ST JOE MANOR

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0623 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the resident and/or the resident’s representative in writing of a transfer or discharge to a hospital, including the reason for transfer for two residents (Resident #61 and #82) of two sampled residents transferred to the hospital. The facility census was 81. 1. Record review of Resident #61’s nurse’s notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation of a letter notifying the resident and/or the resident’s representative of the transfer to the hospital. 2. Record review of Resident #82’s closed record showed the resident transferred to the hospital on [DATE] and did not return to the facility. Review of the resident’s record showed no documentation of a letter notifying the resident and/or the resident’s representative of the transfer to the hospital. During an interview on 11/29/18 at 10:15 A.M., the Administrator said the facility did not provide the resident or the resident’s representative with a written transfer notice at the time of transfer. A facility transfer policy was not provided.
	F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	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. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #61 and #82) of two sampled residents. The facility census was 81. 1. Record review of Resident 61’s nurse’s notes showed the resident transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of the resident’s record showed no documentation the resident or the resident’s representative was informed in writing of the facility’s bed hold policy at the time of transfer on 9/18/18. 2. Record review of Resident #82’s nurse’s notes showed the resident transferred to the hospital on [DATE] and did not return to the facility. Review of the resident’s record showed no documentation the resident or the resident’s representative was informed in writing of the facility’s bed hold policy at the time of transfer on 9/04/18. During an interview on 11/29/18 at 10:15 A.M., the Administrator said the facility did not provide the resident or the resident’s representative with a written bed hold policy at the time of transfer. One is provided only at the time of admission. Record review of the facility Bed Hold Policy, undated showed: – It is the policy of the facility to notify the resident and/or representative of the Bed Hold Policy; – This notification shall be given on admission, at the time of transfer to the hospital and at the time of non-covered therapeutic leave.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to notify the resident and/or the
resident’s representative in writing of a transfer or discharge to a hospital, including
the reason for transfer for two residents (Resident #61 and #82) of two sampled residents
transferred to the hospital. The facility census was 81.
1. Record review of Resident #61’s nurse’s notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed no documentation of a letter notifying the resident
and/or the resident’s representative of the transfer to the hospital.
2. Record review of Resident #82’s closed record showed the resident transferred to the
hospital on [DATE] and did not return to the facility.
Review of the resident’s record showed no documentation of a letter notifying the resident
and/or the resident’s representative of the transfer to the hospital.
During an interview on 11/29/18 at 10:15 A.M., the Administrator said the facility did not
provide the resident or the resident’s representative with a written transfer
notice at the time of transfer.
A facility transfer policy was not provided.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for two residents (Resident #61 and #82) of two sampled residents. The facility
census was 81.
1. Record review of Resident 61’s nurse’s notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
transfer on 9/18/18.
2. Record review of Resident #82’s nurse’s notes showed the resident transferred to the
hospital on [DATE] and did not return to the facility.
Review of the resident’s record showed no documentation the resident or the resident’s
representative was informed in writing of the facility’s bed hold policy at the time of
transfer on 9/04/18.
During an interview on 11/29/18 at 10:15 A.M., the Administrator said the facility did not
provide the resident or the resident’s representative with a written bed hold policy at
the time of transfer. One is provided only at the time of admission.
Record review of the facility Bed Hold Policy, undated showed:
– It is the policy of the facility to notify the resident and/or representative of the Bed
Hold Policy;
– This notification shall be given on admission, at the time of transfer to the hospital
and at the time of non-covered therapeutic leave.

LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURETITLE(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)
Previous Versions Obsolete

Event ID: YL1O11

Facility ID: 265701

If continuation sheet
Page 1 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0625 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few
	F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	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 Based on interview and record review, facility staff failed to complete comprehensive Minimum Data Set assessments (MDS-a federally mandated assessment tool), within the required timeframes for four residents (Residents #5, #10, #30, #1). The facility census was 81. 1. Review of Resident #5’s MDS records showed the following: -An annual MDS dated [DATE]; -A quarterly MDS dated [DATE]; -A quarterly MDS dated [DATE]; -A quarterly MDS dated [DATE]; -No additional comprehensive MDS completed after the 10/5/17 MDS. 2. Review of Resident #10’s MDS records showed the following: -An annual MDS dated [DATE]; -Quarterly MDS dated [DATE]; -Quarterly MDS dated [DATE]; -Quarterly MDS dated [DATE]; -Discharge MDS dated [DATE]; -Entry MDS dated [DATE]; and -A quarterly MDS dated [DATE]. Further review showed staff did not complete a comprehensive MDS at least every 12 months as required. 3. Review of Resident #30’s MDS records showed the following: -An annual MDS dated [DATE]; -A quarterly MDS dated [DATE]; -A quarterly MDS dated [DATE]; -A discharge MDS dated [DATE]; -An entry MDS dated [DATE]; -A quarterly MDS dated [DATE]; and -A quarterly MDS dated [DATE]. Further review showed staff did not complete a comprehensive MDS at least every 12 months as required. 4. Review of Resident # 1’s MDS records showed the facility staff completed the following assessments: -Annual assessment dated [DATE]; -Quarterly assessment dated [DATE]; -Quarterly assessment dated [DATE]; -Quarterly assessment dated [DATE]; -Discharge assessment – return anticipated dated 8/4/18; -Entry tracking record dated 8/6/18; – Quarterly assessment dated [DATE]. Further review showed staff did not complete an annual comprehensive assessment every 12 months. 5. During an interview on 11/29/18 at 11:19 A.M., the MDS Coordinator said the following: -He/she will go to reports look at the due dates of the MDSs, print out a PDF report card

(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 – Few

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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**
Based on interview and record review, facility staff failed to complete comprehensive
Minimum Data Set assessments (MDS-a federally mandated assessment tool), within the
required timeframes for four residents (Residents #5, #10, #30, #1). The facility census
was 81.
1. Review of Resident #5’s MDS records showed the following:
-An annual MDS dated [DATE];
-A quarterly MDS dated [DATE];
-A quarterly MDS dated [DATE];
-A quarterly MDS dated [DATE];
-No additional comprehensive MDS completed after the 10/5/17 MDS.
2. Review of Resident #10’s MDS records showed the following:
-An annual MDS dated [DATE];
-Quarterly MDS dated [DATE];
-Quarterly MDS dated [DATE];
-Quarterly MDS dated [DATE];
-Discharge MDS dated [DATE];
-Entry MDS dated [DATE]; and
-A quarterly MDS dated [DATE].
Further review showed staff did not complete a comprehensive MDS at least every 12 months
as required.
3. Review of Resident #30’s MDS records showed the following:
-An annual MDS dated [DATE];
-A quarterly MDS dated [DATE];
-A quarterly MDS dated [DATE];
-A discharge MDS dated [DATE];
-An entry MDS dated [DATE];
-A quarterly MDS dated [DATE]; and
-A quarterly MDS dated [DATE].
Further review showed staff did not complete a comprehensive MDS at least every 12 months
as required.
4. Review of Resident # 1’s MDS records showed the facility staff completed the following
assessments:
-Annual assessment dated [DATE];
-Quarterly assessment dated [DATE];
-Quarterly assessment dated [DATE];
-Quarterly assessment dated [DATE];
-Discharge assessment – return anticipated dated 8/4/18;
-Entry tracking record dated 8/6/18;
– Quarterly assessment dated [DATE].
Further review showed staff did not complete an annual comprehensive assessment every 12
months.
5. During an interview on 11/29/18 at 11:19 A.M., the MDS Coordinator said the following:
-He/she will go to reports look at the due dates of the MDSs, print out a PDF report card

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0636 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 2) to help determine when MDSs are to be completed; -If the resident goes to the hospital he/she completes a discharge assessment, a reentry when they return, and then a quarterly after the the resident is in the facility for three months; -He/she completes three quarterly MDS after a reentry then the annual; and -Annual assessments are completed yearly.
	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 Based on interview and record review, the facility failed to complete a significant change assessment within 14 days of discontinuation of hospice services for one resident (Resident #28) out of 2 sampled residents. The facility census was 81. 1. Record review of Resident #28’s medical record, showed the following: – admitted to hospice services on 11/28/17; – Discontinued hospice services on 7/19/18. Record review of the resident’s Minimum Data Set (MDS) (a federally mandated assessment instrument required to be completed by facility staff) showed no significant change assessment completed within 14 days of the admission or discontinuation of the resident’s hospice services. 2. During an interview on 10/30/18 at 12:07 P.M., the MDS Coordinator said she does a significant change when a resident goes on hospice or has a decline in status, but did not know she needed to do one if the resident discharges from hospice services. 3. The facility did not provide a policy regarding the completion of significant change assessments.
	F 0638 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Assure that each resident’s assessment is updated at least once every 3 months. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, facility staff failed to complete resident assessments at least every 92 days as required for five residents (Residents #4, #61, #3, #9, #2). The facility census was 81. 1. Review of Resident #4’s Minimum Data Set (MDS), a federally mandated assessment tool, records showed the following: -An admission MDS dated [DATE]; -A quarterly MDS dated [DATE]; -A discharge return aticipated MDS on 9/6/18; and -An entry MDS on 9/7/18. Further review showed staff did not complete an MDS at least every 92 days as required. 2. Review of Resident #61’s MDS records showed the following: – A significant change MDS dated [DATE]; -A quarterly MDS dated [DATE]; -A quarterly MDS dated [DATE]; -Discharge return aticipated MDS dated [DATE]; and -An entry MDS dated [DATE].

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
to help determine when MDSs are to be completed;
-If the resident goes to the hospital he/she completes a discharge assessment, a reentry
when they return, and then a quarterly after the the resident is in the facility for three
months;
-He/she completes three quarterly MDS after a reentry then the annual; and
-Annual assessments are completed yearly.

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

Based on interview and record review, the facility failed to complete a significant change
assessment within 14 days of discontinuation of hospice services for one resident
(Resident #28) out of 2 sampled residents. The facility census was 81.
1. Record review of Resident #28’s medical record, showed the following:
– admitted to hospice services on 11/28/17;
– Discontinued hospice services on 7/19/18.
Record review of the resident’s Minimum Data Set (MDS) (a federally mandated assessment
instrument required to be completed by facility staff) showed no significant change
assessment completed within 14 days of the admission or discontinuation of the resident’s
hospice services.
2. During an interview on 10/30/18 at 12:07 P.M., the MDS Coordinator said she does a
significant change when a resident goes on hospice or has a decline in status, but did not
know she needed to do one if the resident discharges from hospice services.
3. The facility did not provide a policy regarding the completion of significant change
assessments.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assure that each resident’s assessment is updated at least once every 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, facility staff failed to complete resident
assessments at least every 92 days as required for five residents (Residents #4, #61, #3,
#9, #2). The facility census was 81.
1. Review of Resident #4’s Minimum Data Set (MDS), a federally mandated assessment tool,
records showed the following:
-An admission MDS dated [DATE];
-A quarterly MDS dated [DATE];
-A discharge return aticipated MDS on 9/6/18; and
-An entry MDS on 9/7/18.
Further review showed staff did not complete an MDS at least every 92 days as required.
2. Review of Resident #61’s MDS records showed the following:
– A significant change MDS dated [DATE];
-A quarterly MDS dated [DATE];
-A quarterly MDS dated [DATE];
-Discharge return aticipated MDS dated [DATE]; and
-An entry MDS dated [DATE].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0638 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 3) Further review showed staff did not complete an MDS at least every 92 days as required. 3. Review of Resident #3’s MDS records showed staff completed the following assessments: -Significant Change Assessment completed on 12/7/17; -Discharge Assessment with return anticipated dated 1/4/18; -Discharge Assessment with return anticipated dated 2/2/18; -Discharge Assessment with return anticipated dated 3/20/18; -Quarterly Assessment on 7/3/18. Further review showed the facility staff did not complete a quarterly assessment every 92 days after completion of the comprehensive assessment. 4. Review of Resident #9’s MDS records showed staff completed the following assessments: -Annual Comprehensive assessment dated [DATE]; -Quarterly assessment dated [DATE]. Further review showed staff did not complete the quaterly assessments every 92 days after completetion of the comprehensive assessment. Review of Resident #2’s MDS records showed the staff completed the following assessments: -Admission assessment dated [DATE]; -Discharge assessment dated [DATE]; -Rentry Assessment sdated 9/3/18. Further review showed staff did not complete a quarterly assessment 92 days after the admission assessment. 5. During an interview on 11/29/18 at 11:19 A.M., the MDS Coordinator said the following: -He/she will go to reports look at the due dates of the MDSs, print out a PDF report card to help determine when MDSs are to be completed; -If the resident goes to the hospital he/she completes a discharge assessment, a reentry when they return, and then a quarterly after the the resident is in the facility for three months; -He/she completes three quarterly MDS after a reentry then the annual; and -Annual assessments are completed yearly.
	F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the resident and/or representative received a written summary of the baseline care plan (initial plan for delivery of care and services) for three residents (Resident #46, #52, and #69) out of three residents sampled for baseline care plans. The facility census was 81. 1. Review of Resident #46’s medical record, showed: – An admission date of [DATE]; – Baseline care plan completed on 6/11/18; – Resident and/or the resident’s representative did not receive a summary of the baseline care plan. 2. Review of Resident #52’s medical record, showed: – An admission date of [DATE]; – Baseline care plan completed on 6/22/18; – Resident and/or the resident’s representative did not receive a summary of the baseline care plan.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
Further review showed staff did not complete an MDS at least every 92 days as required.
3. Review of Resident #3’s MDS records showed staff completed the following assessments:
-Significant Change Assessment completed on 12/7/17;
-Discharge Assessment with return anticipated dated 1/4/18;
-Discharge Assessment with return anticipated dated 2/2/18;
-Discharge Assessment with return anticipated dated 3/20/18;
-Quarterly Assessment on 7/3/18.
Further review showed the facility staff did not complete a quarterly assessment every 92
days after completion of the comprehensive assessment.
4. Review of Resident #9’s MDS records showed staff completed the following assessments:
-Annual Comprehensive assessment dated [DATE];
-Quarterly assessment dated [DATE].
Further review showed staff did not complete the quaterly assessments every 92 days after
completetion of the comprehensive assessment.
Review of Resident #2’s MDS records showed the staff completed the following assessments:
-Admission assessment dated [DATE];
-Discharge assessment dated [DATE];
-Rentry Assessment sdated 9/3/18.
Further review showed staff did not complete a quarterly assessment 92 days after the
admission assessment.
5. During an interview on 11/29/18 at 11:19 A.M., the MDS Coordinator said the following:
-He/she will go to reports look at the due dates of the MDSs, print out a PDF report card
to help determine when MDSs are to be completed;
-If the resident goes to the hospital he/she completes a discharge assessment, a reentry
when they return, and then a quarterly after the the resident is in the facility for three
months;
-He/she completes three quarterly MDS after a reentry then the annual; and
-Annual assessments are completed yearly.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure the resident and/or
representative received a written summary of the baseline care plan (initial plan for
delivery of care and services) for three residents (Resident #46, #52, and #69) out of
three residents sampled for baseline care plans. The facility census was 81.
1. Review of Resident #46’s medical record, showed:
– An admission date of [DATE];
– Baseline care plan completed on 6/11/18;
– Resident and/or the resident’s representative did not receive a summary of the baseline
care plan.
2. Review of Resident #52’s medical record, showed:
– An admission date of [DATE];
– Baseline care plan completed on 6/22/18;
– Resident and/or the resident’s representative did not receive a summary of the baseline
care plan.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 4) 3. Review of Resident #69’s medical record, showed: – An admitted ,[DATE]//18; – Baseline care plan completed on 10/10/18; – Resident and/or the resident’s representative did not receive a summary of the baseline care plan. During an interview on 11/29/18 at 4:55 P.M., the Director of Nursing said the facility has not been providing the resident and/or representative a written copy of the baseline care plan. The facility did not provide a policy on baseline care plans.
	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 Based on interview and record review, the facility failed to assure staff followed acceptable standards of practice by not following physician’s orders to administer a medication used to treat low blood sugar and did not notify a physician of abnormal blood sugar readings for two residents (Resident #52 and #76) out of two sampled residents for blood sugar monitoring. The facility census was 81. 1. Record review of Resident #52’s (MONTH) (YEAR) Physician’s Order Sheet (POS) showed: – [DIAGNOSES REDACTED]. – An order on 6/21/18 for accucheck (blood sugar monitoring) three times a day; – An order on 6/21/18 for [MEDICATION NAME] (a medication used to treat low blood sugar) 1 milligram (mg) injection as needed for blood sugar less than 60; – an order for [REDACTED]. Review of the resident’s medical record showed the following: – On 9/02/18 at 4:30 P.M., the resident’s blood sugar (bs) 51; – On 9/16/18 at 4:40 P.M., the resident’s bs 53; – On 9/18/18 at 7:00 A.M., the resident’s bs 55; – On 9/23/18 at 7:00 A.M., the resident’s bs 53; – On 9/24/18 at 7:00 A.M., the resident’s bs 48; – On 10/05/18 at 7:00 A.M., the resident’s bs 55; – On 10/7/18 at 4:30 P.M., the resident’s bs 406; – On 10/13/18 at 4:30 P.M., the resident’s bs 44; – On 10/18/18 at 4:30 P.M., the resident’s bs 55; – On 10/20/18 at 7:00 A.M., the resident’s bs 43; – On 10/27/18 at 7:00 A.M., the resident’s bs 47; – On 10/30/18 at 7:00 A.M., the resident’s bs 59; – On 11/22/18 at 7:00 A.M., the resident’s bs 410; – No documentation of administration of [MEDICATION NAME] or insta-glucose; – No documentation of interventions to raise low blood sugar; – No documentation of physician notification of low or high blood sugar readings. 2. Record review of Resident #76’s (MONTH) (YEAR) POS showed: – [DIAGNOSES REDACTED].>- An order on 4/24/18 for accucheck three times a day and at bedtime; – An order on 4/24/18 for [MEDICATION NAME] 1 mg. injection if unresponsive and unable to take by mouth;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
3. Review of Resident #69’s medical record, showed:
– An admitted ,[DATE]//18;
– Baseline care plan completed on 10/10/18;
– Resident and/or the resident’s representative did not receive a summary of the baseline
care plan.
During an interview on 11/29/18 at 4:55 P.M., the Director of Nursing said the facility
has not been providing the resident and/or representative a written copy of the baseline
care plan.
The facility did not provide a policy on baseline care plans.

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**
Based on interview and record review, the facility failed to assure staff followed
acceptable standards of practice by not following physician’s orders to administer a
medication used to treat low blood sugar and did not notify a physician of abnormal blood
sugar readings for two residents (Resident #52 and #76) out of two sampled residents for
blood sugar monitoring. The facility census was 81.
1. Record review of Resident #52’s (MONTH) (YEAR) Physician’s Order Sheet (POS) showed:
– [DIAGNOSES REDACTED].
– An order on 6/21/18 for accucheck (blood sugar monitoring) three times a day;
– An order on 6/21/18 for [MEDICATION NAME] (a medication used to treat low blood sugar) 1
milligram (mg) injection as needed for blood sugar less than 60;
– an order for [REDACTED].
Review of the resident’s medical record showed the following:
– On 9/02/18 at 4:30 P.M., the resident’s blood sugar (bs) 51;
– On 9/16/18 at 4:40 P.M., the resident’s bs 53;
– On 9/18/18 at 7:00 A.M., the resident’s bs 55;
– On 9/23/18 at 7:00 A.M., the resident’s bs 53;
– On 9/24/18 at 7:00 A.M., the resident’s bs 48;
– On 10/05/18 at 7:00 A.M., the resident’s bs 55;
– On 10/7/18 at 4:30 P.M., the resident’s bs 406;
– On 10/13/18 at 4:30 P.M., the resident’s bs 44;
– On 10/18/18 at 4:30 P.M., the resident’s bs 55;
– On 10/20/18 at 7:00 A.M., the resident’s bs 43;
– On 10/27/18 at 7:00 A.M., the resident’s bs 47;
– On 10/30/18 at 7:00 A.M., the resident’s bs 59;
– On 11/22/18 at 7:00 A.M., the resident’s bs 410;
– No documentation of administration of [MEDICATION NAME] or insta-glucose;
– No documentation of interventions to raise low blood sugar;
– No documentation of physician notification of low or high blood sugar readings.
2. Record review of Resident #76’s (MONTH) (YEAR) POS showed:
– [DIAGNOSES REDACTED].>- An order on 4/24/18 for accucheck three times a day and at
bedtime;
– An order on 4/24/18 for [MEDICATION NAME] 1 mg. injection if unresponsive and unable to
take by mouth;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 5) – An order on 4/24/18 for insta-glucose 40% gel one tube by mouth as needed for blood sugar less than 70. Review of the resident’s medical record showed the following: – On 9/18/18 at 6:30 A.M., the resident’s bs 59; – On 9/16/18 at 6:40 A.M., the resident’s bs 62; – On 9/22/18 at 6:00 A.M., the resident’s bs 59; – On 9/26/18 at 7:00 A.M., the resident’s bs 57; – On 9/27/18 at 7:00 A.M., the resident’s bs 58; – On 9/29/18 at 7:00 A.M., the resident’s bs 55, – On 9/30/18 at 6:30 A.M., the resident’s bs 63, – On 10/04/18 at 6:30 A.M., the resident’s bs 63, – On 10/05/18 at 7:00 A.M., the resident’s bs 55, – On 10/08/18 at 7:00 A.M., the resident’s bs 55, – On 10/11/18 at 7:00 A.M., the resident’s bs 51; – On 10/14/18 at 6:30 A.M. the resident’s bs 60; – On 10/19/18 at 6:30 A.M. the resident’s bs 69; – On 10/23/18 at 6:30 A.M. the resident’s bs 65; – On 10/29/18 at 6:30 A.M. the resident’s bs 57; – On 11/12/18 at 6:30 A.M. the resident’s bs 67; – On 11/16/18 at 6:30 A.M. the resident’s bs 55; – On 11/17/18 at 6:30 A.M. the resident’s bs 54; – On 11/20/18 at 6:30 A.M. the resident’s bs 64; – On 11/21/18 at 11:30 A.M. the resident’s bs 68; – On 11/22/18 at 6:30 A.M. the resident’s bs 67; – On 11/29/18 at 6:30 A.M. the resident’s bs 61; – No documentation of administration of [MEDICATION NAME] or insta-glucose; – No documentation of interventions to raise low blood sugar; – No documentation of physician notification. 3. During an interview on 11/301/8 at 9:00 A.M., Licensed Practical Nurse (LPN) K said he/she would call the physician if a resident’s blood sugar reading was less than 60 or higher than 400. He/she tries to raise a resident’s low blood sugar with food before giving [MEDICATION NAME] or insta-glucose. He/she said staff should document interventions and physician notification in the resident’s nursing notes but it doesn’t always get documented. He/she did not know why the physician was not notified when Resident #52 had abnormal blood sugar readings. During an interview on 11/30/18 at 9:30 A.M., the Director of Nursing (DON) said the facility does not have any protocols for staff to follow regarding low and high blood sugar readings. She said she expects staff to hold a resident’s insulin if below 60 and to call the resident’s physician. She said she expects staff to call the resident’s physician if the resident’s blood sugar reading is above 350. She said she expects staff to follow physician’s orders. During an interview on 11/30/18 at 10:31 A.M., LPN L said he/she would call the physician if the resident’s blood sugar was less than 60 or above 500. He/she said he/she did not know why the physician was not notified of Resident #52’s low blood sugar readings. During an interview on 11/29/18 at 10:45 A.M., Registered Nurse (RN) B said he/she did not have an answer as to what he/she does when notified by staff of an abnormally low or high blood sugar. RN B said he/she was not aware of a facility policy regarding blood sugar monitoring. He/she did not know why the physician was not notified when Resident #76 had abnormal blood sugar readings.

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– An order on 4/24/18 for insta-glucose 40% gel one tube by mouth as needed for blood
sugar less than 70.
Review of the resident’s medical record showed the following:
– On 9/18/18 at 6:30 A.M., the resident’s bs 59;
– On 9/16/18 at 6:40 A.M., the resident’s bs 62;
– On 9/22/18 at 6:00 A.M., the resident’s bs 59;
– On 9/26/18 at 7:00 A.M., the resident’s bs 57;
– On 9/27/18 at 7:00 A.M., the resident’s bs 58;
– On 9/29/18 at 7:00 A.M., the resident’s bs 55,
– On 9/30/18 at 6:30 A.M., the resident’s bs 63,
– On 10/04/18 at 6:30 A.M., the resident’s bs 63,
– On 10/05/18 at 7:00 A.M., the resident’s bs 55,
– On 10/08/18 at 7:00 A.M., the resident’s bs 55,
– On 10/11/18 at 7:00 A.M., the resident’s bs 51;
– On 10/14/18 at 6:30 A.M. the resident’s bs 60;
– On 10/19/18 at 6:30 A.M. the resident’s bs 69;
– On 10/23/18 at 6:30 A.M. the resident’s bs 65;
– On 10/29/18 at 6:30 A.M. the resident’s bs 57;
– On 11/12/18 at 6:30 A.M. the resident’s bs 67;
– On 11/16/18 at 6:30 A.M. the resident’s bs 55;
– On 11/17/18 at 6:30 A.M. the resident’s bs 54;
– On 11/20/18 at 6:30 A.M. the resident’s bs 64;
– On 11/21/18 at 11:30 A.M. the resident’s bs 68;
– On 11/22/18 at 6:30 A.M. the resident’s bs 67;
– On 11/29/18 at 6:30 A.M. the resident’s bs 61;
– No documentation of administration of [MEDICATION NAME] or insta-glucose;
– No documentation of interventions to raise low blood sugar;
– No documentation of physician notification.
3. During an interview on 11/301/8 at 9:00 A.M., Licensed Practical Nurse (LPN) K said
he/she would call the physician if a resident’s blood sugar reading was less than 60 or
higher than 400. He/she tries to raise a resident’s low blood sugar with food before
giving [MEDICATION NAME] or insta-glucose. He/she said staff should document interventions
and physician notification in the resident’s nursing notes but it doesn’t always get
documented. He/she did not know why the physician was not notified when Resident #52 had
abnormal blood sugar readings.
During an interview on 11/30/18 at 9:30 A.M., the Director of Nursing (DON) said the
facility does not have any protocols for staff to follow regarding low and high blood
sugar readings. She said she expects staff to hold a resident’s insulin if below 60 and to
call the resident’s physician. She said she expects staff to call the resident’s physician
if the resident’s blood sugar reading is above 350. She said she expects staff to follow
physician’s orders.
During an interview on 11/30/18 at 10:31 A.M., LPN L said he/she would call the physician
if the resident’s blood sugar was less than 60 or above 500. He/she said he/she did not
know why the physician was not notified of Resident #52’s low blood sugar readings.
During an interview on 11/29/18 at 10:45 A.M., Registered Nurse (RN) B said he/she did not
have an answer as to what he/she does when notified by staff of an abnormally low or high
blood sugar. RN B said he/she was not aware of a facility policy regarding blood sugar
monitoring. He/she did not know why the physician was not notified when Resident #76 had
abnormal blood sugar readings.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0658 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 6) During an interview on 11/30/18 at 9:45 A.M., Certified Medication Technician (CMT) C said he/she tells the charge nurse when an abnormally high or low blood sugar reading is taken and holds the resident’s insulin. During a telephone interview on 12/4/18 at 1:56 P.M., the physician’s nurse said the physician expects to be notified by the facility staff if a resident’s blood sugar is less than 60 or greater than 400. The physician expects facility staff to follow the resident’s orders. The facility did not provide a policy on blood sugar monitoring.
	F 0730 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	Observe each nurse aide’s job performance and give regular training. Based on interview and record review, the facility failed to ensure five of five randomly selected Certified Nurse Aides (CNA) received the required annual 12 hour resident care training. This deficient practice had the potential to affect all residents. The facility census was 81. 1. Review of the CNA individual in-service records, showed the following: – CNA E, hired 2/02/16, with 1.25 hours of in-service from 2/02/17-2/01/18; – CNA F, hired 9/01/15, with 1.5 hours of in-service training from 9/01/17-8/31/18; – CNA G, hired 11/14/16, with 3.25 hours of in-service training from 11/14/17-11/13/18; – CNA H, hired 7/12/16, with 4 hours of in-service training from 7/12/17-7/11/18; – CNA I, hired 4/25/16, with 50 minutes of in-service training from 4/25/17-4/24/18. During an interview on 11/30/18 at 8:45 A.M., the Staff Coordinator said the facility has been providing in-service training but has not been recording the length of time for all of the in-services. During an interview on 11/30/18 at 11:28 A.M., the Director of Nursing said she expects staff to record in-service training hours on the CNA in-service record. She said she expects CNA to attend 12 hours of in-service training each year. The facility did not provide a policy on in-service training.
	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, and distribute food under sanitary conditions. This affected all residents of the facility. The facility census was 81. 1. Observation of the kitchen on 11/27/18 at 10:15 A.M., showed: – Ten baking sheets had burned, baked on blackened areas around the edges; – Seven muffin pans had burned, baked on blackened areas around the edges; – Three frying pans had scratched areas on the frying surface; – Grease buildup on the sides of the deep fryer and on the floor behind the fryer; – Grease and dust debris inside the control knobs of the stove; – Grease buildup on the sides of the range; – The ice machine drain in the kitchen area lay in contact with the floor drain;

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
During an interview on 11/30/18 at 9:45 A.M., Certified Medication Technician (CMT) C said
he/she tells the charge nurse when an abnormally high or low blood sugar reading is taken
and holds the resident’s insulin.
During a telephone interview on 12/4/18 at 1:56 P.M., the physician’s nurse said the
physician expects to be notified by the facility staff if a resident’s blood sugar is less
than 60 or greater than 400. The physician expects facility staff to follow the resident’s
orders.
The facility did not provide a policy on blood sugar monitoring.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on interview and record review, the facility failed to ensure five of five randomly
selected Certified Nurse Aides (CNA) received the required annual 12 hour resident care
training. This deficient practice had the potential to affect all residents. The facility
census was 81.
1. Review of the CNA individual in-service records, showed the following:
– CNA E, hired 2/02/16, with 1.25 hours of in-service from 2/02/17-2/01/18;
– CNA F, hired 9/01/15, with 1.5 hours of in-service training from 9/01/17-8/31/18;
– CNA G, hired 11/14/16, with 3.25 hours of in-service training from 11/14/17-11/13/18;
– CNA H, hired 7/12/16, with 4 hours of in-service training from 7/12/17-7/11/18;
– CNA I, hired 4/25/16, with 50 minutes of in-service training from 4/25/17-4/24/18.
During an interview on 11/30/18 at 8:45 A.M., the Staff Coordinator said the facility has
been providing in-service training but has not been recording the length of time for all
of the in-services.
During an interview on 11/30/18 at 11:28 A.M., the Director of Nursing said she expects
staff to record in-service training hours on the CNA in-service record. She said she
expects CNA to attend 12 hours of in-service training each year.
The facility did not provide a policy on in-service training.

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,
and distribute food under sanitary conditions. This affected all residents of the
facility. The facility census was 81.
1. Observation of the kitchen on 11/27/18 at 10:15 A.M., showed:
– Ten baking sheets had burned, baked on blackened areas around the edges;
– Seven muffin pans had burned, baked on blackened areas around the edges;
– Three frying pans had scratched areas on the frying surface;
– Grease buildup on the sides of the deep fryer and on the floor behind the fryer;
– Grease and dust debris inside the control knobs of the stove;
– Grease buildup on the sides of the range;
– The ice machine drain in the kitchen area lay in contact with the floor drain;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0812 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many	(continued… from page 7) – Fifty steam table pans in various sizes have blackened areas around the edges; – Uncovered floor drain behind the stove; – The hand washing sink in the kitchen area measured 55.2 degrees when the hot water lever was in the on position; – The sink labeled hand washing in the serving area measured 56.8 degrees when the hot water lever was in the on position; – A white color substance and standing water under the steamer; – Oven racks covered with black burned on food particles 2 Observation of the kitchen on 11/30/18 at 9:15 A.M., showed: – Ten baking sheets had burned, baked on blackened areas around the edges; – Seven muffin pans had burned, baked on blackened areas around the edges; – Three frying pans had scratched areas on the frying surface; – Grease buildup on the sides of the deep fryer and on the floor behind the fryer; – Grease and dust debris inside the control knobs of the stove; – Grease buildup on the sides of the range; – The ice machine drain in the kitchen area lay in contact with the floor drain; – Fifty steam table pans in various sizes have blackened areas around the edges; – Uncovered floor drain behind the stove; – The hand washing sink in the kitchen area measured 55.6 degrees when the hot water lever was in the on position; – The sink labeled hand washing in the serving area measured 54.2 degrees when the hot water lever was in the on position; – A white color substance and standing water under the steamer; – Oven racks covered with black burned on food particles During an interview on 11/30/18 at 10:00 A.M., the Dietary Manager said she was new to the position, but agreed with all of the identified areas and that they are in need of being cleaned, repaired or replaced whatever it will take to address the identified areas. She said currently they do not have a cleaning schedule that they follow but she is going to implement one. During an interview with the Administrator on 11/30/18 at 10:30 A.M., she said they will develop and implement a cleaning schedule and she will monitor to ensure compliance. The facility did not have a policy to review regarding routine maintenance or cleaning in 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. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain infection control practices for three residents (Resident #3, #53 and #66) out of three sampled residents and one resident (Resident #81) outside the sample. This deficient practice had the potential to affect all residents in the facility. The facility census was 81. 1. Observation on 11/29/18 at 11:13 A.M., showed: – Certified Medication Technician (CMT) J placed the glucometer (machine used for blood sugar monitoring) on the top of the medication cart and then cleaned it for approximately 10 seconds with Clorox Bleach Wipe and placed on a paper towel uncovered; – CMT J used the glucometer to provide blood sugar screening for Resident #81;

(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 7)
– Fifty steam table pans in various sizes have blackened areas around the edges;
– Uncovered floor drain behind the stove;
– The hand washing sink in the kitchen area measured 55.2 degrees when the hot water
lever was in the on position;
– The sink labeled hand washing in the serving area measured 56.8 degrees when the hot
water lever was in the on position;
– A white color substance and standing water under the steamer;
– Oven racks covered with black burned on food particles
2 Observation of the kitchen on 11/30/18 at 9:15 A.M., showed:
– Ten baking sheets had burned, baked on blackened areas around the edges;
– Seven muffin pans had burned, baked on blackened areas around the edges;
– Three frying pans had scratched areas on the frying surface;
– Grease buildup on the sides of the deep fryer and on the floor behind the fryer;
– Grease and dust debris inside the control knobs of the stove;
– Grease buildup on the sides of the range;
– The ice machine drain in the kitchen area lay in contact with the floor drain;
– Fifty steam table pans in various sizes have blackened areas around the edges;
– Uncovered floor drain behind the stove;
– The hand washing sink in the kitchen area measured 55.6 degrees when the hot water
lever was in the on position;
– The sink labeled hand washing in the serving area measured 54.2 degrees when the hot
water lever was in the on position;
– A white color substance and standing water under the steamer;
– Oven racks covered with black burned on food particles
During an interview on 11/30/18 at 10:00 A.M., the Dietary Manager said she was new to the
position, but agreed with all of the identified areas and that they are in need of being
cleaned, repaired or replaced whatever it will take to address the identified areas. She
said currently they do not have a cleaning schedule that they follow but she is going to
implement one.
During an interview with the Administrator on 11/30/18 at 10:30 A.M., she said they will
develop and implement a cleaning schedule and she will monitor to ensure compliance.
The facility did not have a policy to review regarding routine maintenance or cleaning in
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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to maintain
infection control practices for three residents (Resident #3, #53 and #66) out of three
sampled residents and one resident (Resident #81) outside the sample. This deficient
practice had the potential to affect all residents in the facility. The facility census
was 81.
1. Observation on 11/29/18 at 11:13 A.M., showed:
– Certified Medication Technician (CMT) J placed the glucometer (machine used for blood
sugar monitoring) on the top of the medication cart and then cleaned it for approximately
10 seconds with Clorox Bleach Wipe and placed on a paper towel uncovered;
– CMT J used the glucometer to provide blood sugar screening for Resident #81;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few	(continued… from page 8) – CMT J cleaned the glucometer with Clorox Bleach Wipe for approximately 10 seconds and placed on a paper towel uncovered; – CMT J used the glucometer to provide blood sugar screening Resident #66; – CMT J cleaned the glucometer with Clorox Bleach Wipe for approximately 10 seconds and placed on a paper towel uncovered. During an interview on 11/29/18 at 11:45 A.M., CMT J said he/she had been taught to wipe the glucometer with a bleach wipe for just a few seconds and allow to air dry. 2. Observation on 11/29/18 at 12:10 P.M., showed: – Registered Nurse (RN) B placed the glucometer on the top of the medication cart and then cleaned it for approximately 15 seconds with Clorox Bleach Wipe and placed on a paper towel uncovered; – RN B entered Resident #53’s room, he/she placed the blood sugar monitoring supplies on dirty surface of the resident’s bed; – RN B performed blood sugar monitoring for Resident #53; – RN B placed the glucometer (machine used for blood sugar monitoring) on the top of the medication cart and then cleaned it for approximately six seconds with Clorox Bleach Wipe and placed on a paper towel uncovered; – RN B entered Resident #3’s room and used the glucometer to performed blood sugar monitoring for Resident #3; During an interview on 11/29/18 at 12:25 P.M., RN B said he/she used the wipe for about 20 seconds and should have cleaned it for a minute to disinfect the glucometer. During an interview on 11/30/18 at 9:03 A.M., the DON said: – She would expect staff to follow recommended manufacturer’s instructions on cleaning of the glucometer’s. Review of manufacturer’s Cleaning and Disinfecting Procedures for the glucometer showed: – The glucometer should be cleaned and disinfected between each patient; – Environmental Protection Agency (EPA) registered germicidal or bleach wipes may be used to clean and disinfect if approved for use in healthcare settings and for surface cleaning. Review of manufacturer’s disinfection directions showed the surface to be wiped with Clorox Bleach Wipes and to have contact time (amount of time a surface must remain wet with product to achieve disinfection) of one minute for blood borne pathogens and three minutes for the prevention of [MEDICAL CONDITION] (C.diff) cross contamination and allow to air dry. Use as many wipes as needed to achieve contact time. Record review of the facility’s infection control when glucose monitoring policy, no date, showed when procedure completed to follow the manufacturer’s instruction for use and care for the type of equipment used in the facility.
	F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	Develop and implement policies and procedures for flu and pneumonia vaccinations. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide information and education to each resident or the resident’s representative of the pneumococcal vaccines, and offer the pneumococcal vaccines upon admission to five residents (Resident #39, #46, #66, #68, and #69) of five sampled residents for immunizations. The facility census was 81. 1. Review of the US Department of Health and Human Services Centers for Disease Control

(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 – Few

(continued… from page 8)
– CMT J cleaned the glucometer with Clorox Bleach Wipe for approximately 10 seconds and
placed on a paper towel uncovered;
– CMT J used the glucometer to provide blood sugar screening Resident #66;
– CMT J cleaned the glucometer with Clorox Bleach Wipe for approximately 10 seconds and
placed on a paper towel uncovered.
During an interview on 11/29/18 at 11:45 A.M., CMT J said he/she had been taught to wipe
the glucometer with a bleach wipe for just a few seconds and allow to air dry.
2. Observation on 11/29/18 at 12:10 P.M., showed:
– Registered Nurse (RN) B placed the glucometer on the top of the medication cart and then
cleaned it for approximately 15 seconds with Clorox Bleach Wipe and placed on a paper
towel uncovered;
– RN B entered Resident #53’s room, he/she placed the blood sugar monitoring supplies on
dirty surface of the resident’s bed;
– RN B performed blood sugar monitoring for Resident #53;
– RN B placed the glucometer (machine used for blood sugar monitoring) on the top of the
medication cart and then cleaned it for approximately six seconds with Clorox Bleach Wipe
and placed on a paper towel uncovered;
– RN B entered Resident #3’s room and used the glucometer to performed blood sugar
monitoring for Resident #3;
During an interview on 11/29/18 at 12:25 P.M., RN B said he/she used the wipe for about 20
seconds and should have cleaned it for a minute to disinfect the glucometer.
During an interview on 11/30/18 at 9:03 A.M., the DON said:
– She would expect staff to follow recommended manufacturer’s instructions on cleaning of
the glucometer’s.
Review of manufacturer’s Cleaning and Disinfecting Procedures for the glucometer showed:
– The glucometer should be cleaned and disinfected between each patient;
– Environmental Protection Agency (EPA) registered germicidal or bleach wipes may be used
to clean and disinfect if approved for use in healthcare settings and for surface
cleaning.
Review of manufacturer’s disinfection directions showed the surface to be wiped with
Clorox Bleach Wipes and to have contact time (amount of time a surface must remain wet
with product to achieve disinfection) of one minute for blood borne pathogens and three
minutes for the prevention of [MEDICAL CONDITION] (C.diff) cross contamination and allow
to air dry. Use as many wipes as needed to achieve contact time.
Record review of the facility’s infection control when glucose monitoring policy, no date,
showed when procedure completed to follow the manufacturer’s instruction for use and care
for the type of equipment used in the facility.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide information and
education to each resident or the resident’s representative of the pneumococcal vaccines,
and offer the pneumococcal vaccines upon admission to five residents (Resident #39, #46,
#66, #68, and #69) of five sampled residents for immunizations. The facility census was
81.
1. Review of the US Department of Health and Human Services Centers for Disease Control

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.


	F 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 9) (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: – CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate vaccine (PCV 13, Prevnar 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV 23, [MEDICATION NAME] 23); – CDC recommends vaccination with PCV 13 for all adults [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions; – CDC recommends vaccination with PPSV 23 for all adults [AGE] years or older and adults 19 through [AGE] years old with certain medical conditions. 2. Review of Resident #39’s medical record showed: – The resident admitted on [DATE]; – The resident [AGE] years old; – [DIAGNOSES REDACTED]. – Staff did not document the resident’s pneumococcal vaccine history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; – Staff did not obtain a signed consent/refusal form for both vaccines. 3. Review of Resident #46’s medical record showed: – The resident admitted on [DATE]; – The resident [AGE] years old; – [DIAGNOSES REDACTED]. – Staff did not document the resident’s pneumococcal vaccine history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; – Staff did not obtain a signed consent/refusal form for both vaccines. 4. Review of Resident #66’s medical record showed: – The resident admitted on [DATE]; – The resident [AGE] years old; – [DIAGNOSES REDACTED]. – Staff did not document the resident’s pneumococcal vaccine history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; – Staff did not obtain a signed consent/refusal form for both vaccines. 5. Review of Resident #68’s medical record showed: – The resident admitted on [DATE]; – The resident [AGE] years old; – [DIAGNOSES REDACTED]. – Staff did not document the resident’s pneumococcal vaccine history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; – Staff did not obtain a signed consent/refusal form for both vaccines. 6. Review of Resident #69’s medical record showed: – The resident admitted on [DATE]; – The resident [AGE] years old; – [DIAGNOSES REDACTED]. – Staff did not document the resident’s pneumococcal vaccine history; – Staff did not document education provided to the resident or representative regarding the benefits and potential side effects of the pneumococcal vaccines; – Staff did not obtain a signed consent/refusal form for both vaccines. During an interview on 11/30/18 at 9:39 A.M., the Director of Nursing said she expects

(X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
(CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following:
– CDC recommends two pneumococcal vaccines for adults: 13-valent pneumococcal conjugate
vaccine (PCV 13, Prevnar 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV
23, [MEDICATION NAME] 23);
– CDC recommends vaccination with PCV 13 for all adults [AGE] years or older and adults 19
through [AGE] years old with certain medical conditions;
– CDC recommends vaccination with PPSV 23 for all adults [AGE] years or older and adults
19 through [AGE] years old with certain medical conditions.
2. Review of Resident #39’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtain a signed consent/refusal form for both vaccines.
3. Review of Resident #46’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtain a signed consent/refusal form for both vaccines.
4. Review of Resident #66’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtain a signed consent/refusal form for both vaccines.
5. Review of Resident #68’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtain a signed consent/refusal form for both vaccines.
6. Review of Resident #69’s medical record showed:
– The resident admitted on [DATE];
– The resident [AGE] years old;
– [DIAGNOSES REDACTED].
– Staff did not document the resident’s pneumococcal vaccine history;
– Staff did not document education provided to the resident or representative regarding
the benefits and potential side effects of the pneumococcal vaccines;
– Staff did not obtain a signed consent/refusal form for both vaccines.
During an interview on 11/30/18 at 9:39 A.M., the Director of Nursing said she expects

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265701

(X2) MULTIPLE CONSTRUCTION
A. BUILDING	___________
B. WING	___________

(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOE MANOR

STREET ADDRESS, CITY, STATE, ZIP

10 LAKE DRIVE
BONNE TERRE, MO 63628

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 0883 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some	(continued… from page 10) staff to document a resident’s pneumococcal vaccines history, educate the resident and/or family, and offer both types of the pneumococcal vaccines. The facility did not provide a policy on pneumococcal vaccines.

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