Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assure the security of all personal funds of residents deposited with the facility.

Based on interview and record review, the facility failed to maintain a surety bond, to
assure the security of all personal funds of residents deposited with the facility, of one
and one-half times the average monthly balance of resident funds, to ensure protection of
resident funds. The census was 138.
Review of the facility’s Resident Trust General Ledger (cash sheet) for the period of
(MONTH) (YEAR) through (MONTH) (YEAR), showed an average monthly balance of $66,000, which
would require a bond of $103,500.00.
Review of the Department of Health and Senior Services approved bond list, showed the
facility had an approved bond for $100,000.
During an interview on 1/18/19 at 11:44 A.M., the Business Office Manager said the
corporate office is responsible for ensuring the bond is sufficient enough to cover the
resident funds. The month of (MONTH) was higher than the other months because both (MONTH)
and September’s social security was deposited in August. The resident’s social security
for (MONTH) (YEAR) was deposited on 8/31/18. She would expect the resident funds to be
fully covered by the bond amount.
Review of the resident funds deposit for (MONTH) and (MONTH) (YEAR), showed an amount of
$105,922.94.
During an interview on 1/22/18 at 10:45 A.M., the administrator said the corporate office
is responsible for increasing the bond; however, she would expect the bond to be
sufficient to cover the resident’s money and to cover the amount in case there was another
double deposit.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to provide a Skilled Nursing
Facility Advance Beneficiary Notice (SNFABN – form CMS- ) or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits for three sampled
residents who remained in the facility upon discharge from Medicare Part A services
(Residents #192, #61 and #127). The sample was 27. The facility census was 138.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification
memo (S&C -09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC – form CMS- ) is issued when all
covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident’s stay
that Medicare will not pay for skilled nursing or specialized rehabilitative services and
the provider believes that an otherwise covered item or service may be denied as not
reasonable or necessary, the facility must inform the resident or his/her legal
representative in writing why these specific services may not be covered and the
beneficiary’s potential liability for payment for the non-covered services. The SNF’s
responsibility to provide notice to the resident can be fulfilled by use of either the
SNFABN (form CMS- ) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to
pay for them his/herself or through other insurance they may have;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the
initiation,
reduction, or termination of Medicare Part A benefits, the provider has met its obligation
to inform the beneficiary of his/her potential liability for payment and related standard
claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the
beneficiary of his/her right to an expedited review of a service termination.
1. Record review of Resident #192’s Skilled Nursing Facility Beneficiary Protection
Notification Review, completed by facility staff on 1/17/19, showed the following:
-Medicare Part A skilled services start date 9/17/18;
-Last covered day of Medicare Part A service as 10/2/18;
-Facility staff could not provide any documentation they issued the resident or his/her
legal representative the SNFABN form CMS- , alternative denial letter, or a NOMNC form
CMS- .
2. Record review of Resident #61’s Skilled Nursing Facility Beneficiary Protection
Notification Review, completed by facility staff on 1/17/19, showed the following:
-Medicare Part A skilled services start date 9/19/18;
-Last covered day of Medicare Part A service as 12/7/18;
-Facility staff could not provide any documentation they issued the resident or his/her
legal representative the SNFABN form CMS- , alternative denial letter, or a NOMNC form
CMS- .
3. Record review of Resident #127’s Skilled Nursing Facility Beneficiary Protection
Notification Review, completed by facility staff on 1/17/19, showed the following:
-Medicare Part A skilled services start date 10/22/18;
-Last covered day of Medicare Part A service as 12/11/18;
-Facility staff could not provide any documentation they issued the resident or his/her
legal representative the SNFABN form CMS- , alternative denial letter, or a NOMNC form
CMS- .
4. During an interview on 1/17/19 at 9:00 A.M., the administrator said the facility sent
the beneficiary notification letters to the resident’s responsible party, but did not keep
a copy of the letters and did not document they had sent the letters. The responsible
parties did not return the forms. The administrator could not provide any documentation
the letters were issued.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interview, the facility failed to provide a safe, clean,
comfortable and homelike environment, by not ensuring the ceiling, baseboards, and window
blinds were in good repair and clean. In addition, the facility failed to ensure the
toilet base bolts were covered and the protective boarder around the heater/air
conditioner was in place for four of 27 sampled residents and their rooms (Residents #14,
#123, #2, and #27). The census was 138.
1. During an observation of Resident #14’s room on 1/17/19 at 7:18 A.M., showed:
-Approximately 3 feet of the baseboard behind the head of the resident’s bed, pulled away
from the wall;
-The ceiling above the head of the resident’s bed had an approximate 3 feet by 3 feet area

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
where the plaster was cracked, peeling, hung down and an approximate 6 inch by 6 inch area
with the plaster missing;
-The window blinds had approximately 21 slats bent or broken;
-The base of the toilet had 2 bolts exposed and sticking upward approximately 3 inches.
2. Observation of Resident #123’s room on 1/17/19 at 11:39 A.M., 1/18/19 at 9:40 A.M., and
1/22/19 at 9:26 A.M., showed the heater/air conditioner with a hole in the protective
boarder around the wall unit. The hole was approximately 2 inches by 2 inches in size. The
cold air from the outside could be felt blowing into the resident’s room and the outside
could be seen from the hole. The resident’s heater was set to 80 degrees Fahrenheit (F).
During an interview on 1/18/19 at 9:40 A.M., the resident said he/she could feel the cold
air blowing into the room from the hole in the protective boarder around the wall unit.
3. During an observation on 1/16/19 at 11:56 A.M., 1/17/19 at 12:17 P.M., and 1/18/19 at
10:00 A.M., showed Resident #2’s heater/air conditioner wall unit without a protective
boarder on the left side with an opening of approximately 12 inches by 1 inch. The cold
air from the outside could be felt blowing into the resident’s room.
During an interview on 1/18/19 at 10:00 A.M., the resident said he/she could feel the cold
air on the left side of the wall unit. His/her side of the room was closest to the wall
unit, so his/her side of the room was cooler.
During an interview on 1/22/19 at 9:26 A.M., the maintenance director said during the
weekend, there was a problem with the resident’s wall unit. He noticed the wall unit
needed a protective boarder. It was fixed and cold air was no longer blowing into the
resident’s room.
4. During an observation on 1/16/19 at 9:52 A.M., 1/17/19 at 11:45 A.M., 1/18/19 at 2:06
P.M., and 1/22/19 at 9:35 A.M., showed several brown stains on Resident #27’s ceiling that
covered part of his/her side of the room.
During an interview on 1/16/19 at 9:52 A.M., the resident said he/she did not know what
the brown stains on the ceiling were, but they had been there since he/she moved in.
He/she did not feel like his/her room was a homelike environment.
5. During an interview on 1/18/19 at 12:34 P.M., Nurse J showed forms in a box by the door
leading from the hallways to the lobby and said whenever staff identify anything that
needs to be repaired, they fill out the form and then maintenance picks up the completed
form from the box.
6. During an interview on 1/22/19 at 9:26 A.M., the maintenance supervisor said the head
of each department complete rounds and turn in the sheets to maintenance every day. If
there are repairs that needed to be completed then a work order is filled out. He would
expect staff to check the wall units in the resident’s room to ensure the protective
boarder is intact. He was not aware of the damaged protective boarder. He would expect
staff report any damage or stains to the walls and ceilings in the resident’s room.
7. During an interview on 1/22/19 at 10:39 A.M., the administrator said rounds are
completed seven days a week, and the head of the department complete the rounds Monday
through Friday. If there are any repairs that are needed, they are expected to fill out a
work order. She would expect staff to ensure there is a protective boarder around the
resident’s wall unit to ensure cold air is not blowing into the room.

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.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 3)
Based on interview and record review, the facility failed to complete the required
criminal background checks (CBC), employee disqualification list (EDL, a listing
maintained by the Department of Health and Senior Services, of individuals who have been
determined to have abused or neglected a resident or misappropriated funds or property
belonging to a resident) checks and nurse aide (NA) registry check for federal indicators
(FI, an indicator applied to the certification for any certified nursing assistant (CNA)
found guilty of Abuse, Neglect, or Misappropriation of property). Of 10 employee files
reviewed, issues were identified with six. The census was 138.
Review of the facility’s Abuse, Neglect and Grievance procedures, revised (MONTH) 28,
(YEAR), showed:
-Potential employees are screened for a history of abuse, neglect, mistreating of
residents. For details on the employee screening. See the Screening- Applicant, Employee,
Volunteer and Vendor Policy and Procedure.
Review of the facility’s Screening- Applicant, Employee, Volunteer and Vendor Policy and
Procedure, dated 3/1/14, showed:
-Purpose: To establish a written procedure for applicant, employee, volunteer and vendor
background checks and screening.
-Pre-Employment Screening:
-Company Human Resources (HR) will conduct pre-employment screens on applicants to
determine whether the applicant has committed a disqualifying crime, is an excluded
provider of any federal or state healthcare programs, is eligible to work in the United
States and, if applicable, is duly licensed or certified to perform the duties of the
position for which they applied;
-Procedure: HR staff will conduct the following screens on potential employees prior to
hire:
-A. Criminal history. No applicant may be hired if they have been convicted of, pled
guilty or nolo contendere to a crime which under Missouri law would be a class A or B
felony in violation of Missouri codes;
-B. Federal Exclusion List. If the results indicates that the applicant is excluded, they
cannot be hired;
-C. Licensure. If an applicant has any restrictions on their license, that restriction
must be shared with the RCMC Executive Director, Human Resources and the RCMC Chief
Compliance Officer for review before the applicant can be hired;
-D. Family Care Safety Registry (FCSR). This screening will check the sex offender,
employee disqualification list and other Missouri databases automatically. Registration
and background check must be completed before the applicant can begin work;
-E. CNA Registry. The CNA Registry must be checked for all applicants regardless of the
position for which they are applying. Any applicants listed with background problems or
with an inactive or suspended CNA license will not be hired;
-AUDIT: RCMC HR staff will periodically, but not less than annually, review a sample of
employee background check files to ensure the Company HR staff has conducted the
background checks listed in this policy.
1. Review Laundry Aide B’s employee file, showed:
-Date of hire, 11/15/18;
-CBC requested 1/17/19, no documentation the results received;
-EDL check completed 1/17/19;
-NA registry check completed 1/17/19.
2. Review of CNA C’s employee file, showed:
-Date of hire, 4/5/18;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 4)
-Date of separation, 4/11/18;
-CBC requested 7/15/18, and the results received 7/17/18;
-No documentation the EDL check completed;
-NA registry check completed 7/15/18.
3. Review of CNA D’s employee file, showed:
-Date of hire, 6/7/18;
-EDL check completed 6/5/18;
-No documentation the CBC requested or received;
-No documentation the NA registry check completed.
4. Review of Licensed Practical Nurse (LPN) E’s employee file, showed:
-Date of hire, 7/30/18;
-CBC requested 8/31/18, and the results received 8/31/18;
-EDL check completed 8/31/18;
-NA registry check completed 8/31/18.
5. Review of LPN F’s employee file, showed:
-Date of hire, 11/27/18;
-CBC requested 1/17/19, and the results received 1/17/19;
-EDL check completed 1/17/19;
-NA registry check completed 1/17/19.
6. Review of the Assistant Director of Nursing (ADON’s) employee file, showed:
-Date of hire, 10/11/18;
-CBC requested 1/17/19, and the results received 1/17/19;
-EDL check completed 1/17/19;
-NA registry check completed 1/17/19.
7. During an interview on 1/17/19 at 11:45 A.M., the Human Resource (HR) Director she knew
there were some employees that had their background, EDL and FI checks completed, but she
was unable to locate them, so she ran them again. She would expect background, EDL and FI
checks to be completed per facility policy.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written emergency
transfer notices to residents and/or representative as soon as practicable when a resident
was temporarily transferred on an emergency basis to an acute care facility and their
return to the facility was expected. Of the 29 sampled residents, 10 had been recently
transferred to a hospital for various medical reasons, all 10 were expected to return and
had not been issued a written transfer notice upon leaving the facility (Residents #95,
#141, #144, #14, #111, #128, #61, #21, #106 and #127). The census was 138.
1. Review of Resident #95’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfer.
2. Review of Resident #141’s medical record, showed:
-Transferred to the hospital on [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice
upon the emergency transfers.
3. Review of Resident #144’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfer.
4. Review of Resident #14’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to facility from the hospital on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfer.
5. Review of Resident #111’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice
upon the emergency transfers.
6. Review of Resident #128’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative was provided a notice upon the
emergency transfers.
7. Review of Resident #61’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received a written transfer
notice upon the emergency transfer.
8. Review of Resident #21’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received a written transfer
notice upon the emergency transfers.
9. Review of Resident #106’s medical record, showed:
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice
upon the emergency transfers.
10. Review of Resident #127’s medical record, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Transferred to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received a written transfer
notice upon the emergency transfer.
11. During an interview on 1/18/19 at 10:35 A.M., Nurse I said when a resident is sent to
the hospital, a copy of their face sheet, current physician order [REDACTED]. Nursing does
not issue any transfer notice to the resident and/or their representative when the
resident is transferred to the hospital with a return anticipated.
12. During an interview on 1/22/19 at 7:48 A.M., the Director of Nurses (DON) said the
nurses are responsible for issuing the discharge letter to the resident upon an emergency
transfer to the hospital with a return anticipated. This should be documented in the
nurses’ notes. They had not been issuing the transfer notices as required.
13. During an interview on 1/22/19 at 8:03 A.M., the administrator said she was unaware of
the regulation to issue a written transfer notices to the resident upon an emergency
transfer to the hospital and they had not been issued as required.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide written notice to the
resident or their legal representative of the facility bed hold policy at the time of
transfer to the hospital, for eight of 10 sampled residents who were recently transferred
to the hospital for various medical reasons (Residents #141, #144, #14, #111, #128, #61,
#106, and #127). The census was 138.
1. Review of Resident #141’s medical record, showed:
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
2. Review of Resident #144’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility on [DATE];
-No documentation the resident and/or the representative received information in writing
of the facility’s bed hold policy at the time of transfer.
3. Review of Resident #14’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to facility from the hospital on [DATE];
-No documentation the resident and/or the representative received information in writing
of the facility’s bed hold policy at the time of the emergency transfer.
4. Review of Resident #111’s medical record, showed:
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-Discharge to the hospital on [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
5. Review of Resident #128’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received information in writing
of the facility’s bed hold policy at the time of transfers.
6. Review of Resident #61’s medical record, showed:
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received information in writing
of the facility’s bed hold policy at the time of transfer.
7. Review of Resident #106’s medical record, showed:
-Discharge to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
8. Review of Resident #127’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received information in writing
of the facility’s bed hold policy at the time of transfer.
9. During an interview on 1/22/19 at 7:48 A.M., the Director of Nurses (DON) said the
nurses are responsible for issuing the bed hold policy to the resident upon an emergency
discharge to the hospital with a return anticipated. This should be documented in the
nurses notes. They had not been documenting the bed hold policy had been issued and they
should document in the nurses notes.
10. During an interview on 1/22/19 at 8:03 A.M., the Administrator said they have been
giving the bed hold policy to the residents upon emergency discharge to the hospital with
a return anticipated, but could not provide any documentation.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 assure residents
who were unable to carry out activities of daily living (ADLs) received the necessary
services to maintain good grooming and personal hygiene, for one of one sampled residents
who received incontinence care (Resident #14). The sample size was 29. The census was 138.
Review of the facility’s undated Policy and Procedure for incontinence care (perineal care
– peri care, the surface between the thighs and extends to the buttocks), showed to wash
the skin with soap and water, rinse the soap off of the skin and pat dry.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 – Few

(continued… from page 8)
1. Review of Resident #14’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/28/18, showed:
-[DIAGNOSES REDACTED].
-Cognitively impaired with short and long term memory problems;
-Incontinent of bowel and bladder;
-Required total assistance from the staff for transfers, dressing, eating, hygiene and
bathing.
Observation on 1/17/19 at 7:20 A.M., showed the resident lay in bed. Certified Nurse
Assistant (CNA) K brought equipment into the resident’s room, told the resident what
he/she was going to do, washed his/her hands, put on gloves, filled a wash basin with
water and changed his/her gloves. CNA K placed a clean washcloth in the wash basin,
squeezed shampoo and body wash into the wash basin and washed the resident’s perineal area
and genitals. Soap was visible on the resident’s skin. Without rinsing the soap off of the
skin, he/she dried the resident’s perineal area and turned the resident onto his/her right
side. CNA K changed the soapy water in the wash basin and changed his/her gloves. CNA K
placed a clean wash cloth in the clean water, squeezed shampoo and body wash into the wash
basin, washed the resident’s left hip, buttock, back of thigh and rectal area, dried the
areas, turned the resident onto his/her left side, washed and dried the resident’s right
hip, buttocks and back of thigh. Soap was visible on the resident’s skin. CNA K placed a
clean brief on the resident and dressed the resident. At 7:56 A.M., CNA L came into the
room and assisted CNA K to transfer the resident into his/her wheelchair. At 7:58 A.M.,
CNA L took the resident to the main dining room. CNA K did not rinse the soap off of the
resident’s skin prior to dressing or transferring him/her into his/her wheelchair.
Observation of the shampoo and body wash bottle, showed directions to rinse the soap off
the skin.
During an interview on 1/18/19 at 2:30 P.M., the Director of Nurses (DON) said she would
expect staff to rinse the soap off the resident’s skin to prevent skin breakdown and
infections.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 ensure residents
with limited mobility received therapy and services as recommended to maintain or improve
mobility by failing to provide restorative services for one of one resident investigated
for restorative services (Resident #4). The facility census was 138.
Review of Resident #4’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/10/19, showed:
-[DIAGNOSES REDACTED].
-Extensive assistance with one person physical assist required for transfers, dressing,
personal hygiene, and toilet use;
-No rehabilitation or therapy received during assessment period.
Review of the resident’s medical record, showed:
-A physical therapy (PT) discharge order, dated 11/28/18, showed the resident began PT on
10/9/18 with a treatment [DIAGNOSES REDACTED]. He/she was discharged from PT on 11/28/18
to the restorative nursing program (RNP);

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 – Few

(continued… from page 9)
-A Physician order [REDACTED].
-A Nurse’s note, dated 11/28/18, showed restorative nursing orders received;
-A POS for (MONTH) 2019, showed an undated order for restorative as follows:
-RNP three times a week for bilateral (both sides) upper extremity exercises;
-RNP three times a week bilateral therapeutic exercise with three pound (lb.) weights for
15 repetitions standing or bilateral leg bike for 15 minutes;
-Skilled PT four times a week for four weeks;
-Skilled occupational therapy four times a week for four weeks;
-A care plan, updated on 1/17/19, as follows:
-Resident discharged from skilled therapy services and referred to RNP;
-Passive range of motion/stretching to bilateral knees/hamstrings for 10 repetitions and
sit to stand with bilateral upper extremity support as tolerated, three times a week to
maintain bilateral lower extremity range of motion and sit to stand as tolerated;
-Bilateral upper extremity exercise for 20 repetitions. Two lb. dumbbells and hand
gripper for 50 repetitions twice a week to maintain bilateral upper extremity range of
motion and muscle strength for activities of daily living.
During an interview on 1/16/19 at 11:37 A.M., the resident said he/she should have been
receiving restorative therapy, but the restorative aides were too busy to get to him/her.
During an interview on 1/22/19 at 8:23 A.M., Restorative Aide (RA) G said restorative is
provided to residents in the program twice a week. The resident was on his/her caseload in
the past, but could not recall the last time he/she had seen the resident for therapy. At
8:40 A.M., RA G pulled his/her notes regarding the resident and said he/she had begun
restorative with the resident once since the resident had been referred to the program in
(MONTH) (YEAR). Restorative services were not provided in (MONTH) (YEAR) or (MONTH) 2019
by either of the RAs.
During an interview on 1/22/19 at 10:57 A.M., the Director of Nursing (DON) said it is
expected for restorative orders to be followed. Nursing is ultimately responsible for
ensuring restorative services are provided as ordered. It is important to ensure
restorative is provided as ordered in order to maintain a resident’s mobility and range of
motion.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview, and record review, the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service
safety. The facility failed to ensure there was an air gap to the ice machine, failed to
ensure the inside walk in cooler was free of water leaks and frost build up. Additionally,
staff failed to have proper sanitizing solution for the dish machine. These deficient
practices had the potential to affect all residents who ate at the facility. The facility
census was 138.
1. Review of the facility’s dietary dish washer policy and procedure, dated 8/1/18,
showed:
-The dish washer must be temperature and chemical tested before use;
-First step, check all cleaning agents before use;
-Run a wash cycle be the start of the meal service;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 10)
-Test the water temperature level, must be at 120 degrees Fahrenheit (F);
-Test the chlorine and chemical test strip, must be at 50 parts per million (ppm);
-At the end of the service the machine must be cleaned and delimed for the next day
service;
-If the temperature and the chlorine level are not at the correct setting please inform
the manager so that the repair person can be called out;
-This must happen before and after every meal service;
-At no time will the dishes be washed if these steps have not been followed.
During an observation and interview on 1/16/19 at 9:20 A.M., Dietary Aide H used the dish
machine to sanitize the dishes that were used during meal service. Dietary Aide H said the
dish machine used chemical and hot water temperature to sanitize the dishes. The machine
was tested daily with the use of a strip. He/she ran the dish machine and placed a test
strip inside the water that flowed out of the dish machine during the test cycle. The test
strip immediately turned light purple. He/she matched the test strip with the color tube.
He/she confirmed that the light purple test strip indicated it was 10 ppm. He/she ran a
second cycle and used a new test strip. The test strip turned light purple. He/she
confirmed that the second strip was 10 ppm. He/she said he/she did not know what range the
sanitizer should be or where to find the information on the dish machine. Dietary Aide H
said he/she could check the temperature by looking at the temperature gauge on the
machine. The temperature on the gauge showed 120 degrees F. He/she said staff only used
the gauge to check the temperature. There were no test strips or a thermometer. He/she
confirmed that if the sanitizer was low, he/she would get the dish machine serviced.
Further observation, showed a label on the front of the dish machine that showed the
sanitizer should be at least 50 ppm.
During an interview on 1/16/19 at 9:30 A.M., the dietary manager said they have had the
dish machine serviced three times because it was not properly sanitizing the dishes.
2. During an observation of the ice machine in the kitchen, showed:
-On 1/16/19 at 9:10 A.M., a collection of water inside the drain. The ice machine drain
pipe inside the drain and touched the water;
-On 1/17/19 at 10:50 A.M., 1/18/19 at 2:11 P.M., and 1/22/19 at 9:51 A.M., there was no
longer water build up inside the drain; however, water could be seen running out of the
pipe into the drain. The pipe lay directly inside the drain.
3. Observation of the inside of the walk-in cooler, showed:
-On 1/17/19 at 10:50 A.M., water dripped from four different areas of the ceiling on the
left side of the walk-in cooler. Water dripped onto the covered food. There was frost
build up along the bottom part of the door to the entrance of the walk-in freezer;
-On 1/18/19 at 2:11 P.M., there was frost build up along the bottom part of the door to
the entrance of the walk-in freezer;
-On 1/2/19 at 9:51 A.M., icicles approximately 2 inches formed on the ceiling on the left
side of the walk-in cooler. There was frost build up along the bottom part of the door to
the entrance of the walk-in freezer.
4. During an interview on 1/22/19 at 10:12 A.M., the dietary manager said she was not
aware of the need of an air gap from the ice machine pipe to drain; however, it was
problematic if the water traveled up the pipe. It would contaminate the ice. She would
expect staff to test the sanitizer of the dish machine before and after meal service. The
test strip should read 50 ppm. She would expect staff to know that the strip should read
50 ppm and to not use the dish machine if the sanitizer was less than 50 ppm. The dish
machine sanitize chemically, not with a hot water temperature. She would expect staff to
know that information. She was aware of the frost build up on the bottom of the door as
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265823

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

01/22/2019

NAME OF PROVIDER OF SUPPLIER

CRESTWOOD HEALTH CARE CENTER, LLC

STREET ADDRESS, CITY, STATE, ZIP

11400 MEHL AVENUE
FLORISSANT, MO 63033

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 11)
well as the water leaking from the ceiling. Water should not leak inside the walk-in
cooler because it could cause cross contamination to the food.

F 0914

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide bedrooms that don’t allow residents to see each other when privacy is needed.

Based on observation and interview, the facility failed to ensure curtains were placed in
a resident’s room to ensure the resident and their roommate maintained their privacy and
dignity. This affected three residents (Resident #45, #74, and #27). The sample was 29.
The census was 138.
1. Observation on 1/16/19 at 10:33 A.M., 1/17/19 at 11:37 A.M., and 1/22/19 at 9:30 A.M.,
showed Resident #45’s room did not have a privacy curtain on either side of the room.
During an interview, the resident said he/she would like to have privacy. When his/her
roommate was not in the room that was when he/she would get dressed. He/she tried to
coordinate that time when the roommate was not the room.
2. Observation on 1/16/19 at 10:11 A.M., 1/17/19 at 11:59 A.M., 1/18/19 at 10:03 A.M.,
1/22/19 at 9:40 A.M., showed Resident #74’s room did not have a privacy curtain on either
side of the room. During an interview, the resident said he/she would like to have a
curtain.
3. Observation on 1/16/19 at 9:52 A.M., 1/17/19 at 11:45 A.M., 1/18/19 at 2:06 P.M., and
1/22/19 at 9:35 A.M., showed Resident #27’s room had a privacy curtain that was not able
to be pulled to cover the resident’s side of the room. Approximately 6 inches of the
curtain hung down, not connected to the hooks. There were seven hooks attached to the rail
that prevented the privacy curtain from closing. The resident said he/she would wait until
his/her roommate left the room if he/she wanted to get dressed. He/she would also go to
the shower room.
4. During an interview on 1/22/19 at 9:26 A.M., the maintenance supervisor said the head
of each department complete room checks on a daily basis. The sheets are turned in to
maintenance every day. Residents are expected to have a privacy curtain. Housekeeping is
responsible for putting up the privacy curtain. The maintenance staff is responsible for
installing the rails and the breakaways, which are the hooks. If the curtain was pulled,
the breakaway snaps so it does not damage the curtain. The breakaways are preventing
Resident #27’s curtain from closing.
5. During an interview on 1/22/19 at 10:39 A.M., the administrator said she would expect
staff to inspect the resident rooms for damages to the privacy curtain and to ensure that
each resident would have a privacy curtain. If the privacy curtain was pulled down, staff
are expected to make sure that the roommate had some privacy. The head of the each
department are expected to complete rounds Monday through Friday. The weekend managers
complete rounds on the entire building. A work order is filled out and turned into the
maintenance supervisor. There is a system in place, and maintenance has to prioritize the
work orders. The facility was aware of the missing privacy curtains. Residents #74 and #27
have a history of tearing down their privacy curtain, but there are no concerns that would
prevent them from having a privacy curtain.