Friendship Village Chesterfield

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate assistance to prevent accidents when staff failed to use a gait belt and to lock a resident's wheelchair during an assisted transfer, causing the resident to fall (Resident #1). The sample was 3. The census was 92. The administrator was notified on 4/3/26 of the past non-compliance, which occurred on 12/15/25. The facility in-serviced staff regarding safe transfer protocols and staff demonstrated understanding. The deficiency was corrected on 12/16/25. Review of the facility's Transfer Techniques policy, dated August 2019, showed:-Purpose: To transfer the resident from bed to chair and chair to bed safely;-General Instructions:--Identify if resident is wearing proper fitting, non-skid footwear with laces tiedsecurely;-- Resident should move toward the unaffected side (exception: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity. One resident (Resident #3) required staff assistance with mobility and personal care needs. Staff left the resident alone in the bathroom while seated on the toilet and again while the resident hovered over the toilet. Staff made comments about their dislike of the job and/or level of care the resident required. In addition, during a transfer from the wheelchair to the bed, the resident was not properly assisted into bed and was left with legs hanging off the bed. The sample was five. The census was 82. The administrator was notified on 2/21/25, of the past non-compliance. The facility has in-serviced staff and are monitoring staff and resident interactions. The deficiency was corrected on 2/20/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from accident hazards after one resident (Resident #2) reported an injury to the left ankle during a Hoyer lift (full body mechanical lift) transfer. The investigation found staff reported several improper transfers had occurred in the days preceding the injury, to include the resident being transferred with a sit to stand lift (mechanical lift that requires residents to be able to stand with assistance) several days before and one Certified Nursing Assistant (CNA) reported he/she operated the Hoyer lift alone one day instead of using two staff as required. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. Problems were noted in one of two identified facility medication rooms and in two of four medication administration carts. The facility census was 84. Review of the facility's Medication Storage in the Facility policy, no noted revision date, showed: -Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Outdated, contaminated, or deteriorated drugs and biologicals in containers which are cracked, soiled, or without closure will be immediately withdrawn from stock. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis access sites and wounds requiring treatments (Residents #70 and #11). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) received a minimum of 12 hours of ongoing education annually for four out of five sampled CNAs (CNA Q, CNA N, Certified Medicine Technician (CMT) R and CNA P). The census was 84. A policy related to CNA 12-hour training was not provided by the facility. 1. Review of CNA Q's employee file showed: -Hire date: 5/18/23; -CNA hours of training completed: 0. 2. Review of CNA N's employee filed showed: -Hire date: 3/23/23; -CNA hours of training completed: 3. 3. Review of CMT R's employee file showed: -Hire Date: 3/16/09; -CNA hours of training completed: 10.6. 4. Review of CNA P's employee file showed: -Hire Date: 10/2/14; -CNA hours of training completed: 11.7. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice when the facility failed to complete neuro checks (neurological assessments) following unwitnessed falls for two residents, including one fall in which the resident reported he/she hit his/her head (Residents #41 and #27). The sample was 18. The census was 84. Review of the facility's Fall policy, dated August 2019, showed: -Policy: It is the policy of this facility to evaluate each resident immediately after a fall; -Procedure included: -If the fall was unwitnessed or involved a potential head injury, initiate neurological assessment per facility policy; -Document relevant post-fall clinical findings, such as neurological checks, in the resident's record. Review of the facility's Neurological Checks policy, revised January 2022, showed: -Policy: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene in accordance with their needs and preferences (Residents #24 and #11). The sample was 18. The census was 84. Review of the facility's AM (morning) Care policy, dated August 2019, showed: -Policy: It is the policy of this facility to provide the necessary morning care and services based upon the comprehensive assessment of a resident and consistent with the resident's needs and choices, or order to maintain or improve a resident's ability to carry out the activities of daily living; -Purpose included: -To prepare the resident for their day; -To maintain oral health and bodily hygiene; -To provide for physical comfort; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a pre-assessment and post assessment communication form to the dialysis center for one resident (Resident #11) receiving hemodialysis (a treatment to clean the body's blood supply of impurities). The sample was 18. The census was 84. Review of the facility's Hemodialysis Access Policy revised, 1/10/18, showed: -Documentation (for Dialysis Communication forms): -Location of the hemodialysis access point; -Condition of the dressing and any interventions required at the time of assessment; -Prior date or shift of dialysis completed; -Report received from dialysis clinic registered nurse (RN); -Resident observation post-dialysis from nurse assessment of resident and access site; -Physician notifications of unusual observations. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication administration error rate of less than 5%. Out of 25 opportunities for error, three errors occurred, resulting in a medication error rate of 12% which affected two residents (Residents #34 and #9). The sample was 18. The facility census was 84. Review of the facility's Medication Administration policy, revised 8/2019, showed: -All personnel administering medications will ensure that the medication given is the correct medication, the correct dose, the correct person, the correct administration time, and the correct route of administration. 1. Review of Resident #34's physician order sheet (POS), showed an active physician order for Refresh Tears eye drops to be given once daily. Observation and interview on 9/10/24 at 6:45 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent staff misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) for four residents (Residents #1. #2, #3 and #4). This had the potential to affect all residents with controlled substance orders. The census was 82. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, dated 10/2022, showed: -Preface: [...]

Inspectors wroteBased on interview and record review, the facility failed to document on the individual patient narcotic record and the electronic Treatment Administration Record (eTAR) after administering a controlled substance medication to four out of four sampled residents (Residents #1, #2, #3 and #4). The facility also failed to document the effectiveness of pain medication after it was administered to four out of four sampled residents (Residents #1, #2, #3 and #4). In addition, the facility failed to document on the Individual Patient Narcotic Record (IPNR) the signature of the nurse receiving the controlled medication and the date it was received. The facility also failed to update the order on the IPNR when the order changed. This had the potential to affect all residents with pain medication orders and controlled substance orders. The census was 82. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system for records of disposition of all controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) in sufficient detail to enable an accurate reconciliation for three out of three controlled substance shift change count sheets reviewed. In addition, the facility failed to have a system in place to document the destruction in sufficient detail of controlled substances when controlled medications were removed from stock for four out of four sampled residents (Residents #1, #2, #3 and #4). This had the potential to affect all residents with controlled substance orders. The census was 82. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent further misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) by not following the facility's policy for suspension during an investigation. Licensed Practical Nurse (LPN) C reported alleged violations of misappropriation/diversion by LPN A on the morning of 4/23/24 at 7:02 A.M. The facility allowed LPN A to work the evening shift on 4/23/24 while the facility investigated the allegation. LPN B continued the misappropriation/diversion with three residents (Residents #1, #3 and #4) when LPN B was not suspended. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required timeline after a resident (Resident #1) reported a staff member injured his/her arm while providing care. The sample size was three. The census was 79. The Administrator was notified on 10/19/23, of the past non-compliance. The facility has in-serviced all staff on the Abuse Policy: Reporting and Response. The deficiency was corrected on 10/18/23. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated 8/19, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for four of 10 sampled employees hired since the last survey. The facility hired at least 300 new employees since the last survey. The census was 79. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, dated 8/2019, showed the following: -Policy: It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to conduct neurological checks following unwitnessed falls for 1 (Resident #75) of 4 residents who were reviewed for falls.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to conduct a root cause analysis into resident falls to identify a potential accident hazard for 1 (Resident #75) of 4 residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to keep the water temperatures between 105 to 120 degrees Fahrenheit (°F). This affected eight resident rooms where 14 residents resided. The facility census was 84. 1. Review of the hot water temperature logs showed: - On 9/12/19 the water temperatures ranged from 87 to 114 °F; - On 9/19/19 the water temperatures ranged from 106 to 110 °F; - On 9/25/19 the water temperatures ranged from 106 to 110 °F; - On 10/3/19 the water temperatures ranged from 108 to 112 °F; - None of the hot water temperatures were taken out of a resident's room. Observation and interview on 10/9/19, at 2:00 P.M., showed six hot water heaters in the utility room all set to 140 °F. Two circulation pumps were in line with the hot water. [...]

Inspectors wroteBased on record review, observation, and interview, the facility staff failed to establish a policy that provided guidance about labeling, dating, and disposing of food brought to residents from outside sources. Facility staff failed to store food under sanitary conditions when they failed to dispose of expired milk, failed to label the contents of food stored in one-time use containers and place a disposal date on any food item brought into the facility. This deficient practice had the potential to affect 31 residents who receive food from the nutrition center that serves residents of [NAME] Avenue and Main Street. The facility census was 84. Review of the Food Safety Requirements-Use and Storage of Food and Beverage Brought in for Residents, Food Procurement policy dated 08/19 showed: [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure all hoses that extended below the flood plain had a backflow preventer (an anti-siphon device used to keep potentially toxic water from backing up into the potable water supply). This affected three of four shower hoses. The facility census was 84. Observation on 10/9/19, starting at 3:52 P.M., showed shower hoses extended below the flood plain (the hose length extended all the way to the floor): -No backflow preventer on the shower hose in the shower room next to room [ROOM NUMBER] (Main Street). -No backflow preventer on the shower hose in the shower room next to room [ROOM NUMBER] ([NAME] Avenue). -No backflow preventer on the shower hose in the shower room next to room [ROOM NUMBER] (Grand Avenue). [...]