Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to a dignified existence, self-determination, communication,
and to exercise his or her rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to treat each
resident with respect and dignity and care for each resident in a manner and in an
environment that promotes maintenance or enhancement of his or her quality of life, for
one of five residents observed during personal care who was left exposed (Resident #114).
The census was 148.
Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required assessment
instrument completed by facility staff, dated 9/22/18, showed:
-Clear speech, distinct intelligible words;
-Makes self-understood;
-Able to understand others;
-Extensive assistance required for bed mobility, dressing and toilet use;
-Total dependence for personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Activity of daily living (ADL) care deficit related to [MEDICAL CONDITION] and
limited mobility;
-Goal: To be clean, odor free and well groomed on a daily basis;
-Approach: Assist with choosing simple comfortable clothing that enhances ability to dress
self.
Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A entered
the resident’s room and gathered supplies. He/she uncovered the resident, unsecured the
resident’s brief and provided care to the resident. CNA A said he/she needed to get more
towels. He/she exited the resident’s room, closing the door behind him/herself and left
the resident uncovered and exposed. CNA A returned to the resident’s room and continued to
provide care to the resident. There was a knock on the resident’s door. CNA A said come
in. He/she did not cover the resident or verify the identity of the person at the door.
The person at the door entered the room as he/she said nursing, looked in the room, turned
around and exited the room, closing the door behind him/her. CNA A continued to provide
care to the resident.
During an interview on 11/13/18 at 9:0 A.M., the Director of Nursing (DON) said if staff
need to step away during incontinence care, she would expect staff to assure the resident
was covered. If a resident is exposed and someone knocked on the door, she would expect
staff to pull the privacy curtain if in a shared room. In private rooms, staff should ask
the person at the door to wait a minute and cover the resident up. It is not acceptable
for staff to tell someone to come in before knowing who was at the door.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview the facility failed to promote the resident’s
self-determination though support of resident choices when staff failed allow residents to
eat in their room, failed to turn a resident’s television on, and failed to allow a
resident telephone usage. (Resident #114, #11, and #47). The facility census was 148.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
1. Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 9/22/18, showed:
-Clear speech, distinct intelligible words;
-Makes self-understood;
-Able to understand others;
-Extensive assistance required for bed mobility, dressing and toilet use;
-Total dependence for personal hygiene;
-[DIAGNOSES REDACTED].
Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A provided
care to the resident. CNA A entered the resident’s room and gathered supplies. He/she
turned off the resident’s television and provided care to the resident. Several times the
resident requested the television be turned back on. CNA A would either not respond to the
resident’s request or would tell the resident to wait a minute. CNA A finished providing
care to the resident and assisted the resident to his/her wheelchair at 8:07 A.M. CNA A
never turned the resident’s television back on or provided a reason why the television
could not be on.
During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said a
resident’s choice should be honored. If a resident requested their television be turned on
during incontinence care, she would expect staff to turn it on.
2. Review of Resident #11’s quarterly MDS, sated 7/21/18, showed:
-A Brief interview of mental status (BIMS) score of 13 out of a possible score of 15;
-A BIMS score of 8-15 showed the resident understands and was able to make
self-understood;
-Expensive assistance required for locomotion off the unit;
-[DIAGNOSES REDACTED].
Observation on 11/8/18 at 8:35 A.M., showed the resident sat in a wheelchair at the 2
South nurses’ station. He/she asked Activity Assistant B if he/she could use the phone.
Activity Assistant B told the resident he/she could not use the phone and he/she had to go
downstairs to use it. He/she would have to wait. CNA C walked past the resident and
Activity Assistant B asked CNA C if the resident could use the phone. CNA C said he/she
does not usually work on the floor and did not know. CNA C continued to walk past the
resident and down the hall. CNA D walked past the resident and Activity Assistant B asked
CNA D if the resident could use the phone at the nurses’ station. CNA D said the resident
had to go downstairs to use the phone and he/she walked away. Activity Assistant B walked
away. No staff assisted the resident to make a phone call and the resident sat alone at
the nurses’ station. Several minutes later a nurse came to the nurses’ station. The
resident asked if he/she could use the phone and the nurse assisted the resident to use
the phone at the nurses’ station.
During an interview on 11/13/18 at 9:00 A.M., the DON said residents are allowed to use
the phone at the nurses’ station. They also have a resident only phone. If a resident
requested to use the phone, she would expect staff to help them.
3. Review of Resident #47’s admission MDS, dated [DATE], showed;
-A BIMS score of 12, shows the resident was moderately impaired;
-[DIAGNOSES REDACTED].
Observation on 11/6/18 at 12:10 P.M., showed the resident was observed with a bag of chips
and a soda in his/her room. Certified Nurses Aide (CNA) M told the resident it was time to
go to the dining room. The resident asked if he/she could stay in his/her room. CNA M said
he/she had to go to the dining room. The resident walked out of his/her room to the dining
room.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
During an interview on 11/6/18 12:15 P.M., CNA M said if the residents are able to go to
the dining room, then they go. There is a resident that stays in bed all day, and they
serve him/her food, but everyone else would go to the dining room. They are not going to
just serve them in their room.
During an interview on 11/8/18 at 9:00 A.M., the residents in the group meeting said they
CNA’s do not like when the residents eat in their room because they do not like bring them
a plate.
During an interview on 11/13/18 at 10:37 A.M., the administrator said she would expect the
residents to be allowed to eat in their room if they choose to.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure
residents had appropriate access to their trust account, including weekends. The facility
also failed to ensure each resident was afforded the right to withdraw funds from the
amount of their choosing (Resident #50). This deficient practice affected all the
residents who had a resident trust account. The census was 148.
Review of the facility’s undated daily banking procedure, received on 11/9/18, showed:
-Bank request sheets are to be available for requesting funds Monday through Friday,
excluding holidays until 3:00 P.M.;
-The bank request sheets are picked up from every station by the social service designee
(SSD) and delivered to the business office before 4:00 P.M. for processing into RFMS. All
requested funds, if available, are delivered the following morning;
-Beneficiary’s requesting funds on the daily bank request should write their name, the
amount, and the intent for the requested funds. A current balance or trust account
statement can also be requested on the bank request sheet by writing balance next to their
name or on the same line as their name;
-All binders should be revised by SSD before returning to the business office manager
(BOM). Anyone passing money is responsible for the following:
-Obtaining resident’s signature;
-Resident signature, or witness signature if unable to sign;
-Staff signature;
-CIRCLE the resident’s intention for using the funds;
-Any funds not passed will be returned at the time but can request for the following day;
-If self-responsible: The daily cash withdrawal limit is $50.00;
-If request is more than $50.00, funds will be disbursed two business days after the
request is written in the binder or on the bank request sheet;
-Receipts are requested, but not required to be returned to the business office;
-Their authorization and signature is required for all transactions;
-Power of Attorney (POA) not active unless deemed incapacitated;
-Healthcare POA not authorized to handle financial matters;
-Facility is Representative Payee: Daily cash withdrawal limits depend on the individual,
balance availability, and their location;
-Substantial withdrawal requests are reviewed on a case by case basis;
-Daily withdrawal limits are also case by case, but generally anyone that gives their
money away, throws it in the trash, or frequently misplaces it, will be limited to receive

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 3)
$0 to $5 per day, depending on the severity of the situation;
-Social services will monitor beneficiary’s spending activity and will notify the business
office if they suspect misuse of funds or if they have any concerns regarding the
distributed amount. Social services will also determine if a beneficiary’s day to day and
personal needs are being met, then let the BOM know.
1. Review of Resident #50’s medical record, showed:
-admitted on [DATE];
-Own responsible party.
Review of facility’s authorization and agreement to handle resident funds, showed the
resident signed on 5/6/15.
Review of the resident’s social services notes, showed:
-On 1/26/2018, the resident has been reduced to receiving $2.00 day instead of $5.00 due
to being observed by the psych social aide and the nurse giving his/her money away to two
other residents. Resident was redirected by the aide and was counseled on not giving
his/her money away and that he/she will be reduced to $2.00 a day. Resident complied and
did not display a negative reaction. Aide informed the business office manager of the
change in amount;
-On 8/17/2018 at 12:12 P.M., the resident’s family member called to ask social services to
provide resident with $50 so that resident can purchase his/her pastor a birthday present.
Contact the business office manager who stated per state regulations, residents are not
allowed to purchase items with state money for non-immediate family members. State money
is for resident’s needs. In addition, business office manager stated the last time
resident took money, the family member who was supposed to take him/her shopping never
showed up and resident did not return it back to the business office manager and ended up
spending all of it. He/she understood and wanted to know if he/she could at least receive
$20. Advised the family member that resident could receive $20 but receipts have to be
returned along with any change;
-On 8/17/18 2:40 P.M., resident’s family called and will be here tomorrow to pick resident
up to go shopping and requested the $20. Contacted business office manager who said they
need at least one business day notice in advance to make sure we have the money on site;
-On 8/23/2018 at 12:00 P.M., resident’s family member left multiple voice mail messages to
social services requesting $20 for resident to be taken to the beauty supply. Spoke with
the business office manager who said since resident is his/her own responsible party that
money request from family is not allowed and that resident has to follow the procedures to
request his/her own money. Resident has been informed that he/she is to return with
receipts and any unused money.
During the resident group interview on 11/8/18 at 9:00 A.M., the residents said they have
to provide a receipt to show what they purchased. They are grown men and women, and they
want to buy what they want to buy. The facility also has a problem with residents giving
each other money.
During an interview on 11/8/18 at 11:00 A.M., the business office manager said if the
resident wanted to withdrawal money from their resident trust account, they have to sign
up the night before on the money sheet. The funds are sent out to the resident the next
day before 9:00 A.M. If the resident misses the sheet to fill out, they tell the residents
to fill out the sheet next time. If the resident is upset or adamant about their money,
then staff will let it go and the resident could have their money. There are no weekend
hours. The residents are aware they need to fill out the sheet on Thursday if they want
money during the weekend. If a resident needed money during the weekend, they would not be
able to receive it until Monday. If the resident is going out with their family, they
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 4)
usually know in advance, so they fill out the money sheet. The business office manager
holds on to the money until Friday. If it is a holiday, the residents are aware to request
more money the day before. The majority of the residents request money. Today there were
36 residents that requested money from their account. There is a $50.00 limit for the day.
If they want more than $50.00, they have to give the business manager manager one business
day. The residents are started with a $5.00 starting limit a day, so their money can
stretch throughout the month. If they run out of money, they will become upset. The
business office manager tried to spread the money out, especially if that resident
received $30.00 a month. The resident’s daily limit can be decrease if they are misplacing
the money or giving it away. If the resident was their own responsible party, the business
office manager does not adjust their funds. If the facility is the resident’s
representative payee, the facility is allowed to adjust their money and request a receipt
if the resident goes shopping. The resident does not have to submit a receipt; however,
social security is concerned about the intent of use. Some residents say it is none of the
facility’s business. Staff counsels them to bring back the receipt or they will lower the
daily amount. If the resident was observed giving their money away, for example, buying a
soda for another resident or if it appeared the resident was being taken advantage of, the
amount they are able to receive will decrease. The business office manager started working
on a policy, but it had not been passed to the residents. Right now it is communicated
verbally.
During an interview on 11/13/18 at 9:00 A.M., the administrator said the residents fill
out the money sheet and their money is delivered the next day. They do not have access to
their money, and there is no system in place for the residents to receive their money on a
weekend. If the residents are aware they need more for the weekend, they have to fill out
the money sheet in advance. Social security requires the facility to obtain a receipt from
the residents only if the facility is the resident’s representative payee. The guidelines
state that they are supposed to have the money to spend on themselves.
During an interview on 11/13/18 at 12:00 P.M., the business office manager said it is a
case by case basis to determine if a receipt had to be provided. The Medicaid office does
not like the residents gifting in large amounts. A large amount would be $500, but there
are no residents requesting that amount of money. Resident #50 had issues with his/her
family members. He/she might have given his/her family money. They have to make sure the
residents needs are met. The business office manager depends on social services to inform
him/her if there was a problem and if the resident’s amount of money they could receive
needed to be adjusted. Resident #50’s documentation is expected to show the concerns that
lead to the decrease of the money. If the resident gave another resident $1 or $2, that
would not be enough to decrease the amount of money he/she received. The business office
manager did not remember saying the resident could not only purchase gifts for
non-immediate family members. The aides are not allowed to adjust the amount. The business
office manager would expect more communication with him/her before decreasing the daily
amount.

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**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 5)
Based on interview and record review, the facility failed to obtain a signed code status
sheet or failed to obtain physician orders for code status for four of 29 sampled
residents (Residents #131, #452, #154 and #70). The census was 148.
1. Review of Resident #131’s electronic and hard copy medical record, showed:
-An electronic face sheet, with an admission date of [DATE];
-A signed code status sheet, dated [DATE], with a code status of full code (all life
saving methods are preformed);
-An electronic physician order sheet (ePOS), dated (MONTH) (YEAR), showed no code status
ordered as late as [DATE], at 9:45 A.M.
During an interview on [DATE] at 9:45 A.M., the Director of Nurses (DON) verified there
was no order for the resident’s code status on the POS. She would expect staff to obtain a
physician order for [REDACTED].>2. Review of Resident #452 electronic medical record,
showed:
-admitted to the facility on [DATE];
-A POS, dated [DATE] through [DATE], showed no physician order of code status;
-A face sheet, showed no documentation of code status.
Review of the resident’s code status election form, dated [DATE] and signed by the
resident, showed the resident wished to have cardiopulmonary resuscitation (CPR).
3. Review of Resident #154’s electronic face sheet, showed the resident a full code.
Review of the resident’s electronic medical record, showed:
-admitted to the facility on [DATE];
-An active order dated [DATE], for full code status;
-A progress noted dated [DATE] at 5:21 A.M., this nurse called to the resident’s room by a
certified nursing assistant (CNA). Resident noted unresponsive to the touch, no pulse
present, no respirations. Resident is a do not resuscitate (DNR, no life saving measures
to be performed);
-An active order dated [DATE], for DNR.
Review of the resident’s paper chart, showed:
-A code status election form, dated [DATE] and signed by the resident, showed the resident
wished to have cardiopulmonary resuscitation (CPR);
-A code status election form, dated [DATE] and signed by the resident representative,
showed no CPR desired;
-No code status election form completed from the resident’s date of admission on [DATE]
until [DATE].
4. Review of Resident #70’s medical record, showed:
-admitted on [DATE];
-A signed code status form, dated [DATE], with a code status of DNR;
-Physician order sheet (POS), dated [DATE] through [DATE], showed an order, dated [DATE]
and [DATE], for full code status.
5. During an interview on [DATE] at 9:00 A.M., the Director of Nursing (DON) said it is
the responsibility of social services to get a code status election form completed when a
resident is admitted to the facility. After that, it goes into the resident’s chart. There
should be a physician’s order for code status. The code status on the face sheet and
physician order sheet should match. If a resident’s code status were to change, the old
code status order should be discontinued. If staff need to know a resident’s code status,
they would look in the paper chart. Social services meet with the resident and/or family
to determine their wishes. Social services communicate this to the nursing staff. If a
resident is admitted on the weekend, the nurse would be responsible to obtain a code
status for the resident.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 6)

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain furniture and
equipment in good repair for two of 29 sampled residents whose wheelchair locks and foot
pedals did not lock (Resident #114) and whose safety helmet was torn (Resident #126). The
census was 148.
1. Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 9/22/18, showed:
-Extensive assistance required for bed mobility, dressing and toilet use;
-Mobility devices: Wheelchair.
Observation on 11/7/18 at 7:24 A.M., showed Certified Nurse Aide (CNA) A provided care to
the resident and transferred the resident to his/her wheelchair. The back rest of the
wheelchair was torn. CNA A assisted the resident to sit on the edge of his/her bed. CNA A
placed the resident’s wheelchair against the wall and said the resident’s wheelchair
didn’t lock so he/she has to prop it against the wall. CNA A said he/she put in a request
for maintenance to fix it yesterday, but it had been broken for one or two weeks. CNA A
transferred the resident to his/her wheelchair. He/she then placed the left foot rest on
the resident’s wheelchair, placed his/her left foot on the foot rest and then placed the
right foot on top of the left foot. CNA A said the wheelchair was broken and the right
foot rest no longer connected to the wheelchair. CNA A propelled the resident out of the
room and into the hall.
Observation on 11/8/18 at 8:43 A.M., showed the resident sat in his/her room in his/her
wheelchair. The left foot pedal was on and both feet rested on the one pedal. The right
foot rest sat on a table in the resident’s room.
During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) and
administrator said if a resident’s wheelchair was broken, they should report it to
maintenance. Staff should remove the resident from the broken wheelchair and provide the
resident with another wheelchair while their wheelchair is getting fixed. Staff should
report a wheelchair with broken foot rest and that will not lock immediately or as soon as
it is observed to be broken. It is not safe for a resident to be transferred to a
wheelchair that does not lock and it is not safe for a resident to be propelled in a
wheelchair that only has one foot rest.
2. Review of Resident #126’s quarterly MDS, dated [DATE], showed:
-BIMS score of 9 out of 15, showed the resident is cognitively impaired;
-[DIAGNOSES REDACTED].
Observation on 11/6/18 at 1:52 P.M., showed the resident wore a safety helmet as he/she
sat in the dining room.
Observation and interview on 11/6/18 at 2:14 P.M., showed the resident wore a safety
helmet. The safety helmet was torn on both sides that fit around the resident’s ears. The
inside of the helmet that several rips, approximately 1/2 inch in length in the front of
the helmet. The resident said he/she had the helmet for several years, and the facility
would not give him/her a new one. The resident said he/she had to wear the safety helmet
because he/she falls a lot.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
During an interview on 11/8/18 at 11:39 A.M., Licensed Practical Nurse (LPN)H said the
resident wears the safety helmet every day because he/she has [MEDICAL CONDITION] and has
a lot of falls.
During an interview on 11/13/18 at 9:00 A.M., the DON confirmed that the resident wore a
safety helmet to protect him/her in the event of a fall. She would expect it to be
assessed for any rips or tears on a daily basis because it is worn every day. She would
expect staff to notify her that the helmet is torn, so it can be replaced.

F 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to voice grievances without discrimination or reprisal and
the facility must establish a grievance policy and make prompt efforts to resolve
grievances.

Based on interview and record review, the facility failed to establish a grievance policy
that identified the grievance official, included the right to file a grievance anonymously
and that required the facility to maintain evidence demonstrating the result of all
grievances for a period of no less than three years from the issuance of the grievance
decision. The census was 148.
Review of the facility’s Grievance policy, dated 1/10/10, showed:
-The purpose of this policy is to provide a mechanism by which, residents, their families,
friends, significant others, or staff can lodge grievances with the facility as well as
providing for a means for grievance resolution;
-Following notification of the grievant, the form will be filed in the Grievance Binder
for one year;
-The policy failed to identify the grievance official;
-The policy failed to include the right to file a grievance anonymously;
-The policy failed to maintain evidence demonstrating the result of all grievances for a
period of no less than three years from the issuance of the grievance decision.
During an interview on 11/13/18 at 9:00 A.M., the administrator said social services is
the grievance official. She would not necessarily believe the facility grievance policy
should identify the grievance official. Residents and visitors have the right to file a
grievance anonymously, this should be included in the grievance policy. She would expect
the grievance policy identify that grievance be maintained for 3 years.

F 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
right to be free from abuse was not violated when residents were abused by other
resident’s (Resident #126, #47, #12, 143, #39, and #89) for 29 sampled residents. The
facility census was 148 residents.
Review of the facility’s abuse and neglect policies, showed:
-External Reporting of Abuse, Neglect, theft and Crimes policy, dated 1/2012: It is the
policy of this facility to establish external reporting guidelines for facility staff in

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
the event they become aware or formulate a reasonable suspicion that abuse, neglect, theft
or a crime has been committed against a resident of the facility:
-Upon receipt of an allegation of abuse, neglect, theft or that a crime has occurred
against a resident the facility Administrator or his/her designee will initiate external
reports to the department;
-The administrator or designee will contact the department immediately but no later than
24 hours following an observed event, allegation or formulation of a reasonable suspicion
that a crime occurred against a resident that did not result in serious bodily injury;
-In cases of serious bodily injury the administrator will contact the department
immediately but no later than 2 hours from the time of the allegation or formulation of
the reasonable suspicion that a crime was committed against a resident;
-Within 5 business (working) days from the event or report the facility will submit a
report to the department that will contain a description of the initial allegation,
description of the investigation and the facts obtained, a brief conclusion based on the
information obtained during the investigation, a description of any corrective actions
taken if necessary;
-The policy failed to require that in response to any allegations of abuse the facility
must: Ensure all alleged violations are reported immediately. No later than 2 hours if the
allegation involve abuse or result in serious bodily injury;
-Staff obligations to prevent and report abuse, neglect and theft: Federal and state laws
and regulations mandate that a nursing home resident has the right to be free from verbal,
sexual, physical and mental abuse, corporal punishment and involuntary seclusion;
-Abuse means any physical or mental injury or sexual assault inflicted upon a resident
other than by accidental means;
-It is the policy of this facility that employees must always report allegations of
abuse, neglect, theft or crimes committed against its residents;
-Resident Protection During Abuse Investigations policy, dated 1/2012, the facility
desires to establish a resident secure environment and will take steps to protect
residents from exposure to additional acts of mistreatment following an allegation or
reported instance of abuse, neglect, theft or criminal action committed against the
residents while an investigation is conducted:
-Resident to resident events: Residents who allegedly abuse another resident should be
removed from contact with other residents until such time that reasonable clinical
judgement determines that their behavior no longer poses a significant risk to other
residents or until the investigation is concluded.
1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had
moderately impaired cognition;
-No behaviors;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/30/16, showed:
-Focus: Resident gets upset easily and can become verbally & physically aggressive
towards others. Resident can be hard to direct at times. Resident is impulsive and likes
to hug:
-On 4/15/17, aggressive towards peers stating they cannot sit at table with him/her and
he/she knocked over a chair;
-On 12/24/16, attempting to exit locked doors, staff attempted to redirect. Resident
started kicking and rolling around on the floor. History of getting upset when he/she does
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
not win bingo. Will become physical or verbally aggressive;
-On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the hall;
-On 7/4/18, hit peer after argument. Had a resident to resident altercation;
-Resident’s roommate accused him/her of talking about his/her roommate and backed his/her
wheechair into the resident;
-Interventions: Create a positive environment for the resident to gain socially acceptable
patterns of behaviors. Keep resident away from source of agitation. Every 15 min face
checks;
-Focus: Resident is at risk for injury from other residents:
-On 7/24/18, hit by peer and was pulled by purse. No injury;
-On 9/13/18, hit by peer. No injury;
-Interventions: Assess the resident for injury after any physical incident. Alert
physician and responsible party. Remove the resident from the source of aggression;
-Focus: Resident has a history of being verbally/physically aggressive towards others. Has
a history of resident to resident altercations. Resident can be very hard to redirect at
times. Resident needs frequent redirection and supervision;
-Focus: He/she pushed a resident in his/her back four times related to anger, history of
harm to others, and poor impulse and control;
Interventions: The resident’s triggers for physical aggression are (not being allowed to
go on outings). The resident’s behaviors is de-escalated by (providing distractions and
other activities).
Review of the Resident #126’s progress notes, dated 10/30/18, showed he/she was speaking
with another resident, when Resident #47 brushed up against Resident #126 in passing. A
small verbal commotion followed and Resident #126 yelled, I’m not a boy! Resident #126
moved toward Resident #47 in an aggressive manner, but never raised his/her hands in an
attempt to strike. Resident #47 then struck Resident #126 on the right side of his/her
face. Residents swiftly separated. Cold compress applied to right side of face. Slight
swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to touch.
Praised his/her coping skills, of not retaliating physically. Encouraged to walk away from
confrontations. Verbalized understanding.
Review of Resident #47’s admission MDS, dated [DATE], showed;
-A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition;
-No behaviors exhibited;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/15/18, showed:
-Focus: Resident has the potential to be verbally aggressive (screaming, yelling at
others) related to dementia and a [DIAGNOSES REDACTED].
-Interventions: Administer antipsychotic medications as ordered. Monitor/document for side
effects and effectiveness. Give the resident as many choices as possible about care and
activities. Monitor behaviors every 15 minutes. Document observed behavior and attempted
interventions;
-When resident becomes agitated: Intervene before agitation escalates. Guide away from
source of distress. Engage calmly in conversation. If response is aggressive, staff to
walk calmly away, and approach later.
Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in
the hallway, another resident was speaking with someone else, when this resident brushed
up against the first resident in passing. A small verbal commotion followed and the other
resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in
an aggressive manner, but never raised his/her hands in an attempt to strike. This
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
resident then struck the other resident on the right side of his/her face. Residents
swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized
understanding, but still claimed that the other resident is trying to, make you all go
against me. Reiterated to him/her there was no need to strike him/her, especially since
he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict
resolution techniques during confrontations.
During an interview on 11/8/18 at 11:30 A.M., Resident #126 said the altercation was with
Resident #47. He/she bumped into the resident and Resident #47 said he/she was going to
hit him/her.
Observation on 11/8/18 at 12:00 P.M., Resident #126 told Licensed Practical Nurse (LPN) H
that Resident #47 was going to hit him/her. The resident was told to sit far away from
Resident #47 and he/she would monitor everyone in the dining room.
During an interview on 11/8/18 at 12:05 P.M., LPN H said Resident #47 had a history of
[REDACTED].
During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there
was an altercation, she would talk to the residents. The DON was not aware that a resident
was hit. She would expect staff to report and investigate it the incident. There are
systems in place per the facility’s policy if there was a resident to resident
altercation. Staff are expected to talk to the residents, notify the physician, and ask
for a psych consult to make sure it is an isolated incident. If there was an ongoing
problem, they would notify the physician to check labs and medications.
During an interview on 11/8/19 at 12:10 P.M., the care coordinator said Resident #126 was
upset because Resident #47 called the resident a boy. Resident #47 believed Resident #126
was going to strike him/her, so Resident #47 hit the resident. Resident #47 had a history
of [REDACTED].
2. Review of Resident #12’s electronic face sheet, showed [DIAGNOSES
REDACTED].>-Dementia with behavioral disturbances;
-[MEDICAL CONDITION]; and
-Major [MEDICAL CONDITION].
Review of the resident’s quarterly MDS, dated [DATE], showed:
-BIMS score of 8 out of 15, showed moderate cognitive impairment;
-Independent with all Activities of Daily Living (ADLs);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has the potential to be physically injured related to wandering into
others rooms and removing their property. He/she takes other residents clothing and other
items that he/she likes. He/she has had a recent incident in which another resident hit
him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident
after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by
another resident no injuries;
-Goal: The resident will not harm self or others through the review date;
-Interventions: Staff will encourage and redirect the resident out of other resident’s
rooms/personal space as needed;
-Focus: The resident is an elopement risk/wanderer related to disease progression. He/she
is at risk for injuries related to wandering into other resident’s rooms. He/she removes
their items or gets into their personal things. On 7/9/2018 the resident made a statement
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18
physical aggression was received from another resident. On 8/29/18 the resident exhibited
aggressive behaviors toward his/her roommate;
-Goal: The resident’s safety will be maintained through the review date;
-Interventions: Distract him/her from wandering by offering pleasant diversions,
structured activities, food, conversation, television, books. Resident prefers to color in
coloring book, talking with staff at times, etc. Monitor location every 15 min every
shift. Document wandering behavior and attempted diversional interventions in medical
record as needed. Provide structured activities: toileting, walking inside and outside,
reorientation strategies including signs, pictures and memory boxes. Relocate to another
room as needed for safety.
Review of Resident #12’s progress notes, showed:
-On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down
the hall to find him/her. He/she was lying on the floor in another resident’s room
screaming and moving around on the floor. When asked what happen he/she stated he/she
pushed me down. I am hurting. He/she was able to move all extremities without complaints
of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of
the floor by two staff and assisted into a wheelchair;
-On 8/1/18 at 10:36 P.M., Resident alert to self and is confused, redirected several time
throughout shift from other peoples room;
-On 8/2/18 at 3:12 A.M., Day 2 of 3 for incident follow up. Resident in bed, no acute
distress noted. No signs behavior at this time;
-The notes did not show after the initial incident what interventions were put in place to
show how the nursing staff was monitoring Resident #12 in order to prevent him/her from
coming back into contact with the other resident or notification to the Department of
Health and Senior Services (DHSS) of the alleged resident to resident abuse.
Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed:
-The resident had an unwitnessed fall on 7/31/18;
-Upon entering the room, the resident was found lying on his/her back on the ground,
screaming he/she pushed me down and moving;
-The resident stated that he/she was pushed down while in another resident’s room;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident: Blank;
-Pain, consciousness, mobility and mental status [REDACTED].>-Other information: The
resident wanders into other resident’s rooms;
-Witnesses: No witnesses;
-Agencies/people notified: No notifications found;
-No summary of the investigation and no interventions taken at the time of the incident
and post incident noted. No behavior incident report provided upon request;
-The occurrence report did not identify what monitoring measures the facility staff put in
place after the resident first pushed down Resident #12, in order to prevent a second
occurrence;
-The facility was unable to provide an abuse investigation for this incident. The 7/31/18
incident was reported and investigated as a fall only.
Further review of Resident #12’s progress notes, showed:
-On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another
resident. Residents separated. Physical assessment revealed no injury. Physician notified.
No new orders;
-On 8/3/2018 at 1:53 A.M., resident must be redirected out of other room when awake;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-On 8/3/2018 at 3:39 P.M., no discoloration to chest noted;
-On 8/5/2018 at 11:12 A.M., redirected several times throughout shift, resident going
through other clothing, lying in their beds, standing in others room;
-The notes did not show, after the second incident what interventions (other than
separating the residents) were put in place, how the nursing staff was monitoring Resident
#12 in order to prevent him/her from coming back into contact with the other resident or
notification to the department regarding the alleged resident to resident abuse.
Review of the resident’s Physical Altercation Occurrence Report, dated 8/2/18, showed:
-The resident stated another resident hit him/her;
-The residents were separated and a physical assessment was completed;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident: Blank;
-Mental status at the time of the incident: Blank;
-No injuries noted post incident;
-Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing
environmental factors: Blank;
-Predisposing physiological factors: Blank;
-Predisposing situation factors: Wanderer;
-Other information: Blank;
-Witnesses: No witnesses found;
-Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18
at 4:30 P.M. No documentation the department notified;
-No summary of the investigation, no cause, and no interventions taken at the time of the
incident and post incident noted.
Review of Resident #143’s electronic face sheet, showed [DIAGNOSES REDACTED].>-Dementia
with behavioral disturbances;
-Anxiety disorder;
-Restlessness and agitation; and
-Major [MEDICAL CONDITION].
Review of the resident’s Significant Change MDS, dated [DATE], showed:
-BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has potential to be physically aggressive towards others related to
dementia and he/she has recently shown aggression towards one resident. On 7/9/18, accused
of hitting another resident. On 8/2/18, physically aggressive towards another resident. On
8/6/18, bruises to the right/left forearm no open areas noted. 8/10/18, hit another
resident after he/she entered the resident’s room. No injuries. 8/24/18, hit another
resident:
-Goal: The resident will not harm self or others through the review date;
-Interventions: Administer medication as ordered. Monitor/document for side effects and
effectiveness. Assess and anticipate his/her needs: food, thirst, toileting needs, comfort
level, body positioning, pain etc. Provide physical and verbal cues to alleviate anxiety.
Give positive feedback, assist verbalization of source of agitation, and assist to set
goals for more pleasant behavior, encourage seeking out of staff member when agitated.
Monitor every 15 minutes and Document observed behavior and attempted interventions in his
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
medical chart. Monitor other resident’s closely and encourage them from wandering into the
resident’s room. Monitor/document/report PRN any signs and symptoms of him/her posing
danger to self and others. The resident’s triggers for physical aggression are having
personal items removed from his/her room by other residents. The resident’s behaviors is
de-escalated by talking to him/her in a calm approach. When the resident becomes agitated:
Intervene before agitation escalates; Guide away from source of distress; Engage calmly in
conversation; If response is aggressive, staff to walk calmly away, and approach later.
Review of the resident’s Social Services note, dated 8/24/18 at 12:15 P.M., showed: Called
and left a voicemail message for the resident’s family member to contact us regarding a
meeting needing to be scheduled to discuss resident’s behavior in being physically
aggressive toward other residents. Due to the communication barrier, it is best if
resident’s family is involved in order to translate the information.
Review of Resident #143’s progress notes, showed the resident was in a physical
altercation with Resident #12 on 8/10/18 and 8/24/18.
During interviews on 11/9/18 at 12:22 P.M. and 11/13/18, the DON said it was Resident #143
that pushed down Resident #12. Resident #12’s Occurrence Reports for the incidents on
7/31/18 and 8/2/18 were the only documentation the facility had for both incidents.
During an interview on 11/13/18 at 7:40 A.M., and 11/9/18 at 11:48 A.M., Certified Nursing
Assistant (CNA) AA said:
-Resident #12 wanders into other resident rooms, once staff hear him/her hollering out
staff will go get him/her and take him/her to the day area or dining room;
-Resident #143 can be aggressive if someone goes into his/her room. Staff will just remove
the other resident from his/her room;
-He/she heard it was Resident #143 that pushed down Resident #12;
-If a resident accuses another resident of hitting/pushing/kicking/tripping them, staff
separate them and take one to another area of the unit or facility. If one of the
resident’s is in the wrong room staff will separate them and take the resident out of the
other resident’s room. If staff notice anything out of the ordinary, staff will let the
nurse know;
-Any allegations of abuse need to be reported to the nurse immediately;
-There are no residents that require 15 minute checks.
During an interview on 11/13/18 at 7:48 A.M., LPN BB said:
-Any allegations or suspicions of abuse should be documented and followed up on;
-If a resident to resident altercation occurs, staff should immediately separate the
residents, notify the DON and Administrator, call both resident’s physicians and family,
and both residents should be assessed for injury;
-He/she was not present when the incidents occurred between Residents #12 and #143;
-Any incidents such as a resident pushing another resident down or hitting another
resident is abuse and should be reported to DON and Administrator, an incident report
completed, and documented in a nurse’s note;
-If a resident said someone pushed him/her down, it would be both a fall and abuse.
Documentation should reflect both;
-It is not appropriate to just redirect a resident out of the room. There needs to be a
thorough investigation completed;
-He/she is not aware of any residents that require 15 minute checks for behaviors.
3. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-BIMS score of 15 out of 15, shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Has hallucinations.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
Review of the resident’s care plan, dated 10/24/18, showed:
-Focus: Resident had been struck by peer on 10/21/18;
-Interventions: Encourage effective coping skills that help the resident to avoid
confrontations;
-Separate the resident from source of aggression;
-Focus: Resident is verbally aggressive towards staff due to ineffective coping skills;
-Interventions: Administer medications as ordered. Monitor/document for side effects and
effectiveness;
-Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and
document;
-Give resident as many choices as possible about care and activities;
-Provide positive feedback for good behavior. Emphasize the positive aspects of
compliance.
Review of the resident’s progress notes, showed:
-On 10/21/18, resident to resident altercation. A resident hit Resident #39 in the face
and knock off his/her glasses. The resident’s face on left side is slightly swollen.
Residents sent to their rooms. Ice pack applied to the resident’s face but he/she took it
off of his/her face. He/she stated he/she did not want it on his/her face. Physician
notified of the altercation between the residents, no new orders given;
-On 10/22/2018 at 2:39 P.M., resident continued on observation related to physical
aggression. No complaints of pain or discomfort voiced. No swelling to face noted. No mood
changes or negative behaviors noted. Resident voiced that yesterday he/she wanted to hit
the other resident with his/her cup but didn’t because staff told him/her not to. Resident
made aware that staff told him/her correctly and that it is inappropriate to retaliate.
Resident voiced understanding.
During an interview on 11/9/18 at 12:14 P.M., the DON said she was not aware of the
altercation. She would expect staff to notify her.
During an interview on 11/9/18 at 12:20 P.M., Care Coordinator I said he/she remembered
the incident was brought up, but could not provide any additional information.
4. Review of Resident #89’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 14, showed the resident was cognitively intact;
-Physical behaviors in the last one to three days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/4/18, showed:
-Focus: The resident has potential to be physically aggressive related/to anger, history
of harm to others, and poor impulse control. On 10/19/18, struck peer when he/she touched
him/her;
-Interventions: Analyze times of day, places, circumstances, triggers, and what
de-escalates behavior and document;
-Assess and anticipate resident’s needs: food, thirst, toileting needs, comfort level,
body positioning, pain etc.
Review of the resident’s progress notes, dated 10/19/18, showed:
-At 7:07 A.M., therapy reported to nurse that the resident hit another resident,
unwitnessed by staff, when asked what happen, resident stated, he/she pushed me and he/she
hit him/her back. Resident separated, physical assessment performed, no bruising, or
discoloration noted. Denies pain;
-At 2:59 P.M., continues on observation related to unwitnessed altercation. Resident noted
upset with another peer this morning because he/she says that the other resident keeps
asking for food and is always coming in the room. Redirection given to calm resident. No
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
other mood changes or physical aggression noted;
-At 3:19 P.M., nurse practitioner aware of altercation. No new orders received.
During an interview on 11/9/18 at 12:18 P.M., the DON said if there was an unwitnessed
altercation, he/she would expect there to be an investigation. If resident said someone
hit him/her, they would investigate to make sure it really happen. The DON was not aware
of the altercation that involved the resident. She would have expected staff to report all
altercations to her.
5. During an interview on 11/13/18 at 9:05 A.M., the DON said:
-With resident to resident altercations, he/she would expect nursing staff to separate the
residents, the nurse to complete a physical assessment of each resident, notify the
residents physicians and family and follow any physician’s orders [REDACTED].
-He/she would also expect the nursing staff to monitor the residents to ensure their
safety and well-being and the safety and well-being of other residents;
-He/she expects the resident’s care plan interventions to be implemented to help manage
the resident’s behaviors;
-The facility wouldn’t investigate the incident as abuse due to confusion if the resident
alleging the push is confused and so is the resident that pushed him/her down;
-It would be appropriate to separate and monitor to make sure residents are kept away from
each other;
-The incident should be reported to the state agency (the department) as an FYI (for your
information), if nothing else;
-He/she doesn’t know why the incidents were not reported;
-Policy is to notify the DON and Administrator immediately of any abuse allegations or
suspicions;
-He/she expects staff to follow the abuse policy;
-All staff has been educated on the abuse policy;
-He/she knows what abuse is and what to investigate;
-He/she does report abuse to the state agency.

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow their
policy as well as state and federal regulations by not notifying the Department of Health
and Senior Services (DHSS) about an allegation of physical abuse, immediately, but not
later than two hours for seven or 29 sampled residents identified has having been involved
in resident to resident abuse or having an allegation of abuse (Resident #126, #47, #12,
#143, #50, #89, and #39). The census was 148.
Review of the facility’s abuse and neglect policies, showed:
-External Reporting of Abuse, Neglect, theft and Crimes policy, dated 1/2012: It is the
policy of this facility to establish external reporting guidelines for facility staff in
the event they become aware or formulate a reasonable suspicion that abuse, neglect, theft
or a crime has been committed against a resident of the facility:
-Upon receipt of an allegation of abuse, neglect, theft or that a crime has occurred
against a resident the facility Administrator or his/her designee will initiate external
reports to the department;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-The administrator or designee will contact the department immediately but no later than
24 hours following an observed event, allegation or formulation of a reasonable suspicion
that a crime occurred against a resident that did not result in serious bodily injury;
-In cases of serious bodily injury the administrator will contact the department
immediately but no later than 2 hours from the time of the allegation or formulation of
the reasonable suspicion that a crime was committed against a resident;
-Within 5 business (working) days from the event or report the facility will submit a
report to the department that will contain a description of the initial allegation,
description of the investigation and the facts obtained, a brief conclusion based on the
information obtained during the investigation, a description of any corrective actions
taken if necessary;
-The policy failed to require that in response to any allegations of abuse the facility
must: Ensure all alleged violations are reported immediately. No later than 2 hours if the
allegation involve abuse or result in serious bodily injury.
1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had
moderately impaired cognition;
-No behaviors;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/30/16, showed:
-Focus: Resident gets upset easily and can become verbally & physically aggressive
towards others. Resident can be hard to direct at times. Resident is impulsive and likes
to hug. On 4/15/17 aggressive towards peers stating they cannot sit at table with him/her
and he/she knocked over a chair. On 12/24/16 attempting to exit locked doors, staff
attempted to redirect. Resident started kicking and rolling around on the floor. History
of getting upset when he/she does not win bingo. Will become physical or verbally
aggressive. On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the
hall. On 7/4/18, hit peer after argument. Had a resident to resident altercation.
Resident’s roommate accused him/her of talking about his/her roommate and backed his/her
wheel chair into the resident;
-Focus: Resident is at risk for injury from other residents: On 7/24/18, hit by peer and
was pulled by purse. No injury. On 9/13/18, hit by peer. No injury;
-Focus: Resident has a history of being verbally/physically aggressive towards others. Has
a history of resident to resident altercations. Resident can be very hard to redirect at
times. Resident needs frequent redirection and supervision;
-Focus: He/she pushed a resident in his/her back four times related to anger, history of
harm to others, and poor impulse and control.
Review of Resident #126’s progress notes, dated 10/30/18, showed Resident #126 was
speaking with another resident, when Resident #47 brushed up against Resident #126 in
passing. A small verbal commotion followed and Resident #126 yelled, I’m not a boy!
Resident #126 moved toward Resident #47 in an aggressive manner, but never raised his/her
hands in an attempt to strike. Resident #47 then struck Resident #126 on the right side of
his/her face. Residents swiftly separated. Cold compress applied to right side of face.
Slight swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to
touch. Praised his/her coping skills, of not retaliating physically. Encouraged to walk
away from confrontations. Verbalized understanding.
Review of Resident #47’s admission MDS, dated [DATE], showed;
-A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-No behaviors exhibited;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/15/18, showed the resident has the potential
to be verbally aggressive (screaming, yelling at others) related to dementia and a
[DIAGNOSES REDACTED].
Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in
the hallway, another resident was speaking with someone else, when this resident brushed
up against the first resident in passing. A small verbal commotion followed and the other
resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in
an aggressive manner, but never raised his/her hands in an attempt to strike. This
resident then struck the other resident on the right side of his/her face. Residents
swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized
understanding, but still claimed that the other resident is trying to, make you all go
against me. Reiterated to him/her there was no need to strike him/her, especially since
he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict
resolution techniques during confrontations.
Review of DHSS records, showed the facility did not report the 10/30/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there
was an altercation, she would talk to the residents. The DON was not aware that a resident
was hit. She would expect staff to report and investigate it the incident. There are
systems in place per the facility’s policy if there was a resident to resident
altercation. Staff are expected to talk to the residents, notify the physician, and ask
for a psych consult to make sure it is an isolated incident. If there was an ongoing
problem, they would notify the physician to check labs and medications.
2. Review of Resident #12’s quarterly MDS, dated [DATE], showed:
-BIMS score of 8 out of 15, showed moderate cognitive impairment;
-Independent with all Activities of Daily Living (ADLs);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has the potential to be physically injured related to wandering into
others rooms and removing their property. He/she takes other residents clothing and other
items that he/she likes. He/she has had a recent incident in which another resident hit
him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident
after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by
another resident no injuries;
-Focus: The resident is an elopement risk/wanderer related to disease progression. He/she
is at risk for injuries related to wandering into other resident’s rooms. He/she removes
their items or gets into their personal things. On 7/9/2018 the resident made a statement
that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18
physical aggression was received from another resident. On 8/29/18 the resident exhibited
aggressive behaviors toward his/her roommate.
Review of Resident #12’s progress notes, showed:
-On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down
the hall to find him/her. He/she was lying on the floor in another resident’s room
screaming and moving around on the floor. When asked what happen he/she stated he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
pushed me down. I am hurting. He/she was able to move all extremities without complaints
of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of
the floor by two staff and assisted into a wheelchair;
-The notes did not show notification to the department of the alleged resident to resident
abuse.
Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed:
-The resident had an unwitnessed fall on 7/31/18;
-Upon entering the room, the resident was found lying on his/her back on the ground,
screaming he/she pushed me down and moving;
-The resident stated that he/she was pushed down while in another resident’s room;
-Agencies/people notified: No notifications found.
Further review of Resident #12’s progress notes, showed:
-On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another
resident. Residents separated. Physical assessment revealed no injury. Physician notified.
No new orders;
-The notes did not show notification to the department regarding the alleged resident to
resident abuse.
Review of the resident’s Physical Altercation Occurrence Report, dated 8/2/18, showed:
-The resident stated another resident hit him/her;
-The residents were separated and a physical assessment was completed;
-Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18
at 4:30 P.M. No documentation the department notified.
Review of Resident #143’s Significant Change MDS, dated [DATE], showed:
-BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the resident’s care plan, in use at the time of survey, showed the resident has
potential to be physically aggressive towards others related to dementia and he/she has
recently shown aggression towards one resident. On 7/9/18, accused of hitting another
resident. On 8/2/18, physically aggressive towards another resident. On 8/6/18, bruises to
the right/left forearm no open areas noted. 8/10/18, hit another resident after he/she
entered the resident’s room. No injuries. 8/24/18, hit another resident.
Review of DHSS records, showed the facility did not report the 7/31/18 and 8/2/18 resident
to resident abuse.
During interviews on 11/9/18 at 12:22 P.M. and 11/13/18, the DON said it was Resident #143
that pushed down Resident #12. Resident #12’s Occurrence Reports for the incidents on
7/31/18 and 8/2/18 were the only documentation the facility had for both incidents.
During an interview on 11/13/18 at 7:48 A.M., Licensed Practical Nurse (LPN) BB said:
-Any allegations or suspicions of abuse should be documented and followed up on;
-If a resident to resident altercation occurs, staff should immediately separate the
residents, notify the DON and Administrator, call both resident’s physicians and family,
and both residents should be assessed for injury;
-Any incidents such as a resident pushing another resident down or hitting another
resident is abuse and should be reported to DON and Administrator, an incident report
completed, and documented in a nurse’s note.
3. Review of Resident #50’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 15, showed the resident was cognitively intact;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-Had hallucinations and delusions;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 5/23/16, showed the resident has a history of
making false accusations towards other residents and staff.
Observation on 11/6/18 at 9:56 A.M., showed the resident reported to Certified Nursing
Assistant (CNA) W that LPN X and LPN Y pulled his/her hair and poked him/her in the
stomach on a different day. CNA W was observed writing the resident’s interview.
During an interview 11/7/18 at 8:39 A.M., the resident said LPN Y pulled his/her hair and
poked him/her in the stomach. The incident occurred two weeks ago. The resident confirmed
he/she reported it to CNA W, but no one had come to talk to him/her about it. The resident
said LPN Y was working today in the same unit the resident resides in on the 3 South unit.

Review of DHSS records, showed the facility did not report the 11/6/18 allegation of
abuse.
Observation on 11/7/18 at 8:40 A.M., 12:41 P.M., and 1:17 P.M., showed LPN Y at the
nursing station in the 3 South unit.
During an interview on 11/7/18 at 12:05 P.M., the administrator said if a resident
reported abuse, it would be the facility’s policy to investigate, find out which staff
member and if the person was there, they would be suspended, pending the investigation.
They would do a skin assessment to check for injury. Staff did not report the incident to
the administrator. She would expect CNA W to report it to the nurse manager and it would
be reported to the administrator. She would expect them to follow the facility’s policy.
If abuse occurred, they would contact the department within two hours. They would send LPN
Y home pending investigation.
4. Review of Resident #89’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 14, showed the resident was cognitively intact;
-Physical behaviors in the last one to three days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/4/18, showed the resident has potential to be
physically aggressive related/to anger, history of harm to others, and poor impulse
control. On 10/19/18, struck peer when he/she touched him/her.
Review of the resident’s progress notes, dated 10/19/18 at 7:07 A.M., showed therapy
reported to nurse that the resident hit another resident, unwitnessed by staff, when asked
what happen, resident stated, he/she pushed me and he/she hit him/her back. Resident
separated, physical assessment performed, no bruising, or discoloration noted. Denies
pain.
Review of DHSS records, showed the facility did not report the 10/19/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:18 P.M., the DON said if there was an unwitnessed
altercation, he/she would expect there to be an investigation. If resident said someone
hit him/her, they would investigate to make sure it really happen. The DON was not aware
of the altercation that involved the resident. She would have expected staff to report all
altercations to her.
5. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-BIMS score of 15 out of 15, shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Has hallucinations.
Review of the resident’s care plan, dated 10/24/18, showed:
-Focus: Resident had been struck by peer on 10/21/18;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Focus: Resident is verbally aggressive towards staff due to ineffective coping skills.
Review of the resident’s progress notes, showed on 10/21/18, resident to resident
altercation. A resident hit Resident #39 in the face and knock off his/her glasses. The
resident’s face on left side is slightly swollen. Residents sent to their rooms. Ice pack
applied to the resident’s face but he/she took it off of his/her face. He/she stated
he/she did not want it on his/her face. Physician notified of the altercation between the
residents, no new orders given.
Review of DHSS records, showed the facility did not report the 10/21/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:14 P.M., the DON said she was not aware of the
altercation. She would expect staff to notify her.
6. During an interview on 11/13/18 at 9:05 A.M., the DON said:
-With resident to resident altercations, he/she would expect nursing staff to separate the
residents, the nurse to complete a physical assessment of each resident, notify the
residents physicians and family and follow any physician’s orders [REDACTED].
-The facility would not investigate the incident as abuse due to confusion if the resident
alleging the push is confused and so is the resident that pushed him/her down;
-The incident should be reported to the state agency (the department) as an FYI (for your
information), if nothing else;
-He/she doesn’t know why the incidents were not reported;
-Policy is to notify the DON and Administrator immediately of any abuse allegations or
suspicions;
-He/she expects staff to follow the abuse policy;
-All staff has been educated on the abuse policy;
-He/she knows what abuse is and what to investigate;
-He/she does report abuse to the state agency.

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed follow their policy
to conduct a complete and thorough investigation for allegations of abuse, and failed to
submit their investigation in the required time frame to the Department of Health and
Senior Services (DHSS). In addition, the facility failed to prevent further potential
abuse while the investigation is in progress, for seven or 29 sampled residents identified
has having been involved in resident to resident abuse or having an allegation of abuse
(Resident #126, #47, #12, #143, #50, #89, and #39). The census was 148.
Review of the facility’s Resident Protection During Abuse Investigations policy, dated
1/2012, the facility desires to establish a resident secure environment and will take
steps to protect residents from exposure to additional acts of mistreatment following an
allegation or reported instance of abuse, neglect, theft or criminal action committed
against the residents while an investigation is conducted:
-Resident to resident events: Residents who allegedly abuse another resident should be
removed from contact with other residents until such time that reasonable clinical
judgement determines that their behavior no longer poses a significant risk to other
residents or until the investigation is concluded;
-Abuse, Neglect, Theft, Crimes Investigations: The facility will initiate and complete an

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Some

(continued… from page 21)
investigation of all allegations of abuse, neglect, theft or crimes occurring against a
resident of the facility:
-Investigations will be conducted in a systematic and timely manner. Investigations should
begin as soon as practicable but no later than 24 hours following the report of an abuse,
neglect, theft or crime committed against a resident;
-Investigations will be documented, all documentation will be retained in a separate file
and retained in the administrator’s office. After one year, files may be stored in a
remote location, however, they should be retained for a minimum of 3 years following the
discharge of the resident, who was the subject of the investigation.
1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had
moderately impaired cognition;
-No behaviors;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/30/16, showed:
-Focus: Resident gets upset easily and can become verbally & physically aggressive
towards others. Resident can be hard to direct at times. Resident is impulsive and likes
to hug. On 4/15/17 aggressive towards peers stating they cannot sit at table with him/her
and he/she knocked over a chair. On 12/24/16 attempting to exit locked doors, staff
attempted to redirect. Resident started kicking and rolling around on the floor. History
of getting upset when he/she does not win bingo. Will become physical or verbally
aggressive. On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the
hall. On 7/4/18, hit peer after argument. Had a resident to resident altercation.
Resident’s roommate accused him/her of talking about his/her roommate and backed his/her
wheel chair into the resident;
-Focus: Resident is at risk for injury from other residents: On 7/24/18, hit by peer and
was pulled by purse. No injury. On 9/13/18, hit by peer. No injury;
-Focus: Resident has a history of being verbally/physically aggressive towards others. Has
a history of resident to resident altercations. Resident can be very hard to redirect at
times. Resident needs frequent redirection and supervision;
-Focus: He/she pushed a resident in his/her back four times related to anger, history of
harm to others, and poor impulse and control.
Review of the Resident #126’s progress notes, dated 10/30/18, showed Resident #126 was
speaking with another resident, when Resident #47 brushed up against Resident #126 in
passing. A small verbal commotion followed and Resident #126 yelled, I’m not a boy!
Resident #126 moved toward Resident #47 in an aggressive manner, but never raised his/her
hands in an attempt to strike. Resident #47 then struck Resident #126 on the right side of
his/her face. Residents swiftly separated. Cold compress applied to right side of face.
Slight swelling noted. Skin intact. No discoloration noted. Complaints of tenderness to
touch. Praised his/her coping skills, of not retaliating physically. Encouraged to walk
away from confrontations. Verbalized understanding.
Review of Resident #47’s admission MDS, dated [DATE], showed;
-A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition;
-No behaviors exhibited;
-[DIAGNOSES REDACTED].
Review of theh resident’s care plan, dated 8/15/18, showed the resident has the potential
to be verbally aggressive (screaming, yelling at others) related to dementia and a
[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Some

(continued… from page 22)
Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in
the hallway, another resident was speaking with someone else, when this resident brushed
up against the first resident in passing. A small verbal commotion followed and the other
resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in
an aggressive manner, but never raised his/her hands in an attempt to strike. This
resident then struck the other resident on the right side of his/her face. Residents
swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized
understanding, but still claimed that the other resident is trying to, make you all go
against me. Reiterated to him/her there was no need to strike him/her, especially since
he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict
resolution techniques during confrontations.
Review of DHSS records, showed no investigation provided for the 10/30/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there
was an altercation, she would talk to the residents. The DON was not aware that a resident
was hit. She would expect staff to report and investigate it the incident. There are
systems in place per the facility’s policy if there was a resident to resident
altercation.
2. Review of Resident #12’s quarterly MDS, dated [DATE], showed:
-BIMS score of 8 out of 15, showed moderate cognitive impairment;
-Independent with all Activities of Daily Living (ADLs);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has the potential to be physically injured related to wandering into
others rooms and removing their property. He/she takes other residents clothing and other
items that he/she likes. He/she has had a recent incident in which another resident hit
him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident
after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by
another resident no injuries;
-Focus: The resident is an elopement risk/wanderer related to disease progression. He/she
is at risk for injuries related to wandering into other resident’s rooms. He/she removes
their items or gets into their personal things. On 7/9/2018 the resident made a statement
that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18
physical aggression was received from another resident. On 8/29/18 the resident exhibited
aggressive behaviors toward his/her roommate.
Review of Resident #12’s progress notes, showed:
-On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down
the hall to find him/her. He/she was lying on the floor in another resident’s room
screaming and moving around on the floor. When asked what happen he/she stated he/she
pushed me down. I am hurting. He/she was able to move all extremities without complaints
of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of
the floor by two staff and assisted into a wheelchair;
-The notes did not show notification to the department of the alleged resident to resident
abuse.
Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed:
-The resident had an unwitnessed fall on 7/31/18;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Some

(continued… from page 23)
-Upon entering the room, the resident was found lying on his/her back on the ground,
screaming he/she pushed me down and moving;
-The resident stated that he/she was pushed down while in another resident’s room;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident: Blank;
-Pain, consciousness, mobility and mental status [REDACTED].>-Other information: The
resident wanders into other resident’s rooms;
-Witnesses: No witnesses;
-Agencies/people notified: No notifications found;
-No summary of the investigation and no interventions taken at the time of the incident
and post incident noted. No behavior incident report provided upon request;
-The occurrence report did not identify what monitoring measures the facility staff put in
place after the resident first pushed down Resident #12, in order to prevent a second
occurrence;
-The facility was unable to provide an abuse investigation for this incident. The 7/31/18
incident was reported and investigated as a fall only.
Further review of Resident #12’s progress notes, showed:
-On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another
resident. Residents separated. Physical assessment revealed no injury. Physician notified.
No new orders;
-The notes did not show notification to the department regarding the alleged resident to
resident abuse.
Review of the resident’s Physical Altercation Occurrence Report, dated 8/2/18, showed:
-The resident stated another resident hit him/her;
-The residents were separated and a physical assessment was completed;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident: Blank;
-Mental status at the time of the incident: Blank;
-No injuries noted post incident;
-Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing
environmental factors: Blank;
-Predisposing physiological factors: Blank;
-Predisposing situation factors: Wanderer;
-Other information: Blank;
-Witnesses: No witnesses found;
-Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18
at 4:30 P.M. No documentation the department notified;
-No summary of the investigation, no cause, and no interventions taken at the time of the
incident and post incident noted.
Review of Resident #143’s Significant Change MDS, dated [DATE], showed:
-BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the resident’s care plan, in use at the time of survey, showed the resident has
potential to be physically aggressive towards others related to dementia and he/she has
recently shown aggression towards one resident. On 7/9/18, accused of hitting another
resident. On 8/2/18, physically aggressive towards another resident. On 8/6/18, bruises to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Some

(continued… from page 24)
the right/left forearm no open areas noted. 8/10/18, hit another resident after he/she
entered the resident’s room. No injuries. 8/24/18, hit another resident.
Review of DHSS records, showed no investigation provided for the 7/31/18 and 8/2/18
resident to resident abuse.
During interviews on 11/9/18 at 12:22 P.M. and 11/13/18, the DON said it was Resident #143
that pushed down Resident #12. Resident #12’s Occurrence Reports for the incidents on
7/31/18 and 8/2/18 were the only documentation the facility had for both incidents.
During an interview on 11/13/18 at 7:48 A.M., Licensed Practical Nurse (LPN) BB said:
-Any allegations or suspicions of abuse should be documented and followed up on;
-If a resident to resident altercation occurs, staff should immediately separate the
residents, notify the DON and Administrator, call both resident’s physicians and family,
and both residents should be assessed for injury;
-Any incidents such as a resident pushing another resident down or hitting another
resident is abuse and should be reported to DON and Administrator, an incident report
completed, and documented in a nurse’s note.
3. Review of Resident #50’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 15, showed the resident was cognitively intact;
-Had hallucinations and delusions;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 5/23/16, showed the resident has a history of
making false accusations towards other residents and staff.
Observation on 11/6/18 at 9:56 A.M., showed the resident reported to Certified Nursing
Assistant (CNA) W that LPN X and LPN Y pulled his/her hair and poked him/her in the
stomach on a different day. CNA W was observed writing the resident’s interview.
During an interview 11/7/18 at 8:39 A.M., the resident said LPN Y pulled his/her hair and
poked him/her in the stomach. The incident occurred two weeks ago. The resident confirmed
he/she reported it to CNA W, but no one had come to talk to him/her about it. The resident
said LPN Y was working today in the same unit the resident resides in on the 3 South unit.

Observation on 11/7/18 at 8:40 A.M., 12:41 P.M., and 1:17 P.M., showed LPN Y at the
nursing station in the 3 South unit.
During an interview on 11/7/18 at 12:05 P.M., the administrator said if a resident
reported abuse, it would be the facility’s policy to investigate, find out which staff
member and if the person was here, they would be suspended the staff member pending the
investigation. They would do a skin assessment to check for injury. Staff did not report
the incident to the administrator. She would expect CNA W to report it to the nurse
manager and it would be reported to the administrator. She would expect them to follow the
facility’s policy. They would send LPN Y home pending investigation.
4. Review of Resident #89’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 14, showed the resident was cognitively intact;
-Physical behaviors in the last one to three days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 6/4/18, showed the resident has potential to be
physically aggressive related/to anger, history of harm to others, and poor impulse
control. On 10/19/18, struck peer when he/she touched him/her.
Review of the resident’s progress notes, dated 10/19/18 at 7:07 A.M., showed therapy
reported to nurse that the resident hit another resident, unwitnessed by staff, when asked
what happen, resident stated, he/she pushed me and he/she hit him/her back. Resident
separated, physical assessment performed, no bruising, or discoloration noted. Denies

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 – Some

(continued… from page 25)
pain.
Review of DHSS records, showed no investigation provided for the 10/19/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:18 P.M., the DON said if there was an unwitnessed
altercation, he/she would expect there to be an investigation. If resident said someone
hit him/her, they would investigate to make sure it really happen. The DON was not aware
of the altercation that involved the resident. She would have expected staff to report all
altercations to her.
5. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-BIMS score of 15 out of 15, shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Has hallucinations.
Review of the resident’s care plan, dated 10/24/18, showed:
-Focus: Resident had been struck by peer on 10/21/18;
-Focus: Resident is verbally aggressive towards staff due to ineffective coping skills.
Review of the resident’s progress notes, showed on 10/21/18, resident to resident
altercation. Resident hit resident in the face and knock off his/her glasses. The
resident’s face on left side is slightly swollen. Residents sent to their rooms. Ice pack
applied to the resident’s face but he/she took it off of his/her face. He/she stated
he/she did not want it on his/her face. Physician notified of the altercation between the
residents, no new orders given.
Review of DHSS records, showed no investigation provided for the 10/21/18 resident to
resident abuse.
During an interview on 11/9/18 at 12:14 P.M., the DON said she was not aware of the
altercation. She would expect staff to notify her.
6. During an interview on 11/13/18 at 9:05 A.M., the DON said:
-With resident to resident altercations, he/she would expect nursing staff to separate the
residents, the nurse to complete a physical assessment of each resident, notify the
residents physicians and family and follow any physician’s orders [REDACTED].
-The facility would not investigate the incident as abuse due to confusion if the resident
alleging the push is confused and so is the resident that pushed him/her down;
-The incident should be reported to the state agency (the department) as an FYI (for your
information), if nothing else;
-Policy is to notify the DON and Administrator immediately of any abuse allegations or
suspicions;
-He/she expects staff to follow the abuse policy;
-All staff has been educated on the abuse policy;
-He/she knows what abuse is and what to investigate;
-He/she does report abuse to the state agency.

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 transfer
notices to residents and/or their representative upon discharge to a hospital when their
return to the facility was expected. Of the 29 sampled residents, six had been recently

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 26)
discharged to a hospital for various medical reasons, all were expected to return, and
none of those six had been issued a written transfer notice upon leaving the facility
(Residents #124, #112, #57, #84, #143 and #150). The census was 148.
1. Review of Resident #124’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to facility from the hospital on [DATE];
-No documentation the resident was provided a notice upon discharge.
2. Review of Resident #112’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident was provided a notice upon discharge.
During an interview on 11/6/18 at 10:48 A.M., the resident said he/she was in the hospital
recently and does not remember receiving any discharge notice from the facility.
3. Review of Resident #57’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation of dischage notices were provided to the resident by the facility for
the 5/31/18 and 8/12/18 discharges.
During an interview on 11/6/18 at 12:30 P.M., the resident said he/she had been admitted
to the hospital several times recently and does not remember receiving any discharge
notice from the facility.
4. Review of Resident #84’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation of discharge notices were provided to the resident by the facility for
the 9/1/18 and 10/17/18 discharges.
During an interview on 11/7/18 at 7:00 A.M., the resident said he.she had been in the
hospital several times recently for back surgery and does not remember receiving any
discharge notices from the facility.
5. Review of Resident #143’s medical record showed:
-The resident was discharged to the hospital on [DATE].
-Resident returned to the facility from the hospital on [DATE].
-No documentation of a discharge notice was provided to the resident by the facility for
the 10/31/18 discharge.
6. Review of Resident #150’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to hospital on [DATE];
-Returned to facility from the hospital on [DATE];
-No documentation of discharge notices were provided to the resident by the facility for
the 6/12/18 and 10/1/18 discharges.
During an interview on 11/7/18 at 6:53 A.M., the resident said he/she had been in the
hospital recently and does not rember receiving any discharge notices from the facility.
7. During an interview on 11/13/18 at 7:06 A.M., the Administrator said the facility had
not been issuing any discharge notices whenever a resident was discharged to the hospital
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 27)
with return anticipated. At 9:05 A.M., she said she was unaware the facility needed to
issue a discharge notice upon discharge to hospital with return anticipated and they do
not have any policy.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for six of 29 sampled residents who were recently transferred to a hospital for
various medical reasons (Residents #124, #112, #57, #84, #143 and #150). The census was
148.
1. Review of Resident #124’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer.
2. Review of Resident #112’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer.
During an interview on 11/6/18 at 10:48 A.M., the resident said he/she was in the hospital
recently and does not remember receiving any bed hold policy from the facility.
3. Review of Resident #57’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 5/31/18 or 8/12/18.
During an interview on 11/6/18 at 12:30 P.M., the resident said he/she had been admitted
to the hospital several times recently and does not remember receiving any bed hold policy
from the facility.
4. Review of Resident #84’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 9/1/18 or 10/17/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 28)
During an interview on 11/7/18 at 7:00 A.M., the resident said he/she had been in the
hospital several times recently for back surgery and does not remember receiving any bed
hold policy from the facility.
5. Review of Resident #143’s medical record showed:
-The resident was discharged to the hospital on [DATE].
-Returned to the facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 10/31/18.
6. Review of Resident #150’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to hospital on [DATE];
-Returned to facility from the hospital on [DATE].
Review of the resident’s medical record, showed no documentation the resident or the
resident’s representative received information in writing of the facility’s bed hold
policy at the time of transfer on 6/12/18 or 10/1/18.
During an interview on 11/7/18 at 6:53 A.M., the resident said he/she had been in the
hospital recently and does not remember receiving any bed hold policy from the facility.
7. During an interview on 11/13/18 at 7:06 A.M., the Administrator said the facility had
not been issuing any written bed hold policy whenever a resident was discharged to the
hospital with return anticipated. At 9:05 A.M., she said she was unaware the facility
needed to issue a written bed hold policy upon discharge to hospital with return
anticipated and they do not have any policy.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure that each resident
receives an accurate assessment, reflective of the resident’s status at the time of the
assessment, by staff qualified to assess relevant care areas and are knowledgeable about
the resident’s status, needs, strengths, and areas of decline for four residents
identified as having behaviors (Resident #126, #47, #12 and #143) of 29 sampled
resident’s. The census was 148.
1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had
moderately impaired cognition;
-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,
scratching, grabbing): Behavior not exhibited;
-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming
at others, cursing at others): Behavior not exhibited;
-Other behavioral symptoms not directed towards others (e.g., physical symptoms such as
hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds):
Behavior not exhibited;
-Rejection of care: Behavior not exhibited;
-Wandering: Behavior not exhibited;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 29)
-[DIAGNOSES REDACTED].
Review of Resident #126’s care plan, dated 6/30/16, showed:
-Focus: Resident gets upset easily and can become verbally & physically aggressive
towards others. Resident can be hard to direct at times. Resident is impulsive and likes
to hug:
-On 4/15/17 aggressive towards peers stating they cannot sit at table with him/her and
he/she knocked over a chair;
-On 12/24/16 attempting to exit locked doors, staff attempted to redirect. Resident
started kicking and rolling around on the floor. History of getting upset when he/she does
not win bingo. Will become physical or verbally aggressive;
-On 4/24/17, kicking the wall, yelling, and refusing to move to one side of the hall;
-On 7/4/18, hit peer after argument. Had a resident to resident altercation;
-Resident’s roommate accused him/her of talking about his/her roommate and backed his/her
wheel chair into the resident;
-Interventions: Create a positive environment for the resident to gain socially acceptable
patterns of behaviors. Keep resident away from source of agitation. Every 15 min face
checks;
-Focus: Resident is at risk for injury from other residents:
-On 7/24/18, hit by peer and was pulled by purse. No injury;
-On 9/13/18, hit by peer. No injury;
-Interventions: Assess the resident for injury after any physical incident. Alert
physician and responsible party. Remove the resident from the source of aggression;
-Focus: Resident has a history of being verbally/physically aggressive towards others. Has
a history of resident to resident altercations. Resident can be very hard to redirect at
times. Resident needs frequent redirection and supervision;
-Focus: He/she pushed a resident in his/her back four times related to anger, history of
harm to others, and poor impulse and control;
Interventions: The resident’s triggers for physical aggression are (not being allowed to
go on outings). The resident’s behaviors is de-escalated by (providing distractions and
other activities).
During an interview on 11/8/18 at 11:30 A.M., Resident #126 said he/she had an altercation
with another resident.
2. Review of Resident #47’s admission MDS, dated [DATE], showed;
-A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition;
-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,
scratching, grabbing): Behavior not exhibited;
-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming
at others, cursing at others): Behavior not exhibited;
-Other behavioral symptoms not directed towards others (e.g., physical symptoms such as
hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds):
Behavior not exhibited;
-Rejection of care: Behavior not exhibited;
-Wandering: Behavior not exhibited;-[DIAGNOSES REDACTED].
Review of Resident #47’s care plan, dated 8/15/18, showed:
-Focus: Resident has the potential to be verbally aggressive (screaming, yelling at
others) related to dementia and a [DIAGNOSES REDACTED].
-Interventions: Administer antipsychotic medications as ordered. Monitor/document for side
effects and effectiveness. Give the resident as many choices as possible about care and
activities. Monitor behaviors every 15 minutes. Document observed behavior and attempted
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 30)
interventions;
-When resident becomes agitated: Intervene before agitation escalates. Guide away from
source of distress. Engage calmly in conversation. If response is aggressive, staff to
walk calmly away, and approach later.
During an interview on 11/8/18 at 12:05 P.M., Licensed Practical Nurse (LPN) H said
Resident #47 had a history of [REDACTED].
3. Review of Resident #12’s quarterly MDS, dated [DATE], showed:
-BIMS score of 8 out of 15, showed moderate cognitive impairment;
-Independent with all Activities of Daily Living (ADLs);
-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,
scratching, grabbing): Behavior not exhibited;
-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming
at others, cursing at others): Behavior not exhibited;
-Other behavioral symptoms not directed towards others (e.g., physical symptoms such as
hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds):
Behavior not exhibited;
-Rejection of care: Behavior not exhibited;
-Wandering: Behavior occurred 1 to 3 days.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has the potential to be physically injured related to wandering into
others rooms and removing their property. He/she takes other residents clothing and other
items that he/she likes. He/she has had a recent incident in which another resident hit
him/her for coming in his/her room. On 8/10/18 the resident was hit by another resident
after entering the resident’s room. No injuries. On 8/24/18 the resident was hit by
another resident no injuries;
-Goal: The resident will not harm self or others through the review date;
-Interventions: Staff will encourage and redirect the resident out of other resident’s
rooms/personal space as needed;
-Focus: The resident is an elopement risk/wanderer related to disease progression. He/she
is at risk for injuries related to wandering into other resident’s rooms. He/she removes
their items or gets into their personal things. On 7/9/2018 the resident made a statement
that he/she was hit by another resident while in his/her room. Un-witnessed. On 8/2/18
physical aggression was received from another resident. On 8/29/18 the resident exhibited
aggressive behaviors toward his/her roommate;
-Goal: The resident’s safety will be maintained through the review date;
-Interventions: Distract him/her from wandering by offering pleasant diversions,
structured activities, food, conversation, television, books. Resident prefers to color in
coloring book, talking with staff at times, etc. Monitor location every 15 min every
shift. Document wandering behavior and attempted diversional interventions in medical
record as needed. Provide structured activities: toileting, walking inside and outside,
reorientation strategies including signs, pictures and memory boxes. Relocate to another
room as needed for safety.
During an interview on 11/13/18 at 7:40 A.M., Certified Nursing Assistant (CNA) AA said
Resident #12 wanders into other resident rooms, once staff hear him/her hollering out
staff will go get him/her and take him/her to the day area or dining room.
4. Review of Resident #143’s Significant Change MDS, dated [DATE], showed:
-BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment);
-Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing,
scratching, grabbing): Behavior not exhibited;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
-Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming
at others, cursing at others): Behavior not exhibited;
-Other behavioral symptoms not directed towards others (e.g., physical symptoms such as
hitting or scratching self, rummaging, disrobing in public, screaming, disruptive sounds):
Behavior not exhibited;
-Rejection of care: Behavior not exhibited;
-Wandering: Behavior not exhibited.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has potential to be physically aggressive towards others related to
dementia and he/she has recently shown aggression towards one resident. On 7/9/18, accused
of hitting another resident. On 8/2/18, physically aggressive towards another resident. On
8/6/18, bruises to the right/left forearm no open areas noted. 8/10/18, hit another
resident after he/she entered the resident’s room. No injuries. 8/24/18, hit another
resident:
-Goal: The resident will not harm self or others through the review date;
-Interventions: Administer medication as ordered. Monitor/document for side effects and
effectiveness. Assess and anticipate his/her needs: food, thirst, toileting needs, comfort
level, body positioning, pain etc. Provide physical and verbal cues to alleviate anxiety.
Give positive feedback, assist verbalization of source of agitation, and assist to set
goals for more pleasant behavior, encourage seeking out of staff member when agitated.
Monitor every 15 minutes and Document observed behavior and attempted interventions in his
medical chart. Monitor other resident’s closely and encourage them from wandering into the
resident’s room. Monitor/document/report PRN any signs and symptoms of him/her posing
danger to self and others. The resident’s triggers for physical aggression are having
personal items removed from his/her room by other residents. The resident’s behaviors is
de-escalated by talking to him/her in a calm approach. When the resident becomes agitated:
Intervene before agitation escalates; Guide away from source of distress; Engage calmly in
conversation; If response is aggressive, staff to walk calmly away, and approach later.
During an interview on 11/13/18 at 7:40 A.M., CNA AA said Resident #143 can be aggressive
if someone goes into his/her room. Staff will just remove the other resident from his/her
room.
5. During an interview on 11/13/18 at 8:01 A.M., MDS Coordinator K said MDS assessments
should be accurate based on the resident’s condition at the time of the assessment.

F 0644

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Coordinate assessments with the pre-admission screening and resident review program;
and referring for services as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure coordination for
residents admitted to the facility had a DA-124 level I screen (used to evauluate for the
presence of psychiatric conditions to determine if a preadmission screening/resident
review (PASARR) level II screen is required) as required, for four of 29 sampled residents
(Resident #1, #78, #124 and #150). The census was 148.
Review of the Central Office Medical Review Unit (COMRU) Instructional guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASSAR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening. The DA-124 C form must be completed prior to admitting the client to the a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0644

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
nursing facility to ensure the client does not trigger a Level II screening. A Level II
screening refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II;
-The triggers for the Level II screening are:
-The client has had inpatient psychiatric treatment in the past two years;
-The client was suicidal or homicidal (includes dementia clients);
-The client has very aggressive behavior (includes dementia clients);
-The client has a [DIAGNOSES REDACTED].
1. Review of Resident #1’s medical record showed:
-admitted to the facility on [DATE] and readmitted on [DATE];
-[DIAGNOSES REDACTED].
-No DA 124 level I screen found.
2. Review of Resident #78’s medical record showed:
-admitted to facility on 4/10/14;
-Resides in a Medicaid Certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 level I screen found.
During an interview on 11/09/18 at 8:40 A.M., the facility staff development coordinator
said the facility does not have a PASARR for this resident and he/she will be working on
re-submitting it today. The goal is to have it done by the end of the day.
3. Review of Resident #124’s medical record showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Resides in a Medicaid Certified bed;
-No DA 124 level I screen found.
4. Review of Resident #150’s medical record showed;
-admitted to the facility on [DATE] and readmitted on [DATE];
-Resides in a Medicaid Certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 level I screen found.
5. During an interview on 11/8/18 at 8:47 A.M., the Staff Develpoment Coordinator said she
is responsible for the DA124 level I and Level II screen, could not find any DA124 level I
screen for Resident’s #1, #78, #124, or #150.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disabilities had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASSAR) level II screen is required) as required,
for six of 29 sampled residents (Resident #1, #78, #124, #150, #32 and #109). The census
was 148.
Review of the Central Office Medical Review Unit (COMRU) Instructional guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASSAR process:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 33)
-The DA-124 application will assist in identifying a client that requires a Level II
screening. The DA-124 C form must be completed prior to admitting the client to the a
nursing facility to ensure the client does not trigger a Level II screening. A Level II
screening refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II;
-The triggers for the Level II screening are:
-The client has had inpatient psychiatric treatment in the past two years;
-The client was suicidal or homicidal (includes dementia clients);
-The client has very aggressive behavior (includes dementia clients);
-The client has a [DIAGNOSES REDACTED].
1. Review of Resident #1’s medical record, showed:
-admitted to the facility on [DATE] and readmitted on [DATE];
-[DIAGNOSES REDACTED].
-No DA 124 Level I or Level II screen found.
2. Review of Resident #78’s medical record showed:
-admitted to facility on 4/10/14;
-Resided in a Medicaid Certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 Level I screen found.
During an interview on 11/09/18 at 8:40 A.M., the facility staff development coordinator
said the facility does not have a PASARR for this resident and he/she will be working on
re-submitting it today. The goal is to have it done by the end of the day.
3. Review of Resident #124’s medical record showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Resided in a Medicaid Certified bed;
-No PASSAR Level II screen found.
4. Review of Resident #150’s medical record showed;
-admitted to the facility on [DATE] and readmitted on [DATE];
-Resided in a Medicaid certified bed;
-[DIAGNOSES REDACTED].
-No PASSAR Level II screen found.
5. Review of Resident #32’s medical record showed:
-admitted to facility on 3/30/04;
-Resided in a Medicaid Certified bed;
-[DIAGNOSES REDACTED].
-No PASSAR Level II screen found.
6. Review of Resident #109’s medical record, showed:
-admitted to the facility on [DATE] and readmitted on [DATE];
-[DIAGNOSES REDACTED].
-No DA 124 Level I screen found.
7. During an interview on 11/8/18 at 8:47 A.M., the Staff Development Coordinator said she
is responsible for the DA-124 Level I and Level II screens, could not find any Level II
screen for Resident’s #1, #78, #124, #150, #32, or #109. At 10:28 A.M., she said she had
called the agencies where the screenings go to and neither of them had any Level II screen
on the residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**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 baseline care plan consistent with the resident’s specific conditions, needs,
and risks within 48 hours of admission to properly care for one resident (Resident #452)
out of one newly admitted resident sampled. The facility census was 148.
Record review of Resident #452’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 11/1/18, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s electronic and paper medical record, showed no baseline
care plan found.
Observation on 11/7/18 at 6:59 A.M., showed the resident sat on the edge of his/her bed,
awake, call light in reach. The resident could not hear this surveyor ask him/her
questions. The resident shook his/her head at this surveyor and declined to interact.
During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said:
-Base line care plans should be completed with the admission paperwork within 24 hours;
-The admitting nurse is responsible for creating baseline care plans for new admits;
-The current post admission audits do not include a process to ensure the baseline care
plans were completed timely;
-Staff is expected to access baseline care plans in the electronic health record.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
had complete, accurate and individualized care plans, to address the specific needs of the
residents, for six of 29 sampled residents (Residents #1, #114, #139, #150, #39 and #102).
The census was 148.
1. Review of Resident #1’s annual Minimum Data Set (MDS), a federally required assessment
instrument completed by facility staff dated 10/21/18, showed:
-Total dependence on two person physical assist for transfers;
-Functional limitations in range of motion:
-Upper extremity: impairment on one side;
-Lower extremity: impairment on both sides;
-Mobility devices: Wheelchair;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Physical therapy end date, 9/20/18.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident is at risk for falls due to [DIAGNOSES REDACTED].>-Goal: Resident
will not sustain serious injury through the review date;
-Approach: Educate staff to use gait belt during transfers and assist of 2 person for all

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
transfers;
-The care plan failed to correctly identify the resident’s transfer status.
Review of the resident’s electronic medical record activity of daily living (ADL) transfer
documentation, dated 10/31/2018 to 11/12/18, showed:
-No order for transfer status;
-Staff documented extensive assistance (resident involved in activity, staff provide
weight bearing assistance) for transfers.
Observation on 11/07/18 at 10:16 A.M., showed Certified Nursing Assistant (CNA) T and CNA
U transferred the resident from the bed to the shower chair using a mechanical lift.
Observation on 11/07/18 at 3:33 P.M., showed CNA J and CNA V transferred the resident from
the wheelchair to the bed using a mechanical lift.
During an interview on 11/07/18 at 7:23 A.M., CNA D said the resident is the only resident
transferred with a mechanical lift on the floor.
During an interview on 11/09/18 at 9:00 A.M., the Director of Nursing (DON) said if a
resident requires a mechanical lift it should be in the care plan. The care coordinator
updates all care plans and informs staff of changes. The expectation is that care plans
are accurate. Transfer orders are noted for resident in the ADLs found in the electronic
medical record for the resident. Resident’s transfer status is determined based on their
needs and abilities. The DON expects nursing staff to notice change in ADLs and report it
to the nurse.
2. Review of Resident #114’s quarterly MDS, dated [DATE], showed:
-Extensive assistance of two-person physical assist required for transfers;
-Mobility devices: Wheelchair.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: ADL self-care performance deficit related to [MEDICAL CONDITION] and limited
mobility. He/she requires assist with transfers and mobility;
-Goal: Be clean, odor free and well groomed;
-The care plan failed to identify the resident’s transfer status.
During an interview on 11/7/18 at 7:20 A.M., CNA A said he/she just knows how to care for
residents. He/she knows how to care for the resident because he/she had worked at the
facility for four years.
Observation on 11/7/18 at 7:24 A.M., showed CNA A provided care to the resident and
transferred the resident to his/her wheelchair. CNA A transferred the resident to his/her
wheelchair with the use of a gait belt. The resident not able to bear weight or assist in
the transfer.
3. Review of Resident #139’s annual MDS, dated [DATE], showed:
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out
of a possible score of 15;
-A score of 0-7, showed the resident had severe cognitive impairment;
-Total dependence on two-person physical assist for transfers;
-Functional limitation in range of motion;
-Upper extremity: Impairment on one side;
-Lower extremity: Impairment on both sides;
-Mobility devices: Wheelchair;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Physical therapy end date, 6/7/18;
-Restorative nursing program: Not performed.
Review of the resident’s care plan, in use at the time of the survey, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 36)
-Problem: Resident is nonverbal and is provided socialization by staff and family to
provide socialization and conversations. He/she calms down when talked to by others.
He/she screams and yells a lot when he/she does not have attention provided or is
attempting to communicate with others;
-Goal: Psychosocial needs will be met and anticipated by staff and family;
-Approach: Talk with the resident while providing care;
-Problem: Resident required total care with activities of daily living (ADLs) related to
stroke;
-Goal: Be clean, odor free and well groomed;
-Approach: Total care in all aspects of ADL care;
-Resident has contractures (chronic loss of joint motion due to structural changes in
non-bony tissue. These non-bony tissues include muscle, ligaments and tendons) of the
right arm and hand;
-Range of motion (ROM) to be provided with daily care as tolerated;
-Totally dependent on one staff for transferring;
-Problem: Risk for falls: Limitations with lower extremities related to contractures:
-Goal: Remain free from injuries related to falls;
-Approach: Staff will assist the resident with transfers to bed within an hour of meals;
-The care plan failed to identify the resident’s transfer status;
-Activities not care planned.
Review of the medical record, showed no documentation staff assisted the resident with ROM
with daily care as tolerated or how the resident tolerated ROM.
Observations on 11/6/18 at 9:44 A.M. and 10:59 A.M., 11/9/18 at 6:31 AM., showed the
resident sat in his/her room in his/her wheelchair. All extremities were contracted and
the resident yelled out.
Observation on 11/6/18 at 11:05 A.M., showed a music activity taking place on the floor
for the residents. No staff assisted the resident to the activity and the resident
remained in his/her room.
Observation on 11/7/18 at 3:47 P.M., showed CNA E and CNA J transferred the resident from
bed to the wheelchair. Without the use of a gait belt, CNA E stood on one side of the
resident and CNA J stood on the other side. Staff placed one arm under the resident’s arm
and grabbed onto the resident’s waste band with the other hand and picked the resident up
out of the bed. The resident’s extremities contracted and pulled into the resident’s core.
During the transfer, the resident’s legs remained contracted up and did not touch the
floor. Staff placed the resident in the wheelchair.
Observation on 11/13/18 at 6:57 A.M., showed the resident sat in a wheelchair in the hall.
Laundry staff passed out clean laundry to resident rooms. The resident yelled out as a CNA
walked by. The CNA failed to stop to acknowledge the resident. Laundry staff stopped to
talk to the resident and the resident stopped yelling and appeared to watch the laundry
staff with a relaxed look on his/her face. As the laundry staff continued down the hall to
pass out clean laundry, the resident again started to yell.
During an interview on 11/13/18 at 8:01 A.M., MDS Coordinator K said he/she was not the
MDS coordinator who completed the annual MDS for the resident. The MDS coordinator before
him/her completed the MDS and he/she is not sure why they chose not to care plan
activities. The resident would benefit from care planned activities.
During an interview on 11/13/18 at 8:10 A.M., the activity director said the resident
likes television and the radio. He/she does not come down for group activities much
because he/she appears to become anxious in groups. It is hard to say if the resident
would benefit from one on one activities. The resident does enjoy when staff propel
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 37)
him/her up and down the hall and sitting at the nurse’s station.
4. Review of Resident #150’s significant change MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 12 out of a possible 15 ( no cognitive impairment);
-Required minimal assistance from staff for ambulation and eating. Required maximum
assistance from staff for transfers, dressing, hygiene and bathing.
Review of the residents electronic POS, in use during the survey, showed an order dated
10/19/18, for hospice to evaluate, admit and treat the resident.
Review of the resident’s medical record, showed a signed agreement between the resident
and the hospice company, dated 10/11/18.
Review of the residents care plan, in use during the survey, showed staff did not care
plan the resident for hospice.
During an interview on 11/8/18 at 7:31 A.M., the resident said he/she does receive hospice
benefits and someone from the hospice company does come to see him/her several times a
week.
During an interview on 11/13/18 at 9:05 A.M., the Director of Nurses (DON) said she would
expect staff to care plan the resident for hospice.
5. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 15 out of 15, shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Antipsychotics, antianxiety, and antidepressants administered in the last seven days;
-No documentation of a [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/9/17, showed:
-Focus: Resident uses anti-anxiety medications related to anxiety disorder and
antidepressants due to depression and antipsychotic medication use;
-Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for
side effects and effectiveness every shift;
-Monitor/document/report PRN any adverse reactions to anti-anxiety: Drowsiness, lack of
energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation,
depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss,
forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects:
Mania, hostility, rage, aggressive or impulsive behavior, and hallucination;
-Monitor/record occurrence of for target behavior symptoms (specify pacing, wandering,
disrobing, inappropriate response to verbal communication, violence/aggression towards
staff/others, etc.) and document per facility protocol;
-Further review of the resident’s care plan, showed no documentation of a [DIAGNOSES
REDACTED].
Review the resident’s medical record, showed:
-[DIAGNOSES REDACTED].
-POS, dated 11/1/18 through 11/30/18, showed an order dated 11/8/17, for [MEDICATION NAME]
tablet 10 mg, give one tablet by mouth at bedtime for Alzheimer’s;
-MAR, dated 11/1/18 through 11/9/18, showed an order dated, 11/8/17, for [MEDICATION NAME]
10 mg was administered as ordered.
During an interview on 11/13/18 at 9:00 A.M., the DON said she would expect the resident’s
care plan to be person centered. If there was a [DIAGNOSES REDACTED].
6. Review of Resident #102’s medical record, showed:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Review of the physician order [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 38)
-An order, dated 12/6/16, [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION])
3 milligram (mg) tablet at bedtime (HS) for [MEDICAL CONDITION];
-An order, dated 5/27/18, for [MEDICATION NAME] (medication used to treat depression and
[MEDICAL CONDITION]) HCI tablet 150 mg HS for [MEDICAL CONDITION];
-An order, dated 6/27/18, [MEDICATION NAME] Capsule ([MEDICATION NAME][MEDICATION NAME]
HCl, [MEDICATION NAME] used to treat allergy symptoms) 50 mg by mouth (PO) for [MEDICAL
CONDITION] at HS.
Review of the resident’s Medication Administration Record [REDACTED]
-An order, dated 12/6/16, for [MEDICATION NAME] 3 mg HS for [MEDICAL CONDITION] was
administered as ordered;
-An order, dated 5/27/18, for [MEDICATION NAME] 150 mg HS was administered as ordered;
-An order, dated 6/27/18, for [MEDICATION NAME] Capsule 50 mg HS was administered as
ordered.
Review of the resident’s care plan, reviewed 11/9/18, showed no documentation of the
resident’s [MEDICAL CONDITION] or sleep habits and concerns.
Observation of the resident on 11/8/18 at 11:30 A.M., 11/8/18 at 4:41 P.M., showed the
resident in bed with his/her eyes closed.
During an interview on 11/8/18 at 4:46 P.M., Licensed Practical Nurse (LPN) H said the
resident sleeps a lot. He/she is only up for meals. That is his/her routine.
Observation on 11/8/18 at 5:57 P.M., showed the resident in the dining room during meal
service. He/she sat at the table with his/her eyes closed. Staff asked the residents in
the dining room if anyone else needed to be served. The resident continued to sit at the
table with his/her eyes closed. Other residents in the dining room pointed out that the
resident needed to be served before the dietary staff left the room.
During an interview on 11/13/18 at 9:00 A.M., the DON said she would expect the resident’s
[DIAGNOSES REDACTED].
7. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said care
plans should be resident centered. It should include pertinent care information and
resident wishes. A resident’s transfer status should be included in the care plan.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a
comprehensive care plan in seven days after completion of the comprehensive assessment and
no more than 21 days after admission to properly care for one resident (Resident #452) out
29 sampled residents. The facility census was 148.
1. Record review of Resident #452’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 11/1/18, showed
the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Section V: Care Area Assessment Summary triggered the following areas to be care planned
for the resident:
-Cognitive Loss/Dementia;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 39)
-Activities of Daily Living (ADL) Functional/Rehabilitation Potential;
-Communication;
-Behavioral symptoms;
-Falls;
-Nutritional Status;
-Dental Care;
-Pain;
-Return to Community Referral.
Record review of the resident’s electronic and paper medical record, reviewed on 11/13/18,
showed no comprehensive care plan found.
Observation on 11/7/18 at 6:59 A.M., showed the resident sat on the edge of his/her bed,
awake, call light in reach. The resident could not hear this surveyor ask him/her
questions. The resident shook his/her head at this surveyor and declined to interact.
During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said:
-Comprehensive care plans are expected to be developed within 21 days of admission;
-The MDS coordinators are responsible for completing the care plans.

F 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on interview and record review, the facility staff failed to complete a
comprehensive discharge summary for one of one closed record sampled resident (Resident
#152). The census was 148.
Review of Resident #152’s closed medical record, showed the resident discharged to another
long term care facility on 8/16/18. Staff did not complete a discharge summary, which
would include a final summary of the resident’s status, a reconciliation of all pre and
post discharge medications and a post-discharge plan of care.
During an interview on 11/13/18 at 6:48 A.M., the Administrator said the Social Worker is
responsible for completing the discharge summary. The new Social Worker had only been at
the facility since 10/17/18, and the two Social Workers, who left on 10/3/18, had not been
completing any discharge summaries on the discharged residents.
During an interview on 11/13/18 at 8:07 A.M., the Social Worker said she is responsible
for completing the discharge summary on discharged residents, but had not done any as of
this time.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident who is unable to carry out activities of daily living receives the necessary
services to maintain good grooming and personal hygiene, for three residents (Resident #1,
#139 and #89) of 29 sampled residents. Two resident were left soiled after incontinent
episodes and one resident was not provided with proper grooming for facial hair. The

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 40)
census was 148.
Review of the facility’s Perineal Incontinence Care policy, dated 1/1/06, showed the
following:
-Standard: To provide cleanliness and comfort, prevent irritation and infection in the
perineal area during the daily bath and after voiding or defecating;
-Wash, rinse and dry the resident;
-More than one wash or rinse may be necessary to clean the area thoroughly;
-Remove the protective pad from the bed and dispose of it appropriately, if soiled.
1. Review of Resident #1’s annual Minimum Data Set (MDS), a federally required assessment
instrument completed by facility staff, dated 10/21/18, showed the following:
-Total dependence on staff for toilet use;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan, in use at time of the survey, showed the following:
-Problem: Resident requires total care with activities of daily living (ADLs) due to
[DIAGNOSES REDACTED].
-Goal: Staff will continue to provide total care with ADLs through next review;
-Approach: Skin assessment as needed.
Observation on 11/7/18 at 9:57 A.M., showed Certified Nursing Assistant (CNA) T in the
resident’s room provided incontinence care to the resident. A strong urine odor permeated
the room. CNA T removed the urine soaked brief from the resident. The urine soaked brief
had disintegrated. Small, white, gel-like particles of debris from the brief clung to the
resident’s buttocks. CNA T commented that the brief had fallen apart. The resident stated
his/her buttocks hurt.
Observation on 11/7/18 at 3:24 P.M., showed the resident in his/her room. The resident sat
in his/her wheelchair with a mechanical lift pad and folded blanket underneath him/her.
The resident said nursing staff had not checked his/her brief since his/her shower this
morning at 10:00 A.M. The resident said he/she was wet.
Observation on 11/7/18 at 3:34 P.M. showed CNA J and CNA V provided incontinence care to
the resident. CNA J removed the urine soaked brief from the resident and performed
perineal care (peri-care, washing the front and back of the hips, genitals, anal area and
buttocks). CNA J put a clean brief on the resident and then pulled the resident’s pants
up. CNA V said the resident’s pants were soaked with urine and removed them. CNA J and CNA
V put clean pants on the resident without cleaning the resident’s thighs of urine. CNA J
and CNA V repositioned the resident on his/her bed. CNA J and CNA V left the resident
lying on the urine soaked mechanical lift pad that he/she had been sitting on since the
completion of his/her shower at 10:00 A.M. that morning. CNA J and CNA V left the urine
soaked folded blanket on the seat of the resident’s wheel chair and left the room.
2. Review of Resident #139’s annual MDS, dated [DATE], showed the following:
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out
of a possible score of 15;
-A score of 0-7, showed the resident had severe cognitive impairment;
-Total dependence required for toilet use and personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident requires total care with ADLs related to stroke:
-Goal: Be clean, odor free and well groomed;
-Approach: Total care in all aspects of ADL care.
Observation on 11/7/18 at 3:43 P.M., showed CNA E entered the resident’s room and said
he/she needed to check to see if the resident was clean. He/she placed an ungloved hand
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 41)
down the front of the resident’s brief, said the resident was dry, removed his/her hand
and exited the resident’s room. At 3:47 P.M., Licensed Practical Nurse (LPN) L entered the
resident’s room to complete a skin assessment. He/she unsecured the resident’s brief. The
resident was wet with urine and had a soft, partially liquid bowel movement. LPN L used
the resident’s brief to wipe away the majority of the bowel movement, rolled it up to
contain the stool in the brief and removed the brief. Smears of stool remained on the
resident’s buttocks. He/she then called for CNAs to come and finish cleaning the resident.
CNA E and CNA J entered the resident’s room. LPN L said the resident needed to be cleaned
up and then transferred to his/her wheelchair. Neither CNA acknowledged LPN L and LPN L
did not verify the CNAs heard him/her before he/she left the room. CNA E and CNA J placed
a clean brief on the resident without cleaning the urine and/or stool off the resident’s
skin. They then assisted the resident to transfer to his/her wheelchair.
During an interview on 11/7/18 at 4:25 P.M., the administrator said it was not acceptable
to check for incontinence by sticking a hand down the front of a resident’s brief.
3. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said staff
should check residents who are known to be incontinent every two hours. If a resident is
soiled, they should be cleaned. Residents should be cleaned before they get to the point
the brief, pants, blanket or transfer pad become soiled. If the resident’s paints, blanket
and transfer pad does become soiled, the resident should not be allowed to continue to use
them without them being cleaned.
4. Review of Resident #89’s quarterly MDS, dated [DATE], showed the following:
-BIMS score of 14, which shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Limited assistance required for transfers, dressing and hygiene.
Observation on 11/6/18 at 3:53 P.M., 11/7/18 at 8:53 A.M. and 12:52 P.M., and 11/8/18 at
9:51 A.M., showed the resident had gray facial hair on his/her upper lip, chin, and on
both sides of the lower cheeks. The facial hair was approximately 1/2 inch long.
During an interview on 11/9/18 at 8:51 A.M., the resident said staff used to shave
him/her, but not anymore. They no longer offer to shave or do anything outside of bathing.
He/she would like for staff to shave his/her facial hair again.
During an interview on 11/13/18 at 9:00 A.M., the DON said she would expect staff to ask
all residents if they would like to be shaved. In addition to bathing, the residents are
expected to be groomed.
MO 762
MO 873

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to implement an
ongoing resident centered activity program that incorporates the resident’s interests to
maintain and/or improve a resident’s physical, mental and psychosocial well-being, for one
of one resident investigated for activities (Resident #139) of 29 sampled residents. The
census was 148.
Review of Resident #139’s annual Minimum Data Set (MDS), a federally required assessment
instrument completed by facility staff, dated 10/13/18, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 42)
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out
of a possible score of 15, which showed severe cognitive impairment;
-Mobility devices: Wheelchair;
-[DIAGNOSES REDACTED].
-Care Area Assessment (CAA) Summary Care Planning: Activities triggered, not care planned.

Review of the resident’s Pre-Admission Screening and Resident Review (PASRR, used to
determine the most appropriate care setting and services for a resident with mental
illness) Mental Illness (MI) Level II Evaluation, dated (MONTH) 26, (YEAR), showed:
-[DIAGNOSES REDACTED].
-History of symptoms: Crying out for several hours, throwing self onto the floor and
climbing out of bed;
-Communication ability: Communicates with difficulty. Non-verbal, yelling out, dancing in
wheelchair to music in the day room;
-Staff responses to maladaptive behaviors: One on one to communicate with the resident;
-Noted to move body to music when taken to community area by staff.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident is nonverbal and is provided socialization by staff and family to
provide socialization and conversations. He/she calms down when talked to by others.
He/she screams and yells a lot when he/she does not have attention provided or is
attempting to communicate with others:
-Goal: Psychosocial needs will be met and anticipated by staff and family;
-Approach: Talk with the resident while providing care;
-Activities not care planned.
Review of the resident’s Preference for Customary Routine and Activities assessment, dated
10/18/18, showed staff assessment of daily and activity preferences:
-Receiving showers;
-Snacks between meals;
-Staying up past 8:00 P.M.;
-Family or significant other involvement in care discussions;
-Listening to music and television;
-Spending time outdoors;
-Participating in religious activities or practices.
Review of the facility’s (MONTH) (YEAR) activity calendar, showed:
-Religious activities scheduled (MONTH) 6th, 7th, 13th, 14th, 20th, 21st, 27th and 28th
with no time specified and the 13th at 2:00 P.M.;
-Music and/or television activities scheduled (MONTH) 2nd, 4th, 9th, 11th, 18th, 23rd,
25th and 30th at 2:15 P.M.;
-Food/Snack activities scheduled (MONTH) 1st through 5th, 8th through 12th, 15th, 17th
through 19th, 22nd through 26th and 29th through 31st at 8:30 A.M., and the 2nd, 4th, 9th,
11th, 12th, 18th, 23rd, 25th and 30th at 2:15 P.M.;
-No late night activities scheduled past 8:00 P.M.
Review of the resident’s (MONTH) (YEAR) activity participation documentation, showed the
following activities:
-Socials/ice-cream: 10/3, 10/12 and 10/19/18;
-Coffee/news: 10/5 and 10/22/2018;
-One on ones: 10/29/18;
-Own agenda/television: Daily from 10/1 through 10/31/18;
-No documentation if the resident’s participation was active or passive.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 43)
Review of the resident’s one on one room visit documentation, dated 10/29/18 from 3:15
P.M. through 3:30 P.M., showed:
-Resident asleep;
-Woke up when music played;
-Eye contact-watch; facial expression; movement of shifting, nodding, shaking head or
participating.
Review of the resident’s (MONTH) (YEAR) activity participation documentation, reviewed on
11/9/18, showed the following activities:
-Coffee/news: 11/5/18;
-No documentation if the resident’s participation was active or passive.
Review of the resident’s one on one room visit documentation, dated 11/6/18 from 11:45
A.M. through 12:05 P.M., showed:
-Talked with the resident and fed him/her ice-cream;
-Eye contact.
Observations on 11/6/18 at 9:44 A.M. and 10:59 A.M. and 11/9/18 at 6:31 AM., showed the
resident in his/her room in his/her wheelchair and the resident yelled out. The television
on.
Observation on 11/6/18 at 11:05 A.M., showed a music activity taking place on the floor
for the residents. No staff assisted the resident to the activity and the resident
remained in his/her room and yelled out.
Observation on 11/7/18 at 3:47 P.M., showed the resident in his/her room in bed and yelled
out. The television on.
Observation on 11/13/18 at 6:57 A.M., showed the resident sat in a wheelchair in the hall.
Laundry staff passed out clean laundry to resident rooms. The resident yelled out as a
certified nursing assistant (CNA) walked by. The CNA failed to stop to acknowledge the
resident. Laundry staff stopped to talk to the resident and the resident stopped yelling
and appeared to watch the laundry staff with a relaxed look on his/her face. As the
laundry staff continued down the hall to pass out clean laundry, the resident again
started to yell. At 7:09 A.M., staff propelled the resident to the nurses’ station where
the radio was on behind the nurses’ desk. The resident stopped yelling and had a relaxed
look on his/her face.
During an interview on 11/13/18 at 8:01 A.M., MDS Coordinator K said he/she was not the
MDS coordinator who completed the annual MDS for the resident. The MDS coordinator before
him/her completed the MDS and he/she is not sure why they chose not to care plan
activities. The resident would benefit from care planned activities.
During an interview on 11/13/18 at 8:10 A.M., the activity director said the resident
likes television and the radio. He/she does not come down for group activities much
because he/she appears to become anxious in groups. It is hard to say if the resident
would benefit from one on one activities. The resident does enjoy when staff propel
him/her up and down the hall and sitting at the nurse’s station. Activity staff do provide
one on one on activities for the resident, sometimes. These are documented on the one on
one forms. The resident cannot communicate, but he/she will track staff with his/her eyes.
When activity staff visit with him/her they talk to him/her and ask him/her how his/her
day is going.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide
restorative therapy (RT, exercises, braces or splints used to main flexibility or
movement) as recommended by physical, occupational therapy to residents with limited
mobility for two of three sampled residents investigated for positioning and mobility
(Residents #1 and #139). In addition, the facility failed to develop and implement
policies on restorative/rehabilitative treatments/services, based on professional
standards of practice, including who may provide specific treatments and modalities. The
census was 148.
1. Review of Resident #1’s annual Minimum Data Set (MDS), a federally required assessment
instrument completed by facility staff, dated 10/21/18, showed:
-Total dependence on two person physical assist for transfers;
-Functional limitations in range of motion:
-Upper extremity: Impairment on one side;
-Lower extremity: Impairment on both sides;
-Mobility devices: Wheelchair;
-[DIAGNOSES REDACTED].
-Physical therapy end date, 9/20/18.
Review of the resident’s electronic medical record, showed;
-Medical [DIAGNOSES REDACTED].
-Physician order [REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: The resident requires total care with activities of daily living (ADLs)
[DIAGNOSES REDACTED].
-Goal: Staff will continue to provide total care with ADLs thru next review;
-Approach: Allow the resident to choose clothing appropriate for the season (there is no
approach related to range of motion (ROM);
-Restorative nursing not care planned.
Observation on 11/7/18 at 8:42 A.M., showed the resident lay in bed slightly on his/her
right side. The resident ate breakfast from his/her bedside table, using only his/her left
hand. The resident’s right arm contracted.
Observation on 11/7/18 at 3:43 P.M., showed the resident sat in his/her wheelchair in
his/her room. The resident watched his/her T.V. with the remote control in his/her left
hand. The resident’s right arm contracted.
2. Review of Resident #139 annual MDS, dated [DATE], showed:
-Functional limitation in range of motion:
-Upper extremity: Impairment on one side;
-Lower extremity: Impairment on both sides;
-Mobility devices: Wheelchair;
-[DIAGNOSES REDACTED].
-Physical therapy end date, 6/7/2018;
-Restorative nursing program: Not performed.
Review of the resident’s electronic and paper medical records, showed:
-Medical [DIAGNOSES REDACTED]. These non-bony tissues include muscle, ligaments, and
tendons) of muscle right upper arm;
-Occupational therapy (OT) discharge instructions dated 6/21/18, showed the resident will
remain in this facility with assistance from staff for ADLs and functional transfers.
Resident will continue with restorative nursing program 3 times a week as tolerated for
ROM and skin hygiene;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 45)
-PT discharge instructions, dated 6/15/18, showed the resident discharged to same location
with recommendations including establish restorative nursing program.
Review of the resident’s care plan, in use at time of the survey, showed:
-Problem: Resident requires total care with ADLs related to stroke;
-Approach: Total care in all aspects of ADL care;
-Resident has contractures of the right arm and hand;
-ROM to be provided with daily care as tolerated.
Review of the resident’s electronic and paper medical record showed, no documentation
staff assisted the resident with ROM with daily care as tolerated or how the resident
tolerated ROM.
Observation on 11/6/18 at 9:44 A.M. and 10:59 A.M., and 11/9/19 at 6:31 A.M., showed the
resident in his/her room in his/her wheelchair. All extremities contracted and the
resident yelled out.
3. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said:
-A resident’s care plan should reflect a process to prevent further decline in a
resident’s condition when a medical [DIAGNOSES REDACTED].
-The Assistant Director of Nursing (ADON) is responsible for looking at the PT, OT
discharge reports for recommendations;
-Currently, staff are not monitored to ensure they are accurately implementing ROM
exercises during care;
-Nursing staff is not documenting when assisting residents with ROM exercises during care,
nor how residents tolerate ROM;
-There is no restorative nursing program in place currently and she cannot recall the last
time the facility had a restorative therapist;
-The facility does not have a policy for Restorative/Rehabilitative treatments/services;
-Facility just became aware of the new requirement, which took effect last year in (MONTH)
(YEAR), that facility must develop restorative care policies on Restorative/Rehabilitative
treatments/Services, including who may provide specific treatments and modalities. As of
11/12/18, the facility is working on developing a new restorative program that has not yet
been implemented.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
resident environment remained as free of accident hazards as possible and each resident
received adequate supervision and assistance devices to prevent accidents by failing to
assure staff transferred residents safely based on facility policy and acceptable
standards of practice for two of three residents observed during transfers (Residents #139
and #114), failing to monitor a resident during smoking, per their plan of care (Resident
#1), failing to properly investigate falls and set interventions in place to prevent
future falls for three residents (Residents #1, #123 and #12) and failing to ensure
medications and/or razors were not left unattended and accessible to residents. The sample
size was 29. The census was 148.
1. Review of Resident #139’s annual Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 10/13/18, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 46)
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 0 out
of a possible score of 15;
-A score of 0-7, showed severe cognitive impairment;
-Total dependence on two-person physical assist for transfers;
-Functional limitation in range of motion:
–Upper extremity: Impairment on one side;
–Lower extremity: Impairment on both sides;
-Mobility devices: Wheelchair;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s current care plan, in use at the time of the survey, showed:
-Problem: Resident requires total care with activities of daily living (ADLs) related to
stroke:
–Goal: Be clean, odor free and well groomed;
–Approach: Total care in all aspects of ADL care;
—Resident has contractures (chronic loss of joint motion due to structural changes in
non-bony tissue. These non-bony tissues include muscle, ligaments and tendons) of the
right arm and hand;
—Range of motion (ROM) to be provided with daily care as tolerated;
—Totally dependent on one staff for transferring;
-Problem: Risk for falls: Limitations with lower extremities related to contractures:
–Goal: Remain free from injuries related to falls;
–Approach: Staff will assist the resident with transfers to bed within an hour of meals;
-The care plan failed to identify the resident’s transfer status.
Review of the resident’s physician order [REDACTED].
Review of the electronic medical record, showed the ADL: Transfers failed to identify the
resident’s transfer status and only indicated if staff transferred the resident.
Observation on 11/7/18 at 3:47 P.M., showed Certified Nursing Assistant (CNA) E and CNA J
transfer the resident from bed to the wheelchair. Without the use of a gait belt, CNA E
stood on one side of the resident and CNA J stood on the other side. Staff placed one arm
under the resident’s arm and grabbed onto the resident’s waste band with the other hand,
CNA E said one, two, three and staff picked the resident up out of the bed. The resident’s
extremities remained contracted. His/her knees bent in a sitting position and arms pulled
inward. During the transfer, the resident’s legs remained contracted up and his/her feed
did not touch the floor. Staff placed the resident in the wheelchair. CNA J said the
resident is supposed to be a two person assist, but staff can do it with one person if
needed.
2. Review of Resident #114’s quarterly MDS, dated [DATE], showed:
-Extensive assistance of two-person physical assist required for transfers;
-Mobility devices: Wheelchair.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: ADL self-care performance deficit related to [MEDICAL CONDITION] and limited
mobility. He/she requires assist with transfers and mobility;
-The care plan failed to identify the resident’s transfer status.
Review of the resident’s POS, showed no order for transfer status.
Review of the electronic medical record, showed the ADL: Transfers failed to identify the
resident’s transfer status and only indicated if staff transferred the resident.
During an interview on 11/7/18 at 7:20 A.M., CNA A said he/she just knows how to care for
residents. He/she knows how to care for resident because he/she had worked at the facility
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
for four years. The facility does not utilize care cards.
Observation on 11/7/18 at 7:24 A.M., showed CNA A provided care to the resident and
transferred the resident to his/her wheelchair. CNA A assisted the resident to sit on the
edge of his/her bed by pulling on the resident’s hands and sat the resident on the side of
the bed. The resident unable to remain in a seated position and started to fall back and
to the side. CNA A grabbed the resident by the back of his/her neck and pulled the
resident up into a sitting position. CNA A placed a gait belt around the resident’s waste.
As he/she did this, the resident began to slouch and fall over to the side. The resident
remained in a tilted slouched position in the bed as CNA A placed the resident’s
wheelchair against the wall and said the resident’s wheelchair don’t lock so he/she has to
prop it against the wall. CNA A said he/she put in a requested for maintenance to fix it
yesterday, but it had been broken for one or two weeks. CNA A straddled the resident and
instructed the resident to hold on to his/her waste and picked up the resident with the
use of the gait belt. The resident did not bear weight. CNA A twisted the resident and the
tips of the resident’s feet remained on the floor, twisted slightly from the direction of
his/her legs and body. After several prompts from CNA A, given as he/she held the resident
up with the use of the gait belt, the resident was able to pivot his/her feet so they were
no longer twisted. CNA A placed the resident in the wheelchair. He/she then placed the
left foot rest on the resident’s wheelchair, placed his/her left foot on the foot rest and
then placed the right foot on top of the left foot. CNA A said the wheelchair was broken
and the right foot rest no longer connected to the wheelchair. CNA A propelled the
resident out of the room and into the hall with both feet on one foot rest.
3. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said a
resident’s transfer status should be included in the care plan. A resident’s transfer
status is based on the resident’s physical ability to transfer. Staff know how to transfer
a resident by looking in the ADL section of the electronic medical record. This is also
passed on in report. For a gait belt transfer, residents should be able to bear weight.
Staff should use a gait belt. If a resident is unable to bear weight, she would expect
staff to get them in a safe position and get help. Staff should not pull on a resident’s
hands or neck to assist to sit them to sit up. A resident’s feet should touch the floor
during a transfer unless they are contracted. Then two people can just lift them. Everyone
is responsible to make sure residents can be transferred safely. Staff should not pick
residents up by their waste band. Staff should not pick residents up under their arms
because this could cause injury to the residents or staff. She was not aware that
acceptable standards of practice indicate a resident should be able to bear weight and
assist in transfers to qualify for a gait belt transfer.
4. Review of the facility’s Lifting and Transferring Residents policy, dated 1/1/06,
showed:
-All residents requiring assistance with mobility should be lifted and transferred safely;
-Members of the nursing staff are responsible for using good body mechanics, knowing the
proper transfer procedures and properly operating assistive devices. Residents are
assessed by the nursing and/or therapy departments for lifting and transfer needs and for
the most appropriate transfer method(s);
-For residents requiring assistance in lifts and transfers, a gait/transfer belt or
mechanical lift should be used;
-Assess the resident to determine physical limitations and ability to follow directions;
-The method for transfer and/or lift that is appropriate for each resident can be found in
individual resident care plans;
-Lock wheels on bed and/or wheelchair;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 48)
-The resident’s hands should remain free during the transfer;
-Staff should not place their hands under a resident’s arms or shoulders in order to
prevent shoulder injury;
-Grasp transfer belt from underneath;
-The policy failed to identify that residents transferred with the use of a gait belt must
be able to bear weight or what qualified or disqualified a resident from using a gait belt
transfer.
5. Review of Resident #1’s annual MDS, dated [DATE], showed:
-Total dependence on two person physical assist for transfers;
-Functional limitations in range of motion:
-Upper extremity: Impairment on one side;
-Lower extremity: Impairment on both sides;
-Mobility devices: Wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident has a habit of removing his/her seatbelt while propelling
himself/herself throughout unit and with family;
-Goal: The resident will have no major injuries related to non-compliance of seatbelt use;
-Approach: Staff will reinforce the resident to use his/her seatbelt properly;
-Problem: Resident is at risk for falls due to [DIAGNOSES REDACTED].>-Goal: Resident
will not sustain serious injury through the review date;
-Approach: Frequently check to see if self-release belt is in place;
-Approach: Educate staff to use gait belt during transfers and assist of 2 person for all
transfers;
-The care plan failed to identify the resident’s transfer status.
Review of the resident’s electronic and paper medical records, showed:
-Incident note dated 5/20/18, showed, the resident was observed laying on the ground on
the outside patio. Resident laying on his/her left side, with his/her feet entangled in
the footrest of his/her wheelchair. Another resident was pushing the resident in his/her
wheelchair when he/she fell out;
-Fall investigation report dated 5/20/18, showed the fall was witnessed by a resident;
-No neurological checks (neuro-checks) an assessment completed by nursing staff to
monitor for changes in the resident’s neurological (nervous system) status) for the fall
on 5/20/18;
-The outcome of the fall investigation report not documented;
-Incident note dated 6/26/18, showed, the resident was observed lying on his/her right
side on ground in front of the activity room. The resident was being propelled in a
wheelchair when he/she fell forward. Safety belt was unattached. The resident stated
he/she hit his/her head. There was a dime sized raise area on the resident’s right brow
and forehead;
-No fall investigation report for 6/26/18;
-No neuro-checks for 6/26/18;
-Incident note dated 9/13/18, showed, the resident was lowered to the floor and sat on
his/her buttocks by nursing staff while performing a two person transfer from the wheel
chair to the floor for safety;
-The care plan was not updated after the fall during transfer on 9/13/18;
-The outcome of the fall investigation report was not documented.
Review of the resident’s electronic medical record ADL transfer documentation, dated 10/31
to 11/12/18, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 49)
-No order for transfer status;
-Staff documented extensive assistance (resident involved in activity, staff provide
weight bearing assistance) for transfers.
Observation on 11/7/18 at 10:16 A.M., showed CNA T and CNA U transferred the resident from
the bed to the shower chair using a mechanical lift.
Observation on 11/7/18 at 3:33 P.M., showed CNA J and CNA V transferred the resident from
the wheelchair to the bed using a mechanical lift.
During an interview on 11/7/18 at 7:23 A.M., CNA D said the resident is the only resident
transferred with a mechanical lift on the unit.
Further review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Resident smokes daily, is at risk for burns/injuries and has been noted to
remove his/her safety apron while smoking causing [MEDICAL CONDITION] his/her skin;
-Goal: Resident will not smoke without supervision through the next review date;
-Approach: Resident requires supervision while smoking.
Review of the resident’s electronic and paper medical records, showed:
-Incident note dated 5/4/18, showed, the resident was in the smoking room when he/she
removed his/her smoking apron thinking the cigarette was out and burned his/her right
thigh. Upon assessment, blistering was found to his/her right thigh;
-Smoking investigation report dated 5/4/18, showed:
-No witnesses found to incident;
-Resident has short attention and memory span;
-Resident dropped lit ash from cigarette onto his/her right thigh;
-The outcome of the smoking investigation report was not documented.
During an interview on 11/9/18 at 9:00 A.M., the DON said she expects nursing staff to
read and follow resident’s care plans regarding need of supervision during smoking.
Nursing staff are expected to know each resident’s care plan and they can access care
plans in the electronic medical record. Care plans are person centered, and based on
medical needs and personal wishes.
Review of the facility’s Smoking policy, dated 8/20/15, showed:
-All residents must be supervised while smoking, therefore smoking activity will be
conducted in designated areas during designated times, as assigned by the facility.
6. Review of Resident #123’s electronic face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s annual MDS, dated [DATE], showed:
-BIMS score of 00 out of 15, showed the resident with severe cognitive impairment;
-Had two non-injury falls since last assessment;
-Required limited assist of one staff for bed mobility and locomotion on the unit;
-Required extensive assist of two staff for transfers and toileting;
-Totally dependent on staff for dressing and bathing.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Focus: At risk for falls. Unaware of safety needs. Ambulates with a forward bent posture.
At risk for falls related to history of falls. History of falls in room related to
ambulating without assistance and will also get out of the wheelchair and ambulate in the
hall without assistance;
-Goal: Be free of serious injuries related to falls;
-Approach: Anticipate needs, call light in reach and encourage use. Ensure appropriate
footwear. Follow fall protocol. Uses wheelchair for mobility. Provide activities that
minimize the potential for falls while providing diversion and distraction.
Review of the facility’s incident list for last 6 months, provided on 11/6/18 at 3:18
P.M., showed the following for the resident un-witnessed falls on 7/3/18, 7/15/18 and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 50)
9/10/18.
Review of the resident’s progress notes, showed:
-On 7/3/16 at 8:27 A.M., The resident was alert and oriented to self. Resident remains on
observation charting. Resident was asleep halfway through the night then the resident was
found on floor. Range of motion performed on all four extremities passively and actively.
No facial grimacing noted and no moaning at this time. Non-compliant with vital signs for
neuro-checks. Resident up to wheel chair at the nurse’s station. Resident said his/her
bottom hurt. Pain medication provided;
-On 7/15/18 at 14:32, Resident found on the floor in another residents room around 11:00
A.M. today. No apparent injuries observed. Found on his/her buttocks, legs extended out in
front of him/her. Remains alert to self, unable to describe how he/she got onto the floor.
Active range of motion remains to all extremities. No bruising or open areas observed. The
resident’s nurse practitioner notified, no new orders. Neuro-checks initiated. Call placed
and message left for the resident’s family member;
-9/10/8 at 5:25 A.M., at 3:45 A.M., the resident was observed sitting on floor next to bed
on pad leaning back. Neuro-checks adequate, vital signs, range of motion are all within
the resident’s normal limits. Respiration are even non-labored. Skin warm and dry to
touch. Resident refused as needed pain medications resident denies pain at this time. The
physician and resident’s family member aware of above.
During an interview on 11/13/18 at 8:43 A.M., the DON said the fall documentation that had
been provided was the only fall documentation the facility had for this resident. There
was no fall occurrence report for the 7/3/18 fall.
Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/15/18 showed:
-The resident had an unwitnessed fall on 7/15/18;
-Upon entering the room, the resident was found sitting on the ground, with his/her legs
extended out in front of him/her;
-The resident was unable to state what occurred;
-ROM was performed and the resident was assisted into a wheelchair;
-No injuries were observed at the time of the incident;
-The resident was alert at the time of the incident;
-The resident used a wheelchair for mobility at the time of the incident;
-Mental status at the time of the incident: Oriented to person;
-No injuries noted post incident;
-The resident was alert and wheelchair bound post incident;
-Predisposing environmental factors: Wet floor;
-Predisposing physiological factors: Confused, impaired memory and weakness/fainted;
-Predisposing situation factors: Wanderer;
-Witnesses: No witnesses;
-No cause determination, and no interventions taken at the time of the incident and/or
post incident noted.
During an interview on 11/8/18, the DON said she did not know how the floor was determined
to be wet, the nurse must have seen water on the floor or they would not have put it in
the report.
During an interview on 11/13/18 at 7:40 A.M., CNA AA said he/she was not present at the
time of the fall and did not know any information, including how the facility determined
the floor was wet.
During an interview on 11/13/18 at 7:48 A.M., Nurse BB said he/she was not present and
does not know any information on the fall, including how they facility determined the
floor was wet.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 51)
Record review of the resident’s Unwitnessed Fall Occurrence Report, dated 9/10/18, showed:

-The resident had an unwitnessed fall on 9/10/18;
-The resident was found in a sitting position leaning back on bed on pad. The bed was in
the lowest position;
-The resident was unable to state what occurred;
-Neuro checks, vital signs and ROM were performed;
-No injuries were observed at the time of the incident;
-The resident’s consciousness and mobility at the time of the incident: Blank;
-Mental status at the time of the incident: Blank;
-No injuries noted post incident;
-The resident’s consciousness and mobility post incident: Blank;
-Predisposing environmental factors: None;
-Predisposing physiological factors: None;
-Predisposing situation factors: Other;
-Other information: Trying to get out of bed without assistance;
-Witnesses: No witnesses;
-No cause determination, and no interventions taken at the time of the incident and/or
post incident noted.
Review of the resident’s fall risk assessment, dated 10/5/18, showed high risk for falls.
Further review of the resident’s current care plan, in use at time of the survey, showed
no updated interventions after the 7/3, 7/15 and 9/10/18 falls.
Review of the medical record, showed no neurological flow sheets completed for the
resident’s unwitnessed falls on 7/3, 7/15 and 9/10/18.
Observation on 11/06/18 at 12:38 P.M., showed the resident sat in his/her wheelchair in
the dining room and fed himself/herself meatloaf, mixed vegetables and mashed potato
without difficulty. On 11/7/18 at 10:18 A.M., the resident sat in his/her wheelchair in
his/her room
During an interview on 11/13/18 at 7:48 A.M., Registered Nurse (RN) BB said staff know how
to care for residents by looking at the care plan and any day to day report. When a
resident falls, the nurse is responsible to assess the resident, complete the fall report,
notify management/family/physician, and complete neuro checks if the resident hit their
head or the fall was unwitnessed.
During an interview on 11/13/18 at 8:43 A.M., the DON said the fall documentation,
including neuro checks that had been provided was the only fall documentation the facility
had for this resident.
7. Review of Resident #12’s electronic face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE] showed:
-BIMS score of 8 out of 15, indicates moderate cognitive impairment;
-Independent with all ADLs.
Review of the resident’s care plan, in use at the time of survey, showed:
-Focus: The resident has the potential to be physically injured related to wandering into
others rooms and removing their property. He/she takes other residents clothing and other
items that he/she likes;
-Goal: The resident will not harm self or others through the review date;
-Interventions: Staff will encourage and redirect the resident out of other resident’s
rooms/personal space as needed.
Review of the facility’s incident list for last 6 months, showed the following for the
resident. Un-witnessed falls on 7/31/18 and 8/11/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 52)
Review of the resident’s progress notes, showed:
-On 7/31/2018 at 9:22 A.M., the resident was screaming very loudly and this writer went
down the hall to find him/her. He/she was lying on the floor in another resident’s room
screaming and moving around on the floor. When asked what happen he/she stated he/she
pushed me down. I am hurting. ROM initiated and he/she was able to move all extremities
without complaints of pain and no difficulties, grimacing or indication of pain exhibited.
Assisted off of the floor by two staff and assisted into a wheelchair;
-On 8/1/2018 at 10:36 P.M., Resident alert to self and is confused, redirected several
time throughout shift from other peoples room.
-On 8/2/2018 at 3:12 A.M., day 2/3 Incident follow up: Resident in bed, no acute distress
noted. No signs behavior at this time.
Review of the resident’s Unwitnessed Fall Occurrence Report, dated 7/31/18, showed:
-The resident had an unwitnessed fall on 7/31/18;
-Upon entering the room, the resident was found lying on his/her back on the ground,
screaming he/she pushed me down and moving;
-The resident stated that he/she was pushed down while in another resident’s room;
-ROM was performed and the resident was assisted into a wheelchair by two staff members;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident: Blank;
-Mental status at the time of the incident: Oriented to person;
-No injuries noted post incident;
-Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing
environmental factors: Wet floor;
-Predisposing physiological factors: Confused, impaired memory and weakness/fainted;
-Predisposing situation factors: Wanderer and ambulating without assistance;
-Other information: The resident wanders into other resident’s rooms;
-Witnesses: No witnesses;
-No cause determination, and no interventions taken at the time of the incident and/or
post incident noted.
Record review of the resident’s progress notes, showed:
-On 8/11/18 at 1:16 P.M.: Reported this resident was observed sitting on the floor in
his/her room. Denies any pain, no signs or symptoms of distress or discomfort. ROM within
normal limits, skin warm dry and intact. No discoloration noted. Able to and ambulate with
no assistance. Neuro checks started. The physician was notified with no new orders
receive. The resident’s family called, message left.
Review of the resident’s Unwitnessed Fall Occurrence Report, dated 8/11/18 showed:
-The resident had an unwitnessed fall on 8/11/18;
-Observed sitting on the floor in his/her room;
-The resident was unable to state what occurred;
-Physical assessment complete. Neuro checks started;
-No injuries were observed at the time of the incident;
-The resident was alert and ambulatory without assistance;
-Mental status at the time of the incident: Oriented to person;
-No injuries noted post incident;
-Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing
environmental factors: Blank;
-Predisposing physiological factors: confused and incontinent;
-Predisposing situation factors: Blank;
-Witnesses: No witnesses;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 53)
-No cause determination, and no interventions taken at the time of the incident and/or
post incident noted.
Review of the resident’s current care plan, in use at time of the survey, showed no
updated interventions after the fall on 7/31 and 8/11/18.
Review of the medical record, showed no neurological flow sheets completed for the
resident’s unwitnessed falls on 7/31 and 8/11/18.
Observation on 11/07/18 at 7:38 A.M., showed the resident sat at a table in the dining
room. Another resident kept repeating the same phrase over and over. The resident appeared
to get agitated and yelled at the other resident. Numerous staff attempted to calm the
resident. The resident’s meal was served, the resident ate fast and left the dining room.
During an interview on 11/13/18 at 7:40 A.M., CNA AA said the resident wanders into other
resident rooms, once staff hear him/her hollering out, staff will go get him/her and take
him/her to the day area or dining room.
During an interview on 11/13/18 at 8:43 A.M., the DON said the fall documentation,
including neuro checks that had been provided was the only fall documentation the facility
had for this resident.
8. During an interview on 11/9/18 at 9:00 A.M., the DON said if a resident requires a
mechanical lift it should be in the care plan. The care coordinator updates all care plans
and informs staff of changes. The expectation is for care plans are accurate. Transfer
orders are noted for resident in the ADLs found in the electronic medical record.
Resident’s transfer status is determined based on their needs and abilities. The DON
expects nursing staff to notice change in ADLs and report it to the nurse. The expectation
of nursing staff regarding unwitnessed falls is to for the nurse to assess the environment
to find the cause for the fall, ask the resident what happened, and monitor for injury and
conduct neuro checks for 72 hours. The outcome of an investigation should be in the
investigation report and then updated in the resident’s care plan.
9. Review of the facility’s Neurological Observations policy, dated 8/5/13, showed:
-The purpose of this procedure is to provide guidelines for neurological assessment: 1)
upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with
a suspected head injury; or 4) when indicated by resident condition;
-Any change in neurological status should be reported to the physician immediately;
-Documentation of neurological assessment and observations should be documented in the
resident’s medical record. A flow sheet designated to record pertinent assessment
information may be used and placed in the resident’s medical record upon completion;
-Neurological assessments implemented in response to an unwitnessed fall or a fall with a
suspected head injury will be performed for at least 48 hours;
-If a resident refuses to participate or allow a neurological assessment to be completed,
refusal should be documented in the resident’s record and the physician notified;
-Procedure:
-Obtain a copy of the Neurological Observation Flow Sheet for guidance;
-On the initial assessment, obtain a full set of vital signs, to include orthostatic
blood pressure and pulse and check the resident’s blood sugar level;
-Document in the clinical nurses notes every shift x72 hours.
Review of the Neurological Observation Flow Sheet, showed:
-A neurological observation includes the date, time, temperature, respirations, pulse,
blood pressure, level of consciousness, orientation, pupil reaction, extremity motor
functions, pain response, observations and nurse initials;
-Neurological observations scheduled to be completed initially, every 15 minute times
three, every 30 minutes times two, every four hours times four and every eight hours times
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 54)
four.
10. Review of the facility’s Fall Prevention policy, dated 10/28/03, showed:
-This facility is committed to establishing guidelines to minimize falls and their effects
so as to maximize every resident’s wellbeing;
-The care plan coordinator is responsible for all care plan updates related to fall
prevention efforts;
-A narrative summary, written in the nurses notes, shall follow each fall event and shall
include at a minimum: Date and time, brief narrative that describes the details of the
incident, vital signs, level of consciousness/emotional state of the resident at the time
of the fall, reports of pain, any injuries, assistance or care given in response to the
fall, the residents response to this care, notification to the physician and responsible
party;
-Follow-up documentation for each separate fall event shall, at a minimum, be completed
once each shift for 72 hours post fall. This should include at a minimum: Vital signs,
level of consciousness/emotional state, assessment and description of any previous
injuries and/or new injuries;
-Within 24-48 hours of a fall event, facility nursing administrative personnel will review
the fall risk assessment in conjunction with the fall event documentation to verify that
the assessment remains an accurate reflection of the resident’s risk factors;
-Care plans for any resident experiencing a fall event will be updated to reflect the
fall, any newly identified risk factors and interventions designed to prevent
reoccurrences.
11. Observation on the second floor locked unit, on 11/8/18 at 4:27 P.M., showed Licensed
Practical Nurse (LPN) CC at a medication cart. A pack of resident medications sat on the
top of the cart. LPN CC took a resident into the shower room to provide care and left the
medication unattended and on top of the medication cart. Residents moved independently
throughout the unit. He/she returned to the medication cart after providing care, gathered
supplies and took another resident to the shower room to provide care. The medications
remained unattended on the medication cart.
During an interview on 11/9/18 at 9:00 A.M., the DON said medications should be locked
inside the medication cart and should not be left unattended.
12. Observation of the second floor locked unit shower room, on 11/8/18 at 4:27 P.M.,
showed LPN CC entered the shower room to provide care to a resident. The shower room
unlocked and accessible to residents who resided on the locked unit. Three used razors
located in the sink and accessible to residents. After providing care, LPN CC assisted the
resident out of the shower room. The razors remained in the sink. Residents moved
independently throughout the unit. At 4:43 P.M., LPN CC returned to the shower room with
another resident to provide care. After providing care to the resident, LPN CC exited the
shower room with the resident. The razors remained in the sink.
During an interview on 11/9/18 at 9:00 A.M., the DON said used razors should be placed in
the sharps container and should not be accessible to residents.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 55)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
insertion of an indwelling urinary catheter (a tube inserted into the bladder for the
purpose of continual urine drainage). The facility identified one resident with an
indwelling urinary catheter. That one resident was chosen for the sample and did not
receive the appropriate indwelling catheter as ordered (Resident #64). In addition, the
facility failed to provide appropriate perineal care for one of six residents observed
during personal care who had been incontinent of urine (Resident #114). The sample was 29.
The census was 148.
1. Review of Resident #64’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/30/18, showed:
-[DIAGNOSES REDACTED].
-Cognitively intact;
-No behaviors;
-Indwelling urinary catheter;
-Range of motion impairments on both sides of upper and lower extremities;
-Required total assistance from the staff for transfers, dressing, hygiene and bathing.
Review of the resident’s electronic physician order [REDACTED].
-An order dated 3/26/18, to flush and irrigate the indwelling urinary catheter with 60
cubic centimeters (cc) of normal saline twice a day;
-An order dated 4/6/18, to change the indwelling urinary catheter monthly on the 6th and
as necessary. Place a French #16 (size) catheter with a 10 cc balloon (amount of fluid
used to inflate the balloon which holds the catheter in the bladder);
-An order dated 10/6/18, to change the indwelling urinary catheter monthly on the 6th and
as needed with a #16 French catheter with a 10 cc balloon.
Review of the resident’s undated care plan, in use during the survey, showed:
-Problem: Resident has an indwelling catheter in place. Has [DIAGNOSES REDACTED].
-Goal: Resident will show no signs or symptoms of urinary infection;
-Interventions included: Change Foley catheter monthly and as needed, irrigate Foley daily
with 60 cc normal saline, monitor document for pain or discomfort due to catheter and
monitor and report to physician for signs/symptoms of urinary tract infection.
Review of the resident’s progress notes, showed:
-On 7/22/18 at 6:00 P.M., Foley catheter has been replaced, #16 French with a 30 cc
balloon, resident tolerated well;
-On 10/5/18 at 4:23 P.M., #17 French catheter was accidentally pulled out during transfer
from chair to bed. #17 French intact and balloon was still inflated with 2 cc of saline.
#18 French catheter inserted without difficulty at 4:20 P.M.;
-On 10/17/18 at 4:43 A.M., Returned from hospital emergency room . New [DIAGNOSES
REDACTED].#16 French catheter to gravity and draining yellowish – red cloudy urine;
-On 10/21/18 at 10:16 P.M., Resident complained of pressure and discomfort at 3:45 P.M.
Resident catheter flushed with 60 cc normal saline, 30 cc instilled with difficulty and 30
cc spilled out. Removed catheter with a 5 cc balloon. Inserted a #18 French catheter with
10 cc of normal saline in the balloon;
-On 11/6/18 at 11:03 A.M., withdrew 5 cc of clear liquid from balloon of Foley catheter,
removed a #18 French catheter without difficulties using sterile technique. Inserted a #18
French with a 5 cc balloon without difficulties. Catheter draining yellow urine to gravity
without difficulties.
Observation on 11/6/18 at 10:22 A.M., on 11/7/18 at 7:10 A.M., and on 11/8/18 at 7:53
A.M., showed the resident lay in bed. An indwelling urinary catheter tubing hung over the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 56)
side of the bed and went into a drainage bag inside a blue privacy bag on the side of the
bed. The tubing contained a clear, light yellow colored urine.
During an interview on 11/9/18 at 9:45 A.M., the Director of Nurses (DON) looked at the
resident’s indwelling urinary catheter orders and verified the order was for staff to
insert a #16 French Foley catheter with a 10 cc balloon. She looked at the progress notes
and verified staff documented they inserted a French #16 with a 30 cc balloon, a French
#17 and a French #18 with a 5 cc and a 10 cc balloon. She said staff do not have any #17
French Foley catheters in the facility and was not aware that there was such a size. She
verified that Nurse P had changed the resident’s indwelling catheter on 11/6/18.
During an interview on 11/9/18 at 10:10 A.M., Nurse P said he/she changed the resident’s
indwelling urinary catheter on 11/6/18, inserted a #18 French Foley with a 10 cc balloon.
He/she thought the order was for a #18 French, then said they did not have any #16 French
Foley catheters and he/she forgot to call the physician to get the order changed.
During an interview on 11/13/18 at 9:05 A.M., the DON said she would expect staff to
follow the physician orders [REDACTED].
2. Review of Resident #114’s quarterly MDS, dated [DATE], showed:
-Extensive assistance of two-person physical assist required for transfers;
-Mobility devices: Wheelchair.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Activities of Daily Living (ADL) self-care performance deficit related to
[MEDICAL CONDITION] and limited mobility. He/she requires assist with transfers and
mobility;
-Goal: Be clean, odor free and well groomed;
-Approach: Clean and bathe daily and as necessary.
Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A provided
care to the resident. The resident incontinent of urine. CNA A said the resident did not
have a wash basin and there were no extra ones on the floor, so he/she would have to
prepare the washcloths in the resident’s bathroom. CNA A used soap and water to wash the
resident’s abdominal folds and groin, rinsed with water and dried with a towel. He/she
then used water only to cleanse the resident’s genitals. No soap used. CNA A assisted the
resident to reposition and used soap and water cleanse the resident’s buttocks, rinsed
with water and dried with a towel.
During an interview on 11/13/18 at 9:00 A.M., the DON said when providing care, she would
expect staff to use soap and water, not just water. All soiled areas should be cleaned.
Review of the facility’s Perineal Incontinence Care policy, dated 1/1/06, showed:
-Standard: To provide cleanliness and comfort, prevent irritation and infection in the
perineal area during the daily bath and after voiding or defecating;
-Wet washcloth in the basin and then add a small amount of soap or perineal wash;
-Cleanse with the washcloth;
-If soap was used, rinse the washcloth and rinse all areas of soap thoroughly;
-Pat the area dry.

F 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that feeding tubes are not used unless there is a medical reason and the
resident agrees; and provide appropriate care for a resident with a feeding tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 57)
provided care and services to a resident who has a feeding tube, utilizing facility
protocols and staff were competent in the facility protocols to prevent potential
complications, to include occlusion of the tube. During medication administration through
a gastrostomy tube ([DEVICE], a tube that is placed directly into the stomach through an
abdomen wall incision for administration of food, fluids and medications), staff failed to
ensure medications were diluted and a flush administered between medications. This
resulted in the [DEVICE] becoming clogged and staff forcing medications through the tube
with a syringe for one resident observed to receive medications through a [DEVICE] of the
two residents the facility identified as receiving tube feedings (Resident #131). The
census was 148.
Review of Resident #131’s physician order [REDACTED].
Observation on 11/7/18 at 8:12 A.M., showed Licensed Practical Nurse (LPN) G administered
medications to the resident through the resident’s [DEVICE]. LPN G pulled up vitamin C 500
mg one tablet, [MEDICATION NAME] 10 mg two tablets, [MEDICATION NAME] 600 mg one tablet,
[MEDICATION NAME] 500 mg one tablet and Tylenol 325 mg two tablets. LPN G crushed each
individual medication and placed each medication in an individual plastic medication cup.
He/she opened the Juven packet and poured the powdered supplement into a small drink cup.
LPN G added approximately 90 milliliters (ml) of water to the Juven powder. He/she failed
to dilute the crushed pills. LPN G entered the resident’s room, disconnected the tube
feeding, checked placement and flushed the [DEVICE] with approximately 30 ml of water per
gravity. He/she then administered the first medication, in powder form, into the syringe
that was connected to the [DEVICE], followed by approximately 30 ml of water. He/she
swirled the medication several times until the pill was diluted enough to administer per
gravity. LPN G used the same technique for the second medication. After pouring the third
powder medication into the syringe, adding approximately 30 ml of water and swirling the
syringe, LPN G said I have to shake it up so it don’t settle. I don’t think the vitamin C
likes us today, it won’t go down. It is stuck in the tip of the syringe. LPN G used the
syringe plunger to force the medication through the [DEVICE]. LPN G used the same
techniques of adding the powder medication, adding approximately 30 ml of water, swirling
the syringe and then using the plunger to force the fourth medication. After pouring the
powdered medication, adding approximately 30 ml of water and swirling the syringe for the
fifth medication, LPN G flicked the syringe, which contained an occlusion of thick powder
in the tip of the syringe and said why does it have to get stuck? We have this problem
every day. He/she used the plunger to force the medication down the [DEVICE]. LPN G
administered the diluted Juven. The Juven did not easily flow into the [DEVICE]. LPN G
said Seriously! Now this will clog up? After swirling the Juven, the supplement eventually
went into the [DEVICE] per gravity. LPN G flushed the [DEVICE] with approximately 60 ml of
water and reconnected the tube feeding. LPN G failed to flush the [DEVICE] with water
between medications.
During an interview on 11/8/18 at 9:56 A.M., the Director of Nursing said when
administering medications through a [DEVICE], medications should be diluted in water prior
to administering. A flush should be given between medications. A plunger should not be
used to force medications in the [DEVICE].
Review of the facility’s undated Medication Administration Enteral Medications policy,
showed:
-Policy: All enteral medications will be administered in a safe, efficient and accurate
manner to residents for whom they are prescribed and in accordance with current acceptable
nursing practice;
-Medications administered via enteral tube should be diluted with warm liquids;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0693

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 58)
-Crushed medications should be as finely pulverized as possible and should be diluted with
5 to 10 ml of warm water for instillation into the tube;
-Instill the medication into the syringe, hold it slightly above the level of the abdomen
and unclamp the tube, allowing the fluid to flow by gravity into the stomach;
-If more than one medication is being administered, then give each medication separately
and flush the tube with approximately 5 ml of warm water between each medication.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, on-going monitoring and communication with the [MEDICAL TREATMENT] center.
The facility identified four residents who received [MEDICAL TREATMENT]. Of those four,
two were chosen for the sample and issues were found with both residents (Residents #57
and #142). The sample was 29. The census was 148.
1. Review of Resident #57’s significant change Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, dated 8/24/18, showed:
-[DIAGNOSES REDACTED].
-Special treatment for [REDACTED].
Review of the resident’s electronic Physician order [REDACTED].
-An order, dated 8/23/18, to send the resident to [MEDICAL TREATMENT];
-No order the frequency of the [MEDICAL TREATMENT];
-No order to check the arteriovenous (AV) fistula (connection or passageway between an
artery and a vein, surgically created for [MEDICAL TREATMENT] treatments) for bruit/thrill
(the thrill is the vibration you feel as blood flows through the fistula. The bruit is the
sound you hear, heard with a stethoscope);
-No order to check the AV fistula for signs/symptoms of infection and bleeding.
Review of the resident’s care plan, in use during the survey, showed staff did not care
plan the resident for [MEDICAL TREATMENT].
Review of the resident’s progress notes, showed:
-No documentation of assessment and/or monitoring of the fistula;
-No documentation of assessing the fistula for bruit and thrill;
-No documentation of assessing for signs and symptoms of infection and bleeding;
-No documentation of assessing the resident for pain before and after [MEDICAL TREATMENT];
-No documentation of communication between the [MEDICAL TREATMENT] center and facility.
Observation on 11/6/18 at 12:31 P.M., and on 11/8/18 at 7:29 A.M., showed the resident had
an AV fistula in his/her left arm.
2. Review of Resident #142’s electronic face sheet, showed he/she was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].
Review of the resident’s POS, in use during the survey, showed:
-[MEDICAL TREATMENT] every Tuesday, Thursday, Saturday. Pickup at 10:30 A.M.;
-Assess and document thrill and bruit to left AV shunt every shift;
-Renal diet, mechanical soft texture, regular consistency.
Review of the resident’s care plan, in use during the survey, showed:
-Focus: The resident has a [DIAGNOSES REDACTED].>-The resident receives [MEDICAL
TREATMENT] treatments at a [MEDICAL TREATMENT] center on Tuesdays, Thursdays and
Saturdays;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 59)
-The resident has a history of refusing to go to [MEDICAL TREATMENT] which increases
his/her risk for complications such as fluid overload and toxicity;
-The resident also has a history of refusing his medications;
-Goal: The resident will have no signs or symptoms of complications from [MEDICAL
TREATMENT];
-Interventions: Do not draw blood or take a blood pressure in the arm with the shunt.
Educate the resident on the importance of keeping his/her [MEDICAL TREATMENT] schedule.
Monitor and document bruit and thrill at [MEDICAL TREATMENT] shunt. Notify the physician
of any abnormalities. Monitor for dehydration signs and symptoms such as tenting skin,
abnormal labs, dry mucus membranes, decrease intake and output, and increase in confusion.
Notify the physician if present. Monitor for dry skin and apply lotion as needed. Monitor
labs and report to the physician as needed. Monitor vital signs. Notify the physician of
significant abnormalities. Monitor/document/report, as needed, any new or worsening
[MEDICAL CONDITION].
Review of the resident’s nursing notes, dated 10/1/18 through 11/9/18, showed no notes
indicating results of the thrill and bruit checks, shunt site assessments, intake and
output amounts, pain related to [MEDICAL TREATMENT], pre and post [MEDICAL TREATMENT]
vital signs and pre and post [MEDICAL TREATMENT] weights.
During an interview on 11/7/18 at 10:18 A.M., the resident said:
-Staff does check his/her shunt. He/she does not know how often;
-The facility does not weigh him/her before or after [MEDICAL TREATMENT];
-Staff does not check his/her vital signs before or after [MEDICAL TREATMENT];
-Observation of the resident’s left AV shunt showed no redness, and the dressing was
clean, dry and intact.
Review of the resident’s [MEDICAL TREATMENT] communication forms for 10/1/18 through
11/7/18, showed the facility sent the paperwork to the [MEDICAL TREATMENT] clinic for some
visits but not all visits. The [MEDICAL TREATMENT] clinic did not fill out their section
and returned it with just the information the facility placed on it prior to [MEDICAL
TREATMENT].
3. During an interview on 11/9/18 at 9:45 A.M., the Director of Nurses (DON) said she
could not find any documentation for assessment of the residents’ AV fistula, would expect
staff to document in the progress notes every shift for thrill, bruit, any signs or
symptoms of bleeding, infection, or pain. The POS should include how often and time for
[MEDICAL TREATMENT] as well as for the assessment. She would also expect staff to care
plan the resident for [MEDICAL TREATMENT] treatment.

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure that nurses and nurse aides have the appropriate competencies to care for every
resident in a way that maximizes each resident’s well being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure that all
nursing staff possessed the competencies and skill sets necessary to provide nursing and
related services to meet the residents’ needs safely and in a manner that promotes each
resident’s rights, physical, mental and psychosocial well-being by failing to assure staff
were competent in safe transfer techniques and the ability to assess a residents ability
to safely transfer. In addition, the facility failed to assure staff were competent in the
facility abuse protocols related to resident to resident abuse and resident behaviors.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 60)
This affected six of 29 sampled residents and three expanded sampled residents (Residents
#126, #47, #50, #12, #143, #39, #89, #139 and #114). The census was 148.
Review of the facility’s External Reporting of Abuse, Neglect, theft and Crimes policy,
dated 1/2012, showed:
-It is the policy of this facility to establish external reporting guidelines for facility
staff in the event they become aware or formulate a reasonable suspicion that abuse,
neglect, theft or a crime has been committed against a resident of the facility:
-Upon receipt of an allegation of abuse, neglect, theft or that a crime has occurred
against a resident the facility Administrator or his/her designee will initiate external
reports to the department;
-The administrator or designee will contact the department immediately but no later than
24 hours following an observed event, allegation or formulation of a reasonable suspicion
that a crime occurred against a resident that did not result in serious bodily injury;
-In cases of serious bodily injury the administrator will contact the department
immediately but no later than 2 hours from the time of the allegation or formulation of
the reasonable suspicion that a crime was committed against a resident;
-Within 5 business (working) days from the event or report the facility will submit a
report to the department that will contain a description of the initial allegation,
description of the investigation and the facts obtained, a brief conclusion based on the
information obtained during the investigation, a description of any corrective actions
taken if necessary;
-The policy failed to require that in response to any allegations of abuse the facility
must: Ensure all alleged violations are reported immediately. No later than 2 hours if the
allegation involve abuse or result in serious bodily injury.
Review of the facility’s Resident Protection During Abuse Investigations policy, dated
1/2012, the facility desires to establish a resident secure environment and will take
steps to protect residents from exposure to additional acts of mistreatment following an
allegation or reported instance of abuse, neglect, theft or criminal action committed
against the residents while an investigation is conducted:
-Resident to resident events: Residents who allegedly abuse another resident should be
removed from contact with other residents until such time that reasonable clinical
judgement determines that their behavior no longer poses a significant risk to other
residents or until the investigation is concluded.
1. Review of the Resident #126’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief interview for mental status (BIMS) score of 9 out of 15, showed the resident had
moderately impaired cognition;
-No behaviors;
-[DIAGNOSES REDACTED].
Review of the Resident #126’s progress notes, dated 10/30/18, showed Resident A was
speaking with another resident, when Resident B brushed up against Resident A in passing.
A small verbal commotion followed and Resident A yelled, I’m not a boy! Resident A moved
toward Resident B in an aggressive manner, but never raised his/her hands in an attempt to
strike. Resident B then struck Resident A on the right side of his/her face. Residents
swiftly separated. Cold compress applied to right side of face. Slight swelling noted.
Skin intact. No discoloration noted. Complaints of tenderness to touch. Praised his/her
coping skills, of not retaliating physically. Encouraged to walk away from confrontations.
Verbalized understanding.
Review of Resident #47’s admission MDS, dated [DATE], showed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 61)
-A BIMS score of 12 out of 15, showed the resident had moderately impaired cognition;
-No behaviors exhibited;
-[DIAGNOSES REDACTED].
Review of Resident #47’s progress notes, dated 10/31/18, showed staff reported while in
the hallway, another resident was speaking with someone else, when this resident brushed
up against the first resident in passing. A small verbal commotion followed and the other
resident yelled, I’m not a boy! Staff reports that resident moved toward this resident in
an aggressive manner, but never raised his/her hands in an attempt to strike. This
resident then struck the other resident on the right side of his/her face. Residents
swiftly separated. Encouraged him/her to walk away from confrontations. Verbalized
understanding, but still claimed that the other resident is trying to, make you all go
against me. Reiterated to him/her there was no need to strike him/her, especially since
he/she him/herself had not been hit. Also spoke to him/her about utilizing better conflict
resolution techniques during confrontations.
Observation on 11/8/18 at 12:00 P.M., Resident #126 told Licensed Practical Nurse (LPN) H
that resident #47 was going to hit him/her. The resident was told to sit far away from
Resident #47 and he/she would monitor everyone in the dining room.
During an interview on 11/9/18 at 12:04 P.M., the Director of Nursing (DON) said if there
was an altercation, she would talk to the residents. The DON was not aware that a resident
was hit. She would expect staff to report and investigate it the incident. There are
systems in place per the facility’s policy if there was a resident to resident
altercation. Staff are expected to talk to the residents, notify the physician, and ask
for a psych consult to make sure it is an isolated incident. If there was an ongoing
problem, they would notify the physician to check labs and medications.
2. Review of Resident #50’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 15, showed the resident was cognitively intact;
-Had hallucinations and delusions;
-[DIAGNOSES REDACTED].
Observation on 11/6/18 at 9:56 A.M., the resident reported to Certified Nursing Assistant
(CNA) W that LPN X and LPN Y pulled his/her hair and poked him/her in the stomach on a
different day. CNA W was observed writing the resident’s interview.
During an interview on 11/7/18 at 12:05 P.M., the administrator said if a resident
reported abuse, it would be the facility’s policy to investigate, find out which staff
member and if the person was here, they would be suspended the staff member pending the
investigation. They would do a skin assessment to check for injury. Staff did not report
the incident to the administrator. She would expect CNA W to report it to the nurse
manager and it would be reported to the administrator. She would expect them to follow the
facility’s policy. If abuse occurred, they would contact the department within two hours.
3. Review of Resident #12’s quarterly MDS, dated [DATE], showed:
-BIMS score of 8 out of 15, showed moderate cognitive impairment;
-Independent with all Activities of Daily Living (ADLs);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of Resident #12’s progress notes, showed:
-On 7/31/18 at 9:22 A.M., the resident was screaming very loudly and this writer went down
the hall to find him/her. He/she was lying on the floor in another resident’s room
screaming and moving around on the floor. When asked what happen he/she stated he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 62)
pushed me down. I am hurting. He/she was able to move all extremities without complaints
of pain and no difficulties, grimacing or indication of pain exhibited. Assisted off of
the floor by two staff and assisted into a wheelchair.;
-On 8/1/18 at 10:36 P.M., Resident alert to self and is confused, redirected several time
throughout shift from other peoples room.
-On 8/2/18 at 3:12 A.M., Day 2 of 3 for incident follow up. Resident in bed, no acute
distress noted. No signs behavior at this time;
-The notes did not show after the initial incident what interventions were put in place to
show how the nursing staff was monitoring Resident #12 in order to prevent him/her from
coming back into contact with the other resident or notification to the department of the
alleged resident to resident abuse.
Review of Resident #12’s Unwitnessed Fall Occurrence Report, dated 7/31/18 showed:
-The resident had an unwitnessed fall on 7/31/18;
-Upon entering the room, the resident was found lying on his/her back on the ground,
screaming he/she pushed me down and moving;
-The resident stated that he/she was pushed down while in another resident’s room;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident were left blank;
-Pain, consciousness, mobility and mental status [REDACTED].
-Other information: the resident wanders into other resident’s rooms;
-Witnesses: no witnesses;
-Agencies/people notified: No notifications found;
-No summary of the investigation, no cause, and no interventions taken at the time of the
incident and post incident noted. No behavior incident report provided upon request;
-The occurrence report did not identify what monitoring measures the facility staff put in
place after the resident first pushed down Resident #12, in order to prevent the second
occurrence 2 days later;
-The facility was unable to provide an abuse investigation for this incident. The 7/31/18
incident was reported and investigated as a fall only.
Further review of Resident #12’s progress notes, showed:
-On 8/2/18 at 3:55 P.M., reported this resident was struck in the chest by another
resident. Residents separated. Physical assessment revealed no injury. Physician notified.
No new orders;
-On 8/3/2018 at 1:53 A.M., resident must be redirected out of other room when awake;
-On 8/3/2018 at 3:39 P.M., no discoloration to chest noted;
-On 8/5/2018 at 11:12 A.M., redirected several times throughout shift, resident going
through other clothing, lying in their beds, standing in others room;
-The notes did not show, after the second incident what interventions (other than
separating the residents) were put in place to show how the nursing staff was monitoring
Resident #12 in order to prevent him/her from coming back into contact with the other
resident or notification to the department regarding the alleged resident to resident
abuse.
Review of Resident #12’s Physical Altercation Occurrence Report, dated 8/2/18, showed:
-The resident stated another resident hit him/her;
-The residents were separated and a physical assessment was completed;
-No injuries were observed at the time of the incident;
-Pain, consciousness and mobility at the time of the incident: Blank;
-Mental status at the time of the incident: Blank;
-No injuries noted post incident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 63)
-Pain, consciousness, mobility and mental status [REDACTED].>-Predisposing
environmental factors: Blank;
-Predisposing physiological factors: Blank;
-Predisposing situation factors: Wanderer;
-Other information: Blank;
-Witnesses: No witnesses found;
-Agencies/people notified: The physician and the Power of Attorney (POA) notified 8/2/18
at 4:30 P.M. No documentation the department notified;
-No summary of the investigation, no cause, and no interventions taken at the time of the
incident and post incident noted.
Review of Resident #143’s Significant Change MDS, dated [DATE], showed:
-BIMS score of 4 out of 15 (a score of 0-7 indicates severe cognitive impairment);
-Physical behaviors directed toward others: Behavior not exhibited;
-Verbal behaviors directed toward others: Behavior not exhibited;
-Other behaviors not directed at others including pacing and rummaging: Behavior not
exhibited.
Review of the Resident #143’s Social Services Note, dated 8/24/18 at 12:15 P.M., showed:
Called and left a voicemail message for the resident’s family member to contact us
regarding a meeting needing to be scheduled to discuss resident’s behavior in being
physically aggressive toward other residents. Due to the communication barrier, it is best
if resident’s family is involved in order to translate the information.
Review of Resident #143’s progress notes, showed the resident was in a physical
altercation with Resident #12 on 8/10/18 and 8/24/18.
When asked, on 11/13/18, if Resident #12’s Occurrence Reports for the incidents on 7/31/18
and 8/2/18 were the only documentation the facility had for both incidents, the DON said
yes.
During an interview on 11/13/18 at 7:40 A.M., CNA AA said:
-Resident #12 wanders into other resident rooms, once we hear him/her hollering out we
will go get him/her and take him/her to the day area or dining room;
-Resident #143 can be aggressive if someone goes into his/her room. Staff will just remove
the other resident from his/her room;
-If a resident accuses another resident of hitting/pushing/kicking/tripping them, we
separate them and take one to another area of the unit or facility. If one of the
resident’s is in the wrong room staff will separate them and take the resident out of the
other resident’s room. If staff notice anything out of the ordinary, staff will let the
nurse know;
-Any allegations of abuse need to be reported to the nurse immediately;
-There are no residents that require 15 minute checks.
During an interview on 11/13/18 at 7:48 A.M., LPN BB said:
-Any allegations or suspicions of abuse should be documented and followed up on.
-If a resident to resident altercation occurs, staff should immediately separate the
residents, notify the DON and Administrator, call both resident’s physicians and family,
and both residents should be assessed for injury;
-He/she was not present when the incidents occurred between Residents #12 and #143;
-Any incidents such as a resident pushing another resident down or hitting another
resident is abuse and should be reported to DON and Administrator, an incident report
completed, and documented in a nurse’s note;
-If a resident said someone pushed him/her down, it would be both fall and abuse.
Documentation should reflect both;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 64)
-It is not appropriate to just redirect a resident out of the room. There needs to be a
thorough investigation completed;
-He/she is not aware of any residents that require 15 minute checks for behaviors.
4. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-BIMS score of 15 out of 15, shows the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Has hallucinations.
Review of the resident’s progress notes, showed:
-On 10/21/18, resident to resident altercation. Resident hit another resident in the face
and knock off his/her glasses. The resident’s face on left side is slightly swollen.
Residents sent to their rooms. Ice pack applied to the resident’s face but he/she took it
off of his/her face. He/she stated he/she did not want it on his/her face. Physician
notified of the altercation between the residents, no new orders given.
During an interview on 11/9/18 at 12:14 P.M., the Director of Nursing said she was not
aware of the altercation. She would expect staff to notify her.
5. Review of Resident #89’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 14, showed the resident was cognitively intact;
-Physical behaviors in the last one to three days;
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes, dated 10/19/18, showed:
-At 7:07 A.M., therapy reported to nurse that the resident hit another resident,
unwitnessed by staff, when asked what happen, resident stated, he/she pushed me and he/she
hit him/her back. Resident separated, physical assessment performed, no bruising, or
discoloration noted. Denies pain;
-At 2:59 P.M., continues on observation related to unwitnessed altercation. Resident noted
upset with another peer this morning because he/she says that the other resident keeps
asking for food and is always coming in the room. Redirection given to calm resident. No
other mood changes or physical aggression noted;
-At 3:19 P.M., nurse practitioner aware of altercation. No new orders received.
During an interview on 11/09/18 at 12:18 P.M., the DON said if there was an unwitnessed
altercation, he/she would expect there to be an investigation. If resident said someone
hit him/her, they would investigate to make sure it really happen. The DON was not aware
of the altercation that involved the resident. She would have expected staff to report all
altercations to her.
6. During an interview on 11/13/18 at 9:05 A.M., the DON said:
-With resident to resident altercations, he/she would expect nursing staff to separate the
residents, the nurse to complete a physical assessment of each resident, notify the
residents physicians and family and follow any physician’s orders [REDACTED].
-He/she would also expect the nursing staff to monitor the residents to ensure their
safety and well-being and the safety and well-being of other residents;
-He/she expects the resident’s care plan interventions to be implemented to help manage
the resident’s behaviors;
-The facility wouldn’t investigate the incident as abuse due to confusion if the resident
alleging the push is confused and so is the resident that pushed him/her down;
-It would be appropriate to separate and monitor to make sure residents are kept away from
each other;
-The incident should be reported to the state agency (the department) as an FYI (for your
information), if nothing else;
-He/she doesn’t know why the incidents were not reported;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 65)
-Policy is to notify the DON and Administrator immediately of any abuse allegations or
suspicions;
-He/she expects staff to follow the abuse policy;
-All staff has been educated on the abuse policy;
-He/she knows what abuse is and what to investigate;
-He/she does report abuse to the state agency.
7. Review of the facility’s most recent training on resident to resident altercations,
dated 2/26/18, showed:
-The facility desires to establish a resident secure environment and will take steps to
protect residents from exposure to additional acts of mistreatment following an allegation
or reported instance of abuse while an investigation is conducted;
-Resident to resident events: Residents who allegedly abuse another resident should be
removed from contact with other residents until such time that reasonable clinical
judgement determines that their behavior no longer poses a significant risk to other
residents or until the investigation is concluded;
-The in-service failed to clearly train staff that resident to resident altercations
should be reviewed as a potential situation of abuse.
8. Review of the facility’s most recent abuse training, dated 10/5, 10/6, 10/8, 10/16,
10/18, 10/22 and 10/31/18, showed:
-It is the policy of the facility to develop mechanism to reduce the risk of abuse,
neglect, misappropriation of resident property and/or crimes from being committed against
the residents of this facility. This will be done by implementing the following systems
and/or practices;
-Facility staff will investigate and report any allegations of abuse within timeframes
required by Federal law;
-Residents will be protected from harm and/or further abuse during an abuse investigation;
-Any allegation of abuse will be reported immediately to the facility administrator or
designee;
-Report violations of the regulations or facility policy, report any resident abuse,
document care timely;
-Upon receipt of an allegation or upon the formation of a reasonable suspicion that abuse
occurred, the administrator or designee will report to Missouri’s complaint hotline;
-The in-service failed to train staff on resident to resident abuse.
9. Review of Resident #139’s annual Minimum Data Set (MDS), a federally required
assessment instrument completed by facility staff, dated 10/13/18, showed:
-Total dependence on two-person physical assist for transfers;
-[DIAGNOSES REDACTED].
Observation on 11/7/18 at 3:47 P.M., showed Certified Nursing Assistant (CNA) E and CNA J
transfer the resident from bed to the wheelchair. Without the use of a gait belt, CNA E
stood on one side of the resident and CNA J stood on the other side. Staff placed one arm
under the resident’s arm and grabbed onto the resident’s waste band with the other hand,
CNA E said one, two, three and staff picked the resident up out of the bed. The resident’s
extremities remained contracted. His/her knees bent in a sitting position and arms pulled
inward. During the transfer, the resident’s legs remained contracted up and his/her feed
did not touch the floor. Staff placed the resident in the wheelchair. CNA J said the
resident is supposed to be a two person assist, but staff can do it with one person if
needed.
10. Review of Resident #114’s quarterly MDS, dated [DATE], showed:
-Extensive assistance of two-person physical assist required for transfers;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 66)
-Mobility devices: Wheelchair.
Observation on 11/7/18 at 7:24 A.M., showed CNA A provided care to the resident and
transferred the resident to his/her wheelchair. CNA A assisted the resident to sit on the
edge of his/her bed by pulling on the resident’s hands and sat the resident on the side of
the bed. The resident unable to remain in a seated position and started to fall back and
to the side. CNA A grabbed the resident by the back of his/her neck and pulled the
resident up into a sitting position. CNA A placed a gait belt around the resident’s waste.
As he/she did this, the resident began to slouch and fall over to the side. The resident
remained in a tilted slouched position in the bed as CNA A placed the resident’s
wheelchair against the wall and said the resident’s wheelchair don’t lock so he/she has to
prop it against the wall. CNA A said he/she put in a requested for maintenance to fix it
yesterday, but it had been broken for one or two weeks. CNA A straddled the resident and
instructed the resident to hold on to his/her waste and picked up the resident with the
use of the gait belt. The resident did not bear weight. CNA A twisted the resident and the
tips of the resident’s feet remained on the floor, twisted slightly from the direction of
his/her legs and body. After several prompts from CNA A, given as he/she held the resident
up with the use of the gait belt, the resident was able to pivot his/her feet so they were
no longer twisted. CNA A placed the resident in the wheelchair. He/she then placed the
left foot rest on the resident’s wheelchair, placed his/her left foot on the foot rest and
then placed the right foot on top of the left foot. CNA A said the wheelchair was broken
and the right foot rest no longer connected to the wheelchair. CNA A propelled the
resident out of the room and into the hall with both feet on one foot rest.
11. During an interview on 11/13/18 at 9:00 A.M., the Director of Nursing (DON) said a
resident’s transfer status should be included in the care plan. A resident’s transfer
status is based on the resident’s physical ability to transfer. Staff know how to transfer
a resident by looking in the ADL section of the electronic medical record. This is also
passed on in report. For a gait belt transfer, residents should be able to bear weight.
Staff should use a gait belt. If a resident is unable to bear weight, she would expect
staff to get them in a safe position and get help. Staff should not pull on a resident’s
hands or neck to assist to sit them to sit up. A resident’s feet should touch the floor
during a transfer unless they are contracted. Then two people can just lift them. Everyone
is responsible to make sure residents can be transferred safely. Staff should not pick
residents up by their waste band. Staff should not pick residents up under their arms
because this could cause injury to the residents or staff. She was not aware that
acceptable standards of practice indicate a resident should be able to bear weight and
assist in transfers to qualify for a gait belt transfer.
12. Review of the facility’s Lifting and Transferring Residents policy, dated 1/1/06,
showed:
-All residents requiring assistance with mobility should be lifted and transferred safely;
-Members of the nursing staff are responsible for using good body mechanics, knowing the
proper transfer procedures and properly operating assistive devices. Residents are
assessed by the nursing and/or therapy departments for lifting and transfer needs and for
the most appropriate transfer method(s);
-For residents requiring assistance in lifts and transfers, a gait/transfer belt or
mechanical lift should be used;
-Assess the resident to determine physical limitations and ability to follow directions;
-The method for transfer and/or lift that is appropriate for each resident can be found in
individual resident care plans;
-Lock wheels on bed and/or wheelchair;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 67)
-The resident’s hands should remain free during the transfer;
-Staff should not place their hands under a resident’s arms or shoulders in order to
prevent shoulder injury;
-Grasp transfer belt from underneath;
-The policy failed to identify that residents transferred with the use of a gait belt must
be able to bear weight or what qualified or disqualified a resident from using a gait belt
transfer.
13. Review of the facility’s most recent in-service attendance record for transfers, dated
10/31/18, showed:
-Assume for most lifts you will need help or mechanical assistance;
-Definitely get help if the resident is immobile, heavy, uncooperative or attached to
tubes and wires;
-It is sometimes safe to lift residents alone or with minimal help. These situations
include residents who are mobile and require just a little assistance, residents who are
already standing and situations where you can safely perform the lift alone, with the aid
of a mechanical device such as a belt.
14. During an interview on 11/13/18 at 7:53 A.M., the staff development coordinator said
she is responsible for staff training. Staff determine a resident’s transfer status during
the clinical meetings. In-servicing is completed every two weeks. She would expect staff
to be able to recognize when a resident is unable to be transferred with a gait belt
assist. Training is provided in classroom settings. Demonstrations are completed as well.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident monthly
pharmacy drug regimen recommendations were reviewed and failed to notify the physician
and/or medical director of irregularities for two of eight residents investigated for
unnecessary medications (Residents #126 and #123). In addition, the facility failed to
develop and maintain policies and procedures for the monthly drug regimen review that
include, but are not limited to, time frames for the different steps in the process and
steps the pharmacist must take when he or she identifies an irregularity that requires
urgent action to protect the resident. The census was 148.
1. Review of Resident #126’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief Interview for Mental Status (BIMS, determines a resident’s cognitive status) score
of 9 out of 15, which showed moderately impaired cognition;
-[DIAGNOSES REDACTED].
-Displays symptoms of feeling down, depressed, or hopeless;
-No behaviors;
-Antipsychotics, antianxiety, and antidepressants administered in the last seven days;
-Antipsychotics used on a routine basis;
-No gradual dose reduction (GDR) attempted;
-GDR has been documented by a physician as clinically contraindicated;
-Medication follow-up: not assessed/no information.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 68)
Review of the resident’s medical record, showed the following:
-An admission date of [DATE];
-[DIAGNOSES REDACTED].
-A physician order [REDACTED].
-A Medication Administration Record [REDACTED].
Review of the resident’s care plan, dated 12/14/17, showed:
-Focus: Resident uses anti-anxiety medications;
-Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for
side effects and effectiveness every shift;
-Consult with pharmacy and physician to consider dosage reduction to [MEDICATION NAME];
-The resident is taking anti-anxiety medications which are associated with an increased
risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like
dementia and increases risk of falls, broken hips and legs;
-Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness,
lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation,
depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss,
forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS:
Mania, hostility, rage, aggressive or impulsive behavior, and hallucinations.
Review of the resident’s medication regimen review, dated 5/25/18, 7/19/18, and 9/29/18,
showed:
-Discontinue PRN [MEDICATION NAME]. These medications are only valid for 14 days and
require extensive documentation to be continued beyond that window. Please discontinue or
schedule;
-No physician response.
2. Review of the Resident #123’s electronic Face Sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s POS, showed an order, dated 7/30/17, for [MEDICATION NAME]
solution 2 mg per milliliter (ml), inject 0.25 mg IM every six hours PRN for agitation.
Review of the resident’s MAR, dated 10/1/18 through 11/8/18, showed [MEDICATION NAME] 0.25
mg PRN was not administered.
Review of the resident’s medication regimen review, dated 7/19/18, showed:
-Discontinue PRN [MEDICATION NAME]. Please remember this order is only good for 14 days
and requires documentation on behaviors to be continued;
-No physician response.
3. During an interview on 11/09/18 at 11:57 A.M., the Director of Nursing (DON) said if
pharmacy has a recommendation, the written report is given to the DON. Depending on the
recommendation, she will forward it to the physician. She would expect the physician to
respond within seven days. The DON is responsible for ensuring the pharmacy
recommendations are followed through with an answer from the physician and any changes
made to the resident’s medications. The DON was aware PRN [MEDICAL CONDITION] medications
can only be ordered for 14 days. She would expect to have new physician orders [REDACTED].
The facility does not have a pharmacy recommendation review policy.

F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to have adequate
indications to support the use of a resident’s [MEDICAL CONDITION] medications and failed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 69)
to have ongoing monitoring of the effectiveness of the [MEDICAL CONDITION] medications.
This affected one out of eight residents investigated for unnecessary medications
(Resident #102). The census was 148.
Review of Resident #102’s medical record, showed:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-An order, dated 12/6/16, for [MEDICATION NAME] (medication used to treat [MEDICAL
CONDITION]) 3 milligram (mg) tablet at bedtime (HS) for [MEDICAL CONDITION];
-An order, dated 5/27/18, for [MEDICATION NAME] HCI (medication used to treat depression
and [MEDICAL CONDITION]) tablet 150 mg HS for [MEDICAL CONDITION];
-An order, dated 6/27/18, for [MEDICATION NAME] Capsule (used to treat allergy symptoms
and can be used for [MEDICAL CONDITION]) 50 mg for [MEDICAL CONDITION] at HS.
Review of the resident’s Medication Administration Record [REDACTED]
-An order, dated 12/6/16, for [MEDICATION NAME] 3 mg HS for [MEDICAL CONDITION] was
administered as ordered;
-An order, dated 5/27/18, for [MEDICATION NAME] 150 mg HS was administered as ordered;
-An order, dated 6/27/18, for [MEDICATION NAME] Capsule 50 mg HS was administered as
ordered.
Review of the resident’s care plan, reviewed 11/9/18 and in use at the time of the survey,
showed no documentation of the resident’s [MEDICAL CONDITION].
Observation of the resident on 11/8/18 at 11:30 A.M. and 11/8/18 at 4:41 P.M., showed the
resident in bed with his/her eyes closed.
During an interview on 11/8/18 at 4:46 P.M., Licensed Practical Nurse (LPN) H said the
resident sleeps a lot. He/she is only up for meals. That is his/her routine.
Observation on 11/8/18 at 5:57 P.M., showed the resident in the dining room during meal
service. He/she sat at the table with his/her eyes closed. Staff asked the residents in
the dining room if anyone else needed to be served. The resident continued to sit at the
table with his/her eyes closed. Other residents in the dining room pointed out that the
resident needed to be served before the dietary staff left the room.
Review of the resident’s progress notes, showed no documentation of the monitoring the
resident’s [MEDICAL CONDITION], non-pharmological interventions attempted or gradual dose
reduction (GDR) attempted for the use of the [MEDICAL CONDITION] medications.
During an interview on 11/9/18 at 9:00 A.M., the Director of Nursing (DON) said the
facility does not have a pharmacy recommendation review policy. At 11:43 A.M., the DON
said if a resident had [MEDICAL CONDITION] and was alert and oriented enough, they would
tell the staff they were having trouble sleeping. Staff would complete rounds to identify
if a resident was experiencing [MEDICAL CONDITION]. Once there are physician’s orders
[REDACTED]. If a resident was sleeping all day, they would look at other issues to make
sure there was not a new disease process. The nurse practitioner prescribed the
medications. The DON was not familiar with the resident’s sleep habits.
During an interview on 11/9/18 at 11:45 A.M., Care Coordinator I said the resident’s
[MEDICAL CONDITION] could be related to [MEDICAL CONDITION]. His/her behavior cycles and
he/she can be more engaged, pace, and make rounds in the hallway. There is a three month
quarterly evaluation when the medications are reviewed. They discuss the resident’s
medications with the physician and they determine if a GDR is appropriate or if the
resident is stable.
During an interview on 11/9/18 at 11:50 A.M., the resident’s nurse practitioner said the
resident had chronic [MEDICAL CONDITION]. He/she slept 1 or 2 hours and he/she was then
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 70)
awake. The nurse practitioner did not want to give a larger dose of [MEDICATION NAME], so
the resident was prescribed [MEDICATION NAME].

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to obtain stop
dates of 14 days or less on as needed (PRN) [MEDICAL CONDITION] medications and failed to
ensure a resident had appropriate [DIAGNOSES REDACTED]. This affected three out of eight
residents investigated for unnecessary medications (Residents #126, #123 and #39). The
sample was 29. The census was 148.
1. Review of Resident #126’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/4/18, showed:
-Brief Interview for Mental Status (BIMS) score of 9 out of 15, which showed moderately
impaired cognition;
-[DIAGNOSES REDACTED].
-Displays symptoms of feeling down, depressed or hopeless;
-No behaviors;
-Antipsychotics, antianxiety and antidepressants administered in the last seven days;
-Antipsychotics used on a routine basis;
-No gradual dose reduction (GDR) attempted;
-GDR has been documented by a physician as clinically contraindicated;
-Medication follow-up: not assessed/no information.
Review of the resident’s medical record, showed the following:
-[DIAGNOSES REDACTED].
-A physician order [REDACTED].
-A Medication Administration Record [REDACTED]
-No physician documented rationale in the resident’s medical record or indication of the
duration for the PRN order.
Review of the resident’s care plan, dated 12/14/17, showed:
-Focus: Resident uses anti-anxiety medications;
-Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for
side effects and effectiveness every shift;
-Consult with pharmacy and physician to consider dosage reduction for [MEDICATION NAME];
-The resident is taking anti-anxiety medications which are associated with an increased
risk of confusion, amnesia, loss of balance and cognitive impairment that looks like
dementia and increases risk of falls, broken hips and legs;
-Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness,
lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation,
depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss,
forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS:
Mania, hostility, rage, aggressive or impulsive behavior and hallucinations.
Review of the resident’s medication regimen review, dated 5/25/18, 7/19/18, and 9/29/18,
showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 71)
-Discontinue PRN [MEDICATION NAME]. These medications are only valid for 14 days and
require extensive documentation to be continued beyond that window. Please discontinue or
schedule;
-No physician response.
Observation on 11/6/18 at 1:52 P.M., showed the resident wore a safety helmet as he/she
sat in the dining room.
During an interview on 11/9/18 at 11:57 A.M., the Director of Nursing (DON) said she was
aware PRN [MEDICAL CONDITION] medications can only be ordered for 14 days. Medications
should have an indication for use and staff should be documenting the effectiveness of
medications.
2. Review of the Resident #123’s electronic Face Sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s POS, showed an order, dated 7/30/17, for [MEDICATION NAME]
solution 2 mg per milliliter (ml), inject 0.25 mg IM every six hours PRN for agitation.
Review of the resident’s MAR, dated 10/1/18 through 11/8/18, showed [MEDICATION NAME] 0.25
mg PRN was not administered.
Review of the resident’s medication regimen review, dated 7/19/18, showed:
-Discontinue PRN [MEDICATION NAME]. Please remember this order is only good for 14 days
and requires documentation on behaviors to be continued;
-No physician response.
Review of the resident’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/17/18, showed:
-BIMS score of 00 out of 15, which showed severely cognitively impaired.
-[DIAGNOSES REDACTED].
-Displays little interest or pleasure in doing things and is short-tempered and easily
annoyed;
-Displays physical and verbal behaviors directed at others;
-Antipsychotics and antidepressants administered in the last seven days;
-Antipsychotics used on a routine basis;
-No GDR attempted;
-GDR has been documented by a physician as clinically contraindicated;
-Medication follow-up: not assessed/no information.
Review of the resident’s current care plan, in use at time of the survey, showed no care
plan for anti-anxiety medications.
Review of the resident’s medical record, showed no physician documented rationale in the
resident’s medical record and indicate the duration for the PRN order.
Observation on 11/06/18 at 12:38 P.M. showed the resident sat in his/her wheelchair in the
dining room feeding himself/herself meatloaf, mixed vegetables and mashed potatoes without
difficulty. The resident appeared calm and pleasant. No signs of anxiety or agitation
noted. On 11/7/18 at 10:18 A.M., the resident sat in his/her wheelchair in his/her room.
The resident appeared calm with no signs of agitation or anxiety. The resident was
pleasant and said he/she was doing good and had not had any feelings of anxiety that day.
During an interview on 11/9/18 at 11:57 A.M., the DON said she was aware PRN [MEDICAL
CONDITION] medications can only be ordered for 14 days. Medications should have an
indication for use and staff should be documenting the effectiveness of medications.
3. Review of Resident #39’s quarterly MDS, dated [DATE], showed:
-A BIMS score of 15 out of 15, which showed the resident is cognitively intact;
-[DIAGNOSES REDACTED].
-Antipsychotics, antianxiety and antidepressants administered in the last seven days;
-Antipsychotics used on a routine basis;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 72)
-No GDR attempted;
-GDR has not been documented by a physician as clinically contraindicated;
-No documentation of a [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 8/9/17, showed:
-Focus: Resident uses anti-anxiety medications related to anxiety disorder and
antidepressants due to depression and antipsychotic medication use;
-Interventions: Administer anti-anxiety medications as ordered by physician. Monitor for
side effects and effectiveness every shift;
-Monitor/document/report PRN any adverse reactions to anti-anxiety: Drowsiness, lack of
energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation,
depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss,
forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects:
Mania, hostility, rage, aggressive or impulsive behavior, and hallucination;
-Monitor/record occurrence of for target behavior symptoms (specify pacing, wandering,
disrobing, inappropriate response to verbal communication, violence/aggression towards
staff/others, etc.) and document per facility protocol;
-Further review of the resident’s care plan, showed no documentation of a [DIAGNOSES
REDACTED].
Review the resident’s medical record, showed:
-[DIAGNOSES REDACTED].
-A POS, dated 11/1/18 through 11/30/18, showed an order dated 11/8/17, for [MEDICATION
NAME] (medication used to treat [MEDICAL CONDITION]) tablet 10 mg, give one tablet by
mouth at bedtime for Alzheimer’s;
-A MAR, dated 11/1/18 through 11/9/18, showed an order dated, 11/8/17, for [MEDICATION
NAME] 10 mg, documented administered as ordered.
During an interview on 11/13/18 at 9:00 A.M., the DON said she was not sure if the
resident had a [DIAGNOSES REDACTED].
4. During an interview on 1/13/18 at 9:00 A.M., the DON said the facility does not have a
pharmacy regimen review policy.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 25 opportunities observed, four errors
occurred, resulting in a 16% error rate (Resident #66). The census was 148.
Review of Resident #66’s electronic physician order [REDACTED].>-An order dated 2/7/17,
for [MEDICATION NAME] (anti-tremor) 1 milligram (mg) three times a day before meals;
-An order dated 12/4/17, for [MEDICATION NAME] (antipsychotic) 10 mg one tablet three
times a day before meals;
-An order dated 12/4/17, for [MEDICATION NAME] caplet (lactose (protein found in milk)
enzyme supplement) one tablet before meals for indigestion;
-An order dated 12/4/17, for [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 150 mg one
tablet three times a day before meals.
During an interview on 11/7/18 at 1:40 P.M., Licensed Practical Nurse (LPN) F said the
resident just got back from a lunch outing.
Observation on 11/7/18 at 1:40 P.M., showed LPN F administered medications to the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 73)
resident. He/she administered lactose enzyme supplement dietary aide one tablet,
[MEDICATION NAME] 1 mg tablet and [MEDICATION NAME] 150 mg tablet. He/she did not
administer [MEDICATION NAME] to the resident.
During an interview on 11/7/18 at 3:21 P.M., LPN F said the [MEDICATION NAME] was not
administered because it was not available in the facility.
Review of the resident’s progress notes, reviewed on 11/8/18 at 10:19 A.M., showed no
documentation of the physician contacted regarding the medications not administered before
meals as ordered.
During an interview on 11/8/18 at 9:56 A.M., the Director of Nursing said medications
should be administered as ordered. If a medication is ordered to be administered before
meals, she would expect staff to follow these instructions. If a resident is going out for
a scheduled lunch outing, staff should administer the medications before the resident
leaves or they should contact the physician. [MEDICATION NAME] is not a stock medication,
but LPN F said he/she did administer the medication on 11/7/18 because it was available in
the medication dispensing machine. It was administered 2:30 P.M.

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure each
resident receives food prepared in a form designed to meet individual needs by failing to
provide residents with a mechanical soft diet. In addition, the facility failed to have a
system in place to identify residents on a mechanical soft diet during meal service for
three of 29 sampled residents who had orders for mechanically altered diets (Residents
#108, #94 and #109). The census was 148.
1. Review of Resident #108’s physician order [REDACTED].
During an interview on 11/8/18 at 9:00 A.M., the resident said he/she was supposed to have
his/her meat mechanically soft, but the food is never served as ordered.
Observation on 11/8/18 at 12:38 P.M., showed the dietary staff served the residents in the
main dining room. There were several plates of cheese burgers and French fries on the
cart. The dietary staff served the resident a cheese burger, French fries and a side
salad. There were no observed meal tickets used during meal service to show the residents’
diet orders.
2. Review of Resident #94’s POS, dated 11/1/18 through 11/30/18, showed an order, dated
9/26/18, for a regular diet with a mechanical texture.
Review of the resident’s care plan, dated 4/8/17, showed:
-Focus: The resident has oral/dental health problems and no natural teeth. Resident has a
chewing problem. He/she is on a mechanical soft diet;
-Interventions: All staff to be informed of the resident’s special dietary and safety
needs;
-Diet to be followed as prescribed.
Observation on 11/7/18 at 1:25 P.M., showed the resident sat in the dining room on 3
South. He/she was served fried chicken, rice, broccoli and a biscuit. There were no
observed meal tickets on the residents’ tables or the dietary staff steam table to
identify the residents’ diet orders.
3. Review of Resident #109’s POS, dated 11/1/18 through 11/30/18, showed an order, dated

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 74)
2/7/18, for a regular diet, mechanical soft texture, regular consistency.
Observation on 11/6/18 at 12:46 A.M., showed the dietary staff served residents lunch in
the main dining area. The dietary staff had several plates of food on a serving cart. The
dietary staff served the resident a plate of food that consisted of a smothered pork chop,
mashed potatoes and mixed vegetables. There were no observed meal tickets used by dietary
staff when serving the residents lunch to alert dietary staff to the residents’ diet
orders.
4. During an interview on 11/13/18 at 10:37 A.M., the dietary manager said the dietary
aides should know which residents are ordered a mechanical soft diet. There is a list in
the office, so they know how many they have. They had meal tickets, but she wanted to
change to the laminated diet cards. The staff generally know the residents.

F 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Ensure each resident receives and the facility provides food that accommodates resident
allergies, intolerances, and preferences, as well as appealing options.

**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 food that accommodates resident preferences and appealing options of
similar nutritive value to residents who choose not to eat food that is initially served
or who request a different meal choice, by failing to provide all residents the same
alternate meal options. In addition, the facility failed to serve residents food,
beverages and condiments after they were requested (Residents #35, #65, #152, #74, #50,
#66, #2 and #94). This had the potential to affect all residents who ate at the facility.
The sample size was 29. The facility census was 148.
1. Review of Resident #35’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 8/17/18, showed a Brief Interview
for Mental Status (BIMS) score of 11 out of a possible score of 15, which showed the
resident cognitively intact.
During an interview on 11/6/18 at 12:26 P.M., the resident said he/she would like a
greater variety of food. Staff serve the same food all the time.
2. Review of Resident #65’s annual MDS, dated [DATE], showed a BIMS score of 15 out of a
possible score of 15, which showed the resident cognitively intact.
During an interview on 11/6/18 at 12:26 P.M., the resident said the food served is always
the same thing, hamburger, fries and pork chops. Residents are not asked their opinion on
what food they would like served. He/she would like to eat things like chicken strips,
green beans and cornbread. Residents are not served enough food and when residents ask for
alternatives, staff say they do not have one.
3. During an interview on 11/6/18 at 12:32 P.M., Resident #152 said he/she will buy
his/her own soup so he/she has something to eat that he/she likes. The food is not good.
It is either over or under seasoned. Residents tell the dietary manager, but nothing
changes. He/she liked veggie and chicken soup. The facility does not offer these options.
4. Observation of meal service in the main dining room on 11/6/18 at 12:35 P.M., showed
dietary staff brought out 12 plates of food, uncovered, on a cart. Some plates contained
meatloaf with mixed vegetables and new potatoes. The rest of the plates contained a pork
chop, mixed vegetables and mashed potatoes. Staff walked around the dining room and asked
residents if they wanted the pork chop or meatloaf and handed the resident their choice of
plate. The residents were not offered the choice of mashed or new potatoes and were served

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 75)
the potatoes based on the type of meat requested. Staff brought out several more carts of
plates which contained the same food options and passed plates of food until all residents
were served.
During an interview on 11/13/18 at 10:38 A.M., the dietary manager said residents should
be given choices for meals. When staff take the carts with food out, they ask residents
what they want to eat. All residents on a regular diet should be offered the same choice
of sides.
5. Observation on 11/6/18 at 12:42 P.M., showed the residents in the 3 South dining room
were all served meatloaf or smothered pork chops. The sides served were new potatoes and
mixed vegetables. The residents were also served juice, coffee, bread and a chocolate
cake. Resident #74 asked Certified Nurse Aide (CNA) M for more butter. CNA M said, We
don’t have anymore. Resident #74 walked around the dining room and asked another resident
if they had extra butter, but the resident said he/she did not have any. Resident #74
asked another resident for butter and received one slice of butter. Resident #50 asked CNA
M for ice cream. CNA M said, We’re not serving ice cream today. CNA M served the residents
juice after their meals were served. CNA M poured juice into the residents’ glasses until
the three pitchers of juice were empty. CNA said, We ran out of juice. A resident yelled
out for coffee and CNA M said, There’s no more. The same resident asked for more juice,
and the CNA M said, There’s no more. A resident was observed offering his/her slices of
butter to another resident after he/she finished the meal.
6. Review of Resident #66’s quarterly MDS, dated [DATE], showed a BIMS score of 15 out of
a possible score of 15, which showed the resident cognitively intact.
During an interview on 11/6/18 at 12:56 P.M., the resident said there is not enough food
that he/she likes. A few days ago, the facility served hotdogs and all the residents were
given was one hotdog. Residents were not given the option to have seconds.
7. Observation on 11/7/18 at 8:00 A.M., showed the residents sat in the dining room on 3
South. CNA M served the residents their meal. A resident was observed asking for more
coffee and CNA M said there was no more coffee. There were two empty coffee pitchers on
the cart. A resident asked if there was more cereal. CNA M said no.
8. Observation on 11/7/18 at 12:39 A.M., showed the residents in the dining room on 3
South were served taco bake or fried chicken. Residents served taco bake received only
broccoli as the side dish. Residents served fried chicken also received broccoli, rice and
a biscuit.
9. Review of Resident #2’s annual MDS, dated [DATE], showed a BIMS score of 12 out of a
possible score of 15, which showed the resident cognitively intact.
Observation on 11/7/18 at 12:57 P.M., showed the resident sat in the hall outside the 2
South nurses’ station. He/she said the food is dry and flavorless. Staff do not serve the
type of food he/she likes. He/she wants to be served food like greens and cornbread.
He/she does not want what is served and will not eat it. A staff person walked by and
asked the resident if he/she wanted a sub sandwich for a substitute. The resident told the
staff person that he/she could not chew that. The staff person continued to walk down the
hall and did not offer to provide any further food alternatives.
10. During the resident group meeting on 11/8/18 at 9:00 A.M., the residents said dietary
staff make just enough for all the residents to receive one plate. Sometimes seconds are
not served because they run out. Some aides do not want to go to the kitchen to get more
food or beverages. Milk and chocolate milk isn’t served consistently. Sometimes the
residents are not served milk for breakfast and sometimes chocolate milk is served during
lunch or dinner, but not all the time. French fries are always served with burgers or
hotdogs. There are no other options, especially for residents who are diabetic and want to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 76)
watch their carbohydrate intake. They were served one hotdog for dinner last weekend. The
residents said they should have received two hotdogs. French fries were served with the
hotdogs.
11. Observation on 11/8/18 at 12:25 P.M., 12:39 P.M. and 12:45 P.M., showed:
-At 12:25 P.M., there were approximately 45 residents in the main dining room. The
residents in the main dining room were served milk, chocolate milk, water, coffee and
juice. Each table had a pitcher of coffee and juice. At 12:39 P.M., the residents in the
main dining room had a choice of ravioli and salad or cheeseburger and French fries.
Country fried steak was not an option provided;
-At 12:45 P.M., the residents in the dining room on 3 South were served their meal. The
residents were served ravioli and the substitute was country fried steak. The residents
were not served milk or chocolate milk. Cheeseburger was not an option provided.
12. Observation and interview on 11/8/18 at 5:29 P.M., showed:
-The residents in the dining room on 3 South were served beverages. There were three
pitchers of coffee and three pitchers of juice. There were no observations of the
residents served milk or chocolate milk. Resident #74 said they only receive milk and
chocolate milk for breakfast and dinner;
-The board outside the main dining room showed the substitute was hamburger and sweet
potato fries. The residents in the main dining room received grilled turkey melt sandwich
with sweet potato fries. The substitute was cheese burger with French fries. The residents
in the main dining were served milk and chocolate milk with their meal. The residents were
not offered the option between sweet potato fries or French fries;
-At 5:40 P.M., the residents in the dining room on 3 South were served milk and chocolate
milk with their meal. The residents were served a grilled turkey melt sandwich with sweet
potato fries or a cheeseburger with French fries. The residents were not offered the
option between sweet potato fries or French fries;
-At 6:00 P.M., the residents on 3 Main were served chocolate milk and milk. The residents
were served grilled turkey melt sandwiches with sweet potato fries or a cheeseburger with
French fries. After half of the residents were served their meal, Dietary Aide N said they
ran out of hamburger buns and French fries. There were approximately 12 residents that had
not received their meal. At 6:08 P.M., Dietary Aide M returned to the dining room with
French fries and hamburger buns. There were no more sweet potato fries. Dietary Aide N
said they ran out of hamburgers, so the rest of the residents received the grilled turkey
melt sandwiches with French fries. Resident #94 asked for a hamburger, but was told there
was no more. The resident was served a mechanical soft turkey melt.
13. During an interview on 11/9/18 at 2:27 P.M., Cook O said they never run out of food.
The substitutes are decided by how much food is left over. If there was a lot left over
from dinner, then it would be served as an alternate for lunch on the next day.
14. During an interview on 11/13/18 at 10:37 A.M., the dietary manager said if there was a
substantial amount of the main meal left over from the day before, they would use that as
a substitute. If they have extra hotdogs or hamburgers, they would serve that. She wanted
to serve what the residents like. The residents on the third floor are served a different
substitute than the residents eating in the main dining room, but not all the time.
Sometimes there isn’t enough of one item. They will receive something different on another
floor. Sometimes the substitute outweighs the main meal. The turkey melt was the main
meal, but the dietary manager did not prepare enough hamburgers for the residents. She did
not expect the majority of the residents to ask for hamburgers. She would expect the
residents to be aware there are other options for substitutes, not just what is taken to
the third floor. She would expect the residents to have a choice of the side dish.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 0806

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 77)
Residents are able to receive seconds. If they ask for milk, she would expect staff serve
the residents a beverage of their preference. She was not aware of the residents not
offered milk for all three meals, or milk taken to the third floor for the residents. If
the residents wanted chocolate milk, she would expect it to be served. She was aware of
the issue of the residents receiving one hotdog over the weekend. The residents should
have receive two hotdogs if they wanted two. She was told they ran out, but when she
checked, there were plenty of hotdogs left. There were no issues of running out of food.

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 and interview, the facility failed to date all health shakes and
failed to ensure the dish machine sanitized properly. This deficient practice had the
potential to affect all residents who ate at the facility. The facility census was 148.
1. Observations on 11/6/18, 11/8/18 and 11/9/18, showed:
-On 11/6/18 at 9:00 A.M., there were 27 thawed, undated vanilla health shakes in the walk
in cooler;
-On 11/8/18 at 10:40 A.M., there were two thawed, undated vanilla health shakes in the
walk in cooler;
-On 11/8/18 at 12:39 P.M., the undated health shakes were served to the residents on the
second floor;
-On 11/9/18 at 8:00 A.M., there were two undated vanilla health shakes in the walk in
cooler.
2. During an observation and interview on 11/13/18 at 8:30 A.M., Dietary Aide Z tested the
dish machine. He/she confirmed it was a chemical sanitizer. He/she started the dish
machine with a rack of dishes inside. The gauge on the dish machine showed that sanitizer
was released during the test. After the machine stopped, Dietary Aide Z pulled the rack
out of the machine. He/she placed a strip on top of the wet dishes. The strip did not
change colors. He/she pulled another strip out and placed it on top of the wet dishes.
He/she said it normally worked when he/she tested it. He/she started another cycle on the
dish machine. After the machine stopped, Dietary Aide Z placed a clean strip on top of the
wet dishes. The strip did not change colors. He/she said the strip was supposed to turn
purple to show between 100 and 200 part per million (ppm). The dish machine is tested
twice a day, once in the morning and in the afternoon. He/she did not test the sanitizer
in the dish machine that morning. He/she confirmed that he/she had begun to wash the
dishes from breakfast. He/she said the sanitizer was low, so it was possible that was the
reason why the strip did not turn purple.
3. During an interview on 11/13/18 at 11:30 A.M., the dietary manager said he/she was not
aware the health shakes did not have a date on them. He/she thought there was an
expiration date on it. She would expect all food and beverages to be dated. All staff are
educated on how to test the dish machine. She confirmed that the sanitizer was low in the
machine. She would expect the dietary aide to know how to properly test the machine and to
test the machine before it is used to clean dishes.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have a policy regarding use and storage of foods brought to residents by family and
other visitors.

Based on interview and record review, the facility failed to produce an on-site policy
regarding the acceptance, usage, and storage of foods brought into the facility for
residents, by family and other visitors, to ensure the food’s safe and sanitary handling
and consumption. This deficient practice had the potential to affect all residents who ate
food brought in by visitors. The facility census was 148.
Review of the facility’s policies provided, showed no documentation of a policy regarding
foods brought in for residents by family and other visitors.
During an interview on 11/13/18 at 11:23 A.M., the administrator said the policy was
requested and they did not have a policy for food brought in by family or visitors.
During an interview on 11/13/18 at 11:23 A.M., the dietary manager confirmed that the
facility did not have a policy regarding outside food brought in.

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
appropriate infection control measures were utilized by not changing gloves when soiled,
not sanitizing equipment prior to use and not covering equipment to prevent contamination
for three of five residents observed during care (Residents #114, #139 and #58) and not
sanitizing the blood glucose monitor prior to or after resident use for two residents
observed during blood sugar testing (Residents #29 and #111). In addition, the facility
failed to store urine collection devices in a sanitary manor for one shared resident room
(room [ROOM NUMBER]) and one resident (#142). The sample was 29. The census was 148.
Review of the facility’s Hand Hygiene policy, dated 9/2017, showed:
-Purpose: Proper hand hygiene practices reduce the transmission of pathogenic
microorganisms to residents, visitors and other staff members;
-All staff shall follow the handwashing/hand hygiene guidelines and procedures to help
prevent the spread of infections;
-Employees must wash their hands for 10 to 15 seconds using soap and water under the
following conditions:
–When hands are visibly soiled with blood or body fluids;
–After contact with blood, body fluids, secretions, mucous membranes or non-intact skin;
–After handling items potentially contaminated with blood, body fluids or secretions;
-If hands are not visibly soiled then the use of an alcohol-based hand rub/gel for all of
the following situations:
–Before direct care with residents;
–Before placing gloves on;
–Before performing any non-surgical invasive procedure;
–Before handling medications;
–Before handling clean or soiled dressings, gauze pads, etc.;
–Before moving from a contaminated body site to a clean body site during resident care;
–After contact with a resident’s intact skin;
–After handling used dressings, contaminated equipment, etc.;
–After removing gloves.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 79)
Review of the facility’s Perineal Incontinence Care policy, dated 1/1/06, showed:
-Standard: To provide cleanliness and comfort, prevent irritation and infection in the
perineal area during the daily bath and after voiding or defecating;
-Assemble equipment at bedside;
-Wash hands;
-Put on gloves;
-Cleanse the genital area;
-Use different sections of the washcloth with each downward stroke;
-Wash the buttocks area;
-Remove gloves;
-Wash hands;
-The policy failed to address removing gloves when changing from cleansing of the genitals
to the buttocks and/or washing or sanitizing hand after glove changes.
1. Review of Resident #114’s quarterly Minimum Data Set (MDS) a federally required
assessment instrument completed by facility staff, dated 9/22/18, showed:
-Clear speech, distinct intelligible words;
-Makes self-understood;
-Able to understand others;
-Extensive assistance required for bed mobility, dressing and toilet use;
-Total dependence for personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Activity of daily living (ADL) care deficit related to [MEDICAL CONDITION] and
limited mobility;
-Goal: To be clean, odor free and well-groomed on a daily basis;
-Approach: Bathe daily and as necessary.
Observation on 11/7/18 at 7:24 A.M., showed Certified Nursing Assistant (CNA) A provided
care to the resident. CNA A entered the resident’s room and gathered supplies. He/she
placed gloves on and failed to wash or sanitize his/her hands prior to placing gloves on.
CNA A said he/she needed to get more supplies, removed his/her gloves, left the room,
returned and placed new glove on. CNA A failed to wash or sanitize his/her hands after
returning to the room and before placing new gloves on. CNA A unsecured the resident’s
brief. The resident brief wet with urine. CNA A cleansed the resident’s abdominal folds
and pubic area. He/she then cleansed the resident’s genitalia. While wearing the same
gloves CNA A obtained a new washcloth and washed the resident’s underarms. CNA A said
he/she needed to get more supplies and, while wearing the same gloves, opened the
resident’s dresser and searched through the resident’s belongings in the dresser. He/she
then removed his/her gloves and left the resident’s room. He/she returned to the room and
without washing or sanitizing his/her hands, CNA A placed new gloves on. CNA A assisted
the resident to reposition in bed and washed the resident’s buttocks. While wearing the
same gloves, CNA A applied barrier cream to the resident’s buttocks, obtained a clean
brief and placed it under the resident, repositioning the resident by pushing and pulling
on the resident’s knees, hips arms and back. CNA A secured the brief, put deodorant on the
resident, moved the resident’s bedside table, turned on the sink, moistened a new rag and
wiped the resident’s chest area. CNA A continued to wear the same gloves while he/she put
powder on the resident’s chest and rub it into skin folds, grabbed some slacks and
assisted the resident to place them on, assisted the resident to roll side to side, and
touched the resident’s gastric tube (a tube surgically inserted into the stomach for the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 80)
purpose of providing food, fluid and medications). CNA A assisted the resident to put on
shoes and a shirt. CNA A, while wearing the same gloves, assisted the resident to sit up
in bed by pulling on the resident’s hands and back of his/her neck. CNA A transferred the
resident to his/her wheelchair before removing his/her gloves and washing his/her hands.
2. Review of Resident #139’s annual MDS, dated [DATE], showed:
-BIMS score of 0 out of a possible score of 15;
-A score of 0-7 showed the resident rarely or never understood;
-Extensive assistance required for bed mobility;
-Total dependence for transfers, toilet use and personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: The resident requires total care with ADLs related to stroke;
-Goal: The resident will be clean, odor free and well-groomed and neat on a daily basis;
-Approach: Resident totally depending on one staff for repositioning and turning in bed at
least every 2 hours and as necessary. Resident has contractures (loss of muscle tone and
range of motion due to loss of flexibility of the muscles and tendons) of the right arm
and hand. Provide skin care daily and as needed to keep clean and prevent skin breakdown.
Observation on 11/7/18 at 3:43 P.M., showed CNA E entered the resident’s room and said
he/she needed to check to see if the resident was clean. He/she placed an ungloved hand
down the front of the resident’s brief, said the resident was dry, removed his/her hand
and exited the resident’s room. CNA E immediately entered another resident’s room. CNA E
failed to wear gloves, wash or sanitize his/her hands before placing his/her hand inside
the resident’s brief or before leaving the resident’s room and entering another resident’s
room.
During an interview on 11/7/18 at 4:25 P.M., the administrator said it was not acceptable
to check for incontinence by sticking a hand down the front of a resident’s brief.
3. Review of Resident #58’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Severe cognitive impairment with short and long term memory problems;
-No behaviors;
-Range of motion impairment on one side upper and lower extremities;
-Required maximum assistance from staff for transfers, dressing and bathing.
Observation on 11/7/18 at 7:15 A.M., showed the resident lay in bed. CNA S went into the
resident’s room and told the resident he/she was going to get him/her dressed. CNA S
washed his/her hands, put on gloves and picked up a wash basin from directly off the
floor. The wash basin did not have any type of covering and was not on any type of
barrier. Without sanitizing or cleaning the wash basin, he/she filled the wash basin with
water, placed it directly on top of the resident’s dresser, provided the resident with
perineal care, dressed and transferred the resident into his/her wheelchair. After the CNA
had provided care to the resident, he/she rinsed out the inside of the wash basin and
placed it directly on top of the sink counter top. At 7:42 A.M., the CNA left the
resident’s room. The wash basin remained on top of the sink counter top without any type
of covering or barrier.
During an interview on 11/13/18 at 9:05 A.M., the Director of Nursing (DON) said it would
never be appropriate to store or use a wash basin that had been sitting directly on the
floor without any type of covering or barrier due to infection control issues.
4. During an interview on 11/13/18 at 9:00 A.M., the DON said while providing incontinence
care, she would expect staff to change gloves when going from the front area to the back
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 81)
and when the gloves are potentially contaminated. Staff should sanitize their hands when
changing gloves. Staff should not touch the resident or resident surfaces with soiled
gloves. Urine collection devices should be stored in bags and labeled with the resident’s
name.
5. Review of Resident #29’s electronic face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-[MEDICATION NAME] (short acting insulin) Pen Fill Solution Cartridge 100 units/milliliter
(ml) for diabetes.
-Inject subcutaneously (under the skin) before meals as per sliding scale.
Observation of a blood sugar check, on 11/08/18 at 4:27 P.M., showed Licensed Practical
Nurse (LPN) CC:
-Gathered supplies and had the resident follow him/her into the second floor shower room;
-Placed the glucometer (machine used to sets blood sugar levels) onto the dirty shower
room sink with no barrier. He/she failed to sanitize the glucometer prior to placing it on
the sink. Three used razors sat inside the sink. LPN CC placed gloves on and did not wash
his/her hands prior to placing gloves on, picked up the glucometer and performed the blood
sugar check;
-Walked out of the shower room into the dining room and placed the dirty glucometer on the
medication cart, removed and disposed of his/her gloves and did not wash his/her hands.
LPN CC placed the glucometer into the top drawer of the cart without sanitizing it.
6. Review of Resident #111’s electronic face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s POS, showed:
-Humalog Solution (fast acting insulin) 100 units/ml for diabetes;
-Inject subcutaneously three times a day as per sliding scale.
Observation on 11/8/18 at 4:43 P.M., LPN CC:
-Gathered the supplies and had the resident follow him/her into the second floor shower
room;
-Placed the glucometer (un-sanitized) onto the dirty shower room sink with no barrier.
Three used razors sat inside the sink. He/she placed gloves on and did not wash his/her
hands. He/she picked up the glucometer and performed the blood sugar check;
-He/she walked out of the shower room and into the dining room, placed the dirty
glucometer on the resident’s mediation packages that were sitting on top of the cart,
removed and disposed of his/her gloves and did not wash his/her hands;
-Cleaned the top rubber [MEDICATION NAME] of the insulin bottle and drew up 3 units of
Humalog insulin;
-Placed the glucometer into the top drawer of the cart without sanitizing it.
7. Review of Resident #142’s electronic face sheet, showed [DIAGNOSES REDACTED].>-End
stage [MEDICAL CONDITION] (condition in which a person’s kidneys cease functioning on a
permanent basis leading to the need for a regular course of long-term [MEDICAL TREATMENT]
or a kidney transplant to maintain life);
-Dementia with behaviors; and
-Need for assistance with personal care.
Review of the resident’s care plan, in use during this survey, showed:
-The resident had an ADL self-care performance deficit related to Dementia and decrease in
areas of physical functioning;
-The resident required extensive assistance by one staff for toileting;
-The resident required assistance by one staff member with personal hygiene
Observation on 11/6/18 at 8:48 A.M., 11/8/18 at 4:21 P.M., and 11/13/18 at 8:01 A.M.,
showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265585

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

NAME OF PROVIDER OF SUPPLIER

HILLSIDE MANOR HEALTHCARE AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1265 MCLARAN AVENUE
SAINT LOUIS, MO 63147

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 82)
-A urinal hung on the bathroom handrail with a dried yellow substance in the bottom. The
urinal was uncovered and unlabeled;
-A urine hat hung on the bathroom wall rack that was uncovered and unlabeled.
8. Observation of the bathroom for room [ROOM NUMBER], on 11/6/18 at 9:21 A.M. and 11/7/18
at 7:04 A.M., showed 2 urine collection hats located on the left and right handrail of a
resident’s shared bathroom. The collection hats not stored in a bag. One collection hat
labeled the name of a resident who did not reside in the room. The other collection hat
not labeled.
9. During an interview on 11/13/18 at 7:40 A.M., CNA AA said:
-Urinals and urine hats should be cleaned after each use;
-Urinals and urine hats should be stored in a plastic bag and be labeled with the
resident’s name, room number and date opened.
During an interview on 11/13/18 at 7:48 A.M., LPN BB said:
-He/she expected staff to keep urinals and urine hats covered at all times when not in
use;
-Urinals and urine hats should be labeled with the resident’s name, room number and the
date opened.
During an interview on 11/13/18 at 9:05 A.M., the DON said:
-He/she expected staff to keep urinals and urine hats covered at all times when not in
use;
-He/she expected staff to clean urinals and urine hats after each use;
-He/she expected staff to label urinals and urine hats with the resident’s name, room and
the date opened.