Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0554

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Allow residents to self-administer drugs if determined clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
could safely administer their own medications for three of three residents observed with
medications left at the dining room table during mealtime (Resident #36, #10 and #66). The
census was 142.
1. Review of Resident #36’s annual, Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff,dated 10/17/18, showed the following:
-Mild cognitive impairment;
-Required limited assistance from staff for most activities of daily living;
-[DIAGNOSES REDACTED].
Observation of the resident on 1/8/19 at approximately 12:00 P.M., showed Registered Nurse
(RN) E placed a small clear plastic cup containing at least four pills on the table where
the resident sat and walked away. Nurse E did not observe the resident consume the
medications.
Further observation of the resident on 1/10/19 at 8:12 A.M., showed him/her sitting at the
dining room table with a clear plastic cup which contained a red pill, small yellow pill,
pink pill and two white pills. RN E stood at the medication cart and dispensed medications
for other residents.
2. Review of Resident #10’s admission MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent with activities of daily living;
-[DIAGNOSES REDACTED].
Observation of the resident on 1/8/19 at approximately 12:00 P.M., showed the resident sat
at the dining room table with a small plastic clear cup containing at least three pills.
RN E stood at the medication cart across the dining room dispensing medication into other
cups.
3. Review of Resident #66’s admission MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Required limited staff assistance with activities of daily living;
-[DIAGNOSES REDACTED].
Observation of the resident on 1/8/19 at approximately 12:00 P.M., showed the resident sat
at the dining room table with a small plastic clear cup containing at least three pills.
RN E stood at the medication cart across the dining room dispensing medication into other
cups.
4. During an interview on 1/10/19 the Director of Nursing said she expected staff to
observe residents take medication at the time of administration. Only residents with
physical orders to self administer medications could take medication without supervision.
5. Review of a list of residents with physician orders [REDACTED].#36, Resident #10 or
Resident #66.

F 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on observation, interview and record review, the facility failed to maintain survey
reports with respect to all surveys and complaint investigations, including any plan of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 1)
correction in effect, available for review. The census was 142.
Observation on all days of the survey, 1/8, 1/9, 1/10, 1/11, 1/14 and 1/15/19, showed the
facility’s previous survey results maintained in a binder on the receptionist desk at the
front entrance to the building.
Review of the survey binder, showed the results of a revisit survey, dated 10/2/18, and
the survey and plan of correction from the most recent annual survey, dated 11/22/17, and
the two previous years. The survey binder did not include any information regarding
complaint investigations made in the last three years.
During an interview on 1/15/19 at 9:35 A.M., the administrator said she is aware the most
recent survey and last three surveys should be maintained in the survey binder, but was
not aware results of complaint investigations should also be in the binder.
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on interview and record review, the facility’s abuse and neglect policies and
procedures failed to identify when, how and by whom determinations of capacity to consent
to sexual contact will be made and where this documentation will be recorded. Furthermore,
the facility failed to complete criminal background checks (CBC), check the employee
disqualification list (EDL, a list maintained by DHSS, of individuals who have been
determined to have: abused or neglected a resident, patient, client, or consumer;
misappropriated funds or property belonging to a resident) and ensure newly hired
employees were screened to rule out the presence of a Federal Indicator, with the
Certified Nurse Aide (CNA) Registry prior to the start of work. The facility also did not
include reporting all alleged violations to the Administrator, state agency, adult
protective services and to all other required agencies within the required two-hour
timeframe. The deficient practices affected five of 10 sampled employees hired since the
last survey. The facility hired at least 110 new employees since the last survey. The
census was 142.
Review of the facility’s Abuse Prevention Program Overview, revised (MONTH) (YEAR), showed
the following:
-Policy: This facility affirms the right of our residents to be free from abuse, neglect,
misappropriation of resident property, corporal punishment and involuntary seclusion. The
facility desires to establish a resident sensitive and resident secure environment;
-The purpose of this policy is to develop a mechanism to reduce the risk of abuse,
neglect, misappropriation of resident property and/or crimes from being committed against
the residents of this facility;
-Screening: The facility will develop and implement policies and procedures to screen
potential employees and residents in an attempt to obtain information that would assist in
making hiring or admissions decisions;
-Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or
sexual assault;
-The policy did not identify when, how and by whom determinations of capacity to consent
to sexual contact will be made and where this documentation will be recorded.
-Policy: External Reporting:
-Upon receipt of an allegation or upon the formulation of a reasonable suspicion that
abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, theft or

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
that a crime has occurred against a resident, the facility administrator or his/her
designee will initiate external reports to the following; The Department: The
administrator or his/her designee will immediately contact the Department;
-Immediately means; following management of the immediate risk to the resident or
residents, including the administration of necessary medical attention and establishing
the safety of the resident;
-The policy did not include reporting all allegations to the state agency, adult
protective services and to all other required agencies (e.g., law enforcement when
applicable) within the two-hour specified timeframe.
1. During an interview on 1/8/19 at approximately 10:30 A.M., the administrator was asked
to provide the facility’s abuse policy which addressed capacity to consent to sexual
contact.
During an interview on 1/15/19 at 9:35 A.M., the administrator said the Social Service
Director would provide the updated policy.
At the time of exit at 1:30 P.M. on 1/15/19, the facility had not provided an abuse policy
which addressed the capacity to consent to sexual contact.
2. Review of the Department of Health and Senior Services (DHSS) website for the CNA
registry, showed the following: Federal Regulation 42 CFR 483.75 requires the CNA Registry
to document any findings against a CNA of Abuse, Neglect, or Misappropriation of Property.
Any individual who is a CNA, employed in a certified facility and found guilty of Abuse,
Neglect, or Misappropriation of Property will receive a Federal Indicator on the Missouri
State Registry. Certified long-term care facilities are prohibited from allowing a person
to work or volunteer, in any capacity, whose name appears on the Registry with a Federal
Indicator. These providers are required to check the Registry before allowing the
individual to work or volunteer and they must not continue to employ a person whose name
appears on the Registry with a Federal Indicator.
3. Review of CNA G’s employee file, showed the following:
-Hire date: 6/20/18;
-No CBC, EDL or CNA registry check performed.
4. Review of CNA H’s employee file, showed the following:
-Hire date: 12/12/18;
-CBC performed on 1/11/19.
5. Review of registered nurse (RN) I’s employee file, showed the following:
-Hire date: 7/18/18;
-No CBC performed.
6. Review of RN K’s employee file, showed the following:
-Hire date: 11/14/18;
-CBC and EDL check performed on 11/17/18.
7. Review of the Maintenance Director’s employee file, showed the following:
-Hire date: 9/24/18;
-CBC performed on 9/26/18 and CNA registry check performed on 10/15/18.
During an interview on 1/14/19 at 12:00 P.M. the human resource director said the date of
hire was the first day of orientation in the facility. Sometimes he can’t get CBC’s back
immediately because more information is needed to process the request. He was aware the
CNA registry, EDL and CBC need to be completed prior to the date of hire.
During an interview on 1/15/19 at 9:35 A.M., the administrator said she expected employees
to have all required back ground checks completed prior to the date of hire.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required
for two of 28 sampled residents (Residents #20 and #61). The census was 142.
1. Review of Resident #20’s medical record, showed the following:
-admission date of [DATE];
-[DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed the following:
-No DA-124 level I screen found;
-No PASARR level II screen found.
During an interview on 1/16/19 at 9:25 A.M., the social worker said the resident had been
admitted from another facility and it is always difficult to receive the information
regarding a DA-124 and/or PASARR.
2. Review of Resident #61’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed the following:
-DA-124 level I screen completed on 11/4/16 and recommended a level II screening be
conducted for serious mental illness;
-No PASARR level II screen found.
During an interview on 1/16/19 at 9:35 A.M., the administrator said the resident had been
admitted from a different facility and the DA-124 had been sent from that former facility.
She did not know the DA-124 screening recommended further screening for serious mental
illness. She could not produce the recommended follow up mental health screening.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a comprehensive person-centered care plan for each resident that includes
measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and
psychosocial needs, for two of 28 sampled residents (Residents #11 and #33). The census
was 142.
1. Review of Resident #111’s annual Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/6/18, showed the following:
-Moderate cognitive impairment;
-Tired or little energy several days;
-Poor appetite or overeating nearly every day;
-Extensive assistance required for activities of daily living (ADL’s);
-Upper and lower extremity impairment on one side;
-Incontinent of bowel and bladder;
-Received antidepressant medications the previous 7 days;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-An order, dated 2/12/18, for [MEDICATION NAME] (Antidepressant medication) 100 milligrams
(mg) at bedtime for depression;
-An order, dated 2/13/18, for Viibyrd (Antidepressant medication) 40 mg in the morning for
depression.
Review of psychological services progress note, dated 4/8/18, showed the following:
-Received ongoing individual psychological support services;
-Top target symptoms of severe depression with helplessness, loss of pleasure and
interests, nervous, worried and stressed, anxiety, memory loss and withdrawal;
-Long term therapy goal of stabilization/reduction of affective and/or cognitive symptoms.
Review of the resident’s care plan, showed no mention of the resident’s [DIAGNOSES
REDACTED].
2. Review of Resident #33’s annual MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Supervision required for most ADL’s;
-Lower extremity impairment on one side;
-Used a wheelchair;
-Limb prosthetic;
-[DIAGNOSES REDACTED].
Observations of the resident, showed the following:
-On 1/9/19 at 11:05 A.M., 1/11/19 at 11:18 A.M and 1/14/19 at 8:18 A.M., the resident lay
on the bed in his/her room and wore a below the knee prosthetic to the right leg;
-On 1/10/19 at 7:36 A.M., the resident sat in a wheelchair at the dining room table and
wore a below the knee prosthetic to the right leg.
Review of the resident’s care plan, updated on 12/3/18, did not include the right leg[MEDICAL CONDITION], or the right prosthetic worn by the resident.
During an interview on 1/15/19 at 9:35 A.M., the administrator said she expected care
plans to reflect the current needs of the residents. Resident #111’s [DIAGNOSES
REDACTED].#33’s amputation, along with appropriate goals and interventions should be
included on the care plans. Activities should also be included on the care plan.
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure resident
care plans reflected their current needs, goals and interventions, by not updating them
regarding a specific bladder device used by one resident (Resident #48), risk for
elopement for one resident (Resident # 131) and one on one activities for one resident
(Resident #47). The census was 142.
1. Review of Resident #48’s quarterly Minimum Data Set (MDS), a facility mandated
assessment instrument completed by facility staff, dated 11/1/18, showed the following:
-No cognitive impairment;
-Dependent on staff for mobility and personal hygiene;
-[DIAGNOSES REDACTED]. A [MEDICATION NAME] is permanent and does not require a catheter).
Review of the resident’s care plan, dated 10/13/17 and last updated on 10/24/18, showed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
the following:
-Problem: Resident has a condom catheter (a urine storage device that can be used to
treat short-term incontinence. It consists of a flexible sheath that fits over the male
genital and connects to a urinary drainage bag), intermittent (catheterize as needed to
drain urine), suprapubic (small rubber tube surgically inserted through the abdomen in to
the bladder) or indwelling (small rubber tube placed in the urinary meatus (opening) in to
the bladder to drain urine);
-Goal: Resident will be free from catheter related trauma and will have no signs/symptoms
of a urinary tract infection;
-Approaches included: Position the catheter bag below the level of the bladder and away
from the entrance door, change the catheter per the physician’s orders [REDACTED].
During an interview on 1/16/19 at 9:30 A.M., the Director of Nursing and the administrator
said the facility does not have a policy regarding urostomies, however the care plan
needed to be changed to a [MEDICATION NAME] because the resident does not have a catheter.

2. Review of Resident #131’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Wandering: Behavior not exhibited;
-Required limited assistance from staff for personal hygiene, dressing and bed mobility;
-Occasional urinary incontinence;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, revised on 1/7/19, showed the following:
-Focus: Resident is an elopement risk/wanderer related to confusion at times;
-Goals included: Resident will not leave facility unattended through the review date;
-Approaches included: Assess for fall risk, provide structured activities such as
toileting and walking inside and outside.
Review of the resident’s medical record, showed no elopement assessments.
During an interview on 1/15/19 at 9:35 A.M., the facility Nurse Practitioner said the
resident is no longer an elopement risk due to decreased mobility and support from staff.
The care plan should updated to reflect the resident’s current status.
3. Review of Resident #47’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Total dependence on staff for all care;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 11/1/18, showed the following:
-Preferred to spend most of the time in his/her room watching tv, has been getting up out
of bed daily and watching television in the quiet room for a couple hours a day;
-Will participate in one on one activities with activity aid three times per week.
Review of the facility’s list of residents who received one on one activities, did not
show the resident listed.
Observations of the resident, showed:
-On 1/8/19 at 2:50 P.M., the resident sat in a wheelchair in the small TV room by the
nurses station, with no other residents in the room and yelled continuously. No activity
was being conducted. A certified nurse aide said when he/she can’t find the remote
control, or something is wrong, that is what he/she does;
-On 1/9/19 at 11:04 A.M., the resident sat in a wheelchair in the TV room and watched TV
alone, with no activity being conducted;
-On 1/10/19 at 9:56 A.M., the resident sat in a wheelchair in the TV room while another
resident sat in a chair at the back of the room, with eyes closed and no activity being

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
conducted.
During an interview on 1/15/19 at 7:13 A.M., the activity director said the resident used
to receive one on one activities. Sometimes the activity assistant took a small group of
residents into the TV area and provided an activity. The goal is to get everyone off one
to one activities.
4. During an interview on 1/15/19 at 9:35 A.M., the administrator said the care plan
should reflect the resident’s current status.
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

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

Based on observation, interview and record review, the facility failed to ensure and
clarify physician orders [REDACTED]. This affected three of 28 sampled residents (Resident
#293, #67 and #103). The census was 142.
1. Review of Resident #293’s admission Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 12/31/18, showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the physician’s orders [REDACTED].
-An order dated 1/8/19, to insert hyperdermoclysis (subcutaneous (under the skin) infusion
of fluids) and monitor the site for redness, swelling and/or leaking;
-An order dated 1/8/19, to administer D5 (sugar water) NaCL (Normal saline) via
hyperdermoclysis at 60 cubic centimeters (cc)’s every shift for two days.
Review of the Medication Administration Record [REDACTED]. The night shift on 1/8/19 had
no initials.
Observation on 1/10/19 at 9:55 A.M., showed the resident seated in a wheelchair at the
dining room table on the first floor. An IV pole (pole to hold intravenous fluids) stood
next to him/her with a pillowcase over the bag of IV fluids and the tubing stretched to
his/her abdomen.
Observation on 1/10/19 at 10:32 A.M., showed the resident sat in his/her room, the
hyperdermoclysis tubing remained connected to his/her abdomen, the dial-a-flow (device
placed on IV tubing to control the flow rate) set to OPEN and the IV bag hung empty on the
IV pole.
Observation on 1/11/19 at 4:44 A.M., showed the resident lay in bed and D5 NaCL infused
via hyperdermoclysis. The dial-a-flow showed 150 cc/hr and approximately 400 cc remained
in the D5 NaCL bag.
Observation on 1/11/19 at 8:36 A.M., showed the resident in bed with D5 NaCL infusing via
hyperdermoclysis into his/her abdomen and the dial-a-flow set at 150 cc/hour.
Further Review of the POS [REDACTED].
Further review of the MAR, dated 1/1 through 1/31/19, showed no documentation regarding D5
NaCL infusions for 1/10 or 1/1/19.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
During an interview on 1/11/19 at 8:45 A.M., the Assistant Director of Nursing (ADON) said
the hyperdermyclosis should have only been given for two days. She read the order as 60 cc
per hour and said the order should have been clarified to read per hour not per shift.
During an interview on 1/15/19 at 9:30 A.M., the Director of Nursing (DON) and the nurse
practitioner (NP) said the order should have been clarified because the point was for the
resident to receive two full bags of IV fluids, a total of 2000 cc’s. His/her son wanted
to have the fluids stopped during therapy and meal times, which delayed the delivery of
the fluids. The nurses should have recorded the fluids as they were given and document in
the nurse’s notes. A blank space on the MAR indicated [REDACTED]. They both said an IV bag
should never be left hanging when it is empty. Either hang a new bag of fluids or
discontinue the fluids.
2. Review of Resident #67’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Supervision required for all activities of daily living (ADL’s);
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated 11/1/18 through 11/30/18, showed an order, dated
11/30/18, for a urinalysis (UA, laboratory test on urine to detect infection) with culture
and sensitivity (C&S, diagnostic laboratory test used to identify types of bacteria
and to determine types of antibiotic that can be used to treat the bacteria).
Review of the resident’s medical record, showed no results for a UA with CS.
During an interview on 1/15/19 at 9:35 A.M., the administrator said she expected physician
orders [REDACTED].
3. Review of Resident #103’s certified nurse’s aide (CNA) care plan, dated 9/6/18, showed:
-Transfers: Hoyer lift with assist of two staff.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Extensive assistance of two staff needed for all care and transferring tasks;
-No physical, occupational, speech or restorative therapy received.
During an observation and interview on 1/10/19 at 12:58 P.M., CNA A and Restorative Aide
(RT)/CNA B pushed the resident next to the bed. CNA/RT B said he/she needed to get the
Hoyer lift to transfer the resident into bed and he/she left the resident’s room for the
needed equipment. CNA A remained with the resident and said the resident did not have a
Hoyer lift pad under him/her while he/she sat in his/her chair. CNA/RT B returned to the
resident’s room and said the Hoyer lift is not available and was in use. CNA A told CNA/RT
B that there had been no Hoyer pad present to use and to transfer the resident with a gait
belt. CNA/RT B placed a gait belt around the resident’s waist. The gait belt hung loosely
around the resident’s waist. CNA A placed his/her arm under the resident’s arm and grabbed
the gait belt with his/her other hand. CNA/RT B placed an arm under the resident’s left
arm and grabbed the back of the resident’s pant waist band. CNA A and CNA/RT B transferred
the resident into his/her bed. The gait belt used had not been tightened around the
resident’s waist before the transfer and the resident did not attempt to assist in the
transfer, he/she did not bear any weight. CNA A said he/she thinks the resident is
supposed to transfer with a Hoyer lift, but sometimes when the lift is in use, staff will
lift the resident with a gait belt. CNA/RT B said when transferring a resident with a gait
belt, the belt should be snug around the resident’s waist and the staff should use the
gait belt to lift and not the resident’s pants. The resident does not attempt to help with
any transfers and is non weight bearing. He/she did not know the resident should be lifted
with a Hoyer lift and did not know what the CNA care plan card showed for transfers.
During an interview on 1/11/19 at 10:01 A.M., the administrator said the CNA care card
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
showed the resident as a Hoyer lift and assist of two. He/she said that the resident
should probably be transferred with a Hoyer lift since he/she can’t bear any weight. Gait
belts should be applied snuggly around the resident’s waist and staff should not lift a
resident using pants to hold onto the resident.
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide care and assistance to perform activities of daily living for any resident who
is unable.

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

Based on observation, interview and record review, the facility failed to provide and
ensure adequate perineal care (peri-care, cleansing from the front of the hips, in between
the legs and the buttocks) and failed to provide expected personal hygiene needs,
including nail trimming, bathing, showers, shaving of facial hair for male and female
residents. This affected nine of 28 sampled residents (Residents #103, #140, #49, #20,
#87, #293, #73, #61 and #48). The census was 142.
1. Review of Resident #103’s quarterly Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 11/29/18, showed:
-Severe cognitive impairment;
-Needed extensive assistance of two staff for all care needs;
-[DIAGNOSES REDACTED].>-Always incontinent of bowel and bladder;
-Received treatment for [REDACTED].
Review of the resident’s care plan, updated on 11/29/18, showed:
-Activities of Daily Living (ADL, dependence of self care tasks), incontinent of bowel and
bladder. Needs staff assistance to complete care needs;
-Approach: Staff to assist with incontinence care as needed (PRN). Keep clean and dry.
Change and provide toileting every two hours and PRN. Report changes in skin to the nurse.

During an observation and interview on 1/11/19 at 4:25 A.M., the resident lay in the bed
on his/her left side, on top of two bed pads with a dark brown circular ring noted on the
bed pad under him/her. Certified Nurse Aide (CNA) C entered the room, placed a wash cloth
into the room sink, turned on the warm water and applied gloves. He/she removed the sheet
from the resident. A large rolled up bath towel lie in between the resident’s legs at the
groin and was saturated with dark colored urine. CNA C said I don’t know who did this, it
must have been the other aide, I don’t know why they do this. He/she said the resident had
been assigned to him/her for care during his/her shift. He/she removed the soiled bed pads
and placed a clean pad under the resident. CNA C obtained the wash cloth from the sink and
applied soap. He/she assisted the resident onto his/her right side and used the soapy wash
cloth to wipe off the resident’s left hip. He/she applied a clean brief under the resident
and fastened the brief into place. CNA C did not provide any peri-care or cleaning of the
back or lower thighs. CNA C said the residents get checked on every two hours and he/she
does not know how the rolled towel got placed in between the legs of the resident. He/she
could not remember the last time he/she checked on the resident for incontinence care and
did not communicate with the other night shift aide to see if the resident had received
care.
2. Review of Resident #140’s admission MDS, dated [DATE], showed:
-Moderate cognitive impairment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-Total staff assistance for all care tasks;
-Uses catheter (hollow tube inserted into the bladder to allow urine drainage) and
incontinent of bowel;
-[DIAGNOSES REDACTED].
Review of the care plan, updated on 1/3/19, showed:
-Focus: ADL deficit related to right sided paralysis and weakness, dementia, [MEDICAL
CONDITION] and depression. He/she requires total staff assistance for care;
-Interventions: Hygiene, bathing or showering needs or preferences not addressed.
Observations on 1/08/19 at 1:25 P.M. and 1/9/19 at 7:23 A.M., showed the resident lay in
bed. He/she had long finger nails on both hands with dark, flaky substance noted under the
nails.
During an observation and interview on 1/10/19 at 7:23 A.M., the resident lay in bed.
He/she continued to have long fingernails on both hands with dark, flaky substance noted
to remain under the nails. He/she said he/she had been admitted to the facility a few
weeks ago and is getting therapy to become stronger. He/she had not received a bath or
shower since he/she arrived. The CNA’s clean him/her up after incontinence but he/she has
not received a bath. He/she would like to have shorter nails, but no staff had offered to
trim his/her nails. He/she would like to have a bath or shower soon.
Observations on 1/11/19 at 1:01 P.M., 1/14/19 at 12:22 P.M. and 1/15/19 at 6:28 A.M.,
showed the resident continued to have long finger nails on both of his/her hands.
Review of the completed 200 unit shower sheets, dated 1/10/19 through 1/15/19, on 1/15/19
at 6:41 A.M., showed no documentation the resident had received a bath or shower from the
staff.
3. Review of Resident #49’s admission MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Extensive assistance required for transfers;
-Limited assistance with personal hygiene;
-No listed diagnoses.
Review of the [DIAGNOSES REDACTED].
Review of the facility’s shower/bath sheets, showed he/she received a shower/bath on
12/15/18 and 12/20/18. No further shower or bath sheet completed or provided.
During an interview on 1/9/19 at 12:45 P.M., the resident said he/she had not received a
bath in two to three weeks. He/she said staff record that that they provide him/her with a
shower but they do not do it.
4. Review of Resident #20’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the facility’s resident shower/bath sheets, dated 10/17/18 through 12/18/18,
showed the resident received a bath on 11/19/18. No other shower or bath recorded.
5. Review of Resident #87’s annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observations on 1/10/19 at 6:55 A.M. and 11:16 A.M., 1/11/19 at 4:47 A.M., 1/14/19 at 6:12
A.M., 9:45 A.M. and 12:03 P.M. and 1/15/19 at 6:49 A.M. and 8:29 A.M., showed his/her
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
cheeks, chin and neck covered in 1/4 to 1/2 inch whiskers.
6. Review of Resident #293’s admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation of the facility shower sheets, showed no completed shower/bath sheets.
Observation on 1/15/19 at 6:50 A.M., showed the resident lay in bed and his/her hair
appeared oily and matted against his/her head. His/her bedroom smelled strongly of urine.
Upon request, the Assistant Director of Nursing (ADON) checked him/her for incontinence
and found him/her to be dry. The ADON did not respond when questioned about the smell.
7. Review of Resident #73’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Required assistance from staff for hygiene, bathing, dressing and mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, reviewed on 1/7/19 and in use during the survey,
showed staff did not include the resident’s preferences for facial grooming.
Observation and interview on 1/10/19 at 1:36 P.M., showed the resident with numerous
silver hairs around his/her mouth and chin. The resident said he/she was aware of the
facial hair and said it comes with age. Someone has shaved his/her face in the past, but
couldn’t remember when the last time anyone performed facial grooming. He/she preferred
not to have facial hair.
During an interview on 1/15/19 at 9:35 A.M., the administrator said staff should offer to
provide facial grooming, but at times, the resident will refuse because he/she prefers
his/her family to do it. Staff should include this on the resident’s care plan.
8. Review of Resident #61’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Needs extensive staff assistance of one staff for hygiene;
-[DIAGNOSES REDACTED].
Review of the care plan, updated on 11/12/18, showed:
-Focus: Self care deficit related to [MEDICAL CONDITION] and right sided weakness:
-Interventions: Needs moderate staff assistance with bathing and showers twice a week and
PRN.
During an observation and interview on 1/08/19 at 3:23 P.M., the resident said he/she had
not received a bath or shower in several weeks. Staff do not offer to assist him/her with
a shower. A strong body odor was noted in the room.
Review of the electronic CNA care tasks on 1/9/19 at 9:18 A.M., showed no documentation of
bathing or showering tasks had been completed.
Observation and interview on 1/14/19 at 6:38 A.M., showed the resident’s room continued to
have a strong body odor in the bedroom by the resident’s bed area. He/she said he/she has
not received a shower or bath and would like to have a shower.
Further review of the electronic CNA care tasks on 1/15/19 at 6:52 A.M., showed no
documentation the resident had received a bath or shower.
Review of the shower sheets completed 12/20/18 through 1/10/19, did not have the
resident’s name listed as receiving a bath or shower.
9. Review of Resident #48’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Dependent on staff for mobility and personal hygiene;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-[DIAGNOSES REDACTED].
Review of the facility shower/bath sheets, dated 10/17/18 through 12/18/18, showed no
documentation that he/she had received a shower or bath.
Observations on 1/10/19 at 7:00 A.M., 1/11/19 at 10:54 A.M., 1/14/19 at 9:38 A.M. and
1/15/19 A.M. at 6:55 A.M., showed him/her with cheeks, chin and neck covered with whiskers
measuring approximately 1/4 inch long.
During an interview on 1/10/19 at 7:00 A.M., he/she said he/she receives a bed bath two to
three times a week but has not ever received a shower. He/she went on to say that he/she
would love to be shaved but staff have not offered.
10. During an interview on 1/15/19 at 9:30 A.M., the Director of Nursing (DON) and
administrator said that if a resident refuses a shower or bath, it should be documented on
the shower sheet and the CNA should also inform the nurse. The CNA’s do not usually
document showers or baths in the electronic system and they are to document on the shower
sheets. If a shower sheet can not be located for a resident, it means the resident did not
receive a shower or bath. The administrator said that staff do offer to shave men. She
said they had a poor quality of razors so they were sent back to the manufacturer and had
to wait for new ones to arrive. The order should have arrived in three days but presently
it is day four.
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

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

Based on observation, interview and record review, the facility failed to follow their
activity schedule, assist dependent residents to activities, provide one-to-one activities
to those residents who required individual attention and document each individual’s needs
on their care plans for four of 28 sampled residents (Residents #22, #73, #11 and #31).
The census was 142.
1. Review of the activity calendar for 1/8 through 1/11/19 and 1/14/19, showed the
following scheduled activities;
-On 1/8/19, Spa Time at 9:30 A.M. and 11:30 A.M. and You’re Pulling My Leg at 2:00 P.M.;
-On 1/9/19, Bible Study at 10:00 A.M., Current Events at 11:00 A.M., Mark Mane at 2:00
P.M. and Room Visits at 3:00 P.M.;
-On 1/10/19, Book Mobile at 9:25 A.M., Mass at 10:00 A.M., Bingo at 2:00 P.M. and Social
Hour at 3:00 P.M.;
-On 1/11/19, Twist and Shout at 10:00 A.M., Hydration at 11:00 A.M., Puzzle Making Fun at
2:00 P.M. and Room Visits at 3:00 P.M.;
-On 1/14/19, Sing and Praise at 10:00 A.M., Move and Groove at 11:00 A.M. and All About Me
Posters at 2:00 P.M.
Review of a list of canceled activities from 1/8/19 through 1/14/19, provided by the
activity director, showed the following:
-On 1/8/19 the 2:00 P.M. You’re Pulling My Leg activity did not occur;
-On 1/9/19 the 10:00 A.M. Bible Study activity did not occur;
-On 1/11/19 the 10:00 A.M. Twist and Shout and Puzzle Making Fun activities did not occur;
-On 1/12/19 the 10:30 A.M. Chapel Service did not occur;
-On 1/14/19 the 11:00 A.M. Move and Grove activity and All About Me Poster activity did
not occur.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
2. Review of Resident #22’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 4/7/18, showed an interest in
keeping up with the news, music and activities that involved groups of people.
Review of his/her quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Unable to ambulate;
-Extensive to total dependence on staff for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Activity preferences not addressed.
Review of the resident’s quarterly activity assessment, dated 8/17/18, showed the
following:
-Attended group activities and 1:1 activities provided;
-Enjoyed TV and being outside;
-Activity related focus remained appropriate as per the plan of care;
-Activity goals exceeded;
-Interventions/approaches have been effective in reaching goals.
Review of the care plan, dated 4/7/18 and last updated 10/29/18, showed activities not
addressed.
Review of the progress note, dated 11/15/2018 at 2:29 P.M., showed a note written by an
unnamed member of the activity team that showed the resident played bingo on that date,
which he/she did about two times a week along with attending bible study, manicures, hand
massages and gospel music.
Observation on 1/9/19 at 10:00 A.M., showed him/her in bed with his/her eyes closed.
During an interview on 1/10/19 at 9:19 A.M., the resident said that he/she use to go to
activities but has not gone for a while because no one will take him/her and he/she is
unable to take himself/herself.
Observation on 1/11/19 at 10:00 A.M., showed him/her in bed with his/her eyes closed.
Observation on 1/14/19 at 9:42 A.M., showed him/her seated at the dining room table with
eyes closed. An activity aide sat at another table and painted one female resident’s nails
and an overhead page announced worship in the chapel at 10:00 A.M.
During an interview on 1/14/19 at 12:06 P.M., regarding the worship service held in the
chapel that morning, he/she said no one offered to take him/her, which is disappointing
because he/she would have liked to attend. He/she added that all he/she does is sit in
his/her room or the dining room and he/she is very bored.
During an interview on 1/15/19 at 7:35 A.M., the activity director said the resident
always refuses activities. He/she may say he/she wants to participate but then refuses.
She said that information should be documented.
During an interview on 1/15/19 at 9:30 A.M., the administrator said she was unaware the
resident could even voice what he/she wanted because he/she never really talks. She added
that all residents should be invited to activities and activities should be addressed on
every resident care plan.
3. Review of Resident #73’s admission MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Activity preference interview not completed;
-Required limited assistance from staff for activities of daily living such as bathing,
dressing and mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s most recent activity note, dated 8/6/18, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-Resident enjoys church, watching TV and playing bingo;
-Does the resident wish to participate in activities while in the facility? Yes;
-Does the resident wish to participate in group activities? Yes;
-Does the resident wish to have 1:1’s with staff? Yes;
-Does the resident enjoy independent activities? Yes;
-Should any modifications for cognitive, hearing, vision or communication deficits be
made? No;
-Does the resident need assistance getting to activities? Yes.
Review of the resident’s care plan, most recently updated on 1/7/19, showed staff did not
address any of the resident’s activity preferences, goals for the resident to attend
activities or if the resident was currently involved in activities.
Further review of the resident’s medical record, showed no documentation of the resident’s
participation in activities.
During observation and interview on 1/09/19 at 2:37 P.M., the resident sat in his/her room
with the TV off and the blinds closed. The resident was very eager to talk and showed
his/her bird in the cage on the dresser. The resident talked about TV shows he/she likes
to watch on TV, but cannot get anyone to help him/her change the channel. The resident
said he/she enjoys reading too. The resident said he/she wishes there was more to do or
someone would come and get him/her and take him/her out of the room. He/she said it is
small and he/she gets tired of just sitting.
Observation on 1/10/19 at 10:17 A.M., showed the resident sat in his/her room. Staff did
not engage with the resident.
During an interview on 1/10/19 at 1:34 P.M., the resident sat in his/her room. The TV was
on, but going on and off due to no signal. The resident said of course he/she’s bored.
He/she likes to read and watch old movies. He/she wishes he/she had more to do. Yesterday
he/she looked for a book to read. The resident asked the surveyor to stay longer and talk.
Observation of the resident on 1/11/19 at 9:06 A.M., showed the resident sat in his/her
room. Staff did not engage with the resident.
Review of the facility activity calendar on 1/14/19 at 10:00 A.M., showed Sing and Praise
activity scheduled.
Observations of the resident on 1/14/19 from 10:15 A.M. – 10:40 A.M., showed the resident
in his/her room. Staff did not engage him/her.
During an interview on 1/15/19 at 7:15 A.M., the activity director said the resident
normally comes to activities, but has a cold and therefore was not attending. Any
documentation of the resident’s participation would be found in the resident’s medical
record.
During an interview on 1/15/19 at 9:35 A.M., the administrator said it is the activity
departments job to find activities the residents enjoy. If a resident has a cold, activity
staff should provide 1:1’s or provide a mask so the resident could attend group
activities.
4. Review of Resident #11’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Unable to ambulate;
-Enjoys participating in activities that involve groups of people, following the news,
music and religious activities;
-Extensive assistance required for mobility and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated on 10/30/18 and in use during the survey,
showed no documentation regarding activities.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
Review of the resident’s medical record, showed no activity assessment.
Further review of the medical record, showed he/she is gone from the building for several
hours every Monday, Wednesday and Friday for treatment.
Observation on 1/9/19 A.M., showed him/her out of the building for treatment.
Observation on 1/11/19 at 9:50 A.M., showed he/she left the building for treatment.
Observation on 1/14/19 at 9:37 A.M., showed him/her seated at the dining room table with
his/her eyes closed.
Observation on 1/14/19 at 12:05 P.M., showed him/her out of the building for treatment.
During an interview on 1/15/19 at 9:30 A.M., the administrator said activities should be
discussed during care plans and residents evaluated for 1:1 activities.
5. Review of Resident #31’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated on 11/2/18 and in use during the survey,
showed:
-Focus: No or little activity involvement related to depression. His/her spouse visits
daily;
-Interventions: Activities to provide 1:1 room visits as needed, establish and record
prior level of activity involvement and interests by talking with the resident and family
and provide assistance or escort to activity functions.
Review of the facility’s 1:1 documentation binder on 1/14/19 at 9:08 A.M., showed no 1:1
activity provided to the resident during the dates of 1/1/19 through 1/14/19.
6. Review of the facility’s activity calendar on 1/14/19, showed Move and Grove scheduled
for 11:00 A.M. Observations at that time of the main dining room, chapel and mansion
dining room, showed no activity in progress. Observation of the activity room at 11:25
A.M., showed the activity director providing nail care to one resident. Observation of the
200 Hall dining room at 11:30 A.M., showed an activity aide providing nail care to one
resident.
7. During an interview on 1/15/19 at 7:18 A.M., the activities director said the scheduled
activities have not been occurring due to a staff member out on vacation. She assumed
activity staff were doing something somewhere. There is an increasing number of younger
residents and who like games of chance and entertainment and happy hour and not what she
typically schedules on the calendar. She is not able to attend all the care plan meetings
and relies on staff to inform her of changes in resident status or preferences.
8. During an interview on 1/15/19 at 9:35 A.M., the administrator said she expected the
activity department to perform activities as scheduled. Accommodations to the schedule
should be made if a someone is on vacation.
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain physician
ordered treatments for a facility acquired pressure ulcer (injury to skin and underlying
tissue resulting from prolonged pressure on the skin), failed to monitor, document and
ensure appropriate treatments remained intact and in place. This deficient practice

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
resulted in the worsening of a coccyx wound for one of four facility identified residents
with pressure ulcers (Resident #103). The census was 142.
Review of the facility’s skin ulcer/ wound policy, effective date 8/15/18, showed:
-Policy: All caregivers are responsible for preventing, caring for, and providing
treatment for [REDACTED].>-Purpose: To identify at risk residents for potential
breakdown or ulcerations;
-To prevent breakdown of tissue or ulcerations;
-To provide treatment that promotes prevention of ulcerations and healing of existing
ulcerations;
-Risk factors: Impaired or decreased mobility and decreased ability;
-Cognitive impairment;
-Exposure of skin to urinary and fecal incontinence;
-Assessment: Licensed staff will complete a head to toe assessment weekly and as needed
(PRN). The skin assessment will be documented on a skin assessment form and become part of
the resident’s clinical record. Any unusual findings will be documented on the form with a
follow-up note in the nurses’ notes further describing the area of concern;
-Skin ulcer preventions: Staff will institute a plan for any resident who had potential
for skin breakdown or whose condition is deteriorating, this may include turn and
reposition every two hours, promote clean, dry and well moisturized skin;
-Nurse aides will complete body audits weekly or with every bathing opportunity. The body
audits will be turned into the charge nurse for review or completed in the point of care
(P[NAME]) system. If documented in the P[NAME] system, the nurse will review the results
on the clinical dashboard. If the nurse assesses and determines there is a skin condition
present, the facility protocol will be followed;
-Treatment Protocols: Consult wound care providers when appropriate;
-For all open areas, the treatment is determined based on tissue type and drainage;
-For moderate to heavy draining wounds, calcium alginate (dressing used to promote
healing and the formation of healing tissue) is appropriate. Cover with a secondary
dressing to hold in place, change PRN for soiling and drainage;
-For wounds that have slough (dead tissue, usually cream or yellow in color) or unstable
eschar (dry, black, hard dead tissue) present, a debridement agent is required. Change
daily and as needed for soiling or drainage.
Review of Resident #103’s electronic physician order [REDACTED].
-An order dated 10/30/18, to monitor open area to coccyx every shift. Apply barrier cream
each shift for open area;
-An order dated 11/21/18, for Santyl (debridement ointment used to remove unhealthy tissue
from a wound to promote healing) 250 gram (GM) apply to buttock topically daily and PRN
for wound care. Clean right buttock with normal saline, apply Santyl, cover with gauze and
abdominal (thick, long sterile pad) pad and secure in place with tape.
Review of the resident’s weekly skin observation note, dated 11/28/18 at 3:10 P.M., showed
the resident admitted on [DATE]. His/her skin color is normal, skin temperature is normal,
dry and warm. Skin issues present and refer to assessment for more information. Treatment
in place.
Review of the resident’s weekly skin observation assessment, completed on 11/28/18, showed
the following skin issues:
-Coccyx: area open;
-Foot: red areas to both right and left foot;
-Treatment in place.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
instrument completed by facility staff, dated 11/29/18, showed:
-Severe cognitive impairment;
-No behaviors;
-Extensive to total staff assistance needed for toileting, transfers, bed mobility,
hygiene, bathing and dressing;
-Always incontinent of bowel and bladder;
-At risk to develop pressure ulcers;
-[DIAGNOSES REDACTED].
-Current unhealed stage II pressure ulcer (partial thickness loss of dermis (skin)
presenting as a shallow open ulcer with a red, pink wound bed without slough) present;
-Received pressure ulcer treatment, used pad for wheel chair and bed, participates in turn
and reposition program.
Review of the resident’s care plan, revised on 12/6/18, showed:
-Focus: Potential or actual impairment to skin integrity. An open area to the right
buttocks and the right foot;
-Interventions: Educate resident, family, caregivers of causative factors and measures to
prevent skin injury;
-Encourage good nutrition and hydration in order to promote healthy skin;
-Follow facility protocols for treatment of [REDACTED].> -Identify/document potential
causative factors and eliminate/resolve where possible;
-The current care plan does not address any current wounds, treatment plan or preventive
measures.
Further review of the medical record, showed no weekly skin assessments completed or
documented by facility staff for the month of (MONTH) (YEAR).
Further review of the progress notes, showed the following wound/skin notes:
-On 11/29/18 at 11:21 A.M., the resident seen by wound care physician (WCP) on 11/27/18
with moisture associated skin damage (MASD) to the right buttocks, deteriorated. The wound
measures 1.9 centimeters (cm) x 1.5 cm x 0.10 cm. 100 percent (%) granulation tissue
(pink, health skin), no drainage, peri-wound (outer wound edge) intact, denudation (loss
of epidermis (top skin layer) caused by prolonged moisture and friction exposure) present.
Clean the wound with normal saline (NS) or hypochlorous acid (mild cleansing acid used to
kill pathogens), apply skin prep, apply Santyl, cover with a dry dressing. Change daily
and prn, the resident has a low air loss (LAL) mattress with operating settings, cushion
in the chair for comfort, no signs of any distress;
-On 12/6/2018 at 3:07 P.M., the resident seen by WCP on 12/4/2018, he/she has MASD to the
right buttocks and the area is deteriorated 1.9 cm x 1.5 cm x 0.10 cm, 100% red
granulation tissue, no drainage, peri wound intact, denudation present, treatment to
cleanse wound with NS or hypochlorous acid, apply skin prep, apply Santyl, cover with dry
dressing daily and PRN, the resident has a low air loss mattress with operating settings,
cushion in the chair for comfort, no signs of any distress;
-On 12/11/18 at 8:50 P.M., the resident’s skin warm and dry, no new open areas. He/she has
a small red area on the right ankle. Protective boots in place;
-On 12/19/2018 at 11:26 A.M., the resident seen by the WCP on 12/18/2018, the resident has
MASD to the right buttocks. The area is improving, current measurements 1.7 cm x 1.5 cm x
0.2 cm, 76-100% bright red granulation tissue, scant (small) amount of serosanguinerous
(clear) drainage, peri wound intact, denudation present, treatment continues to cleanse
wound with NS or hypochlorous acid, apply skin prep, apply Santyl, cover with dry dressing
daily and PRN. Continues to use LAL mattress with operating settings, cushion in chair for
comfort, no signs of any distress;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-On 12/29/2018 at 3:47 P.M., resident seen by WCP on 12/27/2018, MASD area to the right
buttocks is improving and measures 2.5 cm x 1.5 cm x 0.2 cm, 76-100% bright red
granulation tissue, scant amount of serosanguinerous drainage, peri wound intact,
denudation present, treatment to cleanse wound with NS or hypochlorous acid, apply skin
prep, apply Santyl, cover with dry dressing daily and PRN. Continued to use LAL with
operating settings, cushion in chair for comfort, no signs of any distress.
Further review of the nurse weekly skin observation notes, showed a skin assessment
completed on 1/1/19 at 6:46 P.M., the resident’s skin appeared normal temperature and dry.
An open area noted to his/her coccyx. No further documentation found on assessment
regarding measurements, notification of physician or family or treatments used.
Further review of the progress notes, showed the following wound/skin notes:
-On 1/5/2019 at 12:35 P.M., the resident seen by WCP on 1/3/2018, MASD to the right
buttocks is improving and measured at 4.2 cm x 2.2 cm x 0.2 cm, 76-100% bright red
granulation tissue, scant amount of serosanguinerous drainage, peri wound intact,
denudation present, treatment to cleanse wound with ns or hypochlorous acid, apply skin
prep, apply Santyl, cover with dry dressing daily and PRN. Continues to use LAL with
operating settings, cushion in chair for comfort, no signs or symptoms of any distress;
-On 1/5/2019 at 10:46 P.M., skin ulcer noted on coccyx, approximately measured 3 inches ()
by 1.5 . Barrier and wet to dry dressing applied. Will continue to monitor. No further
documentation of physician notification, wound orders or family notification;
-On 1/6/2019 at 8:52 P.M., wound to right coccygeal (tailbone crease) area remained. Wound
gel and dry dressing applied. Turned and repositioned every two hours. Will continue to
monitor;
-No weekly skin assessments noted after 1/1/19, no certified nurse aide (CNA) shower
sheets located for 1/1/19-1/15/19;
-No further WCP notes located after the 1/3/19 visit.
Review of the resident’s (MONTH) treatment administration record (TAR), on 1/10/19 at 8:20
A.M.,showed:
-An order dated 10/30/18, to monitor open area to coccyx every shift. Apply barrier cream
each shift for open area. Three missed opportunities noted out of 28;
-An order dated 11/21/18, for Santyl 250 GM apply to buttock topically daily and PRN for
wound care. Clean right buttock with normal saline, apply Santyl, cover with gauze and
abdominal pad and secure in place with tape. Two missed opportunities out of 10;
-No wound treatment order noted following discovery of the coccyx wound per progress note
dated 1/5/19.
Observations and interview on 1/10/19 at 12:58 P.M., showed CNA A placed the resident into
his/her bed. CNA A removed the resident’s urine wet brief and exposed the resident’s
buttocks. A healed area noted to the right buttock and an open uncovered wound noted on
the resident’s coccyx. The wound appeared circular shaped, yellow tinged with scant,
bloody drainage noted to the inside back of the brief and measured approximately 3 inches
by 1.5 inches wide, stage II with scant, thick yellow drainage noted to wound bed, 50%
granulation tissue present in wound bed. Area to upper interior right buttock,
approximately 0.2 cm x 0.2 cm, no depth, red wound bed. No drainage noted to the buttock
wound or on the brief. CNA A said he/she checked on the resident around 11:00 A.M., today
and there was no dressing or treatment on the wound. Night shift got the resident up for
the day and the night shift aide did not tell him/her the wound did not have a treatment
on it. He/she did not think to let the charge nurse at the 11:00 A.M. check that the wound
did not have a treatment since the wound care nurse applies the treatment after the
resident eats lunch.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
During an interview on 1/10/19 at 1:15 P.M., the wound care nurse said the CNA’s should
always tell the charge nurse if there is not a dressing to an open area. The charge nurse
would need to assess and either apply a treatment or call him/her and he/she would come an
apply the treatment. The resident should not have gone all day without a dressing to the
wound.
Observations and interviews on 1/11/19, showed the following:
-At 4:15 A.M., the resident slept on his/her left side on two bed pads. A dark circular
ring noted on the top pad the resident lay on. The dark circular area extended to the
middle of the resident’s back;
-At 4:25 A.M., the resident slept on his/her left side. CNA C entered the resident’s room
with the surveyor to perform skin assessment on the resident. CNA C pulled back the sheet
and exposed the resident with a large rolled up, urine saturated bath towel placed in
between the resident’s legs at the groin. The resident lay on two urine saturated bed
pads. Urine saturated both of the bed pads and a dark circular ring extended from the
lower thighs to the resident’s mid upper back. CNA C said I don’t know who did this, it
must have been the other aide, I don’t know why they do this CNA C removed the urine
saturated towel from in between the resident’s legs and placed the towel into the trash
can at the bedside. The towel dripped urine from the bed to the trash can. CNA C obtained
a wash cloth, cleaned the resident’s left hip and assisted the resident to turn onto
his/her right side to expose the buttocks. The coccyx wound contained no treatment and no
treatment found in the resident’s bed. The wound appeared very moist and red. Moderate
amount of yellow, blood tinged drainage noted to the pad that had been placed against the
coccyx. The CNA said he/she had been assigned to care for the resident during the night
shift, and all the aides help each other. He/she checked on the resident last at 1:00
A.M., and the bandage had been wet, he/she threw away the treatment and could not remember
if he/she told the night shift charge nurse. He/she then applied a clean pad and brief
under the resident and secured the brief into place;
-At 5:33 A.M., Registered Nurse (RN) J gathered supplies for the wound change and entered
the resident’s room. He/she said the CNA told him/her the resident’s wound did not have a
treatment on it and the area had been seen by the surveyor. RN J washed his/her hands,
applied gloves, unfastened the resident’s brief and assisted resident onto her side to
expose buttocks. The coccyx wound measured 4 cm x 3.5 cm width x 0 depth. The wound
appeared very moist with yellow blood tinged drainage noted on the inside of the back of
the brief where the wound touched the brief. He/she said the aides should round on the
residents every two hours and provide incontinence care. Towels should never be placed in
between residents legs to absorb urine. Dark urine rings on bed pads usually showed the
resident had not received incontinence care and the urine dried. If wounds are found with
no dressing, the aide is expected to tell the charge nurse right away so the nurse can
apply the appropriate treatments. He/she had not been notified at any time during the
night shift that the resident’s wound did not have a treatment in place. He/she could not
locate information in previous notes or any weekly skin assessments after 1/1/19 to
determine if the wound had worsened. RN J applied a treatment to the coccyx wound and said
he/she would document the measurements and description of the wound into the progress
notes;
-At 5:45 A.M., the administrator said he/she expected the aides to round every two hours
on the residents. Dark circle areas on pads indicate that the resident had been
incontinent and not been changed for several hours. Towels should never be placed in
between resident’s legs for absorption and peri care should always be provided to
incontinent residents. Wounds should have treatments on them and if an aide discovers no
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
treatment on the wound, they should notify the charge nurse immediately.
Further review of the resident’s medical record on 1/14/19 at 6:00 A.M., showed no
documentation, notes or weekly skin assessments regarding treatment and wound measurements
from 1/11/19.
Observation and interview on 1/14/19 at 6:15 A.M., showed the resident up in his/her wheel
chair in the lobby of the unit. CNA O said she had cared for the resident during the night
shift. He/she provided incontinent care to the resident at 1:15 A.M., and he/she removed
the dressing because the resident had a bowel movement. He/she told the nurse that the
dressing was off. He/she got the resident up at 5:30 A.M. The wound did not have a
dressing or treatment on it when he/she got the resident up for the day.
During an interview on 1/14/19 at 6:30 A.M., Licensed Practical Nurse (LPN) P said he/she
had been on shift at the facility since 11:00 P.M. last night, and he/she had not applied
any treatment to the resident’s buttocks.
Observations and interviews on 1/14/19, showed:
-At 6:41 A.M., CNA O placed the resident into his/her bed, assisted the resident onto
his/her side, unfastened the resident’s brief and exposed the resident’s buttocks. The
coccyx wound was open and exposed with no dressing noted on the wound or the inside of the
brief. The brief had thick yellow, red tinged drainage where the brief had been in direct
contact with the wound. The wound appeared moist and had a yellow circular edge around the
entire edge of the wound;
-At 6:45 A.M., LPN P entered the residents room with the treatment cart and said he/she
had been aware the resident had a wound to his/her coccyx but had not assessed or seen the
wound and the only order he/she is aware he/she can apply is barrier ointment. He/she
looked at the exposed coccyx wound and said he/she going to check the orders and see what
needed to be applied to the coccyx;
-At 7:56 A.M., observation showed resident in bed asleep, staff assisted the resident onto
his/her side and exposed his/her buttocks. The coccyx wound was covered with gauze and
dated 1/14/19, 11-7.
During an interview on 1/14/19 at 8:03 A.M., the administrator and DON said the management
team had provided nursing staff inservicing on 1/11/19, regarding expectations for nursing
staff to provide skin assessments, documentation and for the aides to notify the charge
nurse if a wound is found without any treatment in place. The administrator said she had
called the facility over the weekend and verified with the nursing staff the resident’s
coccyx wound had a treatment in place. She had been notified the surveyor had discovered
the coccyx wound did not have a treatment in place earlier that morning. CNA’s are
expected to notify the nurse immediately of any open areas, especially if no treatment is
in place. Residents should never be gotten dressed and up before the nurse does her
assessment and applies a treatment. Nurses should always document measurements, wound
descriptions, notification of the physician and resident’s family. Wound treatment orders
should be specific to the area of the wound and not general wound locations.
Further review of the resident’s (MONTH) TAR on 1/14/18 at 11:10 A.M., showed:
-An order dated 10/30/18, to monitor open area to the coccyx every shift. Apply barrier
cream every shift. Out of 12 day shift opportunities, two noted incomplete. Out of 12
evening shift opportunities, one noted incomplete and 12 night shift opportunities
completed. The order was discontinued on 1/13/19;
-An order dated 11/21/19, for Santyl 250 GM, apply to buttock topically as needed for
wound, PRN. No documentation noted any PRN treatments applied;
-An order dated 11/21/19, for Santyl 250 GM, clean right buttock with NS or hypochlorous
acid, apply Santyl, cover with gauze and abdominal pad, secure with tape. Change daily and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
PRN. Out of 13 opportunities, two noted to be incomplete;
-An order dated 5/29/18 for weekly skin assessments, noted as completed on 1/1/19 and
1/18/19;
-No treatment order found for the open coccyx wound noted in the progress note dated
1/5/19.
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
restorative nursing therapy as ordered for three of 28 sampled residents (Residents #121,
#36 and #11). The census was 142.
1. Review of Resident #121’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/13/18, showed the following:
-Cognitively intact;
-Required total assistance from staff for transfers, dressing and toileting;
-Functional limitation in range of motion (ROM): Impaired on one side of upper and lower
extremities;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Special treatments offered: staff provided restorative therapy (RT) zero minutes in seven
of seven days assessed.
Review of the residents (MONTH) 2019 physician order [REDACTED].
Review of the resident’s care plan, last revised 1/7/19 and in use during the survey,
showed staff did not address the resident’s participation in RT or interventions to be
provided by staff.
During an interview on 1/08/19 at 3:10 P.M., the resident said he/she sometimes gets RT,
but it has been awhile.
Review of the resident’s RT documentation on 1/14/19, showed the following:
-Goal: Order on 10/30/18, to continue from August, 3-5 times per week;
-Plan of Care: Maintain bilateral lower extremity ROM, strength and maintain bed mobility;
-Approach: Perform up to 20 repetitions of supine heel slides, AP’s, hip abductor and
adductor and/or hip flex/LAQ’s. Perform rolling right and left maximum/dependent times
two, right and left with rail assist;
-Staff documented providing RT a total of six times in (MONTH) (YEAR) on 12/10, 12/11,
12/12, 12/17, 12/18 and 12/19/18;
-No documentation staff provided RT in (MONTH) 2019.
During an interview on 1/14/19 at approximately 1:00 P.M., RT aide/CNA D said he/she
wasn’t sure what the RT orders for Resident #121 meant. He/she just did ROM exercises with
the resident. He/she has not completed any RT for (MONTH) and only 6 times in (MONTH) due
to being pulled to work on the floor. When he/she is working on the floor, he/she cannot
perform RT on his/her residents. He/she is responsible for the 400 Hall RT program, but
has been working on 300 Hall.
2. Review of Resident #36’s annual MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Required limited assistance from staff for most activities of daily living;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-Functional limitation in ROM: Impaired on one side of upper and lower extremities;
-[DIAGNOSES REDACTED].
-Special treatments offered: staff provided RT zero minutes in seven of seven days
assessed.
Review of the resident’s (MONTH) 2019 POS, showed an order dated 10/30/18 for RT to be
performed three times a week to maintain ROM, strength and ambulation.
Review of the resident’s undated care plan, in use during the survey, showed staff did not
address the resident’s need for restorative therapy.
Review of the resident’s RT documentation on 1/14/19, showed the following:
-Goal: (MONTH) (YEAR), ROM initiated on 10/30/18 to be performed three times a week;
-Plan of Care: Maintain bilateral lower extremity ROM/strength, ambulation, bilateral
upper extremity ROM/strength;
-Approach: Perform bilateral hip/knee exercises with a 2 pound weight, 15 repetitions on
each side. Ambulate up to 75 feet one time with wheeled walker and caregiver assist and a
wheelchair to follow with oxygen donned, plus gait belt. Perform bilateral upper extremity
ROM/strengthening to all joints and all planes with 2 pound weight, three sets of 1-20
repetitions;
-Staff documented providing RT a total of six times in (MONTH) (YEAR) on 12/10, 12/11,
12/12, 12/17, 12/18 and 12/19/18;
-No documentation staff provided RT in (MONTH) 2019.
During an interview on 1/14/19 at approximately 1:00 P.M., RT aide/CNA D said he/she has
not completed any RT for (MONTH) and only 6 times in (MONTH) due to being pulled to work
on the floor. When he/she is working on the floor, he/she cannot perform RT on his/her
residents. He/she is responsible for the 400 Hall RT program, but has been working on 300
Hall.
During an interview on 1/15/19 at 9:35 A.M., the administrator said she expected staff to
follow physician orders. She was aware restorative therapy was not being completed due
being short staffed.
3. Review of Resident #11’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Unable to ambulate;
-Extensive assistance required for mobility and personal hygiene;
-[DIAGNOSES REDACTED].
-Special treatments offered: staff provided RT zero minutes in seven of seven days
assessed.
Review of the electronic POS, showed an order, dated 10/30/18, to provide RT three times a
week to maintain strength, ROM and bed mobility.
Review of the care plan, dated 7/19/17 and last updated on 10/19/18, showed RT services
not addressed.
Review of the resident’s RT documentation on 1/14/19, showed the following:
-Goals:
-Maintain bilateral upper extremity (BUE) strength;
-Maintain bilateral lower extremity (BLE) strength;
-Maintain bed mobility;
-Approaches:
-BUE exercises with 1-2 pound weights for all repetitions;
-BLE active and passive ROM one to 20 repetitions to hip/knee and ankle;
-Perform rolling right and left with UE support on rail for two to three repetitions;
-Clean hand and use right hand palm protector for at least two hours as tolerated;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-No record of RT services provided in November, (YEAR);
-Resident received RT three times a week in the month of December, (YEAR), although no
documentation regarding the services provided or the amount of time the RT aide spent with
the resident;
-No record of RT services provided in January, 2019.
Further Review of the POS [REDACTED].
During an interview on 1/15/19 at 9:30 A.M., the administrator said that the staff should
follow the POS as written and added that due to staff calling off for their shifts, the RT
aide is often pulled to the floor to work.
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
supervision for one resident (Resident #132) who had a physician’s order for nothing by
mouth (NPO, a medical instruction meaning to withhold food and fluids) when a family
member provided the resident liquids on two observed occasions. The census was 142.
Review of the facility’s Census and Conditions Report, provided on 1/9/19, showed 14
residents who received nutrition via [DEVICE] ([DEVICE], a tube surgically inserted into
the stomach to provide hydration, nutrition and medications).
Review of Resident #132’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/12/18, showed the following:
-Severe cognitive impairment;
-Long and short term memory problems;
-Required total assistance from staff for eating, mobility and personal hygiene;
-Signs and symptoms of possible swallowing disorder: Loss of liquids/solids from mouth
when eating and drinking;
-Nutrition approach: feeding tube ([DEVICE]);
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 physician order sheet, showed an order dated
12/16/18 for NPO.
Review of the resident’s care plan, dated 1/7/19 and in use during the survey, showed the
following:
-Focus: Resident requires tube feeding related to dysphasia (difficulty with swallowing);
-Goal: Resident will be free of aspiration and maintain adequate nutritional and hydration
status;
-Approaches included: discuss with resident/family/caregivers any concerns about tube
feeding; monitor/document/report as needed any signs or symptoms of aspiration, the
resident does not like food related activities as it is upsetting to see others eating,
the resident is dependent with tube feeding and water flushes. See physician orders for
current feeding orders.
Further review of the resident’s medical record, showed no documentation the facility had
addressed any alternative nutrition approaches or exceptions with the resident and/or
his/her family.
Observation of the resident on 1/9/19 from 1:36 P.M. to 1:40 P.M., showed the resident sat
up in a geri chair (reclining wheeled chair) in the hall by the nurse’s station with a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
family member at his/her side. The resident’s tube feeding hung on a pole to the right of
the resident. The family member held a small glass with a straw which contained a cream
colored liquid to the resident’s mouth as the resident sipped it. The charge nurse stood
nearby and dispensed medications. Staff did not intervene.
Further observation of the resident on 1/14/19 at 1:18 P.M., showed the resident sat up in
a geri chair in the hall by the nurse’s station with a family member at his/her side. The
resident’s tube feeding hung on a pole to the right of the resident and beeped. The family
member poured orange juice into a small glass with a straw and held it to the resident’s
mouth as the resident sipped it. The resident asked for food. The speech therapist sat at
the nurse station with his/her back to the resident. The charge nurse then approached the
tube feeding to address the beeping. The resident continued to sip from the straw. Staff
did not intervene.
During an interview on 1/15/19 at 9:35 A.M., the administrator said she expected staff to
follow physician orders. If a resident has an order for [REDACTED]. If the family is not
compliant, all they can do is educate and document.
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

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

Based on observation, interview and record review, the facility failed to ensure
residents’ urinary catheter (a sterile tube inserted into the bladder to drain urine)
drainage bags and tubing were maintained to prevent possible contamination and orders were
obtained for catheter usage and care. This affected three of six facility identified
residents with catheters (Residents #16, #48 and #140). The census was 142.
Review of the facility’s Catheter care policy, dated 4/2013, showed:
-Purpose: To minimize the risk of infection and complications associated with the use of
indwelling urinary catheters;
-Policy: Catheter care will be completed each shift, following incontinent episodes and
where contamination occurred;
-General Guidelines:
-The drainage bag must be positioned lower than the bladder to prevent the urine in the
tubing and drainage bag from flowing back into the bladder;
-Check the resident often and make sure he/she is not lying on the catheter or tubing;
-Be sure the catheter tubing and drainage bag are kept off the floor.
1. Review of Resident #16’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 10/4/18, showed the
following:
-No cognitive impairment;
-Total dependence on staff for care;
-Indwelling urinary catheter;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 10/4/18, showed the following:
-Has indwelling catheter and will remain free from catheter-related trauma and show no
signs or symptoms of urinary infection, through next review date;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-Position catheter bag and tubing below the level of the bladder, change per physicians
order, see physician’s orders [REDACTED].
Review of the resident’s physician order [REDACTED].
-An order, dated 1/7/19, for [MEDICATION NAME] (antibiotic) HCl, 500 milligram (mg) by
mouth two times a day for multi-drug resistant organism (MDRO) Pseudomonas (bacteria)
urinary tract infection [MEDICAL CONDITION] for seven days, start 1/7/19;
-An order, dated 1/7/19, for [MEDICATION NAME] (antibiotic used to treat UTI) [MEDICATION
NAME] capsule 100 mg, give one capsule by mouth two times a day for MDRO Pseudomonas UTI
for seven days, start 1/7/19;
-An order, dated 1/7/19, for indwelling catheter care every shift;
-No order for an indwelling catheter, changing of an indwelling catheter or catheter care.
Review of hospital discharge orders, dated 1/7/19, showed the following:
-Suspected catheter associated UTI and [MEDICAL CONDITION] (blood poisoning);
-Change indwelling catheter as needed and no less than every 30 days.
During observation and interview on 1/9/19 at 10:15 A.M., the resident lay in bed. His/her
catheter tubing extended from the right side of his/her body into a urinary collection
bag, and rested on the floor. The resident said he/she just returned from five days in the
hospital [MEDICAL CONDITION] from a UTI.
Further observations of the resident, showed the following:
-On 1/9/19 at 2:00 P.M., the resident sat in a wheelchair in the resident council meeting
and catheter tubing came from inside a catheter privacy bag and lay on the floor under the
wheelchair for the entire meeting;
-On 1/15/19 at 7:26 A.M., the resident lay in bed with catheter tubing extended from the
right side of his/her body, into a urine collection bag, partially contained in a privacy
bag and resting on the floor.
During an interview on 1/15/19 at 9:35 A.M., the Director of Nursing said there should be
an order on the POS for the indwelling catheter that included the type, size, care and
changing of the catheter. The facility nurse practitioner said the resident had problems
with the catheter leaking and had used several different sizes. She would have to look at
the catheter to determine the current size used.
2. Review of Resident #48’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Dependent on staff for mobility and personal hygiene;
-[DIAGNOSES REDACTED].
Observation on 1/8/19 at 10:36 A.M., showed the resident lay in the bed. The lower half of
the catheter drainage bag, connected to the [MEDICATION NAME] for gravity drainage, rested
on the floor.
Observation on 1/9/19 at 10:00 A.M., showed the resident lay in bed and the urinary
drainage bag lay on the floor with no barrier in place between the drainage bag and the
floor.
Observation on 1/10/19 at 8:06 A.M., the resident lay in bed and the urinary drainage bag
lay on the floor under the bed.
Observations on 1/11/19 at 4:34 A.M., 8:42 A.M. and 10:54 A.M., showed approximately
400-500 cubic centimeters (cc) of yellow urine in the drainage bag, the lower one third of
the bag lay on the floor and the drainage port uncapped and lay approximately 1 inch off
of the floor.
Observation on 1/14/19 at 6:11 A.M., showed the resident lay in bed. The urinary drainage
bag contained approximately 500 cc of yellow urine and rested on the floor.
3. Review of Resident #140’s (MONTH) 2019 POS, showed the following orders dated 12/18/18:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
-Provide catheter care every shift;
-Change the suprapubic catheter and drainage bag monthly on the 15th;
-Suprapubic catheter (hollow tube inserted through the abdominal wall directly into the
bladder) size ordered 16 French (FR, a measurement used for catheter size).
Review of resident’s admission MDS, dated [DATE], showed:
-admitted on [DATE];
-Moderate cognitive impairment;
-Total staff assistance needed for all care tasks;
-Incontinent of bowel;
-Used suprapubic catheter for urinary elimination.
Review of the resident’s care plan, revised on 12/25/18, showed no directives for the
catheter care, orders or changes.
Observations on 1/8/19 at 6:45 A.M. and 2:59 P.M. and 1/10/18 at 7:35 A.M., showed the
resident lay in bed. The bottom of the urinary catheter drainage bag lay on the bedroom
floor.
Observations on 1/11/19 at 8:14 A.M. and 1/14/19 at 7:20 A.M. and 12:25 P.M., showed the
resident sat in his/her wheel chair in his/her room. The catheter tubing lay on the floor
under the resident’s chair.
4. During an interview on 1/15/19 at 9:30 A.M., the Director of Nursing and the
administrator said for infection control measures, the urinary drainage bag and the
urinary tubing should never be allowed to touch or lay on the floor and the drainage port
should always be secured.
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain
acceptable parameters of nutritional status by not ensuring one resident (Resident #67)
was regularly assessed by a registered dietician (RD). The resident experienced
significant weight loss of 16.89% in six months and was not included in seven residents
identified by the facility with unplanned significant weight loss. The census was 142.
Review of the facility’s Policies, Standards, Protocols, and Procedures Manual regarding
nutritional assessments, dated 7/12/13, showed the following:
-Each resident shall undergo a formal nutrition assessment to determine nutrition care
needs and the type of nutrition care to be provided. The formal nutrition assessment shall
be documented within the dietary section of the record and shall be completed by the
facility’s RD;
-Formal nutrition assessments shall be repeated at least every 12 months or in response to
a change in the resident’s condition such as, but not limited to, weight loss, pressure
ulcer development, decreased appetite, etc ;
-During monthly dietician visits, residents with pressure ulcers, tube fed residents,
residents with significant weight loss and residents receiving [MEDICAL TREATMENT] will be
assessed. Other residents can be added to the referral list at the discretion of the
dietary manager, director of nursing, or interdisciplinary care plan team.
1. Review of Resident #67’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 12/31/18, showed the
following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
-Short and long term memory problems;
-Moderately impaired cognitive skills for daily decision making;
-Altered level of consciousness constantly present;
-Limited assistance of staff required for most activities of daily living (ADL’s);
-Received hospice care;
-Complaints of difficulty or pain with swallowing;
-Weight 136 pounds (lbs);
-Weight loss of 5% or more in the last month, or 10% or more in the last six months: no or
unknown;
-Weight gain of 5% or more in the last month or 10% or more in the last six months: yes
and not on a physician prescribed weight gain plan;
-[DIAGNOSES REDACTED].
Review of the resident’s weight record showed the following:
-7/12/18, 148 lbs;
-8/9/18, 146.8 lbs;
-9/14/18, 145.8 lbs;
-10/20/18, 140.6 Lbs;
-11/29/18, 141.2 Lbs;
-12/10/18, 136.2 Lbs;
-1/4/19, 123.0 Lbs;
-The resident experienced a significant weight loss of 16.89% in six months.
Review of the resident’s care plan, last updated on 2/9/18, showed the following:
-At risk for alteration in nutrition and hydration related to mechanically altered diet,
receives regular pureed diet, currently weight is stable and will remain free from
significant weight change by next review;
-Assess for possible disease causing loss of appetite, monitor weights monthly and as
needed, report significant changes to physician, RD and family as needed, provide and
serve supplements as ordered, RD to evaluate and make diet change recommendations as
needed.
Review of the resident’s nutrition/dietary note, dated 5/6/2018, showed the resident’s
diet remained pureed, he/she ate in the main dining room three times daily and fed
him/herself. No additional nutrition/dietary notes or nutrition assessments documented
since 5/6/18.
Review of a physician progress notes [REDACTED]., weight loss, add Ready Care (nutritional
supplement), one cup twice daily with meals.
Review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-An order, dated 10/18/18, for Ensure (nutritional supplement) two times a day and
discontinued on 11/29/18.
Review of the residents Medication Administration Record [REDACTED].
Review of a physician progress notes [REDACTED]. Educated the resident that weight loss is
not healthy, he/she understands and will start to eat.
Review of the resident’s POS, dated 1/1/19 through 1/31/19, showed the following:
-An order, dated 11/30/18, for Ready Care two times a day. Mix Ready Care and 2 Cal HN
(high calorie nutrition supplement), 90 ml total.
Review of the resident’s MAR indicated [REDACTED].
Observation of the resident on 1/11/19 at 8:20 A.M., showed he/she lay in bed on his/her
left side with eyes open. This surveyor asked the resident if he/she was hungry for
breakfast. The resident said don’t bother me.
During an interview on 1/14/18 at 7:59 A.M., a certified nurse aide said the resident got
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
lunch and dinner trays in his/her room, but not usually breakfast. He/she did not eat much
but usually drank a little of the supplement.
During an interview on 1/15/19 at 9:35 A.M., the administrator said the RD comes twice a
month and documents on the residents each time she sees them. Assessments are done
quarterly and annually. The RD was out for a while last year and they had someone else
fill in for her. The resident had some gastrointestinal issues in (MONTH) and some changes
were made then to medication. The facility nurse practitioner and Director of Nursing said
the RD returned in November.
F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident’s drug regimen must be free from unnecessary drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to have adequate
indications for resident’s medications to support their use for three out of 28 sampled
residents (Residents #131, #38 and #4). The census was 142.
1. Review of Resident #131’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/19/18, showed the following:
-Moderately impaired cognition;
-No behaviors;
-Required limited assistance from staff for personal hygiene, dressing and bed mobility;
-Occasional urinary incontinence;
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
-An order, dated 12/12/17, for [MEDICATION NAME] (antidepressant medication), give 30
milligrams (mg) at bedtime for depression;
-An order dated 1/3/18, for Busipirone (antianxiety medication), give 10 mg twice a day
for anxiety;
-An order, dated 3/20/18, for [MEDICATION NAME] (narcotic used to treat severe pain), give
30 mg twice a day for pain;
-An order, dated 9/21/18, for [MEDICATION NAME] (antianxiety medication), give 0.5 mg
every morning for generalized anxiety.
Review of the resident’s care plan, last revised on 1/7/19, showed the following:
-Focus: Resident has a [DIAGNOSES REDACTED].
-Goal: Resident will exhibit indicators of depression, anxiety or sad mood less than daily
by review date;
-Approaches included: Administer medications as ordered and observe for signs/symptoms of
side effects and effectiveness, introduce resident to others with similar interests,
encourage eating in the dining room and conversing with tablemates,
monitor/document/report as needed of any signs/symptoms of depression, including
hopelessness, anxiety, sadness, [MEDICAL CONDITION], negative statements, repetitive
anxious or health-related complaints or fearfulness;
-Staff did not address any triggers for the resident’s anxiety or appropriate
non-pharmacological interventions to attempt when the resident was feeling increased
anxiety.
Review of the resident’s progress notes, showed the following:
-On 9/28/18 at 3:59 P.M., a social services note showed the resident is alert and oriented
to person, place and time with some confusion and is able to make his/her needs known. The

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
resident enjoys some group activities and has a very supportive family member who visits
often and is involved in the resident’s care. The resident can be verbally aggressive
towards staff and others and struggles with redirection from others;
-On 9/28/18 at 11:59 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the as needed (PRN) medication or if the
medication was effective;
-On 10/5/18 at 11:46 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the PRN medication or if the medication was
effective;
-On 10/6/18 at 8:23 P.M., a nurse’s note showed the resident asked for an [MEDICATION
NAME]. The resident’s psychiatrist said he/she would not prescribe anymore one time doses
and would see the resident within the week;
-No documentation the resident was seen by his/her psychiatrist;
-On 10/26/18 at 3:02 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the PRN medication or if the medication was
effective;
-On 11/3/18 at 8:52 P.M., a nurse’s note showed the resident is anxious due to increased
incontinence and it is having a psychological affect on him/her. The nurse educated the
resident on his/her [DIAGNOSES REDACTED]. Whenever the resident is incontinent, it upsets
him/her. Spoke to the resident’s psychiatrist and received a one time order for[MEDICATION NAME] 0.5 mg. Resident calmed down and rested in bed;
-On 11/8/18 at 12:00 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the PRN medication or if the medication was
effective;
-On 11/13/18 at 12:31 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the PRN medication or if the medication was
effective;
-On 12/8/18 at 9:16 P.M., a medication administration note showed the resident was given a
one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation to be given until
12/6/18 at 11:59 P.M. Staff did not document any interventions attempted prior to the PRN
medication or if the medication was effective;
-On 12/10/18 at 6:29 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the PRN medication or if the medication was
effective;
-On 12/21/18 at 4:46 P.M., a social service note showed the resident is alert and oriented
to person and place with periods of confusion. Resident enjoys some group activities and
brief one on one visits from staff. The note did not address the triggers or causes for
the resident’s increased anxiety necessitating the use of PRN [MEDICATION NAME];
-On 12/28/18 at 4:52 P.M., a medication administration note showed the resident was given
a one time only dose of [MEDICATION NAME] 0.5 mg for anxiety/agitation. Staff did not
document any interventions attempted prior to the PRN medication or if the medication was
effective;
-On 12/28/18 at 6:58 P.M., a nurse’s note showed the resident was anxious earlier in the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
shift with family visiting. Support and reassurance offered to the resident. The family
spoke with the facility nurse practitioner and received an order for [REDACTED].
During an interview on 1/15/19 at 7:42 A.M., the resident said, overall, he/she felt ok.
He/she has talked to a therapist in the past about his/her feelings and well-being and
found it very helpful. He/she would be open to talking to someone again.
During an interview on 1/15/19 at 9:27 A.M., the social services director (SSD) said she
is aware of the resident’s anxiety. The resident tends to be focused on other people not
doing things the way he/she thinks they should. For example, the resident has complained
to the SSD about residents not using their napkins properly at meals. However, she has
never seen the resident so upset medication was required. The resident has agreed to
therapy in the past, but will fire them after 6 weeks. The SSD was not aware the resident
had received multiple doses of PRN antianxiety medication. She would expect staff to
document triggers and follow interventions in the care plan. Any successful interventions
should be documented. If PRN medication is administered for behaviors, it is not
communicated with her. It would be helpful if it were, so she could try to put all the
pieces together to better help the resident.
During an interview on 1/15/19 at 9:35 A.M., the facility nurse practitioner said she had
worked with family about PRN medication use. The resident’s family member requests it due
to the worsening of the resident’s dementia. There have been several conversations with
the family member regarding dementia versus anxiety. The resident will often call the
daughter in an anxious state and the daughter will request staff to provide the PRN
medication. Staff should not administer PRN medications only because the family member has
asked them too. The resident becomes focused on others and that gets him/her worked up.
The resident has conversations about how she feels with staff. The resident can request
PRN medications at times too.
2. Review of Resident #4’s quarterly MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Extensive assistance needed for bed mobility, transfers, toilet use and personal hygiene;
-Received antidepressant medication prior seven days;
-Received antianxiety medication one prior day;
-[DIAGNOSES REDACTED].
Review of the resident’s POS’s, dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) 2019,
showed an order, dated 9/5/18, for [MEDICATION NAME] 1 mg, give one tablet by mouth every
12 hours as needed for anxiety.
Review of the resident’s medication administration records (MAR’s), dated (MONTH) (YEAR),
(MONTH) (YEAR) and (MONTH) 2019, showed the following:
-[MEDICATION NAME] 1 mg, give one tablet by mouth every 12 hours as needed for anxiety,
initialed as given 11/2/18 at 9:55 P.M., effectiveness unknown; 11/5/18 at 9:03,
effective; 11/6/18 at 9:32 P.M., effective; 11/8/18 at 7:34 P.M., effective; 11/11/18 at
8:44 P.M., effective; 11/15/18 at 8:30 P.M., effective; 11/16/18 at 7:31 P.M., effective;
and 11/27/18 at 9:17 P.M., effective;
-[MEDICATION NAME] 1 mg, give one tablet by mouth every 12 hours as needed for anxiety,
initialed as given 12/6/18 at 10:25 P.M., effective; 12/9/18 at 10:18 P.M., effective;
12/11/18 at 9:11 P.M., effective; 12/13/18 at 8:01 P.M., effective; 12/14/18 at 9:05 P.M.,
effective; 12/16/18 at 8:39 P.M., effective; 12/18/18 at 8:30 P.M., effective; 12/20/18 at
8:40 P.M., effective; 12/21/18 at 8:38 P.M., effective; 12/25/18 at 9:07 P.M., effective;
12/29/18 at 8:55 P.M., effective and 12/30/18 at 8:02 P.M., effective;
-[MEDICATION NAME] 1 mg, give one tablet by mouth every 12 hours as needed for anxiety,
initialed as given
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
on 1/3/19 at 8:46 P.M., effective; 1/6/19 at 8:02 P.M., effectiveness not indicated;
1/11/19 at 8:19 P.M., effectiveness unknown; 1/12/19 at 7:27 P.M., effective and 1/14/19
at 9:52 P.M., effective.
No documentation was found regarding the reason for administration or non-pharmacological
interventions attempted prior to administration of the medication.
3. Review of Resident #33’s annual MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Supervision required for most ADL’s;
-Received antianxiety medication the past seven days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 10/17/18, showed the following:
-Used [MEDICAL CONDITION] medications related to depression, anxiety and [MEDICAL
CONDITION] disorder and would remain free of [MEDICAL CONDITION] drug related
complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait
disturbance, constipation/impaction or cognitive/behavioral impairment through review
date;
-Administer [MEDICAL CONDITION] medications as ordered by physician, monitor for side
effects and effectiveness, educate about the risks, benefits and the side effects and/or
toxic symptoms of [MEDICAL CONDITION] medication drugs being given.
Review of the resident’s POS, dated 12/1/18 through 12/31/18, showed an order, dated
3/29/17, for [MEDICATION NAME] concentrate (anti-anxiety medication in liquid form) 2
mg/ml, give 0.5 ml by mouth every four hours as needed for anxiety.
Review of the resident’s (MONTH) (YEAR) MAR, showed [MEDICATION NAME] 2 mg/ml, .05 ml
every four hours as needed, initialed as given on 12/1/18 at 2:31 A.M., effective;
12/16/18 at 11:56 A.M., effective and 12/27/18 at 9:02 A.M., effective.
No documentation was found regarding the reason for administration or non-pharmacological
interventions attempted prior to administration of the medication.
4. During an interview on 1/15/19 at 9:35 A.M., the administrator said she would expect
staff to document interventions attempted prior to administering PRN medications as well
as the reason and effectiveness. Staff should document triggers and interventions in the
care plan.
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 25 opportunities observed, two errors
occurred resulting in a 6.45 % error rate (Resident #61). The census was 142.
Review of the facility’s medication administration policy, dated 12/19/2013, showed:
-Policy: Medications will be administered in a safe, efficient and accurate manner to
residents for whom they are prescribed and in accordance with current acceptable nursing
practice;
-Guidelines: If a drug is withheld, refused or given at a time other than the scheduled
time, the individual administering the medication will initial and circle the Medication
Administration Record [REDACTED] 1. Review of Resident #61’s medical record, showed:
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
Review of the (MONTH) electronic physician order [REDACTED].
-An order dated 11/29/18, for [MEDICATION NAME] ([MEDICATION NAME], used to treat
depression) 20 milligrams (mg) administer one tablet once daily at 9:00 A.M., for major[MEDICAL CONDITION];
-An order dated 11/29/18, for levetiracetam( [MEDICATION NAME], used to treat [MEDICAL
CONDITION] disorders) 1000 mg, administer one tablet twice a day, once in the morning and
an evening dose.
Observation and interview on 1/10/19 at 9:03 A.M., showed Certified Medication Technician
(CMT) F sanitized his/her hands and prepared to administer the resident his/her
medications. CMT F said the resident’s [MEDICATION NAME] and [MEDICATION NAME] are not
available. He/she proceeded to administer the remainder of the resident’s scheduled
morning medications. CMT F said he/she will have to check the emergency medication kit
(Ekit) and see if there are any extra [MEDICATION NAME] and [MEDICATION NAME] to borrow
until the resident’s supply is delivered. If the emergency kit does not have the
medication, he/she will need to inform the charge nurse of the missed dose.
Review of the resident’s medication progress notes and nurse progress notes on 1/10/19 at
2:35 P.M., 1/11/19 at 7:02 A.M., and 1/14/19 at 11:02 A.M., showed no documentation
regarding the missed doses of [MEDICATION NAME] and [MEDICATION NAME].
During an interview on 1/14/19 at 12:07 P.M., the Director of Nursing and the
Administrator said that if a medication is missed during the pass, the CMT should check if
the medication is available on the Ekit and administer it if available. If the medication
is not available then the charge nurse should notify the physician, discuss a follow up
plan and notify family. [MEDICATION NAME] is available on one of the other Ekits and the
CMT should have notified the nurse so that could have been pulled and administered as
ordered. If medication is missed there should always be documentation in the resident’s
progress notes.
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

Based on observation and interview, the facility failed to label and store medications in
a safe and effective manner when a nurse predispensed medications into cups and then
stored them in the medication cart to administer at a later time. The facility census was
142.
Review of the facility’s Medication Administration Policy, dated 12/2015, showed the
following:
-Policy: Medications will be administered in a safe, efficient and accurate manner to
residents for whom they are prescribed and in accordance with current acceptable nursing
practice;
-Medications may not be prepared in advance and must be administered within one hour of
their prescribed time, unless otherwise specified.
Observation of the mansion dining room on 1/10/19 from 8:22 A.M. to 8:35 A.M., showed
during breakfast service, Registered Nurse (RN) E dispensed pills from a packet into a
cup, wrote on the cup, and then placed the cup inside a drawer of the medication cart.
This occurred 7 times.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 32)
Observation and interview on 1/10/19 at 8:33 A.M., showed RN E opened the third drawer of
the medication cart to reveal seven cups containing pills with initials on each cup. RN E
said he/she was confused about when to administer the medications. Normally, he/she would
administer them to the resident at their table during breakfast, but he/she was told not
to do this during the survey. To try to stay on time, he/she predispensed the medication
and planned to administer medications as the residents left the dining room.
During an interview on 1/10/19 at 8:35 A.M., the Assistant Director of Nursing (ADON) said
it is not the facility’s policy to predispense medications. Doing so could cause an error
such as if a medication were forgotten. The medications in the cups would need to be
wasted. As long as the resident is comfortable taking medications in the dining room, it
is ok to administer them during meals.
F 0803

Level of harm – Potential for minimal harm

Residents Affected – Many

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, record review and interview, the facility failed to consult with the
registered dietitian before making substitutions to the planned menu to ensure the
substitutions were nutritionally adequate. This practice affected all residents who
received food from the facility’s kitchen. The census was 142.
During an interview on 1/8/19 at 5:20 P.M., Resident # 1 said he/she had been at the
facility for two weeks. He/she had lived there before and just moved back in. He/she said
the food is not as good as it used to be. He/she said they get the same thing fro
breakfast every day: eggs, bacon or sausage, toast and cereal. He/she would like it if
other options were offered, such as biscuits and gravy.
Review of the facility’s approved breakfast menu, showed the following breakfasts
scheduled during the survey:
-1/9/19: choice of juice and cereal, scrambled eggs with bacon and toast;
-1/10/19: choice of juice and cereal, breakfast pot pie;
-1/11/19: choice of juice and cereal, sausage gravy, biscuit and eggs.
Observations of breakfast services in the main dining room, showed the following:
-On 1/9/19 at 8:00 A.M.: cereal, scrambled eggs, bacon, sausage and toast;
-On 1/10/19 at 810 A.M.: cereal, scrambled eggs, bacon, sausage and toast;
-The facility did not serve the approved breakfast;
-On 1/11/19 at 8:37 A.M.: cereal, scrambled eggs, bacon, sausage and biscuit;
-The facility did not serve the approved breakfast.
During an interview on 1/11/19 at 8:37 A.M., Resident #1 said he/she was disappointed
there wasn’t any gravy with the biscuits.
During an interview on 1/11/19 at 8:45 A.M., the dietary manager said the sausage gravy
was not served today because he did not receive their shipment of gravy on Tuesday. He did
not get here early enough this morning to make sausage gravy. They did not serve the
breakfast pot pie because the residents complaint about the vegetables in it. They prefer
omelets. Omelets were only served if a resident specifically asked for one. He was not
aware the substitutions needed to be approved by the dietician.
During an interview on 1/11/19 at 9:00 A.M., the administrator said the dietary manager is
new and has not received all the training necessary with regards to systems. She would
expect the scheduled menu to be served or the dietary manager could go to the store to get

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0803

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 33)
what is needed.
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure pureed
food items were prepared properly to the meet the needs of residents with physician’s
orders [REDACTED]. The facility census was 142.
1. During an interview on 1/8/19 at 11:00 A.M., the dietary manager said they had eight
residents with orders for a pureed diet.
Observation on 1/9/19 at 10:47 A.M., showed Cook Q placed seven pieces of cooked chicken
cordon bleu in the blender, added 2 cups of chicken broth and blended. Cook Q said he/she
was making enough for 10 residents to ensure there was enough. Cook Q blended to a smooth
and thin texture and then placed in a metal pan. Cook Q said the pureed chicken was
completed. Cook Q did not add three additional pieces of chicken cordon bleu to make a
total of 10 servings.
Review of the facility’s recipe for pureed chicken cordon bleu for 10 servings, showed the
following:
-10 servings of prepared chicken cordon bleu;
-10 fluid ounces (oz) of hot chicken broth;
-Measure the number of pureed portions required from the regular recipe;
-Add to food processor and process to fine consistency;
-Gradually add hot broth to meat while processing. All liquid may not be required;
-May add commercial thickener if needed to obtain smooth pudding like consistency.
2. Observation on 1/10/19 at 10:44 A.M., showed Cook Q placed three 4 oz scoops of
spaghetti noodles and sauce in the blender, added one cup of hot water and blended. The
texture was smooth and thin. Cook Q said it was enough spaghetti. The surveyor questioned
how it could be enough for 10 servings. Cook Q added three more 4 oz scoops of noodles
plus one cup of hot water into the blender and blended. He/she then added it to the pan of
previously pureed noodles and sauce. Cook Q did not follow the recipe.
Review of the facility’s recipe for pureed spaghetti with meat sauce for 10 servings,
showed the following:
-10 servings of prepared spaghetti with meat sauce;
-10 fluid oz of hot beef broth;
-Measure the number of pureed portions required from the regular recipe;
-Add to food processor and process to fine consistency;
-Add hot broth to meat mixture and process until smooth.
3. Observation of the breakfast service on 1/15/19 at 7:53 A.M., showed a pan of pureed
sausage on the steam table in the kitchen. A dietary aide took a slotted scoop and placed
a scoop of pureed sausage on a plate. Liquid strained from the slotted spoon of pureed
sausage into the pan on the steam table. The sausage in the pan appeared very grainy and a
pool of liquid formed around it.
During an interview at 7:53 A.M., Cook Q said he/she did not add any bread or thickener to
the sausage. He/she used broth and blended.
Review of the facility recipe, showed commercial thickener could be added if needed to
obtain smooth pudding like consistency.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
4. During an interview at 7:55 A.M., the dietary manager said he expected staff to follow
recipes. Cooks should taste the food they make to ensure proper taste and texture.
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to have a process in place to
check the sanitizer levels in sanitizer buckets, have a process in place to track thawed
health shakes and ensure staff did not use wet dishes during meal service for one meal
observed. These deficient practices had the potential to affect all residents who ate at
the facility. The census was 142.
1. During an interview on 1/10/19 11:06 A.M. the dietary manager (DM) was asked to test
the sanitizer in the sanitizer bucket at the work table by the stove. The DM said he
doesn’t test sanitizer buckets. After looking in his office, he was able to locate the
correct type of strips to test the sanitizer level. He placed the strip in the bucket for
approximately 10 seconds. The test strip showed a dark green color in the 400 parts per
million (ppm) range. After looking at the information on the sanitizer bottle, it was
determined the amount of sanitizer was within range. The DM said he was new, but that
wasn’t an excuse. He was not trained on the need to test sanitizer buckets. He agreed he
should know if the amount of sanitizer being used to clean was at the appropriate level
for sanitation purposes.
2. Observation of the walk in cooler on 1/11/19 at 8:45 A.M., showed a box full of thawed
health shakes without dates. A date on the outside of the box showed 12/21/18. Dietary
Aide (DA) R said the date on the outside of the box is the date they received the box from
the vendor. He/she did not know when the box was placed in the cooler. He/she added more
shakes to the box as it got low.
During an interview at 8:47 A.M., the DM said the date on the outside of the box is when
it was received. He did not know when the shakes were thawed or how long they could be
thawed. He said there were approximately 50 shakes in the box, which he would toss out.
During an interview at 9:00 A.M., the administrator said the DM is new and has not
received all the training necessary with regards to systems.
During an interview at 9:07 A.M., the DM said he spoke with the vendor and the shakes
could be thawed for 14 days and would then need to be thrown away.
3. Observation of the lunch service on 1/08/19 at 11:57 A.M. in the main dining room,
showed staff served lunch from a steam table. At 12:05 P.M., the staff who dished out food
stopped to wait for more plates. At 12:08 P.M., more plates arrived and staff continued to
dish out food for residents. Observation showed water droplets pooled on the plates being
used. Staff used at least six plates with water droplets to serve food to residents.
During an interview on 1/15/19 at 9:00 A.M., with the administrator and the DM, the DM
said staff should never use wet plates. They ran out of plates and had to wash more, which
is why they were wet. They have ordered more plates. The administrator agreed wet plates
should not be used.

F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a policy regarding use and storage of foods brought to residents by family and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0813

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
other visitors.

Based on interview and record review, the facility failed to produce an on-site policy
regarding the acceptance, usage and storage of foods brought into the facility for
residents by family and other visitors, to ensure the food’s safe and sanitary handling
and consumption. This deficient practice had the potential to affect all residents who ate
food brought in by visitors. The facility census was 142.
Review of the facility’s policies provided, showed no documentation of a policy regarding
foods brought in for residents by family and other visitors.
During an interview on 1/15/19 at 9:14 A.M., the administrator said they did not have a
policy for food brought in by family or visitors.
During an interview on 1/15/19 at 9:14 A.M., the dietary manager confirmed that the
facility did not have a policy regarding outside food brought in.

F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Arrange for the provision of hospice services or assist the resident in transferring to
a facility that will arrange for the provision of hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to collaborate with hospice in
the development of a coordinated plan of care for three residents receiving hospice care.
The facility identified eight residents on hospice care and three of those residents were
selected for the sample of 28. Problems were found with all three of those residents
(Residents #242, #22 and #67). The census was 142.
1. Review of Resident #242’s (MONTH) physician order [REDACTED].
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
-Current treatment orders for open wounds to both heels;
-An order, dated 1/3/19, to admit to hospice.
Review of the resident’s hospice binder, showed the following:
-Resident assessed and admitted to hospice on 1/3/19 for terminal [DIAGNOSES REDACTED].
-Hospice nurse to visit two times as week and as needed, hospice certified nurse aide
(CNA) to visit three times a week, hospice social worker and chaplain to visit once a
month and as needed;
-Hospice plan of care reviewed and coordinated with facility;
-No documentation of hospice visits, services provided or communication with facility.
Review of the resident’s care plan, last reviewed on 1/14/19 and in use during the survey,
showed the following:
-Staff did not document the resident’s use of hospice services on the care plan until
1/14/19;
-Focus: Due to terminal prognosis, resident elected to utilize hospice services;
-Goal: Resident’s dignity, autonomy and comfort will be maintained to the highest level
through next review date;
-Interventions: Consult with physician and Social Services to have hospice care for
resident in the facility, work cooperatively with hospice team to ensure the resident’s
spiritual, emotional, intellectual, physical and social needs are met.
During an interview on 1/15/19 at 7:15 A.M., the social service director said she has

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
recently been appointed the liaison to collaborate on resident care with hospice agencies
used by residents.
2. Review of Resident #22’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/8/18, showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-Unable to ambulate;
-Extensive to total dependence on staff for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Received Hospice services.
Review of the medical record, showed the resident admitted to hospice on 4/8/18 with a[DIAGNOSES REDACTED].
Review of the care plan in use during the survey, showed the date of admission to hospice,
the name of the hospice company and the hospice diagnosis. It did not provide a
description of coordination of care with the hospice company, description of services to
be provided by hospice or the hospice visit schedule.
Further review of the medical record, showed no documentation by the hospice CNA of the
services provided during his/her visits.
During an interview on 1/15/19 at 9:30 A.M., the administrator said the hospice company
said the facility would have to ask specifically for the hospice aide notes and the
hospice company would provide them.
3. Review of Resident #67’s significant change MDS, dated [DATE], showed the following:
-Short and long term memory problems;
-Moderately impaired cognitive skills for daily decision making;
-Altered level of consciousness constantly present;
-Limited assistance of staff required for most activities of daily living (ADL’s);
-Occasionally incontinent of bladder;
-Did not have a condition or chronic disease that may result in a life expectancy of less
than six months;
-Received hospice care;
-[DIAGNOSES REDACTED].
Review of the hospice/long term care coordinated task plan of care, kept in a binder at
the nurses’ station, showed the following;
-admitted to hospice care on 12/24/18;
-Hospice aide visits three times weekly;
-Skilled nursing visits twice weekly;
-Social work visits twice monthly;
-Documentation of hospice aide visits;
-No documentation of skilled nursing visits.
Review of the resident’s care plan, updated 12/31/18, showed the following:
-Terminal [DIAGNOSES REDACTED].
-Dignity and autonomy will be maintained at highest level and comfort will be maintained
through the review date;
-Consult with physician and Social Services to have hospice care for the resident in the
facility, work cooperatively with hospice team to ensure the resident’s spiritual,
emotional, intellectual, physical and social needs are met.
4. During an interview on 1/11/19 at 11:26 A.M., the hospice nurse said he/she was there
to see three residents who received hospice services. He/she visited Resident #67 once a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 6/10/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265699

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/15/2019

NAME OF PROVIDER OF SUPPLIER

BEAUVAIS MANOR HEALTHCARE & REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

3625 MAGNOLIA AVENUE
SAINT LOUIS, MO 63110

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0849

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
week, but could always add more visits if they were needed. Resident #67 was pretty new to
hospice. Visits were documented on an electronic tablet. A couple of times a month, the
office would print the notes and he/she would bring them in and place them in a binder
kept at the nurses’ station. He/she always communicated with nursing staff regarding the
visits prior to leaving the building. The hospice aide came three times a week and left
handwritten notes in the binder each visit.
5. During an interview on 1/15/19 at 9:35 A.M., the administrator said she was not aware
the facility care plan needed to reflect the collaboration of services the hospice agency
and facility would provide.
[/fusion_text][/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]