on 3/13/19 at 10:25 A.M., showed: -Licensed Practical Nurse (LPN) F drew up 60 ml of water into the syringe, put the tip of the syringe in the resident’s [DEVICE] and depressed the piston, pushing the water into the resident’s [DEVICE]; -LPN F drew up 10 ml of water into the syringe, put the tip of the syringe into the resident’s [DEVICE] and depressed the piston, pushing the water into the resident’s [DEVICE]; -LPN F drew up crushed aspirin 81 mg, which was diluted in 10 ml of water, into the syringe, placed the tip of the syringe into the resident’s [DEVICE] and depressed the piston, pushing the medication into the resident’s [DEVICE]; -LPN F removed the syringe from the resident’s [DEVICE], inserted the tip of the syringe into the graduated cylinder filled with water and pulled up 5 ml of water into the syringe; -LPN F inserted the tip of the syringe in the resident’s [DEVICE] and depressed the piston pushing the water into the resident’s [DEVICE]. He/she then removed the syringe from the resident’s [DEVICE]; |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) -LPN F took the tip of the syringe, placed it in a medicine cup filled with Carvedilol 3.125 mg diluted with 10 ml water, and pulling the piston back on the syringe, pulled the medicine into the syringe; -LPN F took the tip of the syringe, placed it in the resident’s [DEVICE] and depressed the piston, pushing the medication in to the resident’s [DEVICE]; -LPN F removed the syringe from the resident’s [DEVICE], inserted the tip of the syringe into a graduated cylinder filled with water and pulled up 5 ml of water into the syringe; -LPN F inserted the tip of the syringe in the resident’s [DEVICE] and depressed the piston, pushing the water into the resident’s [DEVICE]. He/she then removed the syringe from the resident’s [DEVICE]. During an interview on 3/13/19 at 10:45 A.M., LPN F stated: -He/she pushed both the aspirin and carvedilol into the resident’s [DEVICE] instead of administering the medications by gravity; -He/she did not know why he/she pushed two out of the nine medications administered, possibly he/she was rushing. During an interview with the administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Director of Clinical Operations on 3/15/19 at 8:32 A.M, the following statements were made: -Nurses are expected to give both medications and water flushes via resident’s [DEVICE] by gravity; -Nursing staff is expected to know the facility’s policy and procedure of medication administration through resident’s [DEVICE]s. Review of medication administration resident’s [DEVICE] policy, dated 12/1/18, showed: -Purpose: To enable the safe administration of oral medication to a resident who is unable to swallow medications; -If tablets or capsules are to be given, crushed tablets or contents should be dissolved in about 30 ml of warm water; -Remove 60 ml syringe. Remove the piston of the syringe. Reinsert the syringe in the gastric tube without the piston. Pour 30 ml of water into the syringe. Unclamp the tube and allow water to enter into the stomach by gravity infusion. If water does not go in automatically you may need to reinsert piston and slowly push; -Administer first dose of medication by pouring into the syringe. Follow with 5-10 ml water flush between medication doses. Unless the resident is on a fluid restriction. Follow the last dose of medication with 30 ml of water flush unless restricted. | |
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 17) ventilation, moisture control, segregation, and security; -Disinfectants and drugs for external use are stored separately from internal and injectable medications; -All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room; -The pharmacy and all medications rooms are routinely inspected by consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. 1. Observation of the 100 hall medication storage room, on 3/12/19 at 1:15 P.M., showed: -The small refrigerator contained: -Two cartons of opened, undated nutritional shakes; -A baggy that contained vials of influenza vaccinations; -A container of banana yogurt stored in the door of the refrigerator; -Emergency kit for insulin from the pharmacy; -On the counter: -Multiple medication packets/bottles. Certified Medication Technician (CMT) G said these were returns to pharmacy; -Medication bottles for current residents; -A take out bag from a local restaurant containing a Styrofoam container of food; -A soda can, open and covered with a cup over it; -On top of the locked fuse box, which hung on wall roughly 6 feet off the ground: -Open box of [MEDICATION NAME] (medication used to treat asthma) nebulizer vials; -Open box of examination gloves; -Open box of ABD pads (a soft, fluffy, absorbent pad for wound dressings). 2. Observation of the 300 hall medication storage room, on 3/12/19 at 1:32 P.M., showed: -The small white refrigerator contained: -Two bottles of Ranch dressing, opened; -A bottle of banana peppers, opened; -A bottle of thickened liquid; -A Styrofoam container filled with peaches, labeled with the date 3/11/19; -Two Evian water bottles; -A package of sliced cheese; -A Hot Pocket brand sandwich; -Several packets of condiments from takeout restaurants; -A bottle of Coffee mate brand creamer; -Two cans of flavored sparkling spring water; -On top of the counter: -A large glass vase full of take out condiment packets; -In the overhead cabinets: -A package of Ramen noodle soup; -A salt shaker; -A Foley catheter (a sterile tube inserted into the bladder to drain urine) insertion kit; -A cell phone; -A bottle of hot sauce; -Three containers of unwashed Tupperware; -A tube of Santyl (an ointment used to debride ulcers) ointment, labeled with a resident’s name, half used; |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0761 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 18) -Two enteral feeding delivery systems, not in bags; -Medication bottles for residents, lying among the debris, on their side; -One bottle of Dakin’s Solution (an antiseptic solution used to cleanse open wounds) opened, half used, not labeled; -Underneath the sink: -A box of lab supplies consisting of urinal specimen cups, specimen swabs and transport bags for specimen collection; -A dirty beverage cup stuffed with paper towels that lay inside a box, on top of lab supplies; -A used toilet brush; -A stack of paper plates and various party hats; -An old radio. 3. During an interview on 3/12/19 at 1:48 P.M., CMT G stated: -CMTs and nurses are responsible for maintaining the medication rooms; -Staff are not allowed to store food in medication rooms or medication refrigerators. 4. During an interview with the administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Director of Clinical Operations on 3/15/19 at 8:32 A.M, the following statements were made: -Staff are expected to store their personal belongings in the break room, they have lockers they can access at all times; -Staff should not store their food and drinks in the medication storage rooms on the counters or in cabinets; -Staff can store their food in the break room refrigerator and the staff ice box in the 300 hall med storage room; -Staff should not store medications or items used for residents in the staff refrigerators. Residents have their own refrigerators in their own rooms; -The night nurse is responsible to maintain cleanliness of both the staff refrigerator in the 300 medication storage room and the medication refrigerators in both medication storage rooms; -Staff are expected to send medications that are no longer in use back to the pharmacy. It is not appropriate to store a half used tube of Santyl in the medication storage room; -There is not a schedule in place for inspection/cleaning of the medication rooms; -Staff are expected to notify administration if they found an issue with the organization or cleanliness of the rooms; -Medication storage rooms are expected to maintain cleanliness and organization. | |
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. **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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0804 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 19) -1/3 cup apple cider vinaigrette; -1 1/4 tablespoon of soy sauce; -1 1/4 teaspoon of black pepper; -6 pounds of pork loin. Observation and interview on 3/14/18 at 10:07 A.M., showed Cook H had the pork loin recipe opened. He/she added liquid browning seasoning sauce to a clear measuring cup, walked over to the sink, and filled the measuring cup with hot water until the cup measured two cups. He/she then walked over to the dishwasher, removed a clear plastic container from the dishwasher, dripping wet, and placed the container on the blender. He/she then added 1 tablespoon of thickener into the blender, poured the contents of an unmeasured pan of chopped pork chops into the wet blender, added the water/seasoning mix, and blended. The dietary manager tested the puree and instructed Cook H to add some gravy. Cook H poured a half cup of white gravy from a pot of gravy on the stove, added the gravy and blended. He/she then walked over to the dishwasher, removed a wet pan from dishwasher and poured the pureed pork chops into the wet pan, covered the pan with aluminum foil, dated the foil and placed the pan in the oven. Cook H said he/she was not aware of the serving size for the puree or which scoop to use for the purees. He/she had four residents with physician orders [REDACTED]. 2. Review of the pancake/syrup puree recipe for four servings, showed the following: -4 pancakes; -4 fluid ounces of milk (1/2 cup). Observation on 3/15/19 at 6:38 A.M., showed Cook I poured 1 cup of milk into a clear plastic container on top of the blender. He/she then added 6 pancakes and 1/4 cup of syrup. He/she blended the contents of the container. He/she opened the milk container and poured two more ounces of milk into a measuring cup. He/she walked over to the microwave and placed the milk inside, closed the microwave and warmed the milk. He/she added the milk and blended the mixture. Cook I said he/she had four residents who received pureed diets, with one resident who received double portions. 3. During an interview on 3/15/19 at 7:00 A.M., the dietary manager said staff should follow the puree recipes. The dietary manager looked at the recipes and said Cook H used the wrong puree recipe for the pork chops. Cook H used the pork loin recipe by mistake and he/she should have used the pork chop recipe. 4. During an interview on 3/15/19 at 9:10 A.M., the administrator said puree recipes must be followed, if they are not, they may be diluted or not have enough fluid in the puree. | |
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 20) -Staff shall clean their hands and wrist area for at least 20 seconds in a hand washing sink that is equipped with warm water, hand washing soap, paper towels and a trash can with a foot operated lid. Employees shall avoid using a food preparation sink, pot washing sink, a service sink or an area designed to dispose of mop water; -The procedure shall include: -Rinsing under clean running water; -Applying soap; -Rubbing vigorously for 10-15 seconds to ensure removal of soil from surface of hands and wrists and underneath nails; -Rinsing under running warm water; -Drying with a single use towel. 1. Observation of the kitchen on 3/12/19 at 8:59 A.M., showed the water from the hand washing sink ran for 3 minutes and failed to turn hot. The dietary staff were observed using the hand washing sink to wash their hands. Observation on 3/14/19 at 1:07 P.M., showed the water from the hand washing sink felt cold. The dietary staff washed their hands one by one, leaving the water running. The dietary manager approached the sink and touched the running water. She continued to put her hand in and out of the water to check the temperature. The dietary manager said she was aware there was no hot water that came from the hand washing sink. When the dish machine was in use, it decreases the hot water. At 1:10 P.M., the dietary manager left the water running in the sink and obtained a digital thermometer from the kitchen. The digital thermometer was placed under the running water for two minutes. At 1:12 P.M., the temperature of the water measured 50.0 degrees Fahrenheit (F). During an interview on 3/15/19 at 8:32 A.M., the administrator said she was not aware that there was no hot water from the hand washing sink in the kitchen. She would expect staff to report the issue to maintenance. Maintenance is responsible for taking the water temperatures in the kitchen on a weekly basis. The administrator was aware there was an issue with the hot water approximately six months ago, but it was addressed. There is a separate water heater for the kitchen and maintenance adjusted it. The administrator would expect staff to follow the hand washing policy and have warm water accessible for hand washing to ensure safe food handling. During an interview on 3/15/19 at 11:07 A.M., the maintenance supervisor said he was not aware the hand washing sink did not have hot water. He tested the hot water in the kitchen on a regular basis, but only the three sink sanitizer. There is a regulator underneath the sink that has to be turned with a wrench, and he is the only one that could do it. 2. Observation on 3/14/19 at 1:07 P.M., showed a large fan with dust buildup, blowing in the kitchen while dietary staff served meals and cleaned dishes. During an interview on 3/15/19 at 11:00 A.M., the dietary manager said the evening shift is responsible for cleaning the fans on a weekly basis. She would expect the fans to be free of dust, so it does not blow on the food. 3. Review of the facility Food Storage policy, showed: -Food inventory will be maintained using first in, first out; -Food stock will be placed with new stock behind old; -Items will be marked with a date prior to storage Observation of the refrigerator in the kitchen, located across from the hand washing sink, showed: -On 3/14/19 at 10:04 A.M., two large clear plastic zip locked bags of frozen sausage patties, undated; -On 3/15/19 at 6:38 A.M., two large clear plastic zip locked bags of frozen sausage |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | (continued… from page 21) patties, undated. During an interview on 3/15/19 at 7:00 A.M., the dietary manager said food should be labeled and dated per facility policy. 4. During an observation on 3/14/18 at 10:07 A.M., showed Cook H prepared puree pork chops. He/she walked over to the dishwasher, removed a clear plastic container from dishwasher, dripping wet, and used the container to blend the puree. He/she then walked over to the dishwasher, removed a wet pan from the dishwasher, and poured the pureed pork chops into the wet pan, covered the pan with aluminum foil, dated the foil and placed the pan in the oven. During an interview on 3/15/19 at 7:00 A.M., the dietary manager said dietary staff were expected to air dry equipment prior to use to prevent bacterial growth. Staff were expected to date all food prior to storage. 5. Observation on 3/15/19 at 6:38 A.M., Cook I poured 1 cup of milk into a clear plastic container on top of the blender. He/she then added 6 pancakes and 1/4 cup of syrup. He/she blended the contents of the container. He/she then removed his/her gloves and used his/her ungloved hand to push open the spout on the milk container and poured two more ounces of milk into a measuring cup. He/she walked over to the microwave and, with ungloved hands, opened the microwave, placed the milk inside, closed the microwave and warmed the milk. He/she added the milk, blended the mixture and then donned new gloves. He/she did not wash his/her hands after removing his/her gloves and prior to touching the milk carton spout and the microwave handle, before blending the warmed milk into the puree pancakes after touching the potentially soiled microwave handle, and/or before donning new gloves. During an interview on 3/15/19 at 7:00 A.M., the dietary manager said staff were expected to wash their hands prior to handling food and/or food prep equipment and prior to donning new gloves. During an interview on 3/15/19 at 9:10 A.M., the administrator said staff are required to wash their hands prior to donning new gloves. | |
| F 0842 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0842 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 22) -[DIAGNOSES REDACTED]. Review of the resident’s physician order [REDACTED]. -An order, dated 10/11/18, for [MEDICATION NAME] (rapid acting) insulin. Inject per sliding scale subcutaneously (into the fatty tissue), three times daily with daily blood glucose monitoring; -Administer insulin unit amounts as follows: -BGL of 151-200, give 3 unit; -BGL of 201-250, give 5 unit; -BGL of 251-300, give 7 unit; -BGL of 301-350, give 9 unit; -BGL of greater than 351, give 11 unit and call the physician. Review of the resident’s Medication Administration Record [REDACTED] -No 6:00 A.M. dosage recorded on 12/4 through 12/6, 12/8 through 12/11, 12/13, 12/15, 12/18, 12/20, 12/22, 12/24, 12/25 and 12/27 through 12/29/18; -No 5:00 P.M. dosage recorded on 12/8, 12/17, 12/22 and 12/23/18. Review of the resident’s MAR, dated 1/1/19 through 1/31/19, showed no documented insulin doses given for the following dates: -No 6:00 A.M. dosage recorded on 1/3, 1/5, 1/9 through 1/11, 1/15, 1/17, 1/19 through 1/21, 1/23 through 1/26 and 1/29 through 1/31/19; -No 5:00 P.M. dosage recorded on 1/19, 1/20 and 1/31/19. Review of the resident’s medication MAR, dated 2/1/19 through 2/28/19, showed no documented insulin doses given for the following dates: -No 6:00 A.M. dosage recorded on 2/2, 2/4, 2/6, 2/8, 2/9, 2/12, 2/17, 2/20 through 2/23 and 2/26 through 2/28/19; -No 12:00 P.M. dosage recorded on 2/5 and 2/8/19; -No 5:00 P.M. dosage recorded on 2/8 and 2/24/19. During an interview on 3/15/19 at 9:00 A.M., the Director of Nursing (DON) said staff should document on the MAR indicated [REDACTED]. They should not leave the area blank if none was given. If no insulin was required, they should document with a zero, the dosage should not be left blank. If staff do not document the dosage, it would be unknown if the resident received a dosage or if they received an accurate dosage. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) -Use additional wipes if needed to assure continuous wet contact time, at a length according to the manufacturer’s recommendations. Let air dry; -The policy failed to instruct staff to use a clean barrier for the placement of the glucometer machine (machine used to check blood sugar levels). 1. Review of Resident #50’s medical record, showed: -[DIAGNOSES REDACTED]. -an order for [REDACTED].>Observation on 3/13/19 at 6:20 A.M., showed Nurse C got the BGT equipment together, put on gloves, took the equipment into the resident’s room along with two paper towel barriers, placed both barriers and the BGT machine directly on top of the resident’s soiled bedside cabinet. He/she obtained the resident’s BGT, told the resident the results, picked up the BGT machine and both barriers, took them out of the resident’s room and placed the soiled barriers directly on top of a stack of clean barriers, located on the top of the medication administration cart. Nurse C removed the soiled gloves, cleaned his/her hands, put on clean gloves and cleaned the BGT machine with a Sani Cloth Plus wipe. He/she removed the top soiled paper towel and placed the cleaned BGT machine directly on top of the second soiled paper towel, that had been on the resident’s bedside cabinet. Nurse C placed another clean Sani Cloth Plus wipe over the BGT machine causing the paper towel underneath the BGT machine to become wet, removed his/her soiled gloves, cleaned his/her hands with alcohol gel and proceeded to the next resident. 2. Review of Resident #42’s medical record, showed: -[DIAGNOSES REDACTED]. -an order for [REDACTED].>Observation on 3/13/19 at 6:30 A.M., showed Nurse C put on gloves, took the BGT machine along with three damp towels that were underneath the soiled paper towels, from on top of the medication cart and took them into the resident’s room. He/she placed them directly on top of the resident’s bed, obtained the resident’s BGT, told the resident the results, threw away the top paper towel barrier, and took the other two barriers along with the BGT machine and placed them directly on top of a stack of clean paper towels on the medication cart. Nurse C changed his/her gloves, cleaned the machine with a Sani Cloth Plus wipe, removed the top two soiled paper towel barriers and placed the sanitized BGT machine directly on top of the soiled paper towels that had been set on the medication cart. At 6:38 A.M., Nurse C said he/she had completed all of the BGTs, placed the BGT machine in the top drawer of the medication cart and threw the paper towels from on top of the medication cart away. 3. Review of Resident #66’s medical record, showed: -[DIAGNOSES REDACTED]. -an order for [REDACTED].>Observation on 3/13/19 at 6:45 A.M., showed Nurse D placed a clean barrier on top of the medication cart and without cleaning his/her hands, put on gloves. He/she got equipment out of the top drawer of the medication cart, placed the BGT machine on the clean barrier, cleaned the BGT machine with 2 Sani Cloth Plus wipes and placed the used Sani Cloth Plus wipes directly on top of a box of tissues. With the same gloves, he/she opened and closed the top drawer of the medication cart three times, took the equipment into the resident’s room, touched the door knob with the gloves and he/she entered. He/she obtained the resident’s BGT, told the resident the results, took the BGT machine out of the room and placed it on the barrier located on top of the medication cart. He/she picked up his/her pen and wrote the results in the resident’s Medication Administration Record [REDACTED]. He/she removed his/her soiled gloves and without cleaning his/her hands, took the medication cart to the nurses station at 6:50 A.M. During an interview on 3/13/19 at 7:45 A.M., Nurse D said he/she thought the same used Sani Cloth Plus wipes could be used to clean the BGT machine both before and after use |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 24) since the next staff person should clean the BGT machine before use. Nurse D verified he/she did not change his/her gloves during the observation and did not clean his/her hands before or after obtaining the BGT. 4. Review of Resident #23’s medical records, reviewed on 3/13/19 at 1:02 P.M., showed: -[DIAGNOSES REDACTED]. -an order for [REDACTED].>Observation on 3/13/19 at 7:31 A.M., showed Registered Nurse (RN) E obtained a BGT on the resident: -RN E gathered the supplies and Lysol Bleach Germicidal wipes out of drawers of the medication cart and placed the supplies on a stack of paper towels, located on top of the medication cart; -RN E donned gloves without first washing his/her hands; -RN E took all supplies gathered on the paper towels and placed them on the resident’s unmade bed; -RN E wiped the BGT machine with germicidal wipe, then immediately dried the BGT machine with a paper towel from the stack, located on the resident’s bed; -With the same gloves, RN E cleansed the resident’s finger with an alcohol pad and obtained a sample of blood; -RN E gathered all of the supplies in the barrier cloth, took them out of the room and threw the bundle away in the trash can on the medication cart; -RN E removed his/her gloves and did not wash or sanitize his/her hands; -RN E wrapped the BGT machine in a germicidal wipe, wiped the BGT machine with the same germicidal wipe, dried it with a paper towel and put it back into the top drawer of the medication cart. 6. During an interview on 3/14/19 at 8:30 A.M., the Director of Nurses (DON) said she would expect staff to wash their hands before starting BGTs. Staff should change gloves after cleaning the BGT machine. After obtaining the BGT, staff should use the Sani Cloth Plus wipes to clean the BGT machine and then throw it away. It is never appropriate to use it a second time to clean the BGT machine after obtaining the BGT. Staff should only use one paper towel barrier, if using several, all should be thrown away after use due to infection control issues. BGT machines are sanitized before and after each use by wiping them with a Sani cloth and allowing it to air dry for 5 minutes. It is not appropriate for staff to dry the BGT machine after using a Sani cloth. 7. Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/18, showed: -Brief interview of mental status (BIMS) score of 13 out of a possible score of 15, which showed the resident as cognitively intact; -Independent with activities of daily living (ADLs); -[DIAGNOSES REDACTED]. Review of the resident’s care plan, dated 2/4/19, showed: -Problem: Resident can have difficulty breathing or experience fatigue and requires oxygen related to a history of [MEDICAL CONDITION]; -Goal: Will be able to engage in daily activities with rest periods; -Approach: Evaluate lung sounds, if short of breath or displaying episodes of coughing. Review of the resident’s medical record, reviewed on 3/14/19 at 11:29 A.M., showed: -A physician order [REDACTED]. -The Medication Administration Record [REDACTED] -The MAR indicated [REDACTED] -There was no record of when the resident received new tubing and mask set for the nebulizer machine noted on the treatment administration record (TAR) or MAR. |
| 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: 265712 |
| (X3) DATE SURVEY COMPLETED 03/15/2019 | |||||||
| NAME OF PROVIDER OF SUPPLIER ESTATES OF ST LOUIS, LLC, THE | STREET ADDRESS, CITY, STATE, ZIP 2115 KAPPEL 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) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 25) Observations, showed: -On 3/12/19 at 10:12 A.M., the resident lay on his/her bed and colored a picture. The nebulizer machine sat on the bedside table, mask draped over the side of the table, tubing not labeled and not in a bag; -On 3/12/19 at 3:33 P.M., 3/13/19 at 8:00 A.M. and 11:45 A.M., 3/14/19 at 8:03 A.M., 11:51 A.M. and 2:26 P.M. and 3/15/19 at 7:26 A.M., showed the nebulizer machine sat on the bedside table, mask draped over the side of the table, tubing not labeled and not in a bag. Review of the facility’s oxygen supplies policy, dated 12/1/18, showed: -Policy: This facility will maintain oxygen device supplies in a clean status, ensuring proper labeling and replacement of supplies as needed/per physician’s orders [REDACTED].>-Oxygen tubing will be changed one time per week, if oxygen is in use; -Oxygen tubing changes will be documented on the associated TAR or MAR; -The policy did not address nebulizer tubing or nebulizer masks. During an interview with the administrator, the DON, the Assistant Director of Nursing (ADON) and the Director of Clinical Operations on 3/15/19 at 8:32 A.M, the following statements were made: -Nebulizer masks are stored in a bag when not in use to lower contamination risk and to maintain infection control; -Nebulizer tubing and masks are changed weekly when in use; -If the order is an as needed order and the resident does not often utilize the machine, staff is expected to discard the tubing and mask and attach new the next time the resident has a treatment; -Nebulizer tubing and masks should have a dated label attached. The facility’s tubing and masks for nebulizers are one piece; -Staff should document when they change the nebulizer tubing and mask on the resident’s TAR. | |
