Friendship Village Chesterfield

In the surveyor’s words

From the most serious findings on record at Friendship Village Chesterfield, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Sep 12, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF880Sep 12, 2024

  42795 Based 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). […]

• No harm, potential for more than minimal, patternF947Sep 12, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF602May 30, 2024

  Based 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: -It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect,… […]

• No harm, potential for more than minimal, patternF658May 30, 2024

  Based 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. […]