ST JOHNS PLACE

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

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

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

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

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

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

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

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

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