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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0567

Level of harm – Potential for minimal harm

Residents Affected – Many

Honor the resident’s right to manage his or her financial affairs.

Based on interview and record review, the facility failed to ensure resident requests for
access to their funds are honored by facility staff as soon as possible but no later than
the same day for amounts less than $100.00 ($50.00 for Medicaid residents) by failing to
ensure residents had access to their trust account funds daily. This deficient practice
had the potential to affect all the residents who had a resident trust accounts held at
the facility. The census was 72.
Review of the facility’s undated banking policy, showed banking will be provided in our
front office/reception area three days per week: Monday, Wednesday and Friday at 11:15
A.M. to 12:15 P.M. If you need access to your funds in between scheduled banking times
please see the business office manager and/or administrator.
During an interview on 3/13/19 at 10:00 A.M., all eight members of a resident group
meeting said they do not have access to their money every day. They receive money on
Monday, Wednesday and Friday at 11:15 A.M. to 11:30 A.M., from the business office
manager.
During an interview on 3/15/19 at 7:10 A.M., the business office manager said the banking
days are Monday, Wednesday and Friday at 11:15 A.M. The resident council was asked to take
a vote and selected the time of 11:15 A.M. Residents continue to knock on the door if they
want to get money at a later time. If a resident wanted to receive money on Tuesday or
Thursday, it depended on the situation. Under special circumstances, such as if they were
going on a leave of absence, they would be able to receive money. It depends if they
really need it or just want it. The business office manager does not work on the weekends,
except one Sunday a month. If the residents are going out on the weekend, they need to
request money ahead of time. She was not aware of the resident’s right to have access to
their money every day, including weekends. The facility used to have banking hours on the
other days of the week; however, it caused the residents to become fixated on receiving
their money every day and it caused behaviors.
During an interview on 3/15/19 at 8:32 A.M., the administrator said she was aware the
banking days are structured on Monday, Wednesday and Friday; however, the residents have
access to their funds any time they want. The residents are aware they can receive their
money on the other days of the week. Most of the residents receive their $30 or $50 in the
beginning of the month. If a resident wanted money on the weekends, the business office
manager would have to be told on Friday, so they can receive their money ahead of time or
the nurse could lock it up until the weekend. If it was short notice, the resident would
have to wait until Monday.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to request, refuse, and/or discontinue treatment, to
participate in or refuse to participate in experimental research, and to formulate an
advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident’s right to
request, refuse and/or discontinue treatment by failing to ensure the resident’s signed
code status sheet for a no code (do not resuscitate (DNR), no life prolonging methods are
performed) status and the physician orders [REDACTED].#32). The census was 72.
Review of Resident #32’s medical record, 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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
-A signed code status sheet, dated 10/12/17, for DNR;
-A physician order [REDACTED].
-A POS, dated 1/3 through 1/31, 2/1 through 2/28 and 3/1 through 3/31/19, with an order
for [REDACTED].
Review of the resident’s care plan, dated 1/3/19, and in use during the survey, showed:
-Problem: Psychosocial wellbeing – Resident has chosen to be a DNR;
-Goal: Resident’s wishes will be filled;
-Interventions: Evaluate yearly. In the event the resident’s heart stops, no life
sustaining measures will be given.
During an interview on 3/14/19 at 9:12 A.M., the Assistant Director of Nurses (ADON)
looked at the resident’s medical record, verified the resident had signed a DNR code
status sheet and that the POSs showed a full code status since 1/3/19. She would expect
the signed code status sheet and the POS to both show the resident’s code status as a DNR.
During an interview on 3/14/19 at 9:18 A.M., the Social Service Designee (SSD) verified
the resident’s code status as a DNR.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Keep residents’ personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a
resident with personal privacy during a medication administration observation by insisting
the resident come into the hallway to receive his/her eye drops and inhalers and failed to
close the door while administering an insulin injection to a resident for two of 18
sampled residents (Residents #57 and #23). The census was 72.
1. Review of Resident #57’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/15/19, showed:
-[DIAGNOSES REDACTED].
-No cognitive impairment or short or long term memory problems;
-No behaviors;
-Independent with transfers, ambulation, dressing, hygiene and bathing.
Observation of medication administration on 3/13/19 at 6:50 A.M., showed the resident lay
in bed in his/her room. Certified Medication Tech (CMT) B stood in the resident’s doorway
and told the resident to come out into the hallway for his/her medications. CMT B repeated
the command at least three times before the resident got out of bed and came out into the
hallway. At 6:56 A.M., CMT B handed the resident an inhaler, instructed him/her to take 2
puffs, handed him/her a plastic cup of water and instructed him/her to rinse his/her
mouth. At 7:03 A.M., the CMT administered eye drops into both of the resident’s eyes. At
7:06 A.M., the CMT handed the resident another inhaler and instructed him/her to take a
puff, then handed the resident a small plastic cup of water and instructed the resident to
rinse his/her mouth. After the resident had taken all of his/her medications, he/she went
back into his/her room and lay down. Other residents and staff were observed in the
hallway and in view of the resident during the inhalers and eye drop administration.
During an interview on 3/13/19 at 7:50 A.M., CMT B said he/she always has the residents
come out of their rooms into the hallway to administer their medications.
During an interview on 3/14/19 at 8:28 A.M., both the administrator and the Director of
Nurses (DON) said it would never be appropriate to make a resident come out of their room
into the hallway to administer medications. Eye drops and inhalers are to be administered

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
in a private area and should never be administered in the hallway for other residents,
staff and visitors to observe due to privacy issues.
2. Review of Resident #23’s medical record, reviewed on 3/13/19 at 1:02 P.M., showed:
-[DIAGNOSES REDACTED].
-Review of a Monthly Summary, dated 2/17/19, showed:
-Wheelchair most of the day;
-Independent with positioning and transfers.
Observation on 3/13/19 at 7:49 A.M., showed Registered Nurse (RN) E administered an
insulin injection to the resident in his/her room:
-RN E entered the room with insulin supplies;
-RN E did not pull the privacy curtain nor shut the door to the resident’s room;
-The resident sat in his/her wheelchair, with his/her shirt pulled up, exposing his/her
left abdomen;
-RN E cleansed the resident’s abdomen with an alcohol pad, inserted the syringe into the
resident’s abdomen, counted to two and withdrew the syringe, then cleansed the insertion
site with an alcohol pad;
-The resident sat in full view of the hallway from the open door during the entire
procedure;
-Other staff and residents were observed in view, in the hall, in front of the resident’s
open doorway during the resident’s insulin administration.
During an interview on 3/15/19 at 8:52 A.M., the DON said it is not appropriate for staff
to administer insulin in open areas. Nurses are expected to administer insulin in private
areas to protect resident’s privacy.

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, in response to allegations of potential
abuse, the facility failed to have evidence that all alleged violations are thoroughly
investigated, report the results of all investigations to the administrator or his or her
designated representative and to other officials in accordance with State law, including
to the State Survey Agency, within 5 working days of the incident when facility staff
identified a resident, who had not been assessed for capacity to consent to sexual
activity, allegedly had been giving sexual favors to unknown individual(s) (Resident #63).
The sample size was 18. The census was 72.
Review of the facility’s abuse, neglect and exploitation policy, dated 11/30/18, showed:
-Each resident has the right to be free from verbal, sexual, physical and mental abuse,
corporal punishment and involuntary seclusion. The resident has a right to be free from
mistreatment, neglect, and misappropriation of property. Resident’s must not be subjected
to abuse by anyone, including, but not limited to; facility staff, other residents,
consultants or volunteers, staff of other agencies serving the resident, family members,
legal guardians, friends or other individuals;
-Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion,
sexually inappropriate interactions, or sexual assault;
-When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or
exploitation occur, it must be communicated to the facility’s Administrator, Department
Head, or Supervisor and the Administrator and/or designee must initiate an investigation;

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-Once the resident is cared for and initial reporting has occurred, an investigation
should be conducted, Components of the investigation may include:
-Interview the involved resident, if possible, and document all responses. If the
resident is cognitively impaired, interview the resident several times to compare
responses;
-Interview all witnesses separately, Include roommates, residents in adjoining rooms,
staff members in the area and any noted visitors in the area. Obtain witness statements,
according to appropriate policies. All statements should be signed and dated by the person
making the statement;
-Document the entire investigation chronologically;
-The facility must report the result of all investigation to the administrator or his or
her designated representative and other officials in accordance with state law, including
to the state survey agency within 5 working days of the incident, and if alleged violation
is verified appropriate corrective action must be taken.
Review of facility’s Sexual Intimacy policy, dated 12/2018, showed:
-Policy: It is the responsibility of The facility to balance a resident’s rights and
provide protection related to sexual contact while an individual is residing in our
facility, through obtaining sexual intimacy history, present activity level, assessing
ability to provide consent, conducting interviews, utilization of information obtained
through observation, analysis of assessment data, safe sex education, and implementation
of interventions;
-Sexual intimacy history: As part of the admission process, the social service worker will
interview the resident or their responsible party to obtain information about a resident’s
past sexual intimacy history. Information obtained by the social service interview will be
documented on the psychosocial history;
-Present sexual activity level: When an observation occurs that a relationship is
developing between residents, a resident is expressing a desire to pursue a relationship,
or witnessed sexual contact between two residents, staff should report this to the charge
nurse, supervisor or administrator. Social service worker, Director of Nursing, nursing
supervisor, charge nurse or administrator will be assigned to interview the resident
and/or residents involved in any of the scenarios;
-Assessment of ability to Consent: Resident’s chart will be reviewed to identify if a
resident or an appointed responsible party is making decisions related to the resident’s
healthcare. Resident’s cognitive assessments will be reviewed to determine the resident’s
level of orientation. Residents will be interviewed separately in a private location using
yes/no and open ended questions, by an appointed staff member to determine the following:
-Understands the distinctively sexual nature of the conduct;
-Understands that their body is private and they have the right to refuse;
-Understands that there may be health risks associated with the sexual act;
-Understands that there may be negative social response to the conduct;
-Analysis of the information: The interdisciplinary team will review the information
obtained through the cognitive assessment to determine the resident’s ability to
understand their actions and if able to give consent for a sexual relationship. The
analysis of information will be documented in the Social Service or Nurses Notes.
Review of Resident #63’s quarterly Minimal Data Set (MDS), a federally mandated assessment
instrument completed by the facility, dated 2/1/19, showed:
-Brief interview for mental status (BIMS) score of 14 out of a possible score of 15, which
showed the resident as cognitively intact;
-Has delusions (misconceptions or beliefs that are firmly held, contrary to reality);
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-Received antipsychotic medications;
-No set up/physical help from staff needed for walking in room and corridor, transfers,
bed mobility or dressing;
-Wheelchair used for mobility;
-[DIAGNOSES REDACTED].
-Resident’s guardian or legally authorized representative participated in assessment.
Review of the resident’s medical record, showed:
-The resident had a legal guardian;
-No documentation that the resident:
-Understands the distinctively sexual nature of the conduct;
-Understands that their body is private and they have the right to refuse;
-Understands that there may be health risks associated with the sexual act;
-Understands that there may be negative social response to the conduct;
-No documentation of the interdisciplinary teams determination of the resident’s ability
to understand their actions and if able to give consent for a sexual relationship.
Review of the resident’s care plan, dated 12/3/18, showed:
-Problem: The resident has a history of disclosing his/her personal information such as
diagnoses, health concerns, etc.;
-Goal: The Resident will only discuss concerns with social services or nursing through the
next review;
-Interventions: Social services to educate resident on appropriate behavior;
-The care plan failed to identify sexual behaviors as a problem, history of allegedly
providing sexual favors and/or documentation the resident had been deemed competent to
consent to sexual activity.
Review of the resident’s Social Services progress notes, dated 2/15/19, showed the social
worker made aware resident giving sexual favors. Resident educated on safe sex and
importance of being aware of partners’ conditions before engaging in these activities.
Guardian made aware. Social worker will continue to support and monitor.
Observation of the resident on 3/14/19 at 9:04 A.M., showed the resident sat in a
wheelchair in his/her room. The resident said he/she wanted a private room but there were
no private rooms available.
During an interview on 3/14/19 at 10:12 A.M., the facility’s social worker said:
-On 2/15/19, the resident stated he/she gave another resident sexual favors but would not
identify the sexual partner;
-The social worker conducted a one on one counseling session with the resident to remind
him/her of safe sex practices and the importance of choosing a partner who is able to give
sexual consent;
-The social worker only documents encounters with residents in their medical records, she
does not document one on one conversations with residents;
-He/she believed the resident was cognitively able to make sexual choices;
-Staff communicates daily and during interdisciplinary team (IDT) meetings on Fridays to
discuss who is sexually active;
-The nursing staff did not know the resident’s sexual partner;
-The social worker asked one resident if they were Resident #63’s sexual partner and
he/she denied it. The social worker does not have documentation of this conversation;
-The social worker did not identify the resident’s sexual partner;
-The social worker did not notify the Administrator as she felt the resident was
protecting his/her privacy by not identifying the sexual partner.
During an interview 3/14/19 at 1:20 P.M., the administrator and the Director of Nursing
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
(DON) stated:
-Protocol for identifying residents who are cognitively able to make choices for sexual
intimacy include: Reviewing BIMS score, cognitive assessments, personal interviews and
feedback from the resident clarifying they understand what occurs with sexual
relationships, how to make safe choices and how to ask for consent from partners;
-There are residents in the facility that are not able to give sexual consent due to
cognitive impairment;
-If staff suspects sexual relationships are occurring between residents, the
administration is to be notified. The administrator will investigate the claim to make
sure the acts are consensual and not abuse;
-When informed a resident has had sexual relations with an unidentified resident in the
facility, the administrator would investigate by interviewing the resident who made the
claim to see if they would identify their partner. If no name is given, then the
administrator and social worker would interview other residents and staff to see if they
could discover who might be the other partner;
-Documentation of the investigation would include the claim of sexual relations, who was
interviewed and when;
-If the facility is unable to identify the second partner, the social worker would focus
on sex education during resident group;
-The social worker will conduct one on one sessions with the resident who would not
identify their partner to make sure the resident understands what a sexual relationship
involves and to insure the resident asks their partner for consent;
-The facility did not investigate the resident’s allegation on 2/15/19, that he/she was
giving sexual favors to an unidentified resident. After the social worker asked one
resident if he/she had sexual relations with Resident #63, which he/she denied, the
facility did not interview any other residents.

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 representatives as soon as practicable when a
resident is temporarily transferred on an emergency basis to an acute care facility and
their return to the facility was expected. Of the 18 sampled residents, seven had been
recently transferred to a hospital for various medical reasons, all seven were expected to
return and had not been issued a written transfer notice upon leaving the facility
(Residents #3, #63, #32, #66, #64, #54 and #56). The census was 72.
1. Review of Resident #3’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility on [DATE];
-Transferred to the hospital on [DATE] and returned to the facility on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
2. Review of Resident #63’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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)
3. Review of Resident #32’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility from the hospital on
[DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
4. Review of Resident #66’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility from the hospital on
[DATE];
-Transferred to the hospital on [DATE] and returned to the facility from the hospital on
[DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfers.
During an interview on 3/12/19 at 1:21 P.M., the resident said he/she had recently been
sent to the hospital and did not receive any transfer notice from the facility.
5. Review of Resident #64’s medical record, showed:
-Transferred to the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
6. Review of Resident #54’s medical record, showed:
-Transferred to the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
7. Review of Resident #56’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility from the hospital on
[DATE];
-Transferred to the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
8. During an interview on 3/14/19 at 9:00 A.M., Nurse A said staff send a copy of the
resident’s face sheet, physician order [REDACTED]. He/she thinks the social service
designee (SSD) sends the responsible party a notice.
9. During an interview on 3/14/19 at 9:19 A.M., the SSD said he does call the responsible
party whenever a resident is discharged to the hospital just to let them know the resident
went to the hospital and will call them again when the resident returns to the facility.
He does not send any paper work with the resident or send any paperwork to the responsible
party if the resident is going to return from the hospital. The only time a resident would
be sent to the hospital with a discharge notice is when they go out and the facility will
not readmit him/her.
10. During an interview on 3/14/19 at 2:30 P.M., both the administrator and the Director
of Nurses (DON) said they were not aware they needed to be issuing an emergency discharge
notice to the resident or their responsible party whenever the resident had an emergency
transfer to the hospital with a return anticipated and had not been issuing any notices.

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.
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

**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
residents or their legal representatives of the facility bed hold policy at the time of
transfer to the hospital, for seven of 18 sampled residents, who were recently transferred
to the hospital for various medical reasons (Residents #3, #63, #32, #66, #64, #54 and
#56). The census was 72.
1. Review of Resident #3’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility on [DATE];
-Transferred to the hospital on [DATE] and returned to the facility 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 transfer.
2. Review of Resident #63’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility 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 transfer.
3. Review of Resident #32’s medical record, showed:
-Transferred to the hospital on [DATE] and 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 transfer.
4. Review of Resident #66’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility from the hospital on
[DATE];
-Transferred to the hospital on [DATE] and 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.
During an interview on 3/12/19 at 1:21 P.M., the resident said he/she had recently been
sent to the hospital and did not receive any written bed hold notice from the facility at
the time of his/her transfer.
5. Review of Resident #64’s medical record, showed:
-Transferred to 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.
6. Review of Resident #54’s medical record, showed:
-Transferred to 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.
7. Review of Resident #56’s medical record, showed:
-Transferred to the hospital on [DATE] and returned to the facility from the hospital on
[DATE];
-Transferred to 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. During an interview on 3/14/19 at 9:00 A.M., Nurse A said staff send a copy of the
resident’s face sheet, physician order [REDACTED]. He/she thinks the social service
designee (SSD) sends the responsible party a bed hold notice whenever the resident is sent
to the hospital.
9. During an interview on 3/14/19 at 9:19 A.M., the SSD said he does call the responsible
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 8)
party whenever a resident is discharged to the hospital just to let them know the resident
went to the hospital and will call them again when the resident returns to the facility.
He does not send any paper work with the resident or provide it to the responsible party
if the resident is going to return from the hospital. The bed hold policy is in the
admission packet.
10. During an interview on 3/14/19 at 2:30 P.M., both the administrator and the Director
of Nurses (DON) said they were not aware they needed to be issuing a written bed hold
policy to the resident or their representative whenever the resident had an emergency
discharge to the hospital with a return anticipated and had not been issuing any notices.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a comprehensive person-centered care plan for each resident that includes
measurable objectives and timeframes to meet a resident’s medical, nursing and mental and
psychosocial needs, for three of 18 sampled residents (Residents #63, #56, and #1). The
census was 72.
1. Review of Resident #63’s quarterly Minimal Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/1/19, showed:
-Brief interview for mental status (BIMS) score of 14 out of a possible score of 15,
showed the resident as cognitively intact;
-Has delusions (misconceptions or beliefs that are firmly held, contrary to reality);
-Received antipsychotic medications;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/3/18, showed:
-Problem: The resident has a history of disclosing his/her personal information such as
diagnoses, health concerns, etc.;
-Goal: The Resident will only discuss concerns with social services or nursing through the
next review;
-Interventions: Social services to educate resident on appropriate behavior;
-The care plan failed to identify sexual behaviors as a problem, history of allegedly
providing sexual favors and/or documentation the resident had been deemed competent to
consent to sexual activity and develop individualized interventions.
Review of the resident’s Social Services progress notes, dated 2/15/19, showed the social
worker made aware of the resident giving sexual favors to another resident. Resident
educated on safe sex and importance of being aware of partners’ conditions before engaging
in these activities. Guardian made aware. Social worker will continue to support and
monitor.
During an interview on 3/14/19 at 10:12 A.M., the facility’s social worker said:
-On 2/15/19, the resident stated he/she gave another resident sexual favors;
-Sexually active residents should have care plans that address their individual needs
concerning sexual intimacy;
-The social worker and the MDS coordinator are responsible for updating care plans.
During an interview 3/14/19 at 1:20 P.M., the administrator and the Director of Nursing

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
(DON) stated care plans should address sexual intimacy for residents who are sexually
active.
Review of facility’s Sexual Intimacy policy, dated 12/2018, showed:
-Policy: It is the responsibility of the facility to balance a resident’s rights and
provide protection related to sexual contact while an individual is residing in our
facility, through obtaining sexual intimacy history, present activity level, assessing
ability to provide consent, conducting interviews, utilization of information obtained
through observation, analysis of assessment data, safe sex education, and implementation
of interventions;
-As part of the admission process, the social service worker will interview the resident
or their responsible party to obtain information about a resident’s past sexual intimacy
history;
-Information obtained by the social service interview will be documented on the
psychosocial history;
-The interdisciplinary team (IDT) will review information obtained through the cognitive
assessment, observations, and the interview to determine the resident’s ability to
understand their actions and if able to give consent for a sexual relationship. The
analysis of information will be documented in the social service or nurses notes;
-If a resident is able to consent:
-The relationship will be monitored and observed for any changes;
-Safe sex practice education will be provided and safe sex practices encouraged;
-If the resident is unable to consent:
-If the resident has an assigned decision-maker, the staff will report the resident’s
sexual relationship status and the result of the analysis of information. If needed, a
family meeting to include the resident will be held to determine how to respect the
resident’s right and provide protection, if needed. This will be documented in the social
service note.
2. Review of Resident #56’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed:
-BIMS score of 12 out of 15;
-A BIMS score of 8-12, showed the resident had moderately impaired cognition;
-[DIAGNOSES REDACTED].
-Has delusions;
-Received antipsychotic medications.
Review of the resident’s behavior/intervention monthly flow record, dated 1/1/19 through
2/28/19, showed:
-Agitation: 2/22/19;
-Hallucination/delusion/paranoid: 2/22/19.
Review of the resident’s care plan, updated 3/3/19, showed:
Problem: At risk for falling, is up as desired and uses a wheelchair at times. He/she has
decreased safety awareness/poor judgement, receives daily antianxiety and diuretic drug
therapies due to a history of [MEDICAL CONDITIONS] and an anxiety disorder;
Approaches:
-Assure the floor is free of glare, liquids and foreign objects;
-Encourage resident to walk on sidewalk during inclement weather;
-Encourage resident to assume standing position slowly;
-Keep personal items and frequently used items within reach;
-Provide proper, well maintained footwear;
-Provide resident an environment free of clutter;
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
-Remind to lock wheelchair brakes prior to any transfer;
-The care plan failed to identify agitation and hallucinations/delusions/paranoia as
problems with goal and interventions.
3. Review of Resident #1’s quarterly MDS, dated [DATE], showed:
-Cognitively impaired;
-One staff person assist for all activities of daily living (ADLs);
-Nutrition, feeding tube;
-Unclear speech;
-Rarely makes self-understood/understands;
-No behaviors;
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-Diet: Nothing by mouth (NPO);
-Elevate head of bed 30 degrees at all times.
Review of the resident’s care plan, in use during the survey, showed the following:
-Problem: Resident is non-compliant with his/her NPO status. He/she continues to go in the
dining room and drink plain coffee, or water;
-Approach: Explain dietary requirements and consequences of dietary non-compliance;
-Problem: At risk for weight loss/gain due to all hydration and nutrition via a
gastrostomy tube ([DEVICE], a tube inserted through the abdomen that delivers nutrition
directly to the stomach), due to dysphagia (difficulty swallowing) from a prior stroke and
is dependent on staff for nutritional needs. He/she may have pleasure feedings of puree
consistency with honey thickened liquids.
Observation and interview on 3/12/19 at 11:59 A.M., showed the resident lay on his/her bed
and appeared asleep while additional residents were observed in the dining room eating
lunch. Nurse A stated the resident’s next tube feeding would be at 2:00 P.M.
During an interview on 3/14/19 at 8:33 A.M., the administrator said the resident is NPO,
but known to buy chips out of the snack machine. On 3/15/19 at 9:23 A.M., the
administrator said the resident was NPO and did not have and order for pleasure feeding or
honey thickened liquids. She was not aware his/her care plan contained pleasure feeding or
honey thickened liquids.
4. During an interview on 3/15/19 at 9:30 A.M., the Director of Nursing (DON) and
Assistant Director of Nursing (ADON) said the care plans are updated weekly and quarterly.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that
residents receive treatment and care in accordance with professional standards of practice
and the comprehensive person-centered care plan by failing to obtain physician orders for
one resident receiving electroconvulsive therapy (ECT, a small electric current this is
passed through the brain, intentionally triggering a brief [MEDICAL CONDITION]) and failed
to assess and monitor the resident’s condition after the ECT treatments (Resident #33).
The facility also failed to complete neurological (neuro) checks after an unwitnessed fall

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
for one resident (Resident #40). The census was 72.
1. Review of Resident #33’s face sheet, showed a [DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/15/18, showed:
-Brief interview for mental status (BIMS) score of 14 out of 15, showed the resident was
cognitively intact;
-[DIAGNOSES REDACTED].
-Has delusions;
-Antipsychotic medications administered in the last seven days;
-Antipsychotic medications received on a routine basis.
Review of the resident’s judgement for involuntary electroconvulsive therapy form, dated
11/8/17, showed:
-Upon clear and convincing evidence the Court finds that the respondent is receiving
outpatient treatment at a private mental health facility;
-The respondent is unable, by reason of a mental illness, to evaluate information in order
to make an informed choice as to the proper medical treatment of [REDACTED].
-The respondent has been treated in the past with electroconvulsive therapy which resulted
in significant improvement in the respondent’s mental disorder for substantial period of
time;
-The electroconvulsive therapy is necessary because there is a strong likelihood that the
therapy will significantly improve the respondent’s mental disorder for a substantial
period of time without causing respondent any serious functional harm, and
electroconvulsive therapy is the most effective and least invasive form of therapy which
can result in substantial improvement in the respondent’s condition.
Review of the resident’s care plan, dated 3/20/18, showed:
-Problem: Receives ECT treatments related to history of [MEDICAL CONDITION];
-Approach: Appointments as ordered. Monitor for adverse effects: headaches, dizziness, jaw
pain, muscle aches, amnesia, fatigue, nausea and vomiting.
Review of the resident’s physician orders sheet (POS), dated 3/1/19 through 3/31/19,
showed:
-[DIAGNOSES REDACTED].
-Further review, showed no physician orders for ECT and/or monitoring and assessing for
adverse effects of the treatment.
Review of the resident’s progress notes, showed:
-On 5/23/18 at 12:00 P.M., resident returned from ECT at hospital. No acute signs or
symptoms of any distress noted. Next ECT date 5/30/18;
-No documentation if the resident attended ECT on 5/30/18;
-On 10/31/18 at 1:30 P.M., resident returned from ECT follow up. ECT for 11/14/18;
-No documentation if the resident attended ECT on 11/14/18;
-On 1/17/19 at 6:30 A.M., spoke to resident’s family member who was made aware of
resident’s desire to not attend ECT session today;
-No further documentation of the resident’s ECT treatments or monitoring and assessing for
adverse effects of ECT.
Observation on 3/12/19 at 10:51 A.M., showed the resident sat in his/her room and said
he/she received ECT treatments for several years. He/she enjoyed reading, but it had
become more difficult because he/she started to have double vision as a result of the ECT.
On 3/13/19 at 1:31 P.M., the resident said he/she has ECT treatments every other
Wednesday.
During an interview on 3/15/19 at 8:32 A.M., the administrator and the Director of Nursing
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
(DON) said the resident received ECT treatments every other week. There are no physician’s
orders for the ECT treatments because they are court ordered. They would expect staff to
assess the resident for any physical side effects when he/she returned from ECT treatments
and document them in the progress notes. They were not aware of the resident’s complaints
of double vision or when the resident last had an eye exam and would expect there to be
physician orders for the ECT.
2. Review of the facility’s policy for Neuro Checks, reviewed on 12/1/18, showed the
following:
-Assess the resident for changes in level of consciousness, which is a cardinal sign of
untoward pathology. Assess the resident immediately after the fall, then frequently
throughout the shift. Assessment should continue for a minimum of 72 hours;
-Notify the physician immediately after the fall, follow the physician’s orders related to
the fall;
-Observe the resident for obvious injuries to the scalp, including lacerations, bruises,
or contusions. Observe for confusion, memory loss, difficulty speaking, gait or balance
problems, pupils of unequal size or reactions, headache, vomiting, visual disturbances, or
periods of coherence alternating with periods of confusion or lethargy. Monitoring must
continue for a minimum of 72 hours (or until the resident is asymptomatic for a specified
period of time);
-Perform frequent neurologic assessments every;
-15 minutes for one hour;
-30 minutes for two hours;
-60 minutes for four hours;
-Eight hours for 16 hours;
-Eight hours until at least 72 hours have elapsed and the resident is stable;
-Neurological assessments include (at a minimum) pulse, respiration and blood pressure
measurements, pupil size and reactivity, equality of hand grip strength. Completing the
post fall neuro check form to help keep findings objective.
Review of Resident #40’s annual MDS, dated [DATE], showed:
-Cognitively impaired;
-One staff person assist for bed mobility, dressing, toilet use, dressing and personal
hygiene;
-Two staff person assist for transfers;
-Upper/lower extremity impairment on one side;
-Wheelchair for mobility;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed the following:
-Problem: Falls, on 1/9/19, the resident rolled out of bed. The bed was in lowest
position, he/she fell on to the fall mat, without injury;
-Approach: Encourage not to transfer him/herself and ask for assistance with transfers.
Continue to use floor mat and ensure bolster mattress is in place and in good condition.
Review of the facility accident/incident log, dated (MONTH) 2019 through (MONTH) 2019,
showed no documented incident/fall for the resident.
Review of the resident’s nurse’s notes, showed on 1/9/19, while seated at the desk, this
nurse was notified the resident was on the floor, beside his/her bed, on the floor mat. No
open or bruised areas noted, the resident stated he/she just laid down to relax. Fall
unwitnessed, neuro checks initiated.
Further review of the resident’s medical record, showed no documented neuro checks for the
fall on 1/9/19.
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
During an interview on 3/14/18 at 11:32 A.M., Nurse A said once neuro checks are
completed, the documentation is turned over to the DON.
During an interview on 3/15/18 at 8:38 A.M., the DON and the administrator said neuro
checks had not been completed after the resident’s fall on 1/9/19. Neuro checks would be
expected after an unwitnessed fall, and the resident’s neuro checks should have been
completed.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide pharmaceutical services to meet the needs of each resident and employ or obtain
the services of a licensed pharmacist.

Based on interview, and record review the facility failed to establishes a system of
records of receipt and disposition of all controlled drugs in sufficient detail to enable
an accurate reconciliation. The controlled substance shift change count check sheets were
missing documentation for 3 of the 5 facility medication carts. The facility census was
72.
Review of the facility’s controlled substances policy, dated 12/2012, showed:
-The facility shall comply with all laws, regulations, and other requirements related to
handling, storage, disposal, and documentation of Schedule II and other controlled
substances;
-Nursing staff must count controlled medications at the end of each shift. The nurse
coming on duty and the nurse going off duty must make the count together. They must
document and report any discrepancies to the Director of Nursing (DON);
-The DON shall investigate any discrepancies in narcotics reconciliation to determine the
cause and identify any responsible parties, and shall give the administrator a written
report of such findings.
1. Review on 3/12/19 at 12:43 P.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the 100 hall certified medical technicians
(CMT) cart, showed:
-11 out of 34 shifts: Count with one nurse documented;
-1 out of 34 shifts: Count without any nurses documented;
-8 out of 34 shifts without count of narcotics.
Review on 3/12/19 at 12:43 P.M., of the facility’s controlled substance shift change count
check sheet, dated (MONTH) 2019, for the 100 hall CMT cart, showed:
-31 out of 83 shifts: Count with one nurse documented;
-6 out of 83 shifts: Count without any nurses documented;
-14 out of 83 shifts without count of narcotics.
2. Review on 3/12/19 at 12:44 P.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the 100 hall nurse’s cart, showed:
-11 out of 34 shifts: Count with one nurse documented;
-2 out of 34 shifts: Count without any nurses documented;
-8 out of 34 shifts without count of narcotics.
Review on 3/12/19 at 12:44 P.M., of the facility’s controlled substance shift change count
check sheet, dated (MONTH) 2019, for the 100 hall nurse’s cart, showed:
-37 out of 83 shifts: Count with one nurse documented;
-4 out of 83 shifts: Count without any nurses documented;
-27 out of 83 shifts without count of narcotics.

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
3. Review on 3/12/19 at 1:09 P.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the 200 hall CMT cart, showed:
-11 out of 34 shifts: Count with one nurse documented;
-5 out of 34 shifts without count of narcotics.
Review on 3/12/19 at 1:09 P.M., of the facility’s controlled substance shift change count
check sheet, dated (MONTH) 2019, for the 200 hall CMT cart, showed:
-9 out of 83 shifts: Count with one nurse documented;
-3 out of 83 shifts without count of narcotics.
4. During an interview with the Administrator, DON, Assistant Director of Nursing (ADON)
and Director of Clinical Operations on 3/15/19 at 8:32 A.M., the following statements were
made:
-The DON is responsible for checking if the narcotic shift change reports are filled out
correctly and conduct a monthly audit of the facility’s narcotics and narcotic shift
change reports;
-The pharmacy conducts a quarterly audit of the facility’s narcotics;
-Staff will notify the DON if the narcotic shift change count is off;
-The DON would investigate the missing narcotic by examining the physical narcotic cards
and verifying the number of narcotics listed on the narcotic shift change report;
-Given the examples of missing documentation on the narcotic shift change reports, they
are not sufficient to obtain accurate reconciliation of narcotics.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 27 opportunities observed, 5 errors occurred
resulting in an 18.51% medication error rate (Residents #57 and #1). The census was 72.
1. Review of Resident #57’s physician order [REDACTED].
-[DIAGNOSES REDACTED].
-An order dated 8/15/18, to administer [MEDICATION NAME] (used for treatment of
[REDACTED].
-An order dated 10/10/18, to administer Incruse Ellipta inhaler (used for treatment of
[REDACTED].
-An order dated 1/2/19, to administer Simbrinza 1% – 0.2% eye drop (used to treat [MEDICAL
CONDITION]) 1 drop in both eyes three times a day.
Observation on 3/13/19 at 6:56 A.M., showed Certified Medication Tech (CMT) B handed the
resident the [MEDICATION NAME] inhaler and told him/her to take 2 puffs. The resident took
the inhaler and administered 2 puffs back to back without waiting between puffs and handed
the inhaler back to the CMT. CMT B did not instruct the resident to wait between puffs.
CMT B handed the resident a plastic cup of water and told him/her to rinse his/her mouth,
the resident drank the water and did not spit the water back out of his/her mouth. Without
trying to have the resident spit out the water, CMT B took the empty cup and said You’re
thirsty this morning. The CMT did not educate the resident on rinsing and not swallowing
the water. At 7:03 A.M., CMT B administered the Simbrinza 1 drop into both eyes, told the
resident to close his/her eyes, but did not tell the resident to keep them closed or for
how long. CMT B turned his/her back to the resident and continued to gather the resident’s
medications. The resident kept his/her eyes closed for approximately 30 seconds and then

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
opened them and wiped his/her eyes with a clean tissue. At 7:06 A.M., CMT B handed the
resident the Incruse Ellipta inhaler. The resident took the inhaler and administered 1
puff. CMT B took the inhaler back, handed the resident a plastic cup of water and told
him/her to rinse his/her mouth. The resident took the cup of water and drank the water.
CMT B did not attempt to have the resident spit the water out into the cup or further
educate the resident on proper rinse procedure.
Review of WebMD instructions for Simbrinza eye drops, showed to apply gentle pressure on
the inner canthus (eye duct) for 1 to 2 minutes before opening the eyes after
administration.
During an interview on 3/14/19 at 8:28 A.M., the Director of Nurses (DON) said the
facility policy is to hold the inner canthus or have the resident keep their eyes closed
for 1 minute after administration of eye drops to prevent the medication from being
absorbed into the blood stream. The facility policy is to wait 1 minute between puffs of
the same inhaler. Both the [MEDICATION NAME] and the Incruse Ellipta inhalers are steroid
medications. Staff should have residents rinse their mouth with water after administration
of the inhalers and not swallow the water to help prevent a thrush (yeast) infection of
the mouth or stomach. She would expect staff to observe the resident as they administer
the inhalers to ensure they are administering them correctly and not turn away from the
resident to continue to gather medications.
2. Review of Resident #1’s quarterly Minimal Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/5/18, showed:
-Short term memory problem;
-Some difficulty making decisions regarding tasks of daily living;
-Total dependence for eating;
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated (MONTH) 2019, showed:
-Flush resident’s [DEVICE] with 70 milliliters (ml) of water before and after each
feeding;
-May crush/open/dissolve appropriate medications;
-An order to administer aspirin 81 milligram (mg) via [DEVICE];
-An order to administer carvedilol (a medication used to treat high blood pressure)
through the [DEVICE].
Observation of medication administration thru the resident’s [DEVICE] on 3/13/19 at 10:25
A.M., showed:
-Licensed Practical Nurse (LPN) F drew up 60 ml of water into the syringe, put the tip of
the syringe in the resident’s [DEVICE] and depressed the piston, pushing the water into
the resident’s [DEVICE];
-LPN F drew up 10 ml of water into the syringe, put the tip of the syringe into the
resident’s [DEVICE] and depressed the piston, pushing the water into the resident’s
[DEVICE];
-LPN F drew up crushed aspirin 81 mg, which was diluted in 10 ml of water, into the
syringe, placed the tip of the syringe into the resident’s [DEVICE] and depressed the
piston, pushing the medication into the resident’s [DEVICE];
-LPN F removed the syringe from the resident’s [DEVICE], inserted the tip of the syringe
into the graduated cylinder filled with water and pulled up 5 ml of water into the
syringe;
-LPN F inserted the tip of the syringe in the resident’s [DEVICE] and depressed the piston
pushing the water into the resident’s [DEVICE]. He/she then removed the syringe from the
resident’s [DEVICE];
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-LPN F took the tip of the syringe, placed it in a medicine cup filled with Carvedilol
3.125 mg diluted with 10 ml water, and pulling the piston back on the syringe, pulled the
medicine into the syringe;
-LPN F took the tip of the syringe, placed it in the resident’s [DEVICE] and depressed the
piston, pushing the medication in to the resident’s [DEVICE];
-LPN F removed the syringe from the resident’s [DEVICE], inserted the tip of the syringe
into a graduated cylinder filled with water and pulled up 5 ml of water into the syringe;
-LPN F inserted the tip of the syringe in the resident’s [DEVICE] and depressed the
piston, pushing the water into the resident’s [DEVICE]. He/she then removed the syringe
from the resident’s [DEVICE].
During an interview on 3/13/19 at 10:45 A.M., LPN F stated:
-He/she pushed both the aspirin and carvedilol into the resident’s [DEVICE] instead of
administering the medications by gravity;
-He/she did not know why he/she pushed two out of the nine medications administered,
possibly he/she was rushing.
During an interview with the administrator, the Director of Nursing (DON), the Assistant
Director of Nursing (ADON) and the Director of Clinical Operations on 3/15/19 at 8:32 A.M,
the following statements were made:
-Nurses are expected to give both medications and water flushes via resident’s [DEVICE] by
gravity;
-Nursing staff is expected to know the facility’s policy and procedure of medication
administration through resident’s [DEVICE]s.
Review of medication administration resident’s [DEVICE] policy, dated 12/1/18, showed:
-Purpose: To enable the safe administration of oral medication to a resident who is unable
to swallow medications;
-If tablets or capsules are to be given, crushed tablets or contents should be dissolved
in about 30 ml of warm water;
-Remove 60 ml syringe. Remove the piston of the syringe. Reinsert the syringe in the
gastric tube without the piston. Pour 30 ml of water into the syringe. Unclamp the tube
and allow water to enter into the stomach by gravity infusion. If water does not go in
automatically you may need to reinsert piston and slowly push;
-Administer first dose of medication by pouring into the syringe. Follow with 5-10 ml
water flush between medication doses. Unless the resident is on a fluid restriction.
Follow the last dose of medication with 30 ml of water flush unless restricted.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure drugs and
biologicals were labeled and stored in accordance with currently accepted professional
principles in two of two medication storage rooms. The census was 72.
Review of the facility’s medication storage policy, dated 2014, showed:
-Policy: Medications housed on our premises are stored in the pharmacy and/or medication
rooms according to the manufacturer’s recommendations. All medications are stored in
designated areas which are sufficient to ensure proper sanitation, temperature, light,

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
ventilation, moisture control, segregation, and security;
-Disinfectants and drugs for external use are stored separately from internal and
injectable medications;
-All medications requiring refrigeration are stored in refrigerators located in the
pharmacy and at each medication room;
-The pharmacy and all medications rooms are routinely inspected by consultant pharmacist
for discontinued, outdated, defective, or deteriorated medications with worn, illegible or
missing labels. These medications are destroyed in accordance with our Destruction of
Unused Drugs Policy.
1. Observation of the 100 hall medication storage room, on 3/12/19 at 1:15 P.M., showed:
-The small refrigerator contained:
-Two cartons of opened, undated nutritional shakes;
-A baggy that contained vials of influenza vaccinations;
-A container of banana yogurt stored in the door of the refrigerator;
-Emergency kit for insulin from the pharmacy;
-On the counter:
-Multiple medication packets/bottles. Certified Medication Technician (CMT) G said these
were returns to pharmacy;
-Medication bottles for current residents;
-A take out bag from a local restaurant containing a Styrofoam container of food;
-A soda can, open and covered with a cup over it;
-On top of the locked fuse box, which hung on wall roughly 6 feet off the ground:
-Open box of [MEDICATION NAME] (medication used to treat asthma) nebulizer vials;
-Open box of examination gloves;
-Open box of ABD pads (a soft, fluffy, absorbent pad for wound dressings).
2. Observation of the 300 hall medication storage room, on 3/12/19 at 1:32 P.M., showed:
-The small white refrigerator contained:
-Two bottles of Ranch dressing, opened;
-A bottle of banana peppers, opened;
-A bottle of thickened liquid;
-A Styrofoam container filled with peaches, labeled with the date 3/11/19;
-Two Evian water bottles;
-A package of sliced cheese;
-A Hot Pocket brand sandwich;
-Several packets of condiments from takeout restaurants;
-A bottle of Coffee mate brand creamer;
-Two cans of flavored sparkling spring water;
-On top of the counter:
-A large glass vase full of take out condiment packets;
-In the overhead cabinets:
-A package of Ramen noodle soup;
-A salt shaker;
-A Foley catheter (a sterile tube inserted into the bladder to drain urine) insertion
kit;
-A cell phone;
-A bottle of hot sauce;
-Three containers of unwashed Tupperware;
-A tube of Santyl (an ointment used to debride ulcers) ointment, labeled with a
resident’s name, half used;
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-Two enteral feeding delivery systems, not in bags;
-Medication bottles for residents, lying among the debris, on their side;
-One bottle of Dakin’s Solution (an antiseptic solution used to cleanse open wounds)
opened, half used, not labeled;
-Underneath the sink:
-A box of lab supplies consisting of urinal specimen cups, specimen swabs and transport
bags for specimen collection;
-A dirty beverage cup stuffed with paper towels that lay inside a box, on top of lab
supplies;
-A used toilet brush;
-A stack of paper plates and various party hats;
-An old radio.
3. During an interview on 3/12/19 at 1:48 P.M., CMT G stated:
-CMTs and nurses are responsible for maintaining the medication rooms;
-Staff are not allowed to store food in medication rooms or medication refrigerators.
4. During an interview with the administrator, the Director of Nursing (DON), the
Assistant Director of Nursing (ADON) and the Director of Clinical Operations on 3/15/19 at
8:32 A.M, the following statements were made:
-Staff are expected to store their personal belongings in the break room, they have
lockers they can access at all times;
-Staff should not store their food and drinks in the medication storage rooms on the
counters or in cabinets;
-Staff can store their food in the break room refrigerator and the staff ice box in the
300 hall med storage room;
-Staff should not store medications or items used for residents in the staff
refrigerators. Residents have their own refrigerators in their own rooms;
-The night nurse is responsible to maintain cleanliness of both the staff refrigerator in
the 300 medication storage room and the medication refrigerators in both medication
storage rooms;
-Staff are expected to send medications that are no longer in use back to the pharmacy. It
is not appropriate to store a half used tube of Santyl in the medication storage room;
-There is not a schedule in place for inspection/cleaning of the medication rooms;
-Staff are expected to notify administration if they found an issue with the organization
or cleanliness of the rooms;
-Medication storage rooms are expected to maintain cleanliness and organization.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure each
resident receives and the facility provides food prepared by methods that conserve
nutritive value, flavor, and appearance by failing to follow two out of two observed puree
recipes for four residents who received pureed diets. The census was 72.
1. Review of the puree pork loin recipe, for 25 servings, showed the following:
-1 cup of Maple syrup;
-1/2 cup of brewpub style mustard;

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
-1/3 cup apple cider vinaigrette;
-1 1/4 tablespoon of soy sauce;
-1 1/4 teaspoon of black pepper;
-6 pounds of pork loin.
Observation and interview on 3/14/18 at 10:07 A.M., showed Cook H had the pork loin recipe
opened. He/she added liquid browning seasoning sauce to a clear measuring cup, walked over
to the sink, and filled the measuring cup with hot water until the cup measured two cups.
He/she then walked over to the dishwasher, removed a clear plastic container from the
dishwasher, dripping wet, and placed the container on the blender. He/she then added 1
tablespoon of thickener into the blender, poured the contents of an unmeasured pan of
chopped pork chops into the wet blender, added the water/seasoning mix, and blended. The
dietary manager tested the puree and instructed Cook H to add some gravy. Cook H poured a
half cup of white gravy from a pot of gravy on the stove, added the gravy and blended.
He/she then walked over to the dishwasher, removed a wet pan from dishwasher and poured
the pureed pork chops into the wet pan, covered the pan with aluminum foil, dated the foil
and placed the pan in the oven. Cook H said he/she was not aware of the serving size for
the puree or which scoop to use for the purees. He/she had four residents with physician
orders [REDACTED].
2. Review of the pancake/syrup puree recipe for four servings, showed the following:
-4 pancakes;
-4 fluid ounces of milk (1/2 cup).
Observation on 3/15/19 at 6:38 A.M., showed Cook I poured 1 cup of milk into a clear
plastic container on top of the blender. He/she then added 6 pancakes and 1/4 cup of
syrup. He/she blended the contents of the container. He/she opened the milk container and
poured two more ounces of milk into a measuring cup. He/she walked over to the microwave
and placed the milk inside, closed the microwave and warmed the milk. He/she added the
milk and blended the mixture. Cook I said he/she had four residents who received pureed
diets, with one resident who received double portions.
3. During an interview on 3/15/19 at 7:00 A.M., the dietary manager said staff should
follow the puree recipes. The dietary manager looked at the recipes and said Cook H used
the wrong puree recipe for the pork chops. Cook H used the pork loin recipe by mistake and
he/she should have used the pork chop recipe.
4. During an interview on 3/15/19 at 9:10 A.M., the administrator said puree recipes must
be followed, if they are not, they may be diluted or not have enough fluid in the puree.

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 by failing to address the lack of hot water from the hand washing sink used by all
dietary staff and/or assure proper handwashing. In addition, the facility failed to keep
the fan used to dry dishes free from dust and debris and date and label food. These
deficient practices had the potential to affect all residents who ate at the facility. The
census was 72.
Review of the facility’s hand washing policy, dated (MONTH) (YEAR), 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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 20)
-Staff shall clean their hands and wrist area for at least 20 seconds in a hand washing
sink that is equipped with warm water, hand washing soap, paper towels and a trash can
with a foot operated lid. Employees shall avoid using a food preparation sink, pot washing
sink, a service sink or an area designed to dispose of mop water;
-The procedure shall include:
-Rinsing under clean running water;
-Applying soap;
-Rubbing vigorously for 10-15 seconds to ensure removal of soil from surface of hands and
wrists and underneath nails;
-Rinsing under running warm water;
-Drying with a single use towel.
1. Observation of the kitchen on 3/12/19 at 8:59 A.M., showed the water from the hand
washing sink ran for 3 minutes and failed to turn hot. The dietary staff were observed
using the hand washing sink to wash their hands.
Observation on 3/14/19 at 1:07 P.M., showed the water from the hand washing sink felt
cold. The dietary staff washed their hands one by one, leaving the water running. The
dietary manager approached the sink and touched the running water. She continued to put
her hand in and out of the water to check the temperature. The dietary manager said she
was aware there was no hot water that came from the hand washing sink. When the dish
machine was in use, it decreases the hot water. At 1:10 P.M., the dietary manager left the
water running in the sink and obtained a digital thermometer from the kitchen. The digital
thermometer was placed under the running water for two minutes. At 1:12 P.M., the
temperature of the water measured 50.0 degrees Fahrenheit (F).
During an interview on 3/15/19 at 8:32 A.M., the administrator said she was not aware that
there was no hot water from the hand washing sink in the kitchen. She would expect staff
to report the issue to maintenance. Maintenance is responsible for taking the water
temperatures in the kitchen on a weekly basis. The administrator was aware there was an
issue with the hot water approximately six months ago, but it was addressed. There is a
separate water heater for the kitchen and maintenance adjusted it. The administrator would
expect staff to follow the hand washing policy and have warm water accessible for hand
washing to ensure safe food handling.
During an interview on 3/15/19 at 11:07 A.M., the maintenance supervisor said he was not
aware the hand washing sink did not have hot water. He tested the hot water in the kitchen
on a regular basis, but only the three sink sanitizer. There is a regulator underneath the
sink that has to be turned with a wrench, and he is the only one that could do it.
2. Observation on 3/14/19 at 1:07 P.M., showed a large fan with dust buildup, blowing in
the kitchen while dietary staff served meals and cleaned dishes.
During an interview on 3/15/19 at 11:00 A.M., the dietary manager said the evening shift
is responsible for cleaning the fans on a weekly basis. She would expect the fans to be
free of dust, so it does not blow on the food.
3. Review of the facility Food Storage policy, showed:
-Food inventory will be maintained using first in, first out;
-Food stock will be placed with new stock behind old;
-Items will be marked with a date prior to storage
Observation of the refrigerator in the kitchen, located across from the hand washing sink,
showed:
-On 3/14/19 at 10:04 A.M., two large clear plastic zip locked bags of frozen sausage
patties, undated;
-On 3/15/19 at 6:38 A.M., two large clear plastic zip locked bags of frozen sausage
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 21)
patties, undated.
During an interview on 3/15/19 at 7:00 A.M., the dietary manager said food should be
labeled and dated per facility policy.
4. During an observation on 3/14/18 at 10:07 A.M., showed Cook H prepared puree pork
chops. He/she walked over to the dishwasher, removed a clear plastic container from
dishwasher, dripping wet, and used the container to blend the puree. He/she then walked
over to the dishwasher, removed a wet pan from the dishwasher, and poured the pureed pork
chops into the wet pan, covered the pan with aluminum foil, dated the foil and placed the
pan in the oven.
During an interview on 3/15/19 at 7:00 A.M., the dietary manager said dietary staff were
expected to air dry equipment prior to use to prevent bacterial growth. Staff were
expected to date all food prior to storage.
5. Observation on 3/15/19 at 6:38 A.M., Cook I poured 1 cup of milk into a clear plastic
container on top of the blender. He/she then added 6 pancakes and 1/4 cup of syrup. He/she
blended the contents of the container. He/she then removed his/her gloves and used his/her
ungloved hand to push open the spout on the milk container and poured two more ounces of
milk into a measuring cup. He/she walked over to the microwave and, with ungloved hands,
opened the microwave, placed the milk inside, closed the microwave and warmed the milk.
He/she added the milk, blended the mixture and then donned new gloves. He/she did not wash
his/her hands after removing his/her gloves and prior to touching the milk carton spout
and the microwave handle, before blending the warmed milk into the puree pancakes after
touching the potentially soiled microwave handle, and/or before donning new gloves.
During an interview on 3/15/19 at 7:00 A.M., the dietary manager said staff were expected
to wash their hands prior to handling food and/or food prep equipment and prior to donning
new gloves.
During an interview on 3/15/19 at 9:10 A.M., the administrator said staff are required to
wash their hands prior to donning new gloves.

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Safeguard resident-identifiable information and/or maintain medical records on each
resident that are in accordance with accepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain medical
records on each resident that are complete, accurately documented, readily accessible and
systematically organized by failing to document insulin doses for one of 18 sampled
residents (Resident #57). The census was 72.
Review of the facility’s Insulin Administration policy, revision date (MONTH) 2010, showed
the following:
-Documentation should include:
-The resident’s blood glucose (sugar) level (BGL) result, as ordered;
-The dose and concentration of the insulin injection;
-Injection site (presence or absence of any bruising, pain, redness, swelling or unusual
marks on or near the injection site).
Review of Resident #57’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/5/19, showed:
-Cognitively intact;
-Insulin, received 7 injections during the last 7 days;

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-An order, dated 10/11/18, for [MEDICATION NAME] (rapid acting) insulin. Inject per
sliding scale subcutaneously (into the fatty tissue), three times daily with daily blood
glucose monitoring;
-Administer insulin unit amounts as follows:
-BGL of 151-200, give 3 unit;
-BGL of 201-250, give 5 unit;
-BGL of 251-300, give 7 unit;
-BGL of 301-350, give 9 unit;
-BGL of greater than 351, give 11 unit and call the physician.
Review of the resident’s Medication Administration Record [REDACTED]
-No 6:00 A.M. dosage recorded on 12/4 through 12/6, 12/8 through 12/11, 12/13, 12/15,
12/18, 12/20, 12/22, 12/24, 12/25 and 12/27 through 12/29/18;
-No 5:00 P.M. dosage recorded on 12/8, 12/17, 12/22 and 12/23/18.
Review of the resident’s MAR, dated 1/1/19 through 1/31/19, showed no documented insulin
doses given for the following dates:
-No 6:00 A.M. dosage recorded on 1/3, 1/5, 1/9 through 1/11, 1/15, 1/17, 1/19 through
1/21, 1/23 through 1/26 and 1/29 through 1/31/19;
-No 5:00 P.M. dosage recorded on 1/19, 1/20 and 1/31/19.
Review of the resident’s medication MAR, dated 2/1/19 through 2/28/19, showed no
documented insulin doses given for the following dates:
-No 6:00 A.M. dosage recorded on 2/2, 2/4, 2/6, 2/8, 2/9, 2/12, 2/17, 2/20 through 2/23
and 2/26 through 2/28/19;
-No 12:00 P.M. dosage recorded on 2/5 and 2/8/19;
-No 5:00 P.M. dosage recorded on 2/8 and 2/24/19.
During an interview on 3/15/19 at 9:00 A.M., the Director of Nursing (DON) said staff
should document on the MAR indicated [REDACTED]. They should not leave the area blank if
none was given. If no insulin was required, they should document with a zero, the dosage
should not be left blank. If staff do not document the dosage, it would be unknown if the
resident received a dosage or if they received an accurate dosage.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
used acceptable infection control procedures during blood glucose testing (BGT) for four
out of four residents observed, who had orders for BGT (Residents #50, #42, #66 and #23),
and for one resident with a nebulizer (machine used for breathing treatments) treatment
(Resident #3). In addition, staff failed to use proper handwashing techniques. The sample
was 18. The census was 72.
Review of the facility’s Blood Glucose Monitoring policy, dated 12/1/18, showed:
-Policy: All residents requiring blood glucose monitoring will have accurate testing with
physician’s orders [REDACTED].
-Wash hands or sanitize and apply gloves;
-After each use clean/disinfect outside of the meter with Bleach Healthcare Grade
disinfectant wipes;

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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-Use additional wipes if needed to assure continuous wet contact time, at a length
according to the manufacturer’s recommendations. Let air dry;
-The policy failed to instruct staff to use a clean barrier for the placement of the
glucometer machine (machine used to check blood sugar levels).
1. Review of Resident #50’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/13/19 at 6:20 A.M., showed Nurse C got the
BGT equipment together, put on gloves, took the equipment into the resident’s room along
with two paper towel barriers, placed both barriers and the BGT machine directly on top of
the resident’s soiled bedside cabinet. He/she obtained the resident’s BGT, told the
resident the results, picked up the BGT machine and both barriers, took them out of the
resident’s room and placed the soiled barriers directly on top of a stack of clean
barriers, located on the top of the medication administration cart. Nurse C removed the
soiled gloves, cleaned his/her hands, put on clean gloves and cleaned the BGT machine with
a Sani Cloth Plus wipe. He/she removed the top soiled paper towel and placed the cleaned
BGT machine directly on top of the second soiled paper towel, that had been on the
resident’s bedside cabinet. Nurse C placed another clean Sani Cloth Plus wipe over the BGT
machine causing the paper towel underneath the BGT machine to become wet, removed his/her
soiled gloves, cleaned his/her hands with alcohol gel and proceeded to the next resident.
2. Review of Resident #42’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/13/19 at 6:30 A.M., showed Nurse C put on
gloves, took the BGT machine along with three damp towels that were underneath the soiled
paper towels, from on top of the medication cart and took them into the resident’s room.
He/she placed them directly on top of the resident’s bed, obtained the resident’s BGT,
told the resident the results, threw away the top paper towel barrier, and took the other
two barriers along with the BGT machine and placed them directly on top of a stack of
clean paper towels on the medication cart. Nurse C changed his/her gloves, cleaned the
machine with a Sani Cloth Plus wipe, removed the top two soiled paper towel barriers and
placed the sanitized BGT machine directly on top of the soiled paper towels that had been
set on the medication cart. At 6:38 A.M., Nurse C said he/she had completed all of the
BGTs, placed the BGT machine in the top drawer of the medication cart and threw the paper
towels from on top of the medication cart away.
3. Review of Resident #66’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/13/19 at 6:45 A.M., showed Nurse D placed a
clean barrier on top of the medication cart and without cleaning his/her hands, put on
gloves. He/she got equipment out of the top drawer of the medication cart, placed the BGT
machine on the clean barrier, cleaned the BGT machine with 2 Sani Cloth Plus wipes and
placed the used Sani Cloth Plus wipes directly on top of a box of tissues. With the same
gloves, he/she opened and closed the top drawer of the medication cart three times, took
the equipment into the resident’s room, touched the door knob with the gloves and he/she
entered. He/she obtained the resident’s BGT, told the resident the results, took the BGT
machine out of the room and placed it on the barrier located on top of the medication
cart. He/she picked up his/her pen and wrote the results in the resident’s Medication
Administration Record [REDACTED]. He/she removed his/her soiled gloves and without
cleaning his/her hands, took the medication cart to the nurses station at 6:50 A.M.
During an interview on 3/13/19 at 7:45 A.M., Nurse D said he/she thought the same used
Sani Cloth Plus wipes could be used to clean the BGT machine both before and after use
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
since the next staff person should clean the BGT machine before use. Nurse D verified
he/she did not change his/her gloves during the observation and did not clean his/her
hands before or after obtaining the BGT.
4. Review of Resident #23’s medical records, reviewed on 3/13/19 at 1:02 P.M., showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/13/19 at 7:31 A.M., showed Registered Nurse
(RN) E obtained a BGT on the resident:
-RN E gathered the supplies and Lysol Bleach Germicidal wipes out of drawers of the
medication cart and placed the supplies on a stack of paper towels, located on top of the
medication cart;
-RN E donned gloves without first washing his/her hands;
-RN E took all supplies gathered on the paper towels and placed them on the resident’s
unmade bed;
-RN E wiped the BGT machine with germicidal wipe, then immediately dried the BGT machine
with a paper towel from the stack, located on the resident’s bed;
-With the same gloves, RN E cleansed the resident’s finger with an alcohol pad and
obtained a sample of blood;
-RN E gathered all of the supplies in the barrier cloth, took them out of the room and
threw the bundle away in the trash can on the medication cart;
-RN E removed his/her gloves and did not wash or sanitize his/her hands;
-RN E wrapped the BGT machine in a germicidal wipe, wiped the BGT machine with the same
germicidal wipe, dried it with a paper towel and put it back into the top drawer of the
medication cart.
6. During an interview on 3/14/19 at 8:30 A.M., the Director of Nurses (DON) said she
would expect staff to wash their hands before starting BGTs. Staff should change gloves
after cleaning the BGT machine. After obtaining the BGT, staff should use the Sani Cloth
Plus wipes to clean the BGT machine and then throw it away. It is never appropriate to use
it a second time to clean the BGT machine after obtaining the BGT. Staff should only use
one paper towel barrier, if using several, all should be thrown away after use due to
infection control issues. BGT machines are sanitized before and after each use by wiping
them with a Sani cloth and allowing it to air dry for 5 minutes. It is not appropriate for
staff to dry the BGT machine after using a Sani cloth.
7. Review of Resident #3’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/4/18, showed:
-Brief interview of mental status (BIMS) score of 13 out of a possible score of 15, which
showed the resident as cognitively intact;
-Independent with activities of daily living (ADLs);
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 2/4/19, showed:
-Problem: Resident can have difficulty breathing or experience fatigue and requires oxygen
related to a history of [MEDICAL CONDITION];
-Goal: Will be able to engage in daily activities with rest periods;
-Approach: Evaluate lung sounds, if short of breath or displaying episodes of coughing.
Review of the resident’s medical record, reviewed on 3/14/19 at 11:29 A.M., showed:
-A physician order [REDACTED].
-The Medication Administration Record [REDACTED]
-The MAR indicated [REDACTED]
-There was no record of when the resident received new tubing and mask set for the
nebulizer machine noted on the treatment administration record (TAR) or MAR.
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:

265712

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

03/15/2019

NAME OF PROVIDER OF SUPPLIER

ESTATES OF ST LOUIS, LLC, THE

STREET ADDRESS, CITY, STATE, ZIP

2115 KAPPEL DRIVE
SAINT LOUIS, MO 63136

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 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
Observations, showed:
-On 3/12/19 at 10:12 A.M., the resident lay on his/her bed and colored a picture. The
nebulizer machine sat on the bedside table, mask draped over the side of the table, tubing
not labeled and not in a bag;
-On 3/12/19 at 3:33 P.M., 3/13/19 at 8:00 A.M. and 11:45 A.M., 3/14/19 at 8:03 A.M., 11:51
A.M. and 2:26 P.M. and 3/15/19 at 7:26 A.M., showed the nebulizer machine sat on the
bedside table, mask draped over the side of the table, tubing not labeled and not in a
bag.
Review of the facility’s oxygen supplies policy, dated 12/1/18, showed:
-Policy: This facility will maintain oxygen device supplies in a clean status, ensuring
proper labeling and replacement of supplies as needed/per physician’s orders
[REDACTED].>-Oxygen tubing will be changed one time per week, if oxygen is in use;
-Oxygen tubing changes will be documented on the associated TAR or MAR;
-The policy did not address nebulizer tubing or nebulizer masks.
During an interview with the administrator, the DON, the Assistant Director of Nursing
(ADON) and the Director of Clinical Operations on 3/15/19 at 8:32 A.M, the following
statements were made:
-Nebulizer masks are stored in a bag when not in use to lower contamination risk and to
maintain infection control;
-Nebulizer tubing and masks are changed weekly when in use;
-If the order is an as needed order and the resident does not often utilize the machine,
staff is expected to discard the tubing and mask and attach new the next time the resident
has a treatment;
-Nebulizer tubing and masks should have a dated label attached. The facility’s tubing and
masks for nebulizers are one piece;
-Staff should document when they change the nebulizer tubing and mask on the resident’s
TAR.