Gasconade Manor Nursing Home

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear Personal Protective Equipment (PPE) (gowns, gloves and/or eye protection), and failed to use appropriate hand hygiene and glove use for five residents (Residents #5, #6, #8, #34, and #42) out of 18 sampled while performing catheter care, wound care, and mechanical lift transfers. The facility census was 61. 1. Review of the facility policy titled Policy for Enhanced Barrier Precautions, dated 04/01/24, showed the facility will implement EBP beginning April 1, 2024, and EBP is designed to reduce the transmission of Multi-Drug-Resistant Organisms (MDROs), a germ that is resistant to many antibiotics, throughout the facility. Residents will be identified for EBP if they meet the following criteria: [...]

Inspectors wroteBased on record review and interview, facility staff failed implement the facility's policy by not checking the Employee Disqualification List (EDL) quarterly for six staff (Certified Nurse Aide (CNA) T, Housekeeper U, Licensed Practical Nurse (LPN) N, Dietary Aide (DA) V, Registered Nurse (RN) W and Certified Medication Technician (CMT) P) of 10 sampled staff. The facility census was 61.1. Review of the facility's policy titled Employee Disqualification List Protocol, dated 06/17/24, instructed staff to complete quarterly re-checks, they must review new EDL listings to ensure no current employees are disqualified. 2. Review of CNA T's employee file showed a quarterly EDL check had not been completed since his/her hire date of 02/15/25. 3. Review of Housekeeper U's employee file showed a quarterly EDL check had not been completed since his/her hire date of 09/03/24. 4. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct inspections of bedrails as a part of regular maintenance program for one resident (#57) and failed to remeasure and reassess all possible entrapment zones for three residents (Resident #2, #8, #9) out of 18 residents sampled. The facility census was 61. Based on observation, interview, and record review, facility staff failed to conduct inspections of bedrails as a part of regular maintenance program for one resident (#57) and failed to remeasure and reassess all possible entrapment zones for three residents (Resident #2, #8, #9) out of 18 residents sampled. The facility census was 61. 1. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #6, #38, and #57) out of 17 residents sampled. The facility census was 61.1. Review of the facility's policy titled Bed Hold Policy, dated 10/17/23, showed in the event a resident leaves the facility for hospitalization, a charge will not be calculated with anticipated return. 2. Review of Resident #6's medical record showed staff documented the resident discharged from the facility on 04/04/25 to the hospital and returned on 04/10/25. The medical record did not contain documentation staff issued a bed hold upon discharge to the resident or the resident's responsible party, and did not notify the ombudsman of the transfer/discharge. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure multi-dose medications were dated when opened in one out of two medication storage carts. The facility census was 61.1. Review of the facility's policy titled Medication Protocol, undated, showed facility staff were directed daily to label/record date when stock medication is opened and check for expired medications.2. [...]

Inspectors wroteBased on observation and interview, the facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. This failure has the potential to affect all residents. The facility census was 61. 1. Observation on 05/28/24 at 10:35 A.M., showed the Certified Dietary Manager (CDM) washed a rack of soiled cups in the chemical sanitizing mechanical dishwasher. Observation showed the CDM did not check the temperature of the dishwasher during the cycle. Observation showed the gauge of the dishwasher registered the water temperature during the wash cycle as 110 degrees Fahrenheit (dF) and the water temperature of the rinse cycle registered 112 dF. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for two residents (#3 and #54) out of two sampled residents. The facility census was 61. 1. Review of the facilities policy titled, Resident acitvity policy, undated, states activities refer to an endeavor, other than routine Activities of Daily Living (ADLs) in which a resident participates that is intended to enhance his/her sense of well-being and to promote physical, cognitive, emotional health. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5% out of 25 opportunities observed, two errors occurred, resulting in a 8% error rate, which affected one resident (Residents #2) of 11 sampled residents. The facility census was 61. 1. Review of the facility's, Insulin Administration Policy, not dated, showed if using an insulin pen, prime needle with two units prior to dialing to the amount of insulin. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/09/24, showed staff documented the resident diagnosis of Diabetes and received insulin injections seven days of the seven days in the look back period. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the required nurse staffing information in an easily accessible place for residents and visitors, and failed to include the required data in the posting. The facility census was 61. 1. Review of the facility's policy titled, Posted Nursing Data, dated 10/23/23, showed per state and federal guidelines, it is the policy of the facility that the day charge nurse post the following data on a daily basis located at the skilled nurses station area: Facility name, current date, census, number of Registered Nurses (RN), Licensed Piratical Nurses (LPN), and Certified Nurse Aides (CNA). Observation on 05/30/24 at 2:00 P.M., showed the nurse staff posting at the nurse's desk behind a locked door, not easily accessible to residents and visitors. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to wear hair restraints to protect food and food-contact surfaces from potential contamination. The facility census was 60. 1. Review of the facility's Food Storage policy, dated 11/01/17, showed the policy directed staff to store food obtained for use by the facility for consumption by the residents properly in the kitchens and the refrigerators and freezers are to be maintained by the dietary staff. [...]

Inspectors wroteBased on record review and interview, the facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a registry that is a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check in accordance with their policy prior to start date for 10 employees (Maintenance Worker L, Dietary Aid (DA) M, Housekeeping Aid N, Licensed Practical Nurse (LPN) O, LPN P, Certified Medical Technician (CMT) E, CMT A, Environmental Aid Q, NA R and Human Resource Director) out of 10 sampled employees. The facility census was 60. 1. Review of the facility's Abuse/Neglect policy, undated, showed: - The facility will not hire or maintain in employment a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide the necessary care and services to maintain good personal hygiene for three sampled residents (Residents #4, #15, and #39) that were unable to perform their own activities of daily living (ADL), and failed to answer call lights in a timely manner for one resident (Resident #28). The facility census was 60. 1. Review of the facility's Bath and Shower policy, dated 10/10/22 showed: -It is the policy of the facility to allow residents their choice with their bath/shower regimen and schedule; -Resident are allowed to choose their preferred time of their bath/shower; -Residents will be bathed/showered minimally twice per week; -Residents have the right to request more showers/baths as they feel needed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when staff failed maintain a clean blood glucose meter (device used to obtain a blood sugar reading) between residents (Resident #15, #4, and #13). The facility census was 60. 1. Review of the facility's Blood Glucose Monitoring Device Care policy, undated, showed: -It is the mission of the facility to prevent transmission of pathogens through blood glucose monitoring devices; -Blood glucose monitoring devices must be disinfected by staff with hydrogen peroxide and/or Clorox wipes before and after each use; -Blood glucose monitoring devices are to be placed in a caddy and carried into the resident room; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one or more individuals completed specialized training in infection prevention and control (IPC) prior to assuming the role of infection preventionist (IP) for the facility's infection prevention and control program. The census was 60. 1. Review of the Centers for Disease Control and Prevention (CDC) website showed: -The Nursing Home Infection Preventionist Training course is designed for individuals responsible for infection prevention and control (IPC) programs in nursing homes; -The course is made up of 23 modules and sub-modules that can be completed in any order and over multiple sessions. Review of the IP's CDC training transcript showed three modules were completed in January 2022 and seven modules in May 2022. Further review showed no additional modules had been completed since May 2022. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for three (Residents #19, #40 and #47) of seven sampled residents. The facility also failed to ensure Resident #51 was offered the flu vaccine. The facility census was 61. 1. Review of the facility's Influenza/pneumococcal vaccination policy, last reviewed October 2022 showed: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to all residents and visitors on the rehabilitation unit. The facility census was 60. 1. Review of the policies provided by the facility showed they did not contain a policy for the required postings. Observations from 2/20/23 at 10:00 A.M. through 2/23/23 at 1:00 P.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents or visitors to use if needed on the rehabilitation unit. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the most recent survey results were posted and readily accessible to residents, family member or representatives of residents. This has the potential to affect all residents in the facility. The facility census was 60. 1. Review of the facility's Resident Rights policy showed the policy did not include information on survey results. Observation on 2/20/23 at 11:00 A.M., showed a table in the entrance of the facility with a sign pointing down with the words last years survey results printed on it. The table did not contain the survey results. Observation on 2/23/23 at 1:00 A.M., showed a table in the entrance of the facility with a sign pointing down with the words last years survey results printed on it. The table did not contain the survey results. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 60. 1. Review of the facility's Grievance policy, undated, showed staff were directed as follows: - The grievance officer is responsible for ensuring that all grievances include; - The date the grievance was received; - A summary statement of the residents grievance; - The steps taken to investigate the grievance; - A summary of the pertinent findings or conclusions regarding the residents' concerns; - At statement as to whether the grievance was confirmed or not confirmed; - Any corrective action taken or to be taken by the facility as a result of the grievance; - The date the written decision was made. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship program and a system to monitor appropriate antibiotic use. The facility census was 60. 1. Review of the facility's Infection Control Program, undated, showed: -Infection Control Program includes: -Review of Monthly infection reports with corrective actions taken by facility if needed; -Antibiotic stewardship program. Review of the facility's Antibiotic Stewardship policy, undated showed: -The facility will implement and maintain an Antibiotic Stewardship Program with the mission to promote the appropriate use of antibiotics while optimizing the treatment of infections; [...]

Inspectors wroteBased on interview and record review, facility staff failed to develop and implement policies and procedures to ensure 100% of staff were fully vaccinated for COVID-19 (a highly contagious virus that causes serious illness or death) or have been granted a qualifying exemption, or have a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC) for three staff members (Certified Nurse Assistant (CNA) J, CNA T and Employee U) out of 107. The facility census was 60. 1. Review of the facility's COVID-19 Vaccination Policy, undated, showed: -When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident or staff member has already been immunized; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a system that assured a full and complete accounting of each resident's personal funds, for all residents that had funds entrusted to the facility on the resident's behalf. Staff failed to provide a description or written receipt for all transactions for two of five sampled residents (Resident #20 and #33) or their designees. The facility census was 60. 1. Review of the facility's policies showed staff did not provide a policy for resident funds. 2. Review of the Resident #20's monthly fund summary for November 2022 showed: -The resident had 50 dollars deposited in his/her envelope; -The resident had two envelope withdrawals totaling 50 dollars; -The summary did not provide dates for deposits or withdrawals; -The summary did not provide a description of the withdrawals. [...]