Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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

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 staff failed to ensure they provided a
safe, comfortable, and homelike environment when they had two areas which contained a
black mold-like substance. This affected all the residents who used the men’s shower room
on the first floor. The facility census was 94.
1. Observation on 6/25/18 at 1:02 P.M., showed a six by six inch area on the ceiling in
the men’s shower room on the first floor A hall. The area had the appearance that it had
been wet and water damaged. The area of the ceiling had sections that hung down as far as
one inch. A dark stain covered the whole area and a black mold-like substance overspread
several areas on the dark colored stain.
During an interview on 6/25/18 at 5:56 P.M., the Maintenance Director (MD) said he did not
know about the area in the men’s shower room. He did not always go into the shower room
and expected staff to let him know of issues like damage to the ceiling. He did not have
anything about the men’s shower room in his maintenance request logs (logs filled out by
staff). He did know of any incident that may have caused the damage to the ceiling.
2. Observation on 6/25/18, at 1:28 P.M., showed a two by three foot area under a
kitchen-like sink on the left side in the upstairs clean utility room. The area under the
sink appeared that it had been water damaged. A dark stain covered the whole area and a
black mold-like substance overspread several areas of the dark colored stain. The
kitchen-like sink had been affixed and could not flow into the left vat of the two vat
sink.
During an interview on 6/25/18, at the same time, the MD said:
– The faucet could not be moved and it could only flow into the vat on the right-hand
side;
– The dark area under the sink was not mold, it was sewage.
– He did not know about the area under the sink;
– He did not know what had happened to cause the damage to the wooden base of the cabinet
under the sink.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow their
abuse and neglect policy and send two staff members home when a resident accused them of
hitting him/her. This affected one of 26 sampled residents (Resident #90). The census was
94.
Review of Resident #90’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/1/18, showed the following:
-[DIAGNOSES REDACTED].
-Short/long term memory loss;
-Short tempered and easily annoyed;
-Verbal behavioral symptoms directed at others;
-Required limited staff assistance for bed mobility, transfers, dressing and toilet use;
-Required extensive staff assistance for personal hygiene and bathing.
Review of the resident’s care plan, updated 6/18/18, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 – Few

(continued… from page 1)
-Problem: The resident alleged he/she was hit with a comb on his/her leg by a staff
member;
-Approach: Assure resident that he/she is safe. Encourage resident to verbalize thoughts.
Social Service Director will visit resident one on one as needed. The patient care team
will observe the resident for signs of fear and insecurity during delivery of care. Take
steps to calm the resident and make him/her feel safe.
Review of the facility’s Statement of Investigation, written by the Activity Director,
dated 6/18/18, showed the following:
-The resident’s family member reported to the Activity Director while he/she sat with the
resident in the dining room two staff members entered;
-The resident began yelling and told the two staff members, a Certified Nurse Aid (CNA)
and a Certified Medication Technician (CMT) to leave the dining room because they hit
him/her;
-The Activity Director notified the administrator and Director of Nurses;
-He/she instructed the CNA to leave the unit;
-No documentation whether he/she instructed the CMT to leave the unit;
-No documentation whether either staff were instructed to leave the facility.
During an interview on 6/26/18 at 10:15 A.M., the Director of Nurses said the staff the
resident identified as hitting him/her weren’t sent home. She believed the resident had
the staff members confused, but staff should have followed the facility’s policy and sent
those two staff members home.
Review of the facility’s policy on Abuse, Neglect and Exploitation, updated 11/1/16,
showed the following:
-VI: Resident protection after alleged Abuse, Neglect and Exploitation: Reassignment of
nursing and or other staff duties. Time off for nursing and or other staff;
-VII: Response and Reporting of Abuse, Neglect and Exploitation: When abuse, neglect or
exploitation is suspected, the licensed nurse should: Obtain witness statements, following
appropriate policies. Suspend the accused employee pending completion of the
investigation. Remove the employee from resident care areas immediately.
MO 869

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident completely in a timely manner when first admitted, and then
periodically, at least every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure comprehensive Minimum
Data Set (MDS), a federally mandated assessment instrument completed by facility staff,
assessments were completed and/or submitted timely as mandated by the Center for Medicare
and Medicaid (CMS). Of the 26 sampled residents, four had comprehensive MDSs due that had
not been completed and/or submitted timely. (Residents #5, #8, #192 and #193) The census
was 94.
1. Review of Resident #5’s MDS submission schedule, showed the following:
-Significant change in status MDS dated [DATE];
-No Annual MDS completed for 3/2018.
2. Review of Resident #8’s MDS submission schedule, showed the following:
-Admission MDS dated [DATE];
-No annual MDS completed for 3/2018.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
3. Review of Resident #192’s MDS submission schedule, showed the following:
-admission date of [DATE];
-No admission MDS submitted.
4. Review of Resident #193’s MDS submission schedule, showed the following:
-admitted d of 4/13/18;
-No admission MDS submitted.
5. During an interview on 6/20/18 at 11:50 A.M., the MDS/Care Plan Coordinator said she is
the only MDS/Care Plan Coordinator for the facility. She looked through her submission
lists and said she could not find evidence where the comprehensive MDSs for Residents #5,
#8, #192 and #193 had been submitted timely. She got behind on the MDS process in (MONTH)
(YEAR) and (MONTH) (YEAR). There are too many MDSs that come do at the same time, and it
is difficult to finish them timely. She does have several MDSs ready to be submitted, but
the Director of Nurses (DON) had not added her electronic signature and she can’t submit
those MDSs without that signature. When she finishes an MDS she lets the DON know so she
is not sure why they have not been signed yet.
6. During an interview on 6/26/18 at 10:20 A.M., the DON said she asks the MDS/Care Plan
Coordinator if there is anything to sign on a weekly basis. She signs them as they are
given to her. She was not aware there are completed MDSs needing her signature.
7. During an interview on 6/26/18 at 6:26 A.M., the Director of Clinical Operations said
she did not know the MDSs were behind.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assure that each resident’s assessment is updated at least once every 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure quarterly Minimum Data
Set (MDS), a federally mandated assessment instrument completed by facility staff,
assessments were completed and/or submitted timely as mandated by the Centers for Medicare
and Medicaid (CMS). Of the 26 sampled residents, six had quarterly MDSs due that had not
been completed and/or submitted timely. (Residents #5, #8, #57, #79, #81 and #192) The
census was 94.
1. Review of Resident #5’s MDS, submission schedule, showed the following:
-A quarterly MDS dated and submitted 12/23/17;
-An annual MDS due but not submitted by 3/23/18;
-No quarterly MDS completed and/or submitted as of 6/26/18.
2. Review of Resident #8’s MDS submission schedule, showed the following:
-A quarterly MDS dated and submitted on 12/24/17;
-An annual MDS due but not submitted by 3/24/17;;
-No quarterly MDS completed and/or submitted as of 6/26/18.
3. Review of Resident #57’s MDS submission schedule, showed the following:
-An annual MDS dated and submitted on 2/17/18;
-No quarterly MDS completed and/or submitted for 5/2018.
4. Review of Resident #79’s MDS submission schedule, showed the following:
-A quarterly MDS dated and submitted on 3/11/18;
-No quarterly MDS completed and/or submitted as of 6/26/18.
5. Review of Resident #81’s MDS submission schedule, showed the following:
-A significant change in status MDS dated and submitted on 9/13/17;
-A quarterly MDS dated and submitted on 12/14/17;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-A quarterly MDS dated and submitted on 3/16/18;
-No quarterly MDS completed and/or submitted as of 6/26/18.
6. Review of Resident #192’s MDS submission schedule, showed the following:
-admission date of [DATE];
-No quarterly MDS completed and/or submitted.
7. During an interview on 6/20/18 at 11:50 A.M., the MDS/Care Plan Coordinator said she is
the only MDS/Care Plan Coordinator for the facility. She got behind on the MDS process in
(MONTH) (YEAR) and (MONTH) (YEAR). There are too many MDSs that come do at the same time,
and it is difficult to finish them timely. She does have several MDSs ready to be
submitted, but the Director of Nurses (DON) had not added her electronic signature and she
can’t submit those MDSs without that signature. When she finishes an MDS she lets the DON
know so she is not sure why they have not been signed yet.
8. During an interview on 6/26/18 at 10:20 A.M., the DON said she asks the MDS/Care Plan
Coordinator if there is anything to sign on a weekly basis. She signs them as they are
given to her. She was not aware there are completed MDSs needing her signature.
9. During an interview on 6/26/18 at 6:26 A.M., the Director of Clinical Operations said
she did not know the MDSs were behind.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 and interview, the facility failed to ensure resident computer
generated care plans, were printed and accessible in the care plan book at the nurse’s
station for the use of all nursing staff. This affected four of 26 sampled residents.
(Residents #8, #57, #79 and #193). The census was 94.
1. Review of Resident #8’s care plan, located in the facility computer system, and last
reviewed on 5/24/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: Activity of daily living ((ADL) bathing, grooming,
transfers, bed mobility, dressing, etc .) assistance required, [MEDICAL CONDITION] which
places the resident at risk for infection, DM, nutritional status, [MEDICAL
CONDITION];[MEDICAL CONDITION] smoking;
-Interventions to assist the resident included: Low concentrated sweets diet, determine
food preferences through one to one interview, encourage relaxation techniques, diet
supplements as ordered and range of motion exercises.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

2. Review of Resident #57’s care plan, located in the facility computer system, and last
reviewed on 6/5/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: ADL assistance required, HTN, falls, nutritional status –
at risk for weight loss, pain – due to knee contractures and [MEDICAL CONDITION]
-Interventions to assist the resident included: Provide resident with two person
assistance with bathing and transfers, monitor resident for unsafe transfers, offer foods
he/she enjoys and supplements, apply knee brace daily, administer pain medications as

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 – Some

(continued… from page 4)
ordered.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

3. Review of Resident #79’s care plan, located in the facility computer system, and last
reviewed on 3/14/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: ADL assistance required, smoking, nutritional status,
antidepressant medication daily, at risk for falling and behavioral symptoms – becomes
agitated easily;
-Interventions to assist the resident included: Chooses to eat in his/her room, monitor
resident’s mood, keep call light in reach, encourage resident to relocate to areas with
less stimuli if he/she seems over stimulated by noise, encourage resident to read books
and do puzzles and encourage resident to seek out staff members for one on one if he/she
is having issues with other residents.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

4. Review of Resident #193’s care plan, located in the facility computer system, and last
reviewed on 6/26/18, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: Smoking, falls, increased independence in bed mobility with
positioning devices, at risk for social isolation, HTN, history of [MEDICAL CONDITION],
chronic pain characterized as severe and incapacitating at times, history of depression
and becomes easily upset or agitated when he/she feels other people are acting obnoxiously
toward him/her;
-Interventions to assist the resident included: Provide reminders about supervised
smoking, close monitoring when ambulating, check positioning devices to ensure they are in
good repair, provide one on one visits for activities, enjoys playing music and cards,
provide alternative therapies for pain and encourage resident go to his/her room if
becoming anxious or angry.
Observation on 6/22/18 at 4:35 A.M., prior to the MDS/Care Plan Coordinator arriving,
showed no care plan in the care plan book located at the nurse’s station for the resident.

5. During an interview on 6/26/18 10:20 A.M., the Director of Nurses said care plans are
completed in the computer by the MDS/Care Plan Coordinator. After normal business hours,
the nurses do not have access to the computer system to view care plans. The care plans
should be printed after they are developed and placed in the care plan book at the nurse’s
station.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation and interview, the facility staff failed to ensure they kept
medication locked at all times. The facility census was 94.
1. Observation on 6/25/18, at 12:17 P.M., showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 – Few

(continued… from page 5)
– The Director of Nurse’s office unlocked;
– No staff in the DON’s office;
– Under the DON’s desk were 13 partial cards of medications and 10 partial bottles of
stock medications.
During an interview on 6/25/18, at 6:19 P.M., the DON said medications in her office were
the expired medications that needed to be destroyed. All medications in the facility
needed to be locked at all times, even if they were expired.

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility staff failed to complete a
comprehensive discharge summary for one of three sampled residents selected for a closed
record review. (Resident #91) The census was 94.
Review of Resident #91’s face sheet, showed an admission date of [DATE] and a [DIAGNOSES
REDACTED].
Review of the resident’s social service notes, showed the following:
-1/11/18 at 3:43 P.M., Plans for discharge to another facility pending the ending results
from [MEDICAL CONDITION] treatment he/she is going through;
-3/20/18 at 11:54 A.M., spoke to the resident’s family member regarding the resident and
moving to a new facility. The family member said the physician would release the resident
if well enough to move within the next 10 days.
Review of the resident’s physician’s orders [REDACTED].
Review of the resident’s discharge Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 4/4/18, showed the following:
-discharge date : 4/4/18;
-Moderate cognitive impairment;
-Limited assistance with transfers, walking in room, locomotion on and off unit, dressing
and toilet use;
-Supervision with eating and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s nurse’s notes, dated 4/4/18, showed the following:
-(No time noted) Informed today is the date for the resident to transfer to another
facility. The resident has oxygen per nasal cannula at two liters as needed, is continent
of bowl and bladder and denies any pain. Report was given to the nurse at the new
facility. Also received phone orders to send medications and narcotics per physician’s
orders [REDACTED].>-1:05 P.M., the resident was discharged to his/her family, to be
taken to the new facility. The resident’s medication were sent with the resident’s family.
The report was already given to the new facility.
Further review of the resident’s medical record, showed no comprehensive discharge summary
for the resident.
During an interview on 6/26/18 at 11:55 A.M., the administrator said the resident should
have had a complete comprehensive discharge summary which includes a summary of the
resident’s stay, a summary of services and medicare and medicaid history.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 ensure staff
processed the Registered Dietician’s recommendations in a timely manner for two of 26
sampled residents. In addition, the facility identified three residents as having a
gastrostomy tube. One was observed receiving tube feeding and did not receive the amount
of tube feeding ordered by the physician. (Residents #79, #57 and #195) The census was 94.
1. Review of Resident #79’s quarterly minimum data set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/11/18, showed the following:
-Adequate hearing and vision;
-Understood and understands;
-Clear speech – distinct intelligible words;
-Supervision and oversight required for eating;
-Weight of 145 pounds (lbs).
Review of the resident’s care plan, last revised on 3/14/18, showed the following:
-[DIAGNOSES REDACTED].
-No problems or interventions for a chronic hoarse throat or a steady gradual weight loss.
Review of the resident’s dietary notes, completed by the Registered Dietician (RD) on
4/11/18, showed a recommendation to discontinue the resident’s health shakes and begin Med
Pass (nutritional supplement) 120 cubic centimeters (cc) two times a day.
Review of the resident’s medication administration records (MAR)s, dated 4/1/18 through
4/30/18 and 5/1/18 through 5/31/18, showed staff documented the resident received health
shakes twice a day, but no order for Med Pass.
Review of the resident’s monthly weights, showed the following:
-12/17 – 149 lbs, 1/18 – 143 lbs, 2/18 – 144 lbs, 3/18 – 148 lbs, 4/18 – 143 lbs, 5/18 –
140 lbs and 6/18 – 137 lbs (this represents a 12 lb or 8.05% weight loss in the past six
months).
Review of the resident’s dietary notes, completed by the RD on 6/6/18, showed weight down
137.4 lbs, 9% in 180 days. Recommend to discontinue health shakes and begin Med Pass 120
cc three times a day.
Review of the resident’s MAR, dated 6/1/18 through 6/30/18, showed an the resident
continued to receive health shakes two times a day, but no order for Med Pass.
During an interview on 6/21/18 at 8:43 A.M., the resident said he/she had lost weight and
was concerned as to why. His/her appetite had been the same as always. He/she had been
having a throat problem since April. His/her throat is not sore, but his/her voice had
been hoarse. He/she does have an appointment later this month with a specialist. The
resident did not know if the problem with his/her voice had anything to do with his/her
weight loss but was suspicious it might.
Observation on 6/21/18 at 12:42 P.M., showed the resident received his/her lunch on a tray
and delivered to his/her room. The lunch tray had no health shake or Med Pass. During an
interview at that time, the resident said he/she does not get a supplement too often. When
he/she does get it, it comes on his/her meal tray. He/she did not get a health shake or
Med Pass on his/her lunch tray.
Observation on 6/22/18 at 8:06 A.M., showed dietary staff prepared the resident’s
breakfast tray and delivered it to his/her room. The breakfast tray had no health shake,
whole milk or Med Pass.
During an interview on 6/22/18 at 8:31 A.M., the resident said he did not receive whole
milk, health shake or Med Pass with breakfast.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 7)
Review of the resident’s physician’s orders [REDACTED].
Observation on 6/25/18, showed staff obtained a weight of 136.7 lbs for the resident.
2. Review of Resident #57’s annual MDS, dated [DATE], showed the following:
-Adequate hearing and vision;
-Understood/understands;
-Clear speech – distinct intelligible words;
-Understood and understands;
-Supervision and oversight required for eating;
-[DIAGNOSES REDACTED].
-Weight of 175 lbs.
Review of the resident’s RD progress notes, dated 4/25/18 and again on 5/16/18, showed
recommendations each time to discontinue the health shakes and start Med Pass 120 cc three
times a day.
Review of the resident’s MAR from 5/1/18 through 5/31/18, showed staff documented
administering the health shakes until 5/29/18, and then documented administering Med Pass
120 cc three times a day.
Review of the resident’s RD progress note, dated 6/20/18, showed the RD recommended to
decrease the Med Pass 120 cc from three times a day to two times a day due to weight gain.
3. During an interview on 6/25/18 at 2:13 P.M., the Director of Nurses said the RD sends
her a report containing recommendations within a week after she leaves the facility. She
gives the recommendations to Nurse H to contact the physicians. She does not know Nurse
H’s system for following up to determine if the physician has responded to the
recommendation. After receiving the RD’s recommendations, it should not take longer than a
week to get a response from the physician.
4. Review of Resident #195’s face sheet, showed an admission date of [DATE] and multiple
[DIAGNOSES REDACTED].
Review of the resident’s care plan, last reviewed on 4/12/18, showed the following:
-Required tube feeding, related to past stroke and dysphagia (swallowing problems) and
also on a pureed diet with thin liquids;
-Difficulty communicating, but can write if given a pen and paper;
-Total dependence on others for all activities of daily living.
Review of the residents POS, dated (MONTH) (YEAR), showed the following:
-An order dated 5/7/18, for [MEDICATION NAME] 1.5 (a nutritional supplement containing 1/5
calories per milliliter (ml)) bolus (a single dose administered all at once) 120 ml via
[DEVICE] (gastrostomy tube, a tube surgically inserted into the stomach through the
abdomen for fluids, nutrition and medication, four times daily;
-An order dated 6/4/18, to change tube feeding bolus to three times a day due to weight
gain.
Observation on 6/22/18 at 5:53 A.M., showed Nurse G took a carton of [MEDICATION NAME] 1.5
from the medication cart, looked at the carton and poured the contents into two plastic
cups. He/she picked up the carton, looked at it again and then put it in the trash. The
carton showed it contained 8 ounces (237 ml). The nurse entered the room and delivered the
contents of the two cups into the resident’s [DEVICE]).
Review of the resident’s MAR, dated (MONTH) (YEAR), showed an order for [REDACTED].
During an interview on 6/22/18 at 6:41 A.M., while looking at the MAR and the carton of
[MEDICATION NAME] 1.5, Nurse G said he/she thought something wasn’t right but he/she
didn’t check.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have a current signed
[MEDICAL TREATMENT] contract for the one resident the facility identified as receiving
[MEDICAL TREATMENT]. (Resident #81) The census was 94.
Review of the facility administration records, showed a [MEDICAL TREATMENT] contract,
dated 10/31/13, with the previous name of the facility.
During an interview on 6/26/18 at 10:41 A.M., the Director of Operations said they could
not get a copy of the current [MEDICAL TREATMENT] contract. The previous contract had the
facility’s previous name. The administration has not been able to get a copy of the
current contract.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the
medical chart, following irregularity reporting guidelines in developed policies and
procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure physician’s addressed
pharmacy medication regimen reviews in a timely manner. Of the 26 residents sampled, two
had pharmacy medication regimen reviews, completed for more than 30 days, without a
physician response to the recommendation and one had a recommendation that was addressed
55 days after it was made. (Residents #5, #8 and #57) The census was 94.
1. Review of Resident #5’s consultant pharmacist’s medication review, dated 4/18/18,
showed the following recommendation:
-Resident is receiving duloxetine (anti-depressant) and aripiprazole (anti-psychotic used
to treat [MEDICAL CONDITION] and bi-polar disease) without appropriate indication for use,
please evaluate and update orders with specific indications for use;
-No physician response.
Review of the resident’s consultant pharmacist’s medication regimen review, dated 5/10/18,
showed the following recommendation:
-Resident has been on [MEDICATION NAME] (medication used to treat acid reflux (heart
burn)) 20 milligrams (mg) every day for greater than 12 weeks. Extended use increases the
risk of fractures and infections;
-Please consider the following: Discontinue (DC) therapy, new order for alternative agent
or medication to be continued at current dose;
-No physician response.
Review of the resident’s physician’s orders [REDACTED].
2. Review of Resident #8’s consultant pharmacist’s medication regimen review, dated
4/18/18, showed the following:
-The resident is currently on [MEDICATION NAME] (anti-psychotic) 4 mg at hour of sleep and
may be indicated for a gradual dose reduction. Please consider reducing to 3 mg at hour of
sleep and document behaviors;
-A handwritten note on the form showing to psych;
-No physician or psychiatrist response.
Review of the resident’s consultant pharmacist’s medication regimen review, dated 5/10/18,
showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
-Resident is currently on [MEDICATION NAME] (anti-depressant/hypnotic (sleeping aide)) 150
mg at hour of sleep and may be indicated for a dose reduction. Please consider reducing
the dose to 125 mg at hour of sleep and document behaviors;
-No physician response.
Review of the resident’s medical record, showed no changes to reflect the recommendations
and no information the physician addressed the pharmacist’s recommendations.
3. Review of Resident #57’s consultant pharmacist’s medication regimen review, dated
3/24/18, showed following:
-Recently initiated [MEDICATION NAME] (medication used to treat major [MEDICAL CONDITION]
and/or anxiety) 60 mg three times a day. Please consider monitoring the resident’s blood
pressure regularly to assess changes from baseline and monitor for adverse reactions. If
not clinically appropriate, please provide rationale below.
Review of the resident’s POS, undated, showed a handwritten order, dated 5/18/18 (55 days
after the recommendation), to monitor the resident’s blood pressure every day per pharmacy
recommendation.
4. During an interview on 6/26/18, the Director of Nurses said they receive copies of the
pharmacist’s recommendations not long after the pharmacist leaves. The pharmacist is in
monthly. They place the pharmacist’s recommendations in the physician’s box to be
addressed by the physicians when they are in the building. Most of the physicians are in
the building weekly or monthly. It should not take longer than a month to have the
physician address the pharmacist’s recommendations. Sometimes they fax the
recommendations. Currently there is no system in place to ensure the recommendations are
being addressed.

F 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide routine and 24-hour emergency dental care for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to address one of
26 sampled resident’s dental needs. (Resident #9) The census was 94.
Review of Resident #9’s last transmitted quarterly Minimum Data Set (MDS), a federally
mandated instrument completed by facility staff, dated 12/24/17, showed the following:
-Severe cognitive impairment;
-Extensive assistance with bed mobility, transfers, locomotion on and off the unit and
dressing;
-[DIAGNOSES REDACTED].
-Oral/Dental status: blank.
Review of the resident’s revised care plan, dated 4/16/18, showed no documentation
regarding the resident oral care or dentures.
Review of the resident’s dietary progress note, dated 5/16/18, showed the resident had a
weight of 85 pounds, was on a regular diet and had no pressure wounds. The resident had
issues with loose dentures noted.
Observation on 6/21/18 at 9:02 A.M., showed the resident self propelled his/her wheelchair
down the hall. The resident had loose dentures.
During an interview on 6/21/18 at 2:30 P.M, the resident said his/her dentures are very
loose. While they do not keep him/her from eating, they are at times uncomfortable. The
dentures hang down and seem like they are going to fall out. It would help if they were
not so loose. The resident said he/she has said something to administration but nothing

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0790

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
has been done.
During an interview on 6/26/18 at 11:48 A.M., the Social Service Designee (SSD) said she
did not know the resident was having problems with his/her dentures. The SSD said she had
not been at the facility very long and was still learning about the residents.
During an interview on 6/26/18 at 1:04 P.M. Certified Nurse Aide (CNA) A said the resident
will assist with his/her care. The resident has loose dentures. Last year the resident had
an issue with the dentures. The resident has mentioned to him/her about the dentures being
loose and he/she would tell the charge nurse.
During an interview on 6/26/18 at 1:10 P.M. Nurse B said the resident’s dentures did not
fit. The resident has a gum issues that would need to be addressed but the resident’s
family did not want to put him/her through it. This happened last year. Nurse B said no
one has told him/her about the loose dentures. The previous Social Service team was
working on the issue but he/she did not know what happened.
During a follow up interview on 6/26/18 at 2:30 P.M., Nurse B said the resident went for a
fitting for his/her new dentures on 10/6/17 and the resident was able to come and pick up
the dentures. This has been scheduled 7/3/18. He/she did not know the resident had gone
out for an appointment regarding his/her dentures.
Review of the resident’s medical record, showed no documentation regarding the resident’s
dentures.
During an interview on 6/26/18 2:37 P.M., the Director Of Operation said the Director of
Nursing should be looking into why the resident’s dentures were loose. She did not know
why there was no follow up after the resident’s appointment, so his/her dentures could be
picked up timely.

F 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide or get specialized rehabilitative services as required for a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assess and
provide therapy services for one resident with a contracted closed hand. the sample was
26. (Resident #15) The census was 94.
Review of Resident #15’s last transmitted quarterly Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 12/29/17, showed the
following:
-No cognitive impairment;
-Total dependence with transfers;
-Extensive assistance with bed mobility, dressing, toilet use and personal hygiene;
-Limited assistance with locomotion on and off the unit;
-Functional limited range of motion to the upper and lower extremity on one side;
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
Observation of the resident on 6/21/17 at 7:47 A.M., showed his/her right hand was
contracted closed.
Review of the resident’s revised care plan, dated 3/13/18, showed no documentation
regarding the contracted right hand.
Review of the resident’s medical record, showed no documentation regarding an assessment
of the contracted right hand.
During an interview on 6/25/18 at 1:52 P.M., the resident said the no one has tried to put

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0825

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
any type of support in his/her contracted right hand. He/she would not mine some type of
support for his/her hand.
During an interview on 6/25/18 at 2:00 P.M., Restorative Aide (RA) C said the resident was
not on the restorative program. Therapy evaluates residents for restorative therapy.
He/she did not paid attention to the resident’s right hand.
Observation with the Director of Nurses (DON) and RA C on 6/25/18 at 2:07 P.M., showed the
resident had a contracted closed right hand. The DON said the resident had been at the
facility for a while and was not sure if he/she was previously on a restorative program.
The resident could benefit from a cushion in the right hand.
During an interview on 6/25/18 2:23 P.M., the Director of Physical Therapy (DOPT) said the
resident has right sided weakness. No one told about the resident’s contracted right hand,
but she should hear about it from the charge nurses. The DOPT looked at the resident’s
contracted closed right hand and said he/she could benefit from a type of cushion for the
hand.
During an interview on 6/26/18 10:39 A.M., the DON said they did get orders put into place
regarding splints for the resident. The DON said they should have stayed on top of the
resident’s splint. The purpose of the splint would be to prevent further contraction and
encourage range of motion.
Review of the facility’s Restorative Nursing Program, review date 12/1/17, showed the
following:
-Policy: It is the policy of the facility that a resident with a length of stay greater
than 90 days is given the appropriate treatment and services to maintain or improve his or
her abilities and to achieve or maintain the highest practicable outcome;
-Procedure: Within 14 days of admission/readmission with significant change or quarterly
thereafter, nursing will complete the Activities of Daily Living Functional Assessment;
-When the resident is discharge from direct therapy services and would benefit from a
restorative nursing program, therapy may make further recommendations for restorative
needs;
-A resident who has been identified as requiring restorative nursing will receive a care
plan outlining their problem, goal and intervention.

F 0837

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Establish a governing body that is legally responsible for establishing and
implementing policies for managing and operating the facility and appoints a properly
licensed administrator responsible for managing the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have an administrator with an
active license issued by the Missouri Board of Nursing Home Administrators. The census was
94.
During an interview on [DATE] at 8:33 A.M. during the entrance conference, the Director of
Clinical Operations said administrator E was the administrator, and he/she was in route to
the facility at that time. Administrator E had been the administrator since [DATE].
During an interview on [DATE] at 11:38 A.M., administrator E said he/she had been the
administrator at the facility for a little over three months. On [DATE], his/her emergency
temporary license (issued by the Missouri Board of Nursing Home Administrators) had
expired. On [DATE], his/her title changed from administrator to Facility Manager and the
Regional Consultant assumed the role of administrator.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0837

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 12)
During an interview on [DATE] at 12:06 P.M., the Regional Consultant said she was
currently the acting administrator at a sister facility. She had been consulting with
administrator E on and off since he/she had been the administrator. She is not now and had
not been the administrator at this facility since administrator E started at the facility.
She did not know, until a few minutes ago, that administrator E’s emergency temporary
license had expired. Administrator E had been performing the duties of administrator up
until today as far as she was aware. Apparently since [DATE], the facility had not had an
legitimate administrator. She had heard administrator E refer to the title of Facility
Manager before, but she just thought he/she was using that title as an interchangeable
title for administrator.
During an interview on [DATE] at 12:27 P.M., administrator E said he/she was not aware
his/her emergency temporary license had expired on [DATE]. The Missouri Board of Nursing
Home Administrators was meeting on [DATE] to determine his/her license status. He/she
assumed the emergency temporary license would not expire until that date. His/her
emergency temporary license has been hanging on the office wall, but he/she had not
noticed the expiration date. It was his/her responsibility to have known the expiration
date of the license and to inform the facility management. He/she had not had any
conversations with any representative from the Missouri Board of Nursing Home
Administrators regarding his emergency temporary license until about 10 minutes ago. That
representative told him/her that an extension for his/her emergency temporary license
could not be granted pending the board’s meeting scheduled on [DATE]. He/she acknowledged
he/she had been working at the facility as the administrator from [DATE] until today, but
is resigning effective immediately and the facility was in search of a new administrator.
He/she would be staying at the facility as Executive Director until he/she received
his/her permanent administrators license. As Executive Director he/she will be responsible
for physical plant operations and will have no duties assumed by the administrator.
Review of administrator E’s temporary emergency license showed the facility name and an
effective date of [DATE] and an expiration date of [DATE]. Underneath the effective and
expiration dates, the following was printed: This Temporary License is only valid between
the dates listed above at the facility listed above.
MO 711

F 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have the Quality Assessment and Assurance group have the required members and meet at
least quarterly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide documentation showing
the quality assurance and assessment (QAA) committee met quarterly for a quality assurance
performance improvement (QAPI) meeting. For the last four quarterly meetings, the facility
could only provide proof the QAA committee met two times, and one of those two times, the
administrator signing the attendance record did not hold a valid administrator’s license.
The census was 94.
During an interview on [DATE] at 10:04 A.M., administrator F said he/she could only find
two of the last four QAPI committee meeting attendance records; [DATE] and [DATE].
Administrator E attended the meeting on [DATE] and signed attendance record as the
administrator. Administrator E’s emergence temporary license expired on [DATE], so a
licensed administrator did not attend that meeting. The administrator is responsible for

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265776

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

06/26/2018

NAME OF PROVIDER OF SUPPLIER

ESTATES OF SPANISH LAKE, THE

STREET ADDRESS, CITY, STATE, ZIP

610 PRIGGE ROAD
SAINT LOUIS, MO 63138

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 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
keeping the attendance records. The facility administrator at the time of those two
meetings was no longer at the facility. He/she can not find that administrator’s
attendance records.
During an interview on [DATE] at 6:21 A.M., the Director of Clinical Operations said she
and Administrator F were unable to locate the attendance records of the two QAPI meetings
held prior to [DATE].