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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Reasonably accommodate the needs and preferences of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure two
residents (Residents #28 and #43) had reasonable access to their call light, in a review
of 22 sampled residents. The facility also failed to ensure functioning call lights in
residents’ rooms. The facility census was 107.
1. Review of the facility’s Use of Call Light Policy, dated (MONTH) (YEAR), showed the
following:
-All facility personnel must be aware of call lights at all times;
-Answer ALL call lights promptly whether or not you are assigned to the resident;
-For bedside call lights, a light and/or sound will appear and be heard over the door of
the resident’s room and on the board at the nurse’s station;
-For emergency call lights in the bathrooms and/or shower/tub rooms, a light and/or a
continuous sound will appear over the door of the room and on the board at the nurses’s
station;
-Your must turn the call light off at the point of origin, this is accomplished by pushing
the switch up or by depressing the ring around the button that activities the call light;
-Answer all call lights in a prompt, calm, courteous manner. Turn off the call light as
soon as you enter the room;
-Never make the resident feel you are too busy to give assistance; offer further
assistance before you leave the room;
-When providing care to residents’ be sure to position the call light conveniently for the
resident’s use;
-Tell the resident where the call light is and tell him/her how to use the light;
-Orient new residents to the call light at the bedside; in the bathroom; and in the shower
rooms. Have the resident demonstrate the use of the call light to be sure he/she
understands your instructions;
-Report any defective light to the charge nurse immediately. The charge nurse should
inform maintenance personnel either verbally or a work order;
-Log defective lights, with exact location, in the maintenance log if the facility used a
log;
-Be sure all call lights are placed on the beds at all times, never on the floor or
bedside table;
-Check the call light system at regular intervals.
2. Review of Resident #28’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument, completed by facility staff, dated 11/14/17, showed the following:
-He/she had moderate cognitive impairment;
-He/she required supervision of one staff member to dress, for bed mobility, walking in
his/her room and personal hygiene;
-He/she was occasionally incontinent of bowel and bladder;
-He/she received an antianxiety medication.
Review of the resident’s care plan, dated 11/14/17, showed the following;
-The resident required assistance of one staff member due to Alzheimer’s, weakness and
incontinent episodes;
-The resident was alert and oriented and able to make his/her needs known;
-The resident liked to eat in his/her room;
-The resident needed help to dress morning and night;
-Monitor for pain;
-Keep the resident’s call light in reach.

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 0558

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
Observation on 3/19/18 at 8:10 A.M. showed the following:
-No call light was available for the resident;
-An adaptor was plugged into the call light wall unit without a cord connected to unit.
Observation on 3/20/18 at 5:24 A.M. showed the following:
-No call light was available for the resident;
-An adaptor was plugged into the call light wall unit wall without a cord connected to the
unit.
Observation on 3/21/18 at 11:54 A.M. showed the following:
-No call light was available for the resident;
-An adaptor was plugged into the call light wall unit with no cord attached.
During an interview on 3/18/18 4:31 P.M., the resident said someone took his/her call
light last week. A Certified Nurse Aide (CNA) said the resident used it too much and
ripped it out of the wall.
During an interview on 3/21/18 at 1:56 P.M., the Assistant Director of Nursing (ADON) said
the following:
-He/she expected staff to ensure residents’ call lights were in reach at all times;
-He/she expected staff to check for placement of the call lights when they walked down the
hall, each time they checked on a resident and after resident care;
-He/she did not notice Resident #28’s call light was missing when she was in the
resident’s room;
-Staff should have noticed Resident #28’s call light was not there and should have had it
replaced.
3. Observation on 3/20/18 at 9:24 A.M. in dually occupied resident room [ROOM NUMBER],
showed the call light for bed B did not operate when tested . Further observations showed
Resident #43 sat in his/her wheelchair by his/her bed (bed A). The call light for Resident
#43 (bed A) was within the sheets of the made bed with the cord pulled down between the
wall and the mattress. The call light was tucked underneath the mattress. The cord was
distressed with the wires inside the call light cord easily visible where the outer sleeve
was missing for approximately two inches near where the cord plugged into the wall. This
observation was confirmed by the Maintenance Supervisor.
During interview on 3/20/18 at 9:27 A.M., Resident #43 said he/she was unable to access
the call light and needed assistance in his/her room. He/she depended on the use of the
call light for help.
4. Observation on 03/21/18 at 1:50 P.M. in occupied room [ROOM NUMBER], showed no call
light was attached to the wall above the resident’s bed (bed A).
5. Observation on 3/20/18 at 11:30 A.M. showed the call light in occupied resident room
[ROOM NUMBER] did not operate when tested . This observation was confirmed by the
Maintenance Supervisor.
6. During an interview on 3/21/18 at 3:30 P.M., the Director of Nursing said staff should
ensure every resident had access to a functioning call light when they were in their
rooms.

F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify each resident of certain balances and convey resident funds upon discharge,
eviction, or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to return resident funds to five

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
discharged residents (Residents #2, #470, #471, #478, and #479) within five days following
discharge and failed to convey the remaining resident balance to the state or the probate
jurisdiction administering the resident’s estate within 30 days of death for 14 residents
(Residents #459, #463, #464, #465, #466, #467, #468, #469, #472, #473, #474, #475, #476,
and #477), in a review of 19 additional residents. The facility census was 107.
1. Review of the facility’s guidelines for maintaining the resident funds account policy,
dated [DATE], showed the following:
-Remaining personal funds for a deceased resident: Upon death of a resident, we will first
contact the Probate court. If there is not an estate, then we are required by law to
submit a written account of the remaining personal funds for any deceased resident who has
received aid, care, assistance or services paid by the Department of Social Services. For
purposes of this guideline, personal funds of the deceased resident shall include all the
resident’s remaining personal funds held in whatever title the account or accounts may be
known. This includes general account. Since we collect patient surplus in advance, if a
resident expires before the end of the month, many times they will end up with a credit
balance on the books. When this happens, you should request a refund check made payable to
the resident trust fund for the resident. The check would be deposited into the trust fund
and reported along with any other remaining trust fund balance to the Division of Medical
Services. The regulation requires that this is done within 60 days of death. The
regulation should not be violated.
-Remaining personal funds for a discharged resident. If a resident discharges and the
facility was their representative payee, any and all funds in the resident trust account,
cash on hand or in the operations account-the conserved funds are to be returned to social
security. The facility has five calendar days to give a complete accounting of personal
funds and the balance of the funds to be compliant with state regulations.
2. Review of Resident #467’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $100.95.
3. Review of Resident #478’s nurse’s notes showed the resident was discharged on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $38.00.
4. Review of Resident #476’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $372.46.
5. Review of Resident #472’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE] showed, the resident had a balance of $101.33.
6. Review of Resident #475’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $27.23.
7. Review of Resident #477’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $1807.89.
8. Review of Resident #464’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of #14.08.
9. Review of Resident #463’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $636.30.
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
10. Review of Resident #470’s nurse’s notes showed the resident was discharged from the
facility on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $180.00.
11. Review of Resident #479’s nurse’s notes showed the resident was discharged on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $2.00.
12. Review of Resident #2’s nurse’s notes showed the resident was discharged on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the the resident had a balance of $38.00.
13. Review of Resident #473’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $25.00.
14. Review of Resident #465’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance $507.07.
15. Review of Resident #474’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $348.72.
16. Review of Resident #459’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $200.00.
17. Review of Resident #468’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE] showed the resident had a balance of $304.91.
18. Review of Resident #466’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $80.00.
19. Review of Resident #469’s nurse’s notes showed the resident expired on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $536.25.
20. Review of Resident #471’s nurse’s notes showed the resident was discharged from the
facility on [DATE].
Review of the facility’s current balance report for the resident funds account, dated
[DATE], showed the resident had a balance of $150.00.
21. During interview on [DATE] at 11:12 A.M., the business office manager/bookkeeper said
when a resident expires or is discharged , he/she immediately contacts the state in
writing and by phone about any funds left in the residents funds account. He/she was
unaware Residents #467, #478, #476, #472, #475, #477, #464, #463, #470, #479, #2, #473,
#465, #474, #459, #468, #466, #469, and #471 still had a resident fund balance. He/She
just started at the facility three weeks ago. She was aware the facility only had 30 days
to return or send to the state all monies an expired or discharged resident has in the
resident fund account.
During interview on [DATE] at 11:14 A.M., the corporate financial consultant said he/she
expected the state to be notified immediately if a resident expired or was discharged and
still had money in the resident funds account. He/she was unaware Residents #467, #478,
#476, #472, #475, #477, #464, #463, #470, #479, #2, #473, #465, #474, #459, #468, #466,
#469, and #471 still had a resident fund balances. He/she was aware the facility only had
30 days to return or send to the state all monies an expired or discharged resident has 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
the resident funds account.
During interview on [DATE] at 11:16 A.M., the administrator said she expected any monies a
resident has in the resident funds account to be returned or sent to the state immediately
if a resident is discharged or expires. She was unaware Residents #467, #478, #476, #472,
#475, #477, #464, #463, #470, #479, #2, #473, #465, #474, #459, #468, #466, #469, and #471
still had a resident fund balances.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 and
update a plan of care consistent with resident’s specific conditions, needs, and risks for
four residents (Residents #12, #29, #44 and #101), in a review of 22 sampled residents.
The facility census was 107.
1. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) Users
Manual, Version 3.0, Chapter 4, dated (MONTH) 2011, showed the following:
-The care plan is driven not only by identified resident issues and/or conditions but also
by a resident’s unique characteristics, strengths, and needs;
-A well-developed and executed assessment and care plan looks at each resident as a whole
human being with unique characteristics and strengths;
-The care plan should be revised on an ongoing basis to reflect changes in the resident
and the care that the resident is receiving;
-The effectiveness of the care plan must be evaluated from its initiation and modified as
necessary;
-Changes to the care plan should occur as needed in accordance with professional standards
of practice and documentation. The interdisciplinary team members should communicate as
needed about care plan changes;
-Federal statute and regulations require that residents are assessed promptly upon
admission (but no later than Day 14) and the results are used in planning and providing
appropriate care to attain or maintain the highest practicable well-being;
-Facilities have seven days after completing the admission RAI assessment to develop or
revise the resident’s care plan;
-Minimum Data Set (MDS), federally mandated assessment instruments, completed by facility
staff, are not required for minor or temporary variations in resident status – in these
cases, the resident’s condition is expected to return to baseline within two weeks.
However, staff must note these transient changes in the resident’s status in the
resident’s record and implement necessary assessment, care planning, and clinical
interventions, even though an MDS assessment is not required.
2. Review of the facility’s comprehensive care plan policy, dated (MONTH) (YEAR), showed
the following:
-An individualized comprehensive care plan that includes measurable goals and time frames
will be developed to meet the resident’s highest practicable physical, mental, and
psychosocial well-being;
-The interdisciplinary care plan team with input from the resident, family, and/or legal
representative will develop and maintain a comprehensive care plan for each resident that
identifies the highest level of functioning the resident may be expected to attain. 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Some

(continued… from page 5)
comprehensive care plan will be based on a thorough assessment that includes, but not
limited to, the MDS. Assessments of each resident is ongoing process and the care plan
will be revised as changes occur in the resident’s condition.
-The interdisciplinary care plan team is responsible for the periodic review and updating
of care plans when a significant change in the resident’s condition has occurred. At least
quarterly. When changes occur that impact the resident’s care (i.e. change in diet,
discontinuation of therapy, changes in care areas that do not require a significant change
assessment).
3. Record review of Resident #101’s nurse’s notes showed the following:
-On 1/25/18, staff sent the resident to the emergency room due to pain in the left hip.
The resident had difficulty bearing weight and was sent by ambulance;
-On 1/28/18, the resident was readmitted and returned to the facility with family members
due to a left [MEDICAL CONDITION]. Surgical repair was performed on the hip on 1/25/18.
The resident was on hip precautions for 12 weeks and was weight bearing as tolerated to
the left leg.
Review of the resident’s physician orders, dated 1/29/18, showed the following:
-Left [MEDICAL CONDITION];
-Non-weight bearing to the right arm;
-Weight bearing as tolerated to the left leg.
Review of the resident’s Significant Change in Status Minimum Data Set (MDS), a federally
mandated assessment instrument required to be completed by facility staff, dated 2/5/18,
showed the following:
-Required extensive assistance of one staff for transfer and toilet use;
-No urinary appliances used;
-Occasionally incontinent of bowel and bladder.
Review of the resident’s comprehensive care plan, dated 2/9/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident experienced bladder incontinence related to memory loss, weakness, and gait
instability;
-Provide assistance for toileting;
-Provide incontinence care after each incontinent episode;
-The resident needed assistance from staff for activities of daily living related to a
fractured right arm;
-Monitor pain;
-Encourage activities;
-Assist to and from the wheelchair and with mobility.
The resident’s care plan, dated 2/9/18, did not address the resident required extensive
assistance of one to transfer and use the toilet or the non-weight bearing status of the
resident’s right arm.
Review of the resident’s nurse’s notes showed the following:
-On 2/21/18 at 6:00 A.M., staff found the resident on the floor. The resident was sent to
the hospital;
-On 2/23/18, the resident returned to the facility.
Review of the resident’s baseline care plan, dated 2/23/18, showed the following:
-The baseline care plan is to be completed within 48 hours of admission;
-After completion, print and file the following community protocols;
-Follow community protocols for catheter care.
Review of the resident’s physician order [REDACTED].
Review of the resident’s five-day MDS, dated [DATE], showed the resident had an indwelling
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Some

(continued… from page 6)
urinary catheter.
Review of the resident’s physician orders, dated 3/6/18, showed the following:
-Weight bearing as tolerated to the upper extremity;
-Non-weight bearing on the left lower extremity;
-There was no order for an indwelling urinary catheter.
Observation throughout the survey from 3/18/18 until 3/21/18 showed the resident had a
urinary catheter in place.
During an interview on 3/21/18 at 10:12 A.M., Occupational Therapist (OT) E said the
resident has had the urinary catheter for quite a while and thought the resident had the
urinary catheter since January, after he/she had been hospitalized for [REDACTED]. The
resident was currently non-weight bearing to the left leg.
During an interview on 3/21/18 at 10:15 A.M., Licensed Practical Nurse (LPN) F said he/she
was not certain how long the resident has had the urinary catheter but thought he/she had
the catheter when he/she returned from the hospital after hip surgery in January.
Review on 3/21/18 of the resident’s comprehensive care plan, dated 2/9/18, located in the
resident’s chart, showed no update the resident had an indwelling urinary catheter or
instructions for its care and maintenance. The care plan did not address the resident’s
non-weight bearing status to the left leg and weight bearing as tolerated status to the
right arm.
4. Review of the Resident #44’s care plan, dated 9/22/17, showed the following:
-The resident required a urinary catheter related to skin issues;
-Change the resident’s catheter per physician orders;
-Staff to provide assistance for catheter cares every shift and as needed.
Review of the resident’s quarterly MDS, dated [DATE], showed he/she required an indwelling
urinary catheter.
Review of the resident’s physician orders, dated 2/2/18, showed the following:
-The resident was readmitted from the hospital with [DIAGNOSES REDACTED].
-On 2/2/18, an order for [REDACTED].
Review of the resident’s physician orders [REDACTED].
-On 2/22/18, Compartmental Syndrome (a condition caused by pressure buildup from internal
bleeding or swelling of tissues;
-On 2/22/18, apply Xeroform (a petroleum based gauze) dressing daily;
On 3/7/18, discontinue previous treatment. Apply Santyl and Silver Alginate (a [MEDICATION
NAME] agent);
-On 3/16/18, discontinue previous treatment. Apply Santyl and [MEDICATION NAME] (an
antibiotic) 1% gel to the wound, cover with an ABD (absorbent dressing) and tape.
Review of the resident’s care plan showed no update for urinary tract infection, use of an
antibiotic or wound care.
5. Review of Resident #12’s nurse’s notes, dated 10/25/17 at 10:22 A.M., showed the
resident was transferred by a mechanical lift.
Review of the resident’s MDS, dated [DATE], showed no documentation the resident required
assistance from two staff members and an assistive device for transfers.
Review of the resident’s hospice admission papers, dated 12/11/17, showed the resident was
admitted to hospice care on 12/11/17.
Review of the resident’s POS, dated (MONTH) (YEAR), showed an order for [REDACTED].
Review of the resident’s care plan, dated 03/10/18, showed no documentation of the
resident receiving hospice care, no documentation the resident required a mechanical lift
for transfers and no documentation the resident was to wear heel protectors while in bed
and while in his/her chair.
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Some

(continued… from page 7)
Observation on 3/20/18 at 7:23 A.M. showed two staff transferred the resident into a broda
chair (a tilt and recline wheelchair) from his/her bed with a mechanical lift. The
resident wore no have heel protectors.
Observation on 03/20/18 at 12:38 P.M. showed two staff assisted the resident into his/her
bed from his/her broda chair with a mechanical lift. The resident wore no heel protectors.
Observation on 03/21/18 at 07:47 A.M. showed the resident in bed with no heel protectors
in place.
During interview on 03/21/18 at 07:52 A.M., Certified Nurse Assistant (CNA) A said three
or four months ago the resident went to the hospital and when he/she returned to the
facility he/she required total assistance and required a mechanical lift for transfers.
6. Review of Resident #29’s admission MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Ability to make daily decisions was moderately impaired;
-The resident had two or more falls without injury since admission;
-The resident had one fall with major injury since admission;
-Required limited assistance of one staff for bed mobility, transfers, toilet use, and
hygiene.
Review of the resident’s care plan, dated 12/1/18, showed the following:
-The resident had a history of [REDACTED].>-The resident fell out of bed on 11/15/17.
An intervention of a bolstered mattress was added on this date;
-Equip the resident with a device that monitors rising.
Observation throughout the survey from 3/18/18 until 3/21/18 showed the resident did not
have a bolstered mattress in place on his/or bed and did not have any device that
monitored rising of the resident on the bed or on the resident’s chair.
During an interview on 3/21/18 at 8:10 A.M., Licensed Practical Nurse (LPN) F said the
resident did not utilize any device that monitored rising. The facility did not utilize
alarms of any kind and hadn’t for several months. LPN F was not sure if the resident had a
bolstered mattress.
During an interview on 3/21/18 at 10:10 A.M., the Director of Nursing (DON) said the
resident was at high risk for falls and had several things in place as interventions to
prevent falls. The DON said the facility did not utilize alarms or devices that alerted
staff of a resident’s rising. The DON said he/she thought the resident had a bolstered
mattress on his/her bed.
During interview on 3/21/18 at 8:39 A.M., the care plan coordinator said she updated the
resident care plans for change of conditions, braces, lifts, and catheters for long-term
care residents. The MDS coordinator updated the resident care plans for residents
receiving Medicare Part A. Any nurse can update the resident care plans. She updated the
resident care plans when changes were brought to her attention. She was responsible for
ensuring the resident care plans were accurate and she did this every three months or as
needed.
During interview on 03/21/18 at 8:46 A.M., the MDS coordinator said she updated the
resident care plan for the residents receiving Medicare Part A. She was responsible to
update the care plan for any changes in the resident’s condition or care needs if the
resident have been out of the facility and return to the facility under Medicare Part A.
She changes the care plans when she does her assessments or when someone makes her aware
there has been a change with the resident. She completes her assessments within eight
days, 14 days, 30 days, 60 days, 90 days, and with a change of therapy or change of
condition. The floor nurses are responsible to complete a 48-hour interim care plan when a
resident returns from 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Some

(continued… from page 8)
During interview on 3/21/18 at 8:16 A.M., the DON said she, the assistant director of
nursing (ADON), the MDS coordinator, and the care plan coordinator updated the care plans
in the residents’ charts. The care plan nurse did the updates in the residents’ electronic
chart. She expected the residents’ care plans to be updated as the resident’s condition
changed. She expected the residents’ care plans to show the residents used lifts, braces,
heel protectors, and any other devices that were needed for their care. She expected the
care plan to show what type of assistance the resident needed for activities of daily
living (ADLs) and how many staff it took to provide those cares.

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, facility staff failed to provide
complete perineal care for one resident (Resident #74) following incontinence and failed
to provide oral care for two residents (Residents #74 and #101), in a review of 22 sampled
residents. The facility census was 107.
1. Review of the facility policy on Oral Hygiene, dated (MONTH) (YEAR), showed the
following:
-Purpose: To cleanse the mouth, teeth, and dentures;
-Offer oral hygiene before breakfast, after each meal, and at bedtime.
2. Review of the 2001 revision of the Nurse Assistant in a Long Term Care Facility manual,
showed the following:
-Purpose of peri-care is to clean the peri area for the resident who is unable to or has
difficulty with adequately cleaning self, prevents itching, burning, and odor, and
prevents infections. The manual also showed the resident who is continent should have
peri-care daily with morning care, the resident who is incontinent, after each voiding or
stool, and perineal care is very important in maintaining the resident’s comfort. More
frequent care is required for residents who are incontinent.
-Procedures staff was to follow when they provided peri care for a male (steps 7 through
13) included the following:
-Cover the resident;
-Expose the perineal areas included, wash the penis from the tip downward, rinse, and dry
(specific instructions for uncircumcised);
-Wash and rinse the scrotum;
-Wash and rinse other skin areas between the legs;
-Wash and rinse the anal area;
-Pat the area dry.
-Procedures staff were to follow when providing peri care for a female (steps 7 through
14) included the following:
-Cover the resident;
-Expose the peri area, wash the inner legs and outer peri area along the outside of the
labia (Labia Majora);
-Use a clean area of the washcloth for each wipe of the peri area;
-Wash the outer skin folds from front to back;
-Wash the inner labia (Labia Minora) from front to 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 9)
-Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area)
from front to back;
-Rinse the area well, start from the innermost area and proceed outward;
-Wash and rinse the anal area;
-Pat the peri area dry.
3. Review of the Nurse Assistant in a Long Term Care Facility manual, revised 2001, showed
the following:
-Purposes of oral hygiene (mouth care)-A clean mouth and properly functioning teeth are
essential for physical and mental well-being of the resident: Prevent infections in mouth,
Remove food particles and plaque, Stimulate circulation of gums, Eliminate bad taste in
mouth; thus food is more appetizing;
-Give oral care before breakfast, after meals, and also at bedtime;
-Specific observations to make: tooth decay, any loose or broken teeth; red or swollen
gums; sores or white patches in the mouth or on the tongue; changes in eating habits; and
poorly fitting dentures;
-A clean mouth is very important to the physical and mental well-being of the resident.
Oral care can prevent infections, the buildup of plaque, and bad breath. It can even
influence the resident’s appetite. Remember to observe the resident during oral care to
identify potential problems.
4. Review of Resident #74’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 1/26/18, showed
the following:
-Long-term and short-term memory problems;
-Required extensive assistance of one staff for toilet use and personal hygiene;
-Frequently incontinent of bladder and bowel.
Review of the resident’s care plan, revised on 1/26/18, showed the following:
-[DIAGNOSES REDACTED].
-Required moderate assistance with dressing, transfers, toileting, hygiene, and bathing
related to a stroke with [MEDICAL CONDITION];
-At risk for skin break down due to decreased mobility and incontinence;
-Provide incontinence care after each incontinence episode;
-Minimize skin exposure to moisture.
The resident’s care plan did not address oral care.
Observation on 3/20/18 at 5:39 A.M. showed the following:
-The resident lay in bed in a gown. There was a strong odor of urine in the room;
-Certified Nurse Aide (CNA) B and CNA C entered the resident’s room to provide morning
care;
-CNA B removed covers from the resident. The resident was incontinent of urine;
-CNA C used wash cloths and perineal wash and wiped the resident’s front perineal area;
-CNA B and CNA C rolled the resident to the left side and washed the resident’s buttocks;
-CNA B and CNA C assisted the resident to his/her back;
-Without washing the resident’s right or left thighs, CNA B placed a clean brief under the
resident;
-CNA C secured the brief. A very strong odor of urine remained in the room;
-CNA B and CNA C dressed the resident and sat him/her on the side of the bed;
-CNA B and CNA C transferred the resident to the wheelchair with a gait belt;
-CNA B bagged the soiled linen and left the room;
-CNA C brushed the resident’s hair and washed the resident’s face;
-CNA C wheeled the resident out of the room in the wheelchair 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 10)
-Neither CNA B nor CNA C offered or assisted the resident with oral care.
During an interview on 3/20/18 at 6:08 A.M., CNA C said he/she was not sure if the
resident had any teeth or not. The resident was incontinent of urine that morning and the
resident’s bed was wet with urine. CNA C said staff should ensure all areas of the
resident are cleaned after incontinence. CNA C did not realize he/she did not wash the
resident’s left or right hips. CNA C said he/she did not offer the resident any oral care
because he/she didn’t think the resident had any teeth.
Observation and interview on 3/20/18 at 8:32 A.M. showed the resident sat in his/her room
in the wheelchair. The resident said he/she did not have teeth. No one had assisted
him/her to clean his/her mouth. Observation showed the resident’s breath had a foul odor.
5. Review of Resident #101’s MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Made decisions tasks of daily life with modified independence, some difficulty in new
situations only;
-Required limited assistance of one staff for personal hygiene;
-Had his/her own teeth.
Review of the resident’s care plan, last revised on 2/9/18, showed the following:
-The resident required assistance with activities of daily living related to a fractured
right arm, weakness, and joint pain;
-The resident required assistance with dressing and all activities of daily living.
Observation and interview on 3/19/18 at 8:33 A.M. showed the resident sat in a wheelchair
in his/her room. The resident said he/she had been to the dining room for breakfast. The
resident said he/she had his/her own teeth. Observation showed the resident’s breath had a
foul odor. The resident said he/she had not had any assistance to brush his/her teeth that
morning and that was typical most days.
Observation on 3/20/18 at 8:01 A.M. showed the following:
-CNA D assisted the resident to dress as the resident sat on his/her bed;
-CNA D put a gait belt on the resident and transferred him/her to the wheelchair;
-CNA D provided the resident with a wet wash cloth for his/her face, and combed the
resident’s hair;
-CNA D gave the resident his/her glasses and pushed the resident to the dining room in the
wheelchair;
-CNA D did not offer or assist the resident with any oral care.
During an interview on 3/20/18 at 8:14 A.M., CNA A said he/she assisted the resident that
morning with dressing and transfer to the dining room. CNA A said he/she was not sure if
the resident had his/her own teeth or not. CNA A said he/she did not offer or provide any
oral care for the resident that morning.
During an interview on 3/21/18 at 3:30 P.M., the Director of Nursing (DON) said he/she
would expect staff to wash all areas of a resident’s skin that had been in contact with
urine or stool. The DON said staff should provide or assist residents with oral care when
the get them up in the morning, at bedtime, and as needed or requested.

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

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

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 11)
evaluate and provide services to address limited range of motion and proper positioning
for two residents (Residents #47 and #84), in a review of 22 sampled residents. The
facility census was 107.
1. Review of Resident #84’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument required to be completed by facility staff, dated 2/1/18, showed the
resident had limited range of motion on one side of the body to both the upper and lower
extremity.
Review of the resident’s care plan, last reviewed on 2/2/18, showed the following:
-[DIAGNOSES REDACTED].>-The resident required assistance from one staff member for
activities of daily living related to a stroke with left sided [MEDICAL CONDITION]
(paralysis of one side of the body);
-Assist with dressing and personal hygiene;
-Assist with transfers. The resident could propel self once in the wheelchair.
The resident’s care plan did not address any restorative or therapy services for range of
motion or positioning devices to maintain proper positioning for the resident’s [MEDICAL
CONDITION].
Observation and interview on 3/18/18 at 6:15 P.M. showed the resident sat in a wheelchair
in his/her room. The resident was completely flaccid (hanging limply) on his/her right
side (the resident’s care plan indicated the resident was paralyzed on the left side). The
resident said he/she was not receiving any therapy and no one was working with him/her to
regain any movement. The resident had one footrest on his/her wheelchair on the right
side. The resident’s right foot rested on the floor. The resident responded with a
frustrated no when asked if his/her right foot would stay on the footrest.
Observation on 3/20/18 at 7:36 A.M. showed the resident propelled himself/herself
backwards down the hall. The resident’s right foot had fallen off the foot rest and drug
the floor. A staff member stopped and put the resident’s right foot back on the foot rest.
The resident indicated it would not stay on the footrest. The resident’s right arm was
flaccid and laid in the wheelchair next to the resident’s right hip.
Observation on 3/20/18 at 11:47 A.M. showed the Assistant Director of Nursing (ADON)
placed the resident’s right arm in a sling.
During an interview on 3/20/18 at 11:50 A.M., the ADON said there was no order and it was
not on the resident’s care plan to wear the sling but the resident had requested to wear
it. The ADON would call the resident’s physician for an order and see if physical therapy
(PT) could evaluate him/her to see if the sling was on correctly.
During an interview on 3/20/18 at 1:19 P.M., the resident said the sling helped to keep
his/her arm comfortable and he/she liked to have it on.
Observation on 3/20/18 at 2:22 P.M. showed the resident propelled himself/herself in the
hallway in the wheelchair. The resident’s right foot was off the footrest and drug the
floor.
Observation on 3/21/18 at 7:54 A.M. showed the resident sat in wheelchair in his/her room
and had a sling in place to his/her right arm.
During an interview on 3/21/18 at 8:08 A.M., Licensed Practical Nurse (LPN) F said therapy
staff brought the sling over for the resident on 3/19/18. LPN F was not sure why therapy
staff brought the sling for the resident but said the resident had been wearing it and
seemed happy with the sling.
During an interview on 3/21/18 at 9:39 A.M., the Director of the Therapy Department said
the resident asked him/her for the sling and he/she provided the sling earlier in the
week. Nursing staff got an order from the physician for the sling. The therapy department
would evaluate the resident to ensure nursing staff placed it on the resident correctly
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 12)
and to ensure it fit. The resident had never been seen by therapy in the past because
he/she did not qualify due to insurance coverage. The therapy director did not think a
restorative program had been attempted for the resident.
During an interview on 3/21/18 at 10:02 A.M. Certified Nurse Aide/Restorative Aide
(CNA/RA) said he/she had worked with the resident previously applying hot packs and
providing massage to the resident’s right shoulder but had not worked with the resident in
over a year. The resident had not always been willing to participate in the past.
2. Review of Resident #47’s care plan, dated 12/15/16, showed the resident was to wear
bilateral palm protectors for contracture management.
Review of the resident’s readmission face sheet, dated 5/23/17, showed the resident’s
[DIAGNOSES REDACTED].
Review of the resident’s Restorative Nursing, dated 8/17/17, showed [DIAGNOSES REDACTED].
Bilateral hand splints for up to four to six hours or to resident’s tolerance of hand
hygiene.
Review of the resident’s admission MDS, dated [DATE], showed the following:
-He/she did not ambulate or transfer;
-The resident required extensive assistance on one staff member for bed mobility;
-He/she required total assistance of one staff member to dress, eat, toilet, and for
personal hygiene.
-He/she had limited range of motion/impairment of both upper extremities.
Review of the resident’s physician order [REDACTED].
-an order for [REDACTED].>-A line marked through the order with no date and marked
discontinue (DC).
During an interview on 4/3/18 at 2:39 P.M., the Director of Nursing (DON) said she could
not find any written order for the resident’s bilateral hand splints to be discontinued.
She said the facility had a licensed practical nurse (LPN) come into the facility to recap
orders but does not know why the LPN would have drawn a line through the order and write
discontinue without a date. She did not believe the facilty had an order to discontinue.
Observation on 03/19/18 at 8:08 A.M. showed the resident lay in bed. Both of the
resident’s hands were contracted. The resident was not wearing splints or braces on
his/her hands.
Observation on 03/19/18 at 1:50 P.M. showed the resident did not wear splints or braces on
his/her hands.
Review of the resident’s Treatment Administration Record (TAR), dated 3/19/18, showed the
following:
-Resident to wear bilateral hand splints at all times as tolerated;
-A blank area with no signature for the 6:00 A.M. to 2:00 P.M.
-Staff initialed the resident’s TAR for the 2:00 P.M. to 10:00 P.M. shift as completed;
-Staff initialed the resident’s TAR for the 10:00 P.M. to 6:00 A.M. shift as completed;
Observation on 03/20/18 at 5:20 A.M. showed the resident lay in bed, he/she did not have
splints on his/her hands.
Observation on 03/20/18 at 6:15 A.M. showed the resident in bed, the resident did not have
splints or braces on his/her hands.
Observation on 03/20/18 at 7:10 A.M. showed the resident lay in bed, he/she did not have
splints or braces on his/her hands.
Observation on 03/20/18 at 7:45 A.M. showed the resident lay in bed, he/she did not have
splints or braces on his/her hands.
Review of the resident’s Treatment Administration Record (TAR) at 10:37 A.M. showed the
following:
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 13)
-Resident to wear hand splints at all times as tolerated;
-Staff signed the TAR as completed.
Observation on 3/20/18 at 12:32 P.M. showed the resident did not have splints or braces on
his/her hands.
Observation on 3/20/18 at 1:00 P.M. showed the following:
-Occupational Therapist (OT) E found a set of gray wrist, hands and finger orthotic (WHFO)
brace in the resident’s closet;
-He/she did not put the braces on the resident, he/she put them back in the closet.
During an interview on 3/20/18 at 1:00 P.M., OT E said he/she was not aware the resident
had hand braces (since he/she started work at the facility in (MONTH) (YEAR)). He she/he
said due to staff and management changes and lack of communication between nursing and
therapy, he/she did not know if the residents got what they needed.
During an interview on 3/20/18 at 2:40 P.M., LPN J said the following:
-The resident wore braces on his/her left hand;
-He/she did not have time to put the braces on the resident today;
-He/she documented he/she put the braces on the resident today but did not put them on.
Observation on 03/21/18 at 8:00 A.M. showed the resident sat in his/her wheelchair. The
resident did not have splints or braces on his/her hands.
During an interview on 03/21/18 at 9:42 A.M., LPN H said the following:
-The resident had a blue hand splint for his/her right hand and a wash cloth for his/her
left hand; A CNA put these on this morning;
-The blue splints were the facility’s splints (not ordered special by therapy);
-He/she was not aware the resident had splints ordered by therapy;
-He/she did not know why the resident did not have any splints on his/her hands on
3/19/18.
During an interview on 03/21/18 at 10:24 A.M., OT E said to his/her knowledge the resident
had specified splints the evaluating therapist ordered.
During an interview on 03/21/18 at 2:02 P.M., the ADON said the following:
-Staff should know what braces residents are to wear;
-If a resident had an order for [REDACTED].>-This should be on the resident’s TAR and
care plan;
-He/she expected staff to document on the TAR when the brace was put on the resident;.
During an interview on 3/21/18 at 3:30 P.M., the DON said she would expect staff to
provide Resident #84 with devices to maintain proper positioning without him/her having to
ask. The DON expected staff to apply braces and other positioning devices as ordered by
the physician and to document appropriately on the treatment administration record. Staff
should not document something as completed if it wasn’t and should document the reason an
ordered treatment was not completed.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, facility staff failed to provide the
appropriate care and maintenance of indwelling urinary catheters, according to acceptable
standards of professional practice, for four residents (Residents #44, #88, #101 and #157)

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
and failed to identify the presence of and purpose for an indwelling urinary catheter in
the medical record for one resident (Resident #101), in a review of 22 sampled residents.
The facility identified nine residents with urinary catheters. The facility census was
107.
1. Review of the Nurse Assistant in a Long-Term Care Facility, Student Reference, 2001
Revision, showed the Steps of Procedure for Giving Peri Care with a Catheter (a sterile
tube inserted and left in the bladder to drain urine) included the following instructions:
-More frequent care is required for residents who have an indwelling catheter;
-Expose the perineal area; separate the labia of the female resident and gently wash
around the opening of the urethra with soap and water;
-Wash the catheter tubing from the opening of the urethra outward four inches and further
if needed;
-Using a fresh wash cloth continue washing and rinsing the peri area; -The bladder is
considered sterile, the catheter, drainage tubing, and bag are a sterile system;
-Drainage tubing/bags must not touch the floor; always hook to unmovable part of the bed
frame or chair;
-When transferring residents from bed to chair, always move the drainage bag over to the
chair before moving the resident;
-The drainage bag should always be below the level of the bladder;
-If moved above, urine could flow back into the bladder.
Review of the 2001 revision of the Nurse Assistant In a Long Term Care Facility manual,
showed the procedures staff were to follow when they provided peri care for female
included the following:
-For the female resident included the following:
-Cover the resident;
-Expose the peri area, wash the inner legs and outer peri area along the outside of the
labia (Labia Majora);
-Use a clean area of the washcloth for each wipe of the peri area;
-Wash the outer skin folds from front to back;
-Wash the inner labia (Labia Minora) from front to back;
-Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area)
from front to back;
-Rinse the area well, start from the innermost area and proceed outward;
-Wash and rinse the anal area;
-Pat the peri area dry.
Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual,
showed the procedures staff were to follow when they provided peri care for a male
included the following:
-Cover the resident;
-Expose the perineal areas included, wash the penis from the tip downward, rinse, and dry
(specific instructions for uncircumcised);
-Wash and rinse the scrotum;
-Wash and rinse other skin areas between the legs;
-Wash and rinse the anal area;
-Pat the area dry.
Also needs to include for male resident so it isn’t clear to the reader the sex of the
residents in the SOD. **added**
2. Review of the facility’s Catheter Care policy from the Nursing Guidelines Manual, dated
(MONTH) (YEAR), showed the following:
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
-The purpose is to prevent infection and reduce irritation;
-For the female, use a clean washcloth with warm water and soap to cleanse the labia;
-Use one area of the wash cloth for each downward, cleansing stroke;;
-Change the position of the wash cloth with each downward stroke;
-Next, change the position of the cloth and cleanse around the urethral meatus;
-With a clean washcloth, rinse with warm water using the above technique;
-Use a clean wash cloth with warm soapy water to cleanse the catheter from the insertion
site to approximately four inches outward;
-Secure catheter utilizing a leg band (optional);
-Check drainage tubing and bag to ensure that the catheter is draining properly.
3. Review of Resident #101’s nurse’s notes showed on 1/19/18, the resident had increased
confusion. The resident’s family requested laboratory studies be obtained to check for a
urinary tract infection [MEDICAL CONDITION]. Staff received new orders from the physician
to obtain a urinary analysis (UA, a test of a urine sample that can reveal problems of the
urinary tract, such as infections).
Review of the resident’s UA, dated 1/19/18, showed the resident’s urine was positive for
the presence of bacteria. There were no culture and sensitivity results found in the
resident’s record for the UA dated 1/19/18.
Review of the resident’s nurse’s notes showed on 1/20/18, staff received new orders from
the physician [MEDICATION NAME](oral antibiotic) 500 milligrams (mg) for three days
pending the culture and sensitivity report (C and S, further microscopic study of the
urine to determine the presence of specific bacteria).
Review of the resident’s Significant Change in Status Minimum Data Set (MDS), a federally
mandated assessment instrument required to be completed by facility staff, dated 2/5/18,
showed the following:
-Required extensive assistance of one staff for transfer and toilet use
-Limited assistance of one staff for personal hygiene;
-No urinary appliances used;
-Occasionally incontinent of bowel and bladder.
Review of the resident’s comprehensive care plan, dated 2/9/18, showed the following:
-[DIAGNOSES REDACTED].
-The resident experienced bladder incontinence related to memory loss, weakness, and gait
instability;
-Provide assistance for toileting;
-Provide incontinence care after each incontinent episode;
-Report signs of urinary tract infection [MEDICAL CONDITION].
Review of the resident’s UA with C and S, dated 2/20/18, showed the resident’s urine was
positive for [MEDICATION NAME] faecalis (bacterial species found in human feces).
Review of the resident’s nurse’s notes showed the following:
-On 2/21/18 at 6:00 A.M., staff found the resident on the floor. The resident was sent to
the hospital;
-On 2/23/18, the resident returned to the facility.
Review of the resident’s baseline care plan, dated 2/23/18, showed the following:
-The baseline care plan is to be completed within 48 hours of admission;
-After completion, print and file the following community protocols;
-Follow community protocols for catheter care.
Review of the resident’s physician order [REDACTED].
Review of the resident’s UA with C and S, dated 3/3/18, showed the resident’s urine was
again positive for [MEDICATION NAME] faecalis, as well as staphylococcus aureus (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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
bacterium found on human skin and is the leading cause of skin and soft tissue
infections).
Review of the resident’s five day MDS, dated [DATE], showed the resident had an indwelling
urinary catheter.
Review of the resident’s nurse’s note, dated 3/3/18, show staff reported the results of
the C and S to the resident’s physician and received an order for [REDACTED].
Review of the resident’s nurse’s note, dated 3/17/18, showed the resident’s urinary
catheter was patent and drained amber urine with sediment.
Observations of the resident showed the following:
-On 3/18/18 at 1:26 P.M., the resident sat in a wheelchair in his/her room. The resident
had a urinary catheter. The catheter tubing was on the floor under the wheelchair;
-On 3/18/18 from 5:29 P.M. until 5:57 P.M., the resident sat in the dining room in a
wheelchair. His/her catheter tubing lay on the floor underneath the wheelchair;
-On 3/18/18 at 5:57 P.M., the resident’s visitor wheeled the resident back to his/her room
from the dining room. The catheter tubing drug the floor under the wheelchair. The urine
in the catheter tubing was cloudy yellow with sediment present;
-On 3/19/18 at 11:59 A.M., the resident sat in the common area at a table eating with a
visitor. The resident’s catheter tubing lay on the floor underneath the wheelchair. The
urine in the catheter tubing was cloudy, amber in color, with sediment;
-On 3/19/18 at 2:08 P.M., the resident remained seated in the common area with a visitor.
The resident’s catheter tubing remained on the floor under the resident’s wheelchair.
Observation of the resident on 3/19/18 at 2:34 P.M. showed the following:
-The resident sat in a wheelchair is his/her room. The resident’s catheter tubing lay in
the floor under his/her wheelchair;
-Certified Nurse Aide (CNA) D entered the resident’s room to transfer the resident to bed;
-CNA D removed the catheter bag from under the resident’s wheelchair and clipped the
catheter bag to the waist band of his/her pants, well above the level of the resident’s
bladder. Urine was observed to back flow in the tubing;
-CNA D applied a gait belt on the resident and assisted him/her to stand and pivot from
the chair to the bed;
-CNA D removed the catheter bag from his/her pants and attached it to the bed frame. The
resident’s urine was dark amber and cloudy;
-The resident requested to get back into the wheelchair;
-CNA D again attached the resident’s catheter bag to his/her pants, well above the level
of the resident’s bladder, and transferred the resident from the bed to the wheelchair;
-CNA D secured the catheter bag under the resident’s wheelchair. The catheter tubing was
in contact with the floor underneath the wheelchair.
Observation on 3/19/18 at 3:34 P.M. showed the resident wheeled himself/herself down the
hall in the wheelchair. The resident’s catheter tubing drug the floor under the chair.
Several staff passed by the resident and did not adjust the placement of the tubing.
Observation on 3/20/18 at 6:21 A.M. showed the resident lay in his/her room on a low bed.
The catheter bag was in a cloth privacy cover which lay on the fall mat on the floor next
to the bed.
Observation on 3/20/18 at 8:01 A.M. showed the following:
-CNA A was in the room with the resident assisting him/her to get dressed;
-CNA A assisted the resident to sit on the side of the bed and transferred the resident
from the bed to the wheelchair;
-CNA A removed the catheter bag from the bed frame and slid it across the floor under the
wheelchair and secured the bag under the chair;
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-The resident’s catheter tubing was on the floor;
-CNA A pushed the resident to the dining room in the wheelchair while the catheter tubing
drug the floor underneath the resident.
During an interview on 3/20/18 at 8:14 A.M., CNA A said catheter bags and tubing should be
kept off the floor and below the level of the resident’s bladder. He/She was not aware the
resident’s catheter tubing was on the floor.
Observations of the resident on 3/20/18 showed the following:
-At 8:18 A.M., the resident sat in the wheelchair in the dining room. The catheter tubing
lay on the floor underneath him/her.
-At 8:45 A.M., the resident had finished eating and propelled himself/herself out of the
dining room towards his/her room. The catheter tubing drug the floor under the wheelchair;

-At 2:37 P.M., the resident’s visitor wheeled him/her out of the dining room. The
resident’s catheter tubing drug the floor under the wheelchair.
Observation of the resident on 3/21/18 showed the following:
-At 8:11 A.M., the resident sat in the dining room. The catheter tubing lay on the floor
under his/her wheelchair;
-At 9:11 A.M., the resident sat in the common area. The catheter tubing lay on the floor
under the resident’s wheelchair;
-At 9:21 A.M., the resident propelled himself/herself down the hall to his/her room in the
wheelchair. The catheter tubing drug the floor under the resident.
During an interview on 3/21/18 at 8:10 A.M., Occupational Therapist (OT) E said the
resident has had the urinary catheter for quite a while and thought the resident had the
catheter since (MONTH) after he/she had been hospitalized for [REDACTED].
During an interview on 3/21/18 10:15 A.M., Licensed Practical Nurse (LPN) F said he/she
was not certain how long the resident has had the urinary catheter but thought the
resident had the catheter when he/she returned from the hospital after hip surgery in
January.
4. Review of Resident #88’s quarterly MDS, dated [DATE], showed the following:
-Required extensive assistance from one staff for bed mobility, transfers, dressing,
toilet use, and personal hygiene;
-Required limited assistance from one staff for locomotion on and off the unit;
-Wheelchair use for mobility;
-Indwelling catheter.
Observation on 03/18/18 at 6:06 P.M. showed the resident sat in his/her wheelchair at the
dining room table. The urinary catheter tubing touched the floor. The catheter bag was
attached to the back of the resident’s wheelchair and was not below the level of his/her
bladder. The tubing had creamy peach colored urine. None of the staff who passed by the
resident repositioned the bag or tubing.
Observation on 03/18/18 at 6:45 P.M. showed the resident sat in his/her wheelchair. The
catheter tubing remained on the floor, and the catheter bag remained on the wheelchair
above the level of the resident’s bladder.
Observation on 03/18/18 at 6:52 P.M. showed the resident wheeled himself/herself away from
the table and down the hall. The catheter tubing drug the floor. He/she asked Licensed
Practical Nurse (LPN) G to push him/her on down the hall to his/her room. LPN G wheeled
the resident in his/her wheelchair as the catheter tubing drug the floor.
Observation on 03/19/18 at 3:20 P.M. showed the resident sat in the front activity area in
his/her wheelchair. The resident’s catheter tubing lay on the floor. Various nursing staff
walked by the resident and did not reposition the tubing.

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
Observation on 03/19/18 at 4:09 P.M. showed the resident sat in his/her room in his/her
wheelchair with the catheter tubing on the floor.
Observation on 03/20/18 at 6:09 A.M. showed the resident in his/her bed with the catheter
tubing on floor. The catheter drainage bag was hooked to side of his/her bed with the
lower part of bag touching the floor.
Observation on 03/20/18 at 8:45 A.M. showed LPN F pushed the resident in his/her
wheelchair. The resident’s catheter tubing drug the floor.
Observation on 03/20/18 showed the following:
-At 10:30 A.M., the resident sat in wheelchair in the dining room; the catheter tubing lay
on the floor.
-At 11:10 A.M., the catheter tubing remained on the floor;
-At 12:40 P.M., the catheter tubing remained on the floor;
-At 1:00 P.M., the resident sat in his/her wheelchair in his/her room with the catheter
tubing on floor.
During interview on 03/20/18 at 1:14 P.M., CNA H said catheter tubing should not be on the
floor and the bag should be below the level of the bladder.
5. Review of the Resident #44’s care plan, dated 9/22/17, showed the following:
-The resident required a urinary catheter related to skin issues;
-Staff to provide assistance for catheter cares every shift and as needed.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-He/she required an indwelling catheter;
-He/she required assistance of two staff members for toilet use and personal hygiene.
Review of the resident’s physician orders, dated 2/2/18, showed the following:
-The resident readmitted from the hospital with [DIAGNOSES REDACTED].>-On 2/2/18 an
order for [REDACTED].
Observation on 03/19/18 at 9:51 A.M. showed the following:
-LPN H gathered supplies for urinary catheter care;
-He/she used a soapy wash cloth and wiped the resident’s left groin with a brown/yellow
debris left on the cloth after wiping;
-He/she/she did not wipe the area again;
-He/she used a soapy wash cloth and wiped the resident’s right groin with a brown/yellow
debris left on the cloth after wiping;
-He/she/she did not wipe the area again;
-He/she used a new wash cloth and wiped the resident’s meatus and urinary catheter tubing
one time only;
-A brown, yellow stain was observed on the wash cloth;
-He/she did not wipe the area again;
-He/she changed gloves. Staff turned the resident to his/her side. LPN H did not wipe the
resident’s posterior peri area, rectum or buttocks.
During an interview on 03/21/18 at 9:46 A.M., LPN H said the following:
-When providing catheter care he/she should clean the left and right groin and wipe the
skin folds front to back;
-Rinse thoroughly, repeat steps to rinse, and use the towel to dry;
-During the resident’s pericare, he/she should have rinsed the wash cloth and repeated
each process until no visible debris.
6. Review of Resident #157’s physician orders [REDACTED].
Review of the resident’s baseline care plan, dated 3/16/18, showed the following:
-Required assistance from one staff with toileting and grooming/hygiene;
-Sometimes incontinent of bowel;
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-Urinary catheter;
-Urinary catheter care;
-Assist with appliance as per protocols (catheter).
Observation on 3/20/18 at 6:43 A.M. showed the following:
-CNA G and CNA M transferred the resident to his/her wheelchair and took him/her into the
bathroom;
-CNA M assisted the resident to stand, removed the catheter drainage bag from inside the
dignity bag attached to the wheelchair and lay the drainage bag directly on the bathroom
floor;
-CNA M put socks on the resident, guided the catheter through the resident’s pant legs and
placed the catheter drainage bag back on the floor.
7. During an interview on 3/21/18 at 3:30 P.M., the Director of Nursing (DON) said she
expected staff to maintain a resident’s catheter bag and tubing up off the floor and below
the level of the resident’s bladder. He/she would expect staff to wash all areas of a
resident’s skin that had been in contact with urine or stool.
Surveyor: Terri Cordray

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to return
medications of discharged or expired residents and/or ensure medications that the facility
was unable to return to the pharmacy were destroyed in a timely manner for 11 residents
(#7, #25, #258, #259, #260, #457, #458, #459, #460, # 461, #462). The facility census was
107.
1. Review of the facility’s destruction of medications policy, dated (MONTH) (YEAR),
showed the following:
-Purpose-The facility will destroy and dispose of medication in a safe manner and in
accordance to applicable law;
-Guidelines-1. All medications not returned to the issuing pharmacy will be destroyed.
2. Review of Resident #258’s face sheet showed the resident expired at the facility on
12/28/17.
Observation on 3/20/18 at 11:45 A.M. of the medication room on the 100 hall showed the
following medications for the resident:
-I-vite (a supplement), one card containing four tablets;
-Setraline (antidepressant) 50 milligram (mg) tablet, card containing four tablets;
-[MEDICATION NAME] (an anticoagulant/blood thinner) 4 mg tablet, one card containing four
tablets;
-[MEDICATION NAME] (treats fluid retention) 40 mg tablet, one card containing 15 tablets;
-Methanenamine (an antibiotic) 1 gram, one card containing four tablets and a second card
containing five tablets;
-[MEDICATION NAME] (an antacid) 300 mg tablet, one card containing six tablets;
-Spiroanolactone (treats fluid retention, high blood pressure and [MEDICAL CONDITION]) 25
mg tablet, one card containing four tablets;
5. Review of Resident #259’s face sheet showed the resident was discharged from 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
facility on 1/10/18.
Observation on 3/20/18 at 11:45 A.M. of the medication room on the 100 hall showed the
following medications for the resident:
-Carvidilol (blood pressure medication) 3.125 mg tablet, one card containing 30 tablets,
second card containing 17 tablets, and third card containing 25 tablets;
-[MEDICATION NAME] (blood pressure medication) 40 mg tablet, one card containing two
tablets and another card containing 30 tablets;
-Atorvastatin (cholesterol medication) 40 mg tablet, one card containing 29 tablets;
-Vitamin D3 a supplement) 5000 unit capsule, one card containing 16 capsules.
6. Review of Resident #260’s face sheet showed the resident was discharged from the
facility on 1/4/18.
Observation on 3/20/18 at 11:45 A.M. of the medication room on the 100 hall showed the
following medications for the resident:
-[MEDICATION NAME] 3 mg tablet, one card containing two tablets;
-[MEDICATION NAME] 2.5 mg tablet, one card containing four tablets;
-Fludrocortisone (used to treat adrenogential syndrome and postural [MEDICAL CONDITION]) 1
mg tablet, one card containing six tablets, a second card containing six tablets, and a
third card containing 15 tablets;
-[MEDICATION NAME] 4 mg tablet, one card containing five tablets and a second card
containing 12 tablets;
-[MEDICATION NAME] 6 mg tablet, one card containing eight tablets.
7. Review of Resident #459’s nurse’s notes showed the resident expired on 12/10/17.
Observation on 03/20/18 at 12:41 P.M. of the 300 hall medication room showed one bottle of
[MEDICATION NAME] sulfate (liquid iron), labeled for the resident.
8. Review of Resident #457’s nurse’s notes showed the resident expired on 02/13/18.
Observation on 03/20/18 at 12:41 P.M. of the 300 hall medication room showed one bottle of
swish and spit (an oral treatment for [REDACTED].
9. Review of Resident #7’s physicians orders showed the following:
-The (MONTH) and (MONTH) (YEAR) physician order sheets showed no physician order for
[REDACTED].>-An order dated 12/20/17 to discontinue [MEDICATION NAME] (blood pressure
medication) 0.1 mg;
-An order dated 2/28/18 to discontinue [MEDICATION NAME] (prostate medication) 0.4 mg.
Observation on 03/20/18 at 12:41 P.M. of the 300 hall medication room showed a paper bag
labeled please destroy. The bag contained the resident’s medications including one card of
14 tablets of [MEDICATION NAME] 40 mg; one card containing 22 tablets of [MEDICATION NAME]
0.1 mg (expiration date of 02/06/18); one card containing 21 tablets of [MEDICATION NAME]
10 mg; and one card containing five tablets of [MEDICATION NAME] 0.4 mg.
10. Review of Resident #25’s physician orders showed the following:
-The (MONTH) and (MONTH) (YEAR) physician orders sheet showed no physician order for
[REDACTED].>-An order dated 11/21/17 to discontinue [MEDICATION NAME] 5 mg.
Observation on 03/20/18 at 12:41 P.M. of the 300 hall medication room showed a paper bag
labeled please destroy. The bag contained the following medications for the resident: One
card of 27 tablets of Astrovastatin 10 mg, and one card of five tablets of [MEDICATION
NAME] 5 mg.
11. Review of Resident #458’s nurse’s notes showed the resident expired on 01/05/18.
Observation on 03/20/18 at 12:41 P.M. of the facility 300 hall medication room showed a
paper bag labeled please destroy. The bag contained the following for the resident: One
card of 28 tablets of Tylenol (a pain reliever) 650 mg, and a second card containing 30
tablets of Tylenol 650 mg.
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
12. Review of Resident #461’s nurses notes on 03/21/18 at 10:09 A.M. showed the resident’s
family had contacted the facility on 01/28/18 to notify the facility the resident had
expired.
Observation on 03/21/18 at 10:02 A.M. of medication cart number one, for the 200 hall,
showed one card containing one tablet of [MEDICATION NAME] (a high blood pressure
medication) 100 mg, labeled for the resident.
13. Observation on 3/20/18 at 11:29 A.M. of the medication room on the 100 hall showed the
following expired medications/supplements:
-Three boxes of Boost (nutritional supplement), expired 9/2/17;
-One open bottle of [MEDICATION NAME] (pain reliever) 220 mg, containing 44 tablets,
expired (MONTH) (YEAR);
-An 8-ounce bottle of NephroTherapeutic nutrition, expired on 9/1/17;
-An 8-ounce can of Ensure Plus, expired (MONTH) (YEAR).
14. During interview on 03/21/18 at 8:22 A.M., the Director of Nursing (DON), said she
expected expired medications to be removed from the medication carts. She expected expired
medications in the medication rooms to either be destroyed or sent back to the pharmacy.
If a resident expires, if the residents medications expire, or medications are
discontinued, she expected the nurses to either send the medication back to the pharmacy
or destroy them within a week.

F 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide each resident with a nourishing, palatable, well-balanced diet that meets his
or her daily nutritional and special dietary needs.

Based on observation, interview, and record review, the facility failed to ensure food was
prepared to preserve nutritive value and according to the recipe for six of six residents
with a physician-ordered pureed diet. The facility census was 107.
1. Record review of the facility policy, Food Preparation and Distribution, dated (MONTH)
2011, showed the following guidelines:
-The Dining Services Department will prepare foods by methods that are safe and sanitary
while conserving nutritive value as well as enhancing flavor;
-Foods are prepared by methods that conserve nutritive value, flavor, and appearance;
-Recipes should be followed on each item prepared.
2. Record review of the facility Diet Report, dated 3/19/18, showed six residents in the
facility had a physician-ordered pureed diet.
Record review of the facility Diet Spreadsheet (Fall/Winter (YEAR)- Week 5, Day 30) for
the dinner meal showed residents on a pureed diet were to receive a #8 scoop of pureed
black eyed peas.
Record review of the recipe for five servings of pureed black eyed peas showed the
following directions:
-Food Thickener: 2 tablespoons and 1 teaspoon;
-Step 4. Blend 1 teaspoon of bulk food thickener per serving and process until smooth.
-Note: Amount of thickener required may vary relative to liquid content of cooked
vegetable. For best results, alternate adding thickener with processing, checking product
consistency periodically.
Record review of the recipe for ten servings of pureed black eyed peas showed the
following directions:

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 0800

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
-Food Thickener: ? cup and 2 teaspoons;
-Step 4. Blend 1 teaspoon of bulk food thickener per serving and process until smooth.
-Note: Amount of thickener required may vary relative to liquid content of cooked
vegetable. For best results, alternate adding thickener with processing, checking product
consistency periodically.
Observation and interview on 3/19/18 at 1:10 P.M. showed Dietary Staff Q scooped cooked
black-eye peas into a small pan. He/she removed six servings of peas with a #8 scoop into
the pan and then dumped the peas into the blender bowl. Dietary Staff Q said the recipe
called for adding 1 tablespoon of food thickener per portion, so he/she could add 6
tablespoons in total. He/she liked to start with 3 tablespoons first and see how the
mixture looked. Observation showed he/she added 3 tablespoons of thickener to the peas and
started the blender. Dietary Staff Q stopped the blender after approximately 30 seconds,
added one more tablespoon of thickener then re-started the blender. After approximately 30
seconds, he/she added one more tablespoon and re-started the blender. After approximately
30 seconds had passed, he/she stopped the blender and added one more tablespoon for a
total of 6 tablespoons and re-started the blender. After approximately 30 seconds, he/she
stopped the blender and said the mixture should be smooth and a texture of refried beans
or mashed potato consistency. The mixture appeared to be thick, dense, and pasty.
3. During an interview on 3/20/18 at 10:30 A.M., the Dietary Manager said staff was to
utilize recipe books, weekly menu lists and diet spreadsheets to know how to prepare food
items as well as how to know what items need to be prepared for each meal.

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
followed dietary menus by not preparing or serving pureed potatoes to the residents on a
physician-ordered pureed diet. The facility also failed to ensure gravy was prepared and
served over the meatloaf for all residents on a pureed or mechanical soft
physician-ordered diet. The facility census was 107.
1. Record review of the facility Diet Report, dated 3/19/18, showed six residents in the
facility had a physician-ordered pureed diet.
Record review of the facility diet spreadsheet (Fall/Winter (YEAR), Week 5, Day 30) for
lunch on 3/19/18, showed residents on a physician-ordered pureed diet were to receive a
#10 scoop of pureed baked potato.
Record review of the recipe for pureed baked potato showed the following directions:
-Pare potatoes, remove skin and partially cook, about 10 minutes;
-Place potatoes on well-greased baking sheets;
-Bake at 450 degrees Fahrenheit for one hour or until tender;
-Prepare slurry;
-Process until smooth adding 1 ounce slurry per portion.
Observation on 3/19/18 at 11:11 A.M. showed Dietary Staff P started plating lunch trays in
the kitchen. A pan of whole baked potatoes with the peels intact sat in the steamtable. No
pureed baked potatoes were visible on the steam table.
Observation on 3/19/18 at 11:34 A.M. showed Dietary Staff P peeled the skin off a whole
baked potato, sliced the potato down the middle and placed the whole potato on a plate for

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
a resident on a pureed diet.
Observation on 3/19/18 at 12:23 P.M. showed meal service had been completed. All residents
on a pureed diet received a whole peeled baked potato and did not receive pureed baked
potatoes as directed by the dietary spreadsheet.
2. Record review of the facility diet report, dated 3/19/18, showed six residents had a
physician ordered pureed diet and 14 residents had a physician order [REDACTED].>Record
review of the facility diet spreadsheet (Fall/Winter (YEAR), Week 5 Day 30) for lunch on
3/19/18, showed the following:
-Residents on a pureed diet were to receive a #8 scoop of pureed meatloaf and 2-ounces of
gravy;
-Residents on a mechanical soft diet were to receive a #8 scoop of ground meatloaf and
2-ounces of gravy.
Observation on 3/19/18 at 11:11 A.M. showed Dietary Staff P started plating lunch trays in
the kitchen. Further observation showed pureed meatloaf and ground meatloaf were visible
on the steamtable; however, no gravy was observed on the steam table.
Observation on 3/19/18 at 11:32 A.M. showed Dietary Staff P plated a mechanical soft diet
tray with a #8 scoop of ground meatloaf. No gravy or sauce was placed on the ground meat
or anywhere on the tray.
Observation on 3/19/18 at 11:34 A.M. showed Dietary Staff P plated a pureed tray with a #8
scoop of pureed meatloaf, however, no sauce or gravy was placed on the meatloaf.
Observation on 3/19/18 at 12:23 P.M. showed meal service had been completed. All residents
on a pureed diet or on a mechanical soft diet received the appropriate texture of
meatloaf; however, no gravy or sauce was prepared or served with the pureed meatloaf or
the ground meatloaf as directed by the dietary spreadsheet.
3. During an interview on 3/20/18 at 10:30 A.M., the Dietary Manager said staff was
expected to utilize recipe books, weekly menu lists and diet spreadsheets to know how to
prepare food items correctly and how to know what items need to be prepared for each meal.
Residents on a pureed diet were supposed to have been given a whole baked potato with the
skin removed. The gravy wasn’t prepared because the residents don’t like the brown gravy
on the meatloaf and just prefer ketchup. The Dietary Manager confirmed the dietary
spreadsheet showed the mechanical and pureed diets indicated gravy was supposed to be
served with the meatloaf.
During an interview on 3/20/18 at 11:20 A.M., the facility’s Dietician said residents on a
pureed diet should not have received a whole peeled baked potato for lunch. The potato
should have been pureed or should have been substituted for instant mashed potatoes.
Residents on both mechanical and pureed diets should have been served gravy on top of the
ground meatloaf and on top of the pureed meatloaf. Ketchup would not provide the same
nutritional content as gravy would provide. Gravy should have been prepared and served.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation, interview, and record review, the facility failed to ensure staff
utilized proper sanitary handwashing and gloving procedures, failed to ensure freezer
temperatures were maintained at 0 degrees Fahrenheit (F) or below, failed to ensure
dishware was air dried and failed to ensure staff members’ personal items were not stored

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 24)
in the food preparation areas. The facility census was 107.
1. Observation and interview on 3/19/18 at 1:10 P.M. showed Dietary Staff Q used a paper
towel to wipe water out a small steam table pan, lifted the trash can lid and threw the
paper towel away. Dietary Staff Q did not wash his/her hands after touching the trash can
lid and put on a new pair of gloves. He/she began to scoop black-eyed peas from a large
pan and placed them into a smaller pan. He/she removed scoops of black-eyed peas from the
small pan and placed them in a blender to prepare pureed black-eyed peas.
Observation on 3/19/18 at 1:14 P.M. showed Dietary Staff Q wore gloves and rinsed a small
dirty steam table pan under running water from the three-compartment sink faucet. Dietary
Staff Q removed his/her gloves, lifted the trash can lid, and threw his/her gloves in the
trash. He/she did not wash his/her hands and put on a new pair of gloves. Dietary Staff Q
scraped pureed black-eyed peas into a steam table pan and covered the pan with plastic
wrap.
Observation on 3/19/18 at 2:50 P.M. showed Dietary Staff Q wore gloves and began to slice
ham and then weighed the ham slices with a scale. He/she removed his/her gloves, lifted
the trash can lid with bare fingers and threw the dirty gloves in the trash can. Dietary
Staff Q did not wash his/her hands and put on a new pair of gloves. He/she removed a clean
steam table pan from the storage rack and used his/her gloved hands to place slices of ham
into the pan. Dietary Staff Q removed his/her gloves, lifted the trash can lid and threw
the gloves into the trash can. He/she reached above the food preparation counter, picked
an iced coffee drink off the top of the shelf, took a drink of coffee and walked to the
rear of the kitchen.
Record review of the facility policy, Glove Use, dated (MONTH) 2011, showed the following
guidelines:
-To ensure safe and proper food handling during food preparation and service.
-Hand washing per guidelines should occur between each task;
-Gloves should be worn if handling food is necessary. Extra caution should be taken when
multiple tasks are being completed;
-Gloves should be removed when changing or walking away from specific tasks and hands
should be washed per guidelines;
-Note: Hands should be washed after disposing of trash or food; after handling dirty
dishes; after handling raw meat, poultry or eggs; when changing tasks; and any other time
deemed necessary.
2. Observation on 3/19/18 at 2:56 P.M. showed the maintenance shop, located next to the
main dining room and the kitchen, had an upright freezer. The external display showed the
internal temperature in the unit was +10 degrees F. A thermometer inside the freezer
showed an internal temperature of +20 degrees F. The freezer contained approximately 20 or
more cream pies, four bags of whipped topping, two boxes of cookie dough, and garlic bread
sticks. All items were soft to the touch inside the freezer and were not frozen solid.
Observation on 3/19/18 at 3:49 P.M. of the upright freezer in the maintenance shop showed
the external display showed the internal temperature in the unit was +8 degrees F. The
thermometer inside the freezer showed a temperature of +18 degrees F. Items inside the
freezer were soft to the touch and not frozen solid.
Observation on 3/20/18 at 9:15 A.M. showed the upright reach-in freezer inside the
maintenance shop had an internal thermometer temperature of +15 degrees F. Food items were
soft to touch inside the freezer and were not frozen solid.
Observation on 3/20/18 at 10:29 A.M. showed the reach-in freezer in the maintenance shop
had an exterior display that showed an internal temperature of +8 degrees F. The
thermometer inside the freezer showed a temperature of +12 degrees F. Food items inside
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 25)
were soft and not frozen.
Record review of the facility policy, Refrigerator and Freezer Temperatures, dated (MONTH)
2011, showed temperatures of freezers should be 0 degrees F or below.
3. Observation and interview on 3/19/18 at 1:10 P.M. showed Dietary Staff Q used a paper
towel to wipe water out of a small steam table pan. He/she placed scoops of black-eyed
peas into the pan.
Observation on 3/19/18 at 1:12 P.M. showed Dietary Staff P dried the inside of clean
serving scoops and both sides of sharp knives off with a paper towel. The items had been
placed on the drying on rack after being removed from the three-compartment sink. He/she
placed the knives on the knife magnetic knife wall holder and stored the serving scoops in
a drawer.
4. Observation on 3/19/18 at 2:50 P.M. showed a large plastic cup/lid with iced coffee
inside and a set of car keys sat on top of a metal storage cabinet above the spice storage
shelf and over a food preparation metal countertop. Two large whole chunks of ham sat
below the personal items on the food preparation counter. The ham was unwrapped from the
packaging that sat in a steam table pan. Dietary Staff Q sliced and weighed ham slices
with a scale, directly underneath the coffee and car keys. He/she removed a clean steam
table pan from the storage rack and placed slices of ham into the pan. Dietary Staff Q
finished moving slices of ham into the pan and threw his/her gloves in the trash. He/she
reached above the food preparation counter, picked up the iced coffee drink off the top
shelf, took a drink of coffee and walked to the rear of the kitchen.
Record review of the facility policy, Handwashing-Additional Guidelines, dated (MONTH)
2011, showed the following:
-Eating and drinking in the dietary department is to occur in designated areas only;
-Personal items are to be located in a designated area away from preparation, service and
storage areas.
5. During an interview on 3/20/18 at 10:30 A.M., the Dietary Manager said staff should
wash their hands as much as possible during working hours and in between glove use. He/she
said the facility had some newer dietary staff members that probably needed some
additional training. Dishware, utensils etc. that has been washed, should be air dried and
not dried with paper towels. Freezers should be maintained at 0 degrees F or colder.
Temperatures were checked twice a day (at approximately 4:30 A.M. and 4:00 or 5:00 P.M.)
If temperatures were elevated, he/she would have someone look at the unit. He/she thought
some items on the top shelf of the freezer in the maintenance shop were blocking the air
vents from working correctly. Staff personal items and beverages should not be in the food
preparation areas. In the past, he had allowed drinks with lids in the kitchen, but
beverages were not supposed to be in a food preparation area.
6. During an interview on 3/20/18 at 11:20 A.M., the facility’s dietician said dishware
should be air dried and not towel dried. Freezer temperatures should be maintained at 0
degrees F or below. Staff was expected to wash their hands between glove use and
clean/dirty tasks.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 nursing
staff washed their hands and changed gloves after each direct resident contact, before

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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Few

(continued… from page 26)
touching items with soiled hands and gloves, and when indicated by professional standards
of practice during personal care for one resident (Residents #74), in a review of 22
sampled residents. The facility also failed to apply appropriate contact precautions for a
resident (Resident #209) with [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium that
causes diarrhea and more serious intestinal conditions such as [MEDICAL CONDITION].) The
facility census was 107.
1. Review of the facility’s Handwashing Policy from the Nursing Guideline Manual, dated
(MONTH) (YEAR), showed the following:
-Purpose: To reduce transmission of organisms from resident to resident, nursing staff to
resident and resident to nursing staff;
-Equipment: Soap, comfortably hot water, and disposable hand towel;
-Guidelines: Turn on water and adjust temperature, soap hands well, rub hands briskly,
paying special attention to area between fingers. Use a brush to clean under nails as
necessary. Rinse with hands lowered to allow soiled water to drain directly into the sink.
Do not splash water onto clothing. Do not allow hands to touch sink. Use disposable hand
towel to turn off faucet and dry hands well, especially between fingers. Apply moisture
barrier if desired.
2. Review of the facility’s policy, Gloves from the Nursing Guidelines Manual, dated
(MONTH) (YEAR), showed the following:
-Wear gloves when it can be reasonably anticipated that hands will be in contact with
mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound
drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these
substances) and/or persons with a rash. Gloves must be changed between residents and
between contacts with different body sites of the same resident;
-REMEMBER: Gloves are not a cure-all. They should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects.
Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a
glove easier than to the skin on your hands. Handling medical equipment and devices with
contaminated gloves is not acceptable;
-Change gloves between contacts (as defined above) with different residents or with
different body sites of the same resident.
3. Review of the facility’s policy on [MEDICAL CONDITIONS], from the Infection Control
Manual, dated (MONTH) (YEAR), showed the following:
-Purpose: To provide guidelines for the care of persons with [MEDICAL CONDITION] and to
prevent the transmission of [MEDICAL CONDITION] to others;
-Equipment: Gloves, gown, disinfectant (ensure disinfectant kills [MEDICAL CONDITION]
spores), and biohazard waste containers;
-Prevention: Wash the resident’s hands when soiled with feces, after they handle items
which may be contaminated and before self-feeding;
-Wear gowns when potential for soiling of clothing is likely;
-Disinfect any visible fecal contamination;
-Contain all fecal soiling;
-The resident’s clothing and bedding should be placed in a biohazard container and
laundered separately;
-All focally contaminated articles must be considered potentially infectious.
4. Review of the facility’s policy on body substance precautions regarding resident
placement, activity restriction, and the use of private rooms for infection control, dated
(MONTH) of (YEAR), showed the following:
-The physician and person responsible for infection control should assesses individual
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Few

(continued… from page 27)
residents as to the potential for transmitting infectious organisms. Room assignments and
restriction of activities are determined by this assessment;
-Coherent residents, colonized or infected with a specific pathogen, may participate in
nursing home activities and may eat in the dining hall. All residents should have wounds
or invasive sites cleansed and covered and have their hands washed before leaving their
rooms;
-Each resident should be assessed individually.
5. Review of Resident #209’s discharge summary from the hospital, dated 3/8/18, showed the
resident’s discharge [DIAGNOSES REDACTED].
Review of the resident’s admission physician order [REDACTED].
-No diagnoses listed;
-[MEDICATION NAME] (antibiotic) 50 milligrams (mg) per milliliter (ml) solution, give 2.5
ml by mouth every six hours for 14 days for [MEDICAL CONDITION].
Review of the resident’s admission baseline care plan, dated 3/8/18, showed the following:
-The resident was on [MEDICAL CONDITION] precautions and to follow the community protocols
for [MEDICAL CONDITION];
-The resident required the assistance of one staff member for toileting and hygiene;
-The resident was sometimes incontinent of bowel.
Review of the resident’ Medication Administration Record [REDACTED].
Observation on 3/18/18 at 1:55 P.M. showed there was no cart containing personal
protective equipment inside or outside the resident’s room.
Observation on 3/18/18 at 2:52 P.M. showed the resident propelled himself/herself up and
down the 300 hall (the hall opposite of the location of his/her room) in a wheelchair. The
resident stopped and turned every door knob and opened every closed door on the 300 hall.
The resident picked up a drinking glass of clear liquid that sat in the hallway on an over
bed table, took several drinks through a straw, and returned the glass to the over bed
table
Observation on 3/18/18 at 4:44 P.M. showed the resident again propelled himself/herself up
and down the 300 hall and turned the door knobs on all the closed doors and opened them.
Observation on 03/19/18 at 1:25 P.M. showed the resident was moved to a different room on
the 100 hall. There was no personal protective equipment inside or outside the room.
During an interview on 3/20/18 at 10:35 A.M., Licensed Practical Nurse (LPN) J said he/she
was the charge nurse on the resident’s unit. The resident was admitted on [DATE] and
tested positive for [MEDICAL CONDITION]. To his/her knowledge, the resident had never been
on any precautions. LPN J had never observed any personal protective equipment (PPE) such
as gowns, gloves, disinfectants, or biohazard bags or barrels inside or outside of the
resident’s room. The resident was moved to a different room on the same unit either one or
two days ago, after he/she went into another resident’s room and flooded the toilet with
either a brief or clothing. LPN J had not observed any PPE or biohazards bags or barrels
inside or outside of either room.
During an interview on 3/20/18 at 11:00 A.M., Certified Nurse Aide/Certified Medication
Technician (CNA/CMT) K said he/she had not observed any PPE or biohazard bags or barrels
inside or outside of the resident’s room. When a resident was on precautions for [MEDICAL
CONDITION], it meant staff should wear a gown and gloves when working with the resident in
their room. Usually these items were placed on a cart outside of the resident’s room and
biohazard bags were placed in the resident’s room for clothing, linen, and trash. CNA/CMT
K had not seen these items in the resident’s room but thought the resident had been
positive for [MEDICAL CONDITION] when he/she was first admitted . CNA/CMT K said the
resident required assistance in the bathroom and was incontinent of bowel at times, but
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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Few

(continued… from page 28)
would often take himself/herself to the bathroom unassisted.
During an interview on 3/20/18 at 11:50 A.M., the Assistant Director of Nursing (ADON)
said the resident was on contact precautions for [MEDICAL CONDITION].
Observation and interview on 3/20/18 at 11:55 A.M. with the ADON of both the resident’s
current and previous rooms showed no PPE or biohazard bags or barrels in either room. The
ADON said maybe the PPE and biohazard barrels were not moved with the resident when
his/her room was changed.
During interview 03/20/18 at 1:09 P.M., CNA H said he/she started two weeks ago and worked
the 100 short hall last week where the resident resided. There were no PPE inside or
outside the resident’s room at that time. CNA H said he/she heard this resident had
[MEDICAL CONDITION]. Another staff told him/her this resident should have PPE available
when providing care.
During interview 03/20/18 at 2:10 P.M., CNA I said he/she was not aware of any precautions
for the resident. He/she was just asked to come and help on the hall where the resident
resided.
During an interview on 3/21/18 at 10:10 A.M., the Director of Nursing said the resident
was admitted to the facility with [MEDICAL CONDITION] and was originally placed in a room
on the 200 hall and was on contact precautions at that time. Contact precautions for
[MEDICAL CONDITION] consisted of PPE outside or inside of the resident’s room as well as
biohazard container for the resident’s laundry and trash. The resident was moved
approximately five days to a week ago to a different room on a different hall in the
facility after another resident had complained of him/her opening up his/her room door.
The DON thought the resident remained on contact precautions after the first room change.
The resident was again moved to another room on the same hall the night of 3/18/18, after
he/she went into another resident’s room and flooded his/her toilet by attempting to flush
a brief or item of clothing. The DON said he/she thought this second room change was when
staff did not move the contact precaution items along with the resident. The DON said
he/she felt it was a breakdown in communication among staff.
6. Review of Resident #74’s quarterly MDS, dated [DATE], showed the following:
-Required extensive assistance of one staff for toilet use and personal hygiene;
-Frequently incontinent of bladder;
-Frequently incontinent of bowel.
Review of the resident’s care plan, revised on 1/26/18, showed the following:
-Diagnoses included [MEDICAL CONDITION] (paralysis of one side of the body) following a
stroke affecting the left side, lack of coordination, need for assistance with personal
care, dementia, and muscle weakness;
-Required moderate assistance with dressing, transfers, toileting, hygiene, and bathing
related to a stroke with [MEDICAL CONDITION];
-At risk for skin break down due to decreased mobility and incontinence;
-Provide incontinence care after each incontinence episode;
-Minimize skin exposure to moisture.
Observation on 3/20/18 at 5:39 A.M. showed the following:
-The resident lay in bed in a gown;
-CNA B and CNA C entered the resident’s room to provide morning care;
-CNA B and CNA C washed their hands and put on gloves;
-CNA B removed the covers from the resident. The resident was incontinent of urine;
-CNA C wiped the resident’s front perineal area;
-CNA B and CNA C rolled the resident to the left side and washed the resident’s buttocks;
-CNA B removed and bagged the soiled linen from under 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:

265160

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

NAME OF PROVIDER OF SUPPLIER

LEWIS & CLARK GARDENS

STREET ADDRESS, CITY, STATE, ZIP

1221 BOONSLICK ROAD
SAINT CHARLES, MO 63301

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 – Few

(continued… from page 29)
-Without removing their gloves, CNA B and CNA C assisted the resident to his/her back, CNA
B placed a clean brief under the resident, and CNA C secured the brief;
-Without removing their soiled gloves, CNA B and CNA C dressed the resident, assisted
him/her to sit on the side of the bed, and transferred the resident to the wheelchair with
a gait belt;
-Without removing his/her soiled gloves, CNA B took the soiled linen and left the room.
-CNA C removed his/her gloves and washed his/her hands.
During an interview on 3/20/18 at 6:08 A.M., CNA C said the resident was incontinent of
urine that morning and the resident’s bed linen was wet with urine. CNA C said staff
should wash their hands before starting care and once care is finished before they leave
the room.
7. During an interview on 3/21/18 at 3:30 P.M., the Director of Nursing (DON) said staff
should wash their hands prior to any resident contact, between glove changes, and after
care had been completed. The DON said staff should change their gloves and wash their
hands after touching soiled items before they touched any clean items such as briefs or
clothing.