Lutheran Senior Services at Meramec Bluffs

Inspectors wroteBased on observation, interview and record review, the facility failed to notify Next of Kin (NOK) of a resident fall for one resident (Resident #1). The sample size was three. The census was 67. Review of the facility's Event Reporting Policy, revised 7/29/21, showed: -Policy statement: Event reporting is essential to providing resident and client care. Events involving a resident, visitor, or other person (non-employee) that are outside of usual or normal happenings and present a potential liability, and events that are not in keeping with standards, policies, procedures or practices and may have an adverse outcome will be documented. The documentation of an event and its investigation, outside of what is documented in the medical chart, is confidential. Applicable authorities will be notified as appropriate. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services per acceptable standards of practice for one resident (Resident #1), when facility staff failed to use a gait belt when transferring the resident from the floor to the wheelchair. The sample size was 3. The census was 67. Review of the facility's Event Reporting Policy, revised 7/29/21, showed: -Policy statement: Event reporting is essential to providing resident and client care. Events involving a resident, visitor, or other person (non-employee) that are outside of usual or normal happenings and present a potential liability, and events that are not in keeping with standards, policies, procedures or practices and may have an adverse outcome will be documented. The documentation of an event and its investigation, outside of what is documented in the medical chart, is confidential. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #20) with limited mobility, received appropriate equipment and assistance to maintain mobility when staff failed to ensure the resident wore palm protectors properly and daily in accordance with physician orders and recommendations by therapy to address hand contractures (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement). The sample was 12. The census was 43 with 29 residents in certified beds. Review of Resident #20's medical record, showed: -Diagnoses included contracture to unspecified joint, Alzheimer's disease, and dementia; -A physician order, dated 5/23/24, for restorative - splint/brace. Please place splints on resident's hands every day and remove every night. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer call lights in a timely manner and to ensure all clinical nursing staff carried a call light pager per the facility's call light exception, approved by the Department of Health and Senior Services (DHSS). This affected three of three residents sampled for call light concerns (Residents #18, #8 and #1). The census was 68 with 24 residents in certified beds. Review of the facility's exception letter, approved by DHSS, dated 7/28/20, showed for each approval listed, the facility is required to comply with the stipulations that follow: -The operator will ensure that all direct care staff carry and utilize the wireless nurse call pagers at all times; -The operator will ensure that a wireless nurse call system report is available for review upon request. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to store food in accordance with professional standards for food service safety, by failing to cover stored food and by failing to completely air-dry dishes before use. This had the potential to affect all residents who eat from the facility kitchen. The census was 121 with 51 in certified beds. 1. Observation on 6/18/19 at 3:21 P.M., showed a large wheeled metal storage rack with approximately six large trays filled with sliced fish, uncovered, located next to the walk in refrigerator. Two additional large metal storage racks filled with sliced zucchini and okra, uncovered, located next to the walk in refrigerator. Observation and interview on 6/19/19 at 2:13 P.M., showed a large wheeled metal storage rack with approximately six large trays filled with chopped potatoes, located in the rear of the kitchen, uncovered. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures to identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded by failing to assess residents ability to consent to sexual activity for two residents (Residents #10 and Resident #11). The facility census was 121 with 51 in certified beds. Review of the Centers for Medicare and Medicaid services (CMS) State Operations Provider Certification, showed §483.12 Freedom from Abuse, Neglect, and Exploitation: -Sexual abuse, is defined at §483.5 as non-consensual sexual contact of any type with a resident; -Generally, sexual contact is nonconsensual if the resident either: -Appears to want the contact to occur, but lacks the cognitive ability to consent; or -Does not want the contact to occur; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the services provided or arranged by the facility meet professional standards of practice by failing to ensure all physician orders were followed when staff failed to administer a treatment for one sampled resident, who had a preventative treatment order (Resident #108). In addition, the facility failed to follow the fall management policy for one of one sampled resident that experienced unwitnessed falls. Staff failed to complete the neurological assessments for a fall and did not care plan updated interventions to prevent future falls for one of three falls the resident experienced since admission (Resident #38). The sample size was 13. The census was 121 with 51 residents in certified beds. 1. Review of Resident #108's electronic physician order sheet (ePOS), in use during the survey, showed: [...]

Inspectors wroteBased on observation, interview and record review and based upon current professional standards of practice, the facility failed to follow facility policy and ensure catheter orders contained the diagnosis for catheter use, catheter size and the catheter balloon size, for one of three sampled residents who used indwelling urinary catheters (Resident #273). The census was 121 with 51 residents in certified beds. Review of the facility's physician orders policy, dated 4/26/18, showed: -Policy statement: Orders for medication and treatment will be consistent with principles of safe and effective order writing. All orders will be transcribed and followed as directed; -Recording Foley catheter (brand of indwelling urinary catheter, a flexible tube that is placed into the bladder to drain urine) orders: [...]