Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to treat each
resident with respect and dignity and care for each resident in a manner and in an
environment that promotes maintenance or enhancement of his or her quality of life by
posting resident’s personal information on signs, not providing visual privacy, not
speaking to resident’s in a dignified manner, and by not covering residents during
incontinence care, for four residents (Resident #169, #216, #20, #320). The sample was 20.
The census was 96.
1. Review of Resident #169’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/1/19, showed:
-Focus: The resident has limited physical mobility related to weakness;
-Interventions:
-The resident is weight bearing;
-Provide gentle range of motion as tolerated with daily care;
-Provide supportive care and assistance with mobility as needed. Document assistance as
needed;
-Physical therapy (PT), occupational therapy (OT) as ordered as needed (PRN).
Review of the resident’s progress notes, dated 3/19/19, showed he/she had a fall on the
weekend of 3/9/19 through 3/10/19 when ambulating at night by him/herelf to bathroom.
Resident reported that his/her knee gave out.
Observation and interview of the resident on 3/21/19, showed the following:
-At 10:00 A.M., he/she sat in his/her room with the door open. He/she sat on the commode
next to his/her bed. The resident had a towel over his/her lap and, he/she was visible
from the hallway. Staff walked by the resident’s room, but did not look in the resident’s
direction. The Assistant Director of Nursing (ADON) walked by, but did not go into the
resident’s room;
-At 10:15 A.M., Certified Medication Technician (CMT) J arrived to the resident’s room and
placed the medication cart in front of the resident’s door. The resident continued to sit
on the commode in his/her room. The CMT entered the resident’s room, prepared and
administered the resident’s oral medication;
-At 10:21 A.M., CMT J was in the resident’s room while the door remained open. The
medication cart no longer sat in front of the resident’s door. The resident sat on the
commode. The towel no longer lay on the resident’s lap. The resident’s thigh and buttock
was exposed to the hallway as he/she sat on the commode;
-At 10:33 A.M., CMT J left the resident’s room and went to the next room. The resident
continued to sit on the commode, visible to the hall. The resident placed the towel over
his/her lap. Staff and visitors continued to walk by the resident’s room;
-At 11:00 A.M., the resident sat on the commode with a towel over his/her legs. The
resident said he/she waited for PT to assist him/her off the bedside commode, but they
never came back. The resident’s call light lay on his/her bed, out of reach. Two staff
entered the room with the resident’s roommate. The resident asked for assistance.
During an interview on 3/21/19 at 1:21 P.M., the resident said the incident today was not
the first time he/she was left on the commode. It happened during the night shift, and
he/she did not receive assistance until the next shift. The door was also left open. The
staff are rude and often ignore him/her when he/she needed help. The resident said the
room is located on a hall that has a lot of traffic. Staff and visitors have to walk on
his/her hall to get to the other halls in the facility, so they are able to look into

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
his/her room. His/her privacy was violated because he/she was exposed. He/she used a towel
to cover his/herself because he/she did not want people to see him/her without pants and
on the bedside commode. A certified nurse aide (CNA) assisted him/her on the commode, but
therapy was supposed to come to the room to assist him/her because they needed to see
him/her stand and raise his/her pants up. The same CNA eventually assisted him/her off the
bedside commode. The resident said his/her legs were weak from sitting on the commode for
such a long time. He/she did not attempt to stand because he/she did not want to fall
again. The light call was on the bed, so it was not in reach.
During an interview on 3/26/19 at 4:00 P.M., the Director of Nursing (DON) said it was not
appropriate for the resident to be left on the commode with the door open. She would
expect the CMT to not administer medications while the resident was on the commode. She
would have expected the CMT to call staff to assist the resident. The DON said the
resident’s privacy was violated. She would expect staff to respect the resident’s dignity,
and to not have left him/her on the commode.
2. Review of Resident #216’s (MONTH) 2019 physician order [REDACTED].
-an order for [REDACTED].>-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed:
-Problem: Activity of daily living (ADL) self-care performance deficit due stroke and
abnormalities of gait and mobility;
-Approach: The resident is able to feed self. Requires a bib related to extrapyramidal
movements (continuous spasms and irregular, jerky movements).
Observation on 3/22/19 at 1:00 P.M., showed the resident entered the facility after he/she
went outside on a smoke break, under staff supervision, with dried food on his/her chin
and face. At 1:03 P.M., the resident continued down the hallway, with dried food on
his/her chin and face, and sat at the nurse’s station.
During an interview on 3/27/19 at 9:34 A.M., the DON said some of the care plans in the
computer were not person centered. The care plans should be person centered and include
the resident’s assistance needs.
3. Review of Resident #20’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 11/7/18, showed:
-Brief interview for mental status (BIMS) score of 6 out of 15, indicating severe
cognitive impairment;
-Extensive assistance with one staff assist for bed mobility, locomotion on and off unit,
dressing and personal hygiene;
-Total dependence with two staff assist with transfers;
-Always incontinent of bowel and bladder;
-Medical [DIAGNOSES REDACTED].
Observation on 3/25/19 at 7:00 A.M., showed CNA E and CNA F performed incontinence care
for the resident:
-A sign posted over the resident’s bed, taped to the wall that read to please use sit to
stand (mechanical lift) to transfer to wheelchair, typed in bold letters;
-The resident lay in bed on urine soaked sheets and incontinence pads. His/her pants urine
soaked all the way up the resident’s back;
-CNA E asked the resident, You wet, again? Huh? Wet again? in a undignified voice;
-CNA F called the resident’s brief a diaper in front of the resident;
-CNA E removed the resident’s urine soaked brief;
-CNA E did not cover the resident’s exposed perineum (the portion of the body in the
pelvis occupied by urogenital passages and the rectum) when not actively cleansing the
resident of urine;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0550

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
-Staff walked into the room twice without knocking or waiting for permission to enter.
When the staff opened the door, the resident was exposed to the hallway;
-Staff and residents walked in the hallway, past the resident’s room.
4. Review of Resident #320’s medical record, reviewed on 3/22/19 at 2:05 P.M., showed:
-[DIAGNOSES REDACTED].
-Health status progress note, dated 3/5/19 at 5:03 P.M., showed incontinent of bowel and
bladder;
-Social service progress noted, dated 3/6/19 at 12:35 P.M., showed the resident:
-Alert and oriented times two (able to recall person and place), with some confusion and
forgetfulness;
-Required limited assistance of 1-2 people for transfers and assistance of 1 person for
activities of daily living;
-Propelled self by wheelchair.
Observation on 3/22/19 at 7:12 A.M., showed:
-The resident sat on the edge of his/her bed, naked, with urine a soaked brief on the
floor at the resident’s feet. A visible puddle of urine on the resident’s bed and soaked
the sheets and incontinence pads with a strong odor of urine in the room;
-The resident visible to the hall from the open door. Staff and residents walked in the
hallway past the resident’s room;
-CNA B walked in and out of the resident’s room and then returned to the room a total of
three times between 7:12 A.M. and 7:32 A.M. CNA B left the door open to the hallway with
the resident exposed to the staff and residents who were observed to walk past the
resident’s room, in the hallway;
-CNA B did not offer to cover the resident, nor close the curtain such that he/she was
protected from view.
5. During an interview on 3/26/19 at 2:19 P.M., the DON said:
-Staff should not refer to incontinent briefs as diapers as it is disrespectful to the
resident;
-Staff should knock on resident’s room doors and wait for an invitation into the room
before opening the door;
-Staff is expected to cover residents for privacy;
-Doors and curtains are closed during incontinent care to maintain the privacy and dignity
of the residents;
-Posting signs announcing a resident’s transfer status is not allowed as they are a
violation of resident’s dignity and privacy.

F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to promote the
resident’s self-determination through support of resident choices when staff failed ensure
a system to accommodate a resident’s choice for being in an intimate relationship
(Resident #63). The sample was 20. The facility census was 97.
Review of Resident #63’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/26/18, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-Focus: Resident is currently involved in an intimate relationship with a resident in the
facility;
-Goals: Resident’s decision to be involved in this relationship will be respected and
honored;
-Interventions:
-Always knock before entering the room and announce yourself;
-Encourage him/her to discuss any issues/concerns with staff as needed;
-Encourage him/her to rest if needed before engaging in sexual activity due to his/her
breathing issues;
-Provide education as needed;
-Provide/allow privacy as needed/requested;
-Respect his/her rights.
Review of the resident’s progress notes, showed:
-On 12/10/18, resident asked administrator, can we have sex in here? Administrator
informed resident that he/she could as long as both residents are alert and are
cognitively able to make their needs known and able to understand what sex is and risks
associated with it. Discussed sex education, condoms, privacy, and plan of care;
-On 1/8/19, social services spoke to the resident in private yesterday afternoon to see if
he/she wanted to open up about his/her relationship with another resident. Resident was
okay with talking about his/her relationship. He/she stated that he/she had a relationship
with another resident for a little over a month now, and that they both enjoy one
another’s company. Resident was asked if he/she was having a sexual relationship with the
resident and he/she said yes. The resident was reminded that the facility will provide
privacy for him/her when they choose to have a sex. He/she agreed to let them know when
they decide on having sexual relations. Resident was asked if they needed condoms, and
he/she said yes. The social servcie worker gave him/her some condoms and put them in a
spot where he/she felt only he/she knew where they were. Social services will continue to
follow and monitor him/her for any new concerns or needs that he/she might have;
-On 1/23/19, the resident stated to therapy staff that he/she wants his/her own room so
that he/she may be as sexually active as he/she wants to be;
-On 3/11/19, resident had another resident in bed with him/her. Escorted other resident
out of the room.
Observation and interview on 3/22/19 at 10:21 A.M., showed the resident sat in his/her
room. The room was occupied by two residents and not a private room. The resident said
some of the staff respect his/her choices, but there was one nurse who always escorted
his/her partner out of the room. The nurse found the two of them in bed watching
television. The nurse told the partner to leave the room. The resident said they were only
watching television. The resident went to the administrator to complain about it. Staff
are aware he/she is in a relationship, and it should be respected.
During an interview on 3/27/19 at 7:31 A.M., Nurse H said he/she wrote in the resident’s
progress notes that he/she found another resident in bed with the resident on 3/11/19.
He/she did not know that the resident had a partner. Nurse H did not know that the
residents were allowed to have sex in the facility. At 7:53 A.M., Nurse H said when he/she
found the residents in bed, they were just watching television. They were not intimate. I
would had freaked out if they were intimate and he/she added, Ewww.
During an interview on 3/26/19 at 4:00 P.M., the Director of Nursing (DON) said she was
aware that the resident was in a relationship with another resident in the facility. She
was aware that a problem occurred recently because the resident spoke to the administrator
about it, but the DON did not know a resident was escorted out of the room. On 3/27/19 at
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
10:30 A.M., the DON said she would expect staff to be aware of the residents who are
involved in intimate relationships. It is documented in the care plan. The nurse had no
right to remove a resident. She would expect staff to respect the resident’s decision to
be sexually active.
Review of the facility’s sexual expression of resident’s policy, dated (MONTH) (YEAR),
showed:
-Policy: It is the policy of this facility to respect all residents and their rights. This
policy applied to individuals who exhibit intact cognitive decision making capacity.
Residents residing in the facility will be allowed to express themselves in a way they
prefer, given they have the mental capacity to make informed decision;
-Policy interpretation and Implementation: Staff will document observation of residents
engaging in intimacy and/or sexual activity and notify social service and the Director of
Nursing (DON);
-Social services will notify the interdisciplinary team;
-Social services will educate the resident about any diseases processes and the residents’
right;
-Residents with decisional capacity have the right to seek out and engage in consensual
intimacy and/or sexual expression;
-The physician will be notified regarding all residents participating in sex for a
clinical and cognitive evaluation to determine intact cognitive decision-making capacity
and capacity to give consent;
-The decision to conduct a cognitive re-assessment will be made by the interdisciplinary
team and based upon noticing a change in resident’s behavior;
-Care plan meetings with the interdisciplinary team shall be scheduled as soon as possible
from initial notification of the social services staff;
-The interdisciplinary team shall conduct a review of situations and accounts of sexual
expression among or between residents or with visitors to determine a solution that best
meets the needs of and protects those involved;
-Outcomes of the interdisciplinary team review will be shared with the residents involved
and documented in the plan of care;
-Based on the plan of care, intimacy and sexual expression shall be permitted if both
parties consent and the risks do not exceed the benefits;
-The facility will ensure the resident’s right to privacy, including providing a private
place for intimacy and/or sexual expression;
-The staff will re-direct residents engaging in intimacy and/or sexual expression in
public areas;
-Residents who express the desire to be sexually active will receive education on the
definition of abuse, sexual assault, and who to contact to report any issues.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have written authorization
for management of personal funds for eight out of a sample of 10 resident reviewed for
funds authorization (Resident #122, #272, #47, #18, #66, #38, #15, and #67). The census
was 97.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
1. Review of Resident #122’s medical record, showed the resident admitted on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
2. Review of Resident #272’s medical record, showed the resident admitted on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
3. Review of Resident #47’s medical record, showed the resident admitted on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
4. Review of Resident #18’s medical record, showed the resident admitted on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
5. Review of Resident #66’s medical record, showed the resident admitted on [DATE] and
discharged on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
6. Review of Resident #38’s medical record, showed the resident admitted on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
7. Review of Resident #15’s medical record, showed the resident admitted on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
8. Review of Resident #67’s medical record, showed the resident admitted on [DATE] and
expired on [DATE].
Review of the resident’s authorization for management of personal funds, showed no
signature from the resident or the responsible party.
9. During an interview [DATE] at 12:25 P.M., the Business Office Manager (BOM) said he/she
was not aware that there were residents that did not have signed authorization forms from
the resident or responsible party for the facility to manage personal funds. He/she did
not have a system in place to ensure authorization forms were signed. He/she began working
at the facility one month ago and had not checked the forms or had new residents sign the
authorization form at this time.
10. During an interview on [DATE] at 12:40 P.M., the administrator said he would expect
the facility to have signed authorization forms to hold resident funds. He would expect
the business office to have a system in place to ensure all authorization forms are signed
and to follow up for any changes.

F 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Properly hold, secure, and manage each resident’s personal money which is deposited
with the nursing home.

Based on interview and record review, the facility failed to provide quarterly resident
fund statements within 30 days after the end of the quarter and failed to provide bank
statement for four out of 12 months. In addition, the facility failed to ensure resident
trust fund (RTF) accounts were not overdrawn for 13 additional residents reviewed for
accounting of funds (Resident #316, #170, #171, #124, #12, #30, #215, #43, #65, #35, #50,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
#172, and #10). This had the potential to affect all residents who had personal funds held
by the facility. The facility census was 97.
1. Review of the resident trust fund (RTF) documentation, showed the following:
-March (YEAR): Bank statement not available. The facility monthly reconciliation form,
showed an ending balance amount of $31,908.71;
-April (YEAR): Bank statement not available. The facility monthly reconciliation form,
showed an ending balance amount of $38,160.89;
-November (YEAR): Bank statement not available. The facility monthly reconciliation form,
showed an ending balance amount of $26,700.41;
-December (YEAR): Bank statement not available. The facility monthly reconciliation form,
showed an ending balance amount of $32,478.67.
2. Further review of the RTF documentation, showed no quarterly statements sent to the
residents and/or their representatives.
During an interview on 3/26/19 at 2:14 P.M., Resident #24 said he/she has a resident trust
account with the facility. He/she lived at the facility for two years and never received a
quarterly statement.
3. During an interview on 3/26/19 at 12:35 P.M. and 3/27/19 at 8:00 A.M., the Business
Office Manager (BOM) said he/she did not have bank statements for March, April, (MONTH)
and (MONTH) (YEAR). He/she tried to contact the corporate office, but could not contact
anyone who had access to the bank statements. He/she was aware that quarterly statements
had not been mailed out. He/she has only worked at the facility for a month, so he/she
mailed them out during his/her first month at the facility. He/she received phone calls
from resident representatives telling him/her that they never received statements before.
On 3/27/19 at 8:00 A.M., the BOM said he/she went to the bank to retrieve the missing four
bank statements.
4. During an interview on 3/26/19 at 12:40 P.M., the administrator said he would expect
the business office manager to have access to the bank statements to accurately reconcile
the resident funds. He confirmed that there would be no way to know if the reconciliation
ledger for the four months were correct. He would expect the residents and their
representative to be mailed a quarterly statements.
5. Review of Resident #316’s facility RTF statement, dated 2/28/19, showed the following:
-On 10/1/18, showed an opening balance of $0.00;
-On 10/5/18, showed a hair dressing charge of $7.00;
-On 10/6/18 through 2/28/19, showed a negative balance of $7.00.
6. Review of Resident #170’s facility RTF statement, dated 2/28/19, showed a negative
balance of $0.20.
7. Review of Resident #171’s facility RTF statement, dated 2/28/19, showed a negative
balance of $15.00.
8. Review of Resident #124’s facility RTF statement, dated 2/28/19, showed a negative
balance of $1.69.
9. Review of Resident #12’s facility RTF statement, dated 2/28/19, showed a negative
balance of $33.58.
10. Review of Resident #30’s facility RTF statement, dated 2/28/19, showed the following:
-On 2/1/19, an opening balance of $0.36;
-On 2/1/19, a cash withdrawal of $15.00, leaving a negative balance of $14.64;
-On 2/7/19, a cash withdrawal of $15.00, leaving a negative balance of $29.64;
-On 2/14/19, a cash withdrawal of $21.00, leaving a negative balance of $50.64.
11. Review of Resident #215’s facility RTF statement, dated 2/28/19, showed a negative
balance of $99.00.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
12. Review of Resident #43’s facility’s RTF statement, dated 2/28/19, showed a negative
balance of $7.00.
13. Review of Resident #65’s facility RTF statement, dated 2/28/19, showed the following:
-On 2/1/19, an opening balance of $0.01;
-On 2/1/19, a cash withdrawal of $21.00, leaving a negative balance of $20.99;
-On 2/14/19, a deposit of $1,556.00.
14. Review of Resident #35’s facility RTF statement, dated 2/28/19, showed the following:
-On 2/1/19, an opening balance of $10.01;
-On 2/4/19, a cash withdrawal of $30.00, leaving a negative balance of $19.90;
-On 2/7/19, a cash withdrawal of $17.00, leaving a negative balance of $36.90;
-On 2/14/19, a deposit of $482.00.
15. Review of Resident #50’s RTF statement, dated 2/28/19, showed the following:
-On 2/1/19, an opening balance of $0.71;
-On 2/1/19, a cash withdrawal of $21.00, leaving a negative balance of $20.29;
-On 2/7/19, a cash withdrawal of $15.00, leaving a negative balance of $35.29;
-On 2/14/19, a cash withdrawal of $5.00 and $9.00, leaving a negative balance of $49.29;
-On 2/14/19, a deposit of $1,042.00.
15. Review of Resident #172’s RTF statement, dated 2/28/19, showed a negative balance of
$5.00.
16. Review of Resident #10’s RTF statement, dated 2/28/19, showed the following:
-On 2/1/19, an opening balance of $39.92;
-On 2/1/19, a cash withdrawal of $50.00 and $10.00, leaving a negative balance of $20.08;
-On 2/14/19, a deposit of $1,278.30.
17. During an interview on 3/26/19 at 12:40 P.M., the administrator said he would expect
the business office manager to ensure there is enough funds in the resident’s account
before the resident is allowed to withdrawal money.

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 money in a timely
manner for six sampled residents who were discharged from the facility (Resident #173,
#174, #66, #6, #176, and #175). The census was 97.
1. Review of Resident #173’s medical record, showed the resident discharged on [DATE].
Review of the resident trust fund (RTF) statement, dated [DATE], showed a balance of
$30.00.
2. Review of Resident #174’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $28.22.
3. Review of Resident #66’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $2,423.24.
4. Review of Resident #6’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $9.01.
5. Review of Resident #176’s medical record, showed the resident discharged on [DATE].
Review of the RTF statement, dated [DATE], showed a balance of $1,267.02.
6. Review of Resident #175’s medical record, showed the resident discharged on [DATE].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 8)
Review of the RTF statement, dated [DATE], showed a balance of $646.47.
7. During an interview on [DATE] at 12:35 P.M., the Business Office Manager (BOM) said
he/she was aware there were several residents that had either been discharged or expired
that continued to have money in the facility’s trust account. He/she had been trying to
clean it up since starting one month ago.
8. During an interview on [DATE] at 12:40 P.M., the administrator said he would expect the
resident’s money to be sent to either the resident, their responsible party, or the
Department of Health and Senior Services in a timely manner. It is not acceptable to hold
on to money several months after the resident had been discharged .

F 0570

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to maintain an approved surety
bond to ensure the protection of resident funds. The census was 96.
Review of the Department of Health and Senior Services approved bond list, showed the
facility did not have an approved surety bond.
1. Review of the resident trust fund account, for (MONTH) (YEAR) through (MONTH) 2019,
showed an average monthly balance of $33,000.00 which would required a surety bond of
$49,500.00.
2. Review of the facility’s yearly bond renewal, showed:
-September 2014 through (MONTH) (YEAR), the facility’s bond was $70,000;
-September (YEAR) through (MONTH) (YEAR), the facility’s bond was $50,000;
-September (YEAR) through (MONTH) 2019, the facility’s bond was $60,000.
3. During an interview on 3/26/19 at 12:00 P.M., the Business Office Manager said the
current surety bond was $60,000. He/she did not have documentation to show that the surety
bond was approved by Department of Health and Senior Services. He/she had been at the
facility for one month and was not aware that the surety bond was not approved.
4. During an interview on 3/26/19 at 12:35 P.M., the administrator said he would expect
the facility to have an approved surety bond. He received documentation from their
corporate office that DHSS approved their bond.
Review of the facility’s surety bond letter, dated 3/26/19, showed DHSS approved the
surety bond for $60,000.
5. During an interview on 3/26/19 at 1:00 P.M., the administrator and Business Office
Manager confirmed the surety bond was approved on 3/26/19.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident’s right to
request, refuse, and/or discontinue treatment by failing to obtain physician orders

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
[REDACTED].#33). The census was 96.
Review of Resident #33’s medical record, showed:
-A face sheet, with an admission date of [DATE];
-A signed DNR code status sheet, dated 12/7/18;
-Physician order [REDACTED].
-No orders found for a DNR status.
During an interview on 3/27/19 at 8:34 A.M., the Director of Nurses (DON) verified the
resident had signed a DNR code status sheet, the POSs showed for staff to perform a full
code and she could not find any orders for the resident to be a DNR. The signed code
status sheet and the POS should match, she would expect staff to obtain a physician order
[REDACTED].

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a
comfortable homelike environment and ensure resident room temperatures remained between a
temperature range of 71 degrees to 81 degrees Fahrenheit (F) for one of 20 sampled
residents (Residents #18). The census was 96.
Review of Resident #18’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/25/18, showed the following:
-Cognitively intact;
-Independent with all activities of daily living (ADLs);
-Ambulatory;
-No behaviors;
-[DIAGNOSES REDACTED].
During an observation and interview on 3/22/19 12:42 P.M., showed the resident sat in
his/her bed beside his/her window. The window raised approximately 5 inches, a small fan
sat on a bedside table beside the window. The resident said his/her room was always hot
and he/she just sits in his/her room and sweats. It was so hot and he/she had difficulty
sleeping due to the heat. He/she wanted to sleep naked to help stay cool, but was fearful
someone would walk in. He/she complained about his/her room being so hot, and the social
worker gave him/her the fan to use to help cool the room. The residents have a designated
smoking area outside his/her room and the fan pulls the smoke inside his/her room, and the
smoke burned his/her eyes. He/she would open his/her door to help cool the room down, but
the resident’s walk by and stare at him/her like someone looking at an animal in a zoo,
which made him/her feel uncomfortable. He/she complained to staff all the time about the
heat, but nothing was done about it. Observation at this time, showed the surveyor used a
calibrated digital thermometer to take the temperature of the resident’s room and the
temperature gauge, showed 89.1 degrees F.
During an interview on 3/22/19 at 12:45 P.M., the social worker said he was not aware the
resident had complained about his/her room being too warm and could not remember if he/she
gave the resident a fan to use.
During an interview on 3/22/19 at 12:51 P.M., the maintenance director said the previous
maintenance director had been terminated recently and he had just taken over the position.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
He was aware of the room getting too warm and the previous maintenance director had to
always physically adjust the vent inside the resident’s room to control the temperature.
The resident’s room should be kept at a comfortable temperature.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow their abuse, neglect,
misappropriation policy for lost or stolen money for one resident who reported an
allegation of missing money (Resident #272). The census was 96.
Review of the facility’s Abuse, Neglect, Mistreatment and Misappropriation of Resident
Property policy, dated (MONTH) 17, (YEAR), showed:
-Investigation procedures:
-The appointed investigator will, at minimum, attempt to interview the person who reported
the incident, anyone who likely to have knowledge of the incident and the resident if
interviewable;
-Any written statements that have been submitted will be reviewed, along with any
pertinent medical records or other documents.
Review of Resident #272’s care plan, in use during the survey, showed:
-Focus: Problems with keeping track of my money related to [MEDICAL CONDITION]. On (MONTH)
16, 2019, the resident was unable to locate $10 that was in his/her wallet;
-Goal: Keep money locked in the lock box in the reception office;
-Interventions included: Assist to the reception office to get a few dollars for snacks.
Inform of the amount and denomination of money given.
Review of the facility’s investigation showed:
-The resident resided on the 300 hall;
-No staff interviews conducted regarding the resident’s missing money;
-No review of the video footage, of the camera on 300 hall during the investigation.
During an interview on 3/26/19 at 9:00 A.M., the administrator said the data on the video
(on the resident’s hall) was gone.
During an interview on 3/27/19 at 10:35 A.M., the Director of Nursing (DON) said if items
are reported lost or stolen, she completes a self-report. The facility staff would search
to find the items or money that was reported missing. Residents and the staff that work on
that unit are to be interviewed. The facility should have interviewed the staff on that
unit before now and should have attempted to review the camera/video.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written Emergency
Transfer notices to residents and/or representatives as soon as practicable when a
resident is temporarily transferred on an emergency basis to an acute care facility and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
their return to the facility was expected. Of the 20 sampled residents, seven had been
recently transferred to a hospital for various medical reasons, six were expected to
return and had not been issued a written transfer notice upon leaving the facility
(Residents #64, #47, #56, #320, #62 and #116). The census was 96.
1. Review of Resident #64’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfers.
2. Review of Resident #47’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
3. Review of Resident #56’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
4. Review of Resident #320’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
5. Review of Resident #62’s medical record showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
6. Review of Resident #116’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident and/or the representative received written notice upon the
emergency transfer.
7. During an interview on 3/26/19 at 8:35 A.M., Nurse G stated when sending out residents
to the hospital, the charge nurses send a copy of the resident’s physician order
[REDACTED]. He/she has never sent discharge notices with the resident.
8. During an interview on 3/26/19 at 8:47 A.M., the Social Worker and the Director of
Nursing (DON) said:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-The DON writes a discharge summary in the resident’s chart and a recapitulation of their
stay, under the assessments tab in the electronic medical record;
-The facility does not send discharge notices when residents are sent out to hospitals for
emergencies.
9. During an interview on 3/26/19 at 5:36 P.M., the DON said they were not aware they
needed to be issuing an emergency discharge notice to the resident or their responsible
party whenever the resident had an emergency transfer to the hospital with a return
anticipated and had not been issuing any notices.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide written notice to the
resident or their legal representative of the facility bed hold policy at the time of
transfer to the hospital, for seven of 20 sampled residents, who were recently transferred
to the hospital for various medical reasons (Residents #64, #47, #56, #320, #62, #116 and
#267). The census was 96.
1. Review of Resident #64’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
2. Review of Resident #47’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
3. Review of Resident #56’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfer.
4. Review of Resident #320’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
5. Review of Resident #62’s medical record, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
6. Review of Resident #116’s medical record, showed:
-discharged to a local hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfer.
7. Review of Resident #267’s medical record, showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received written notice of
the facility’s bed hold policy at the time of transfers.
8. During an interview on 3/26/19 at 8:35 A.M., Nurse G stated when sending out residents
to the hospital, the charge nurses send a copy of the resident’s physician order
[REDACTED]. He/she has never sent bed hold notice with the resident.
9. During an interview on 3/26/19 at 8:47 A.M., the Social Worker and the Director of
Nursing (DON) said the facility does not send the facility policy for bed holds with
residents when residents are sent to the hospital.
10. During an interview on 3/26/19 at 5:36 P.M., the DON said they were not aware they
needed to be issuing a written bed hold policy to the resident or their representative
whenever the resident had an emergency discharge to the hospital with a return anticipated
and had not been issuing any notices.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete a comprehensive
assessment of a resident’s needs, strengths, goals, life history and preferences, using
the resident assessment instrument (RAI) specified by the Centers for Medicare and
Medicaid Service (CMS) within 14 calendar days after admission and not less than once
every 12 months, for three of 24 residents reviewed for resident assessments (Resident
#62, #17 and #122). The census was 96.
1. During an interview on 3/26/19 at 11:16 A.M., the Director of Nursing (DON) said,
currently the facility does not have a Minimum Data Set (MDS, a federally mandated
assessment instrument completed by facility staff) coordinator and MDS assessments are not
being completed.
2. Review of Resident #62’s medical record, showed:
-admitted on [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-No admission MDS, dated [DATE];
-An admission MDS, dated [DATE], in progress.
3. Review of Resident #17’s medical record, showed:
-Readmitted on [DATE];
-An annual MDS, dated [DATE], in progress
4. Review of Resident #122’s medical record, showed:
-Readmitted on [DATE];
-An annual MDS, dated [DATE], in progress.
5. During an interview on 3/27/19 at 10:43 A.M., with the DON and Administrator, the DON
said if the MDS indicates in progress that means it is not yet completed. She would expect
MDS be completed per regulation.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to assess residents using the
quarterly review instrument specified by the State and approved by the Centers for
Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 17
of 24 residents reviewed for resident assessments (Resident #22, #16, #5, #10, #21, #7,
#9, #18, #12, #38, #13, #19, #15, #4, #11, #10, and #116). The census was 96.
1. During an interview on 3/26/19 at 11:16 A.M., the Director of Nursing (DON) said,
currently the facility does not have a Minimum Data Set (MDS, a federally mandated
assessment instrument completed by facility staff) coordinator and MDS assessments are not
being completed.
2. Review of Resident #22’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
3. Review of Resident #16’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
4. Review of Resident #5’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
5. Review of Resident #20’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
6. Review of Resident #21’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
7. Review of Resident #7’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
8. Review of Resident #9’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
9. Review of Resident #18’s medical record, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
10. Review of Resident #12’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
11. Review of Resident #38’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
12. Review of Resident #13’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
13. Review of Resident #19’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
14. Review of Resident #15’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
15. Review of Resident #4’s medical record, showed:
-Readmitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
16. Review of Resident #11’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
17. Review of Resident #10’s medical record, showed:
-admitted on [DATE];
-A quarterly MDS, dated [DATE], in progress.
18. Review of Resident #116’s medical record, showed:
-Readmitted on [DATE];
-A quarterly MDS, dated [DATE], export ready.
19. During an interview on 3/27/19 at 10:43 A.M., with the DON and Administrator, the DON
said in progress indicates the MDS is not yet complete. Export ready indicates the MDS is
completed, but not yet exported. She would expect MDS be completed and exported per
regulation.

F 0640

Level of harm – Potential for minimal harm

Residents Affected – Many

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to encode and be capable of
transmitting the resident assessment instrument within 7 days after completing a
resident’s assessment, to include a subset of items upon a resident’s transfer, reentry,
discharge, and death, for eight of 24 residents reviewed for resident assessments
(Resident #21, #8, #19, #4, #6, #63, #122 and #267). In addition, the facility failed to
electronically transmit encoded, accurate, and complete Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) data to the Centers for
Medicare and Medicaid Services (CMS) system within 14 days after a facility completes a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0640

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 16)
resident’s assessment. The census was 96.
1. During an interview on 3/26/19 at 11:16 A.M., the Director of Nursing (DON) said,
currently the facility does not have an MDS coordinator and MDS assessments are not being
completed.
2. Review of Resident #21’s medical record, showed:
-admitted on [DATE];
-A discharge return anticipated MDS, dated [DATE], in progress;
-An entry MDS, dated [DATE], in progress.
3. Review of Resident #8’s medical record, showed:
-admitted on [DATE] and discharged on [DATE];
-A discharge return not anticipated MDS, dated [DATE], in progress.
4. Review of Resident #19’s medical record, showed:
-admitted on [DATE];
-A discharge return anticipated MDS, dated [DATE], in progress.
5. Review of Resident #4’s medical record, showed:
-Readmitted on [DATE];
-A discharge return anticipated MDS, dated [DATE], in progress;
-An entry MDS, dated [DATE], in progress;
-A discharge return anticipated MDS, dated [DATE], in progress;
-No entry MDS completed;
-A discharge return anticipated MDS, dated [DATE], in progress.
6. Review of Resident #6’s medical record, showed:
-admitted on [DATE] and discharged on [DATE];
-A discharge return not anticipated MDS, dated [DATE], in progress.
7. Review of Resident #63’s medical record, showed:
-Readmitted on [DATE];
-A discharge return anticipated MDS, dated [DATE], in progress;
-An entry MDS, dated [DATE], in progress.
8. Review of Resident #122’s medical record, showed:
-admitted on [DATE];
-A discharge return anticipated MDS, dated [DATE], in progress.
9. Review of Resident #267’s medical record, showed:
-admitted on [DATE];
-Discharge return anticipated MDS, dated [DATE], in progress.
10. During an interview on 3/26/19 at 5:44 P.M., the DON said she could only find one
stack of transmittal reports in the former MDS coordinator’s office. She does not know how
far back they go.
Review of the transmittal reports, provided by the DON, showed:
-On 12/10/18- 2 MDS submitted, 1 submitted late;
-On 12/10/18- 31 MDS submitted, 2 rejected, of the 29 accepted, 11 submitted late;
-On 1/2/19- 9 MDS submitted, 1 submitted late;
-On 1/3/19- 1 MDS submitted, 1 submitted late;
-On 1/3/19- 7 MDS submitted, 3 rejected, of the 4 accepted, 3 submitted late;
-On 1/8/19- 6 MDS submitted, 1 submitted late;
-On 1/9/19- 24 MDS submitted, 11 submitted late;
-On 1/17/19- 9 MDS submitted, 1 submitted late;
-On 1/23/19- 8 MDS submitted, 1 submitted late;
-On 1/25/19- 10 MDS submitted, 1 submitted late.
11. During an interview on 3/27/19 at 10:43 A.M. with the DON and Administrator, the DON
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0640

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 17)
said MDS should be completed and transmitted per regulation.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure the
resident’s Minimum Data Set (MDS, a federally mandated assessment instrument completed by
facility staff) accurately reflect the resident’s status for three of 20 sampled residents
(Resident #38, #33 and #7). The census was 96.
1. Review of Resident #38’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Stroke not documented as a diagnoses.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Issues communicating due to stroke;
-Goal: The resident will maintain current level of communication function by being able to
verbalize needs;
-Interventions: Discuss with resident/family concerns or feelings regarding communication
difficulty. Encourage resident to continue stating thoughts even if resident is having
difficulty. Focus on a word or phrase that makes sense, or responds to the feeling
resident is trying to express. Monitor/document for physical/nonverbal indicators of
discomfort or distress, and follow-up as needed.
2. Review of Resident #33’s significant change MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].>-Special services received while a resident: Hospice Care;
-Does the resident have a condition or chronic disease that may result in life expectancy
less than six months: No;
-Staff failed to accurately document the resident’s condition resulted in a life
expectancy of less than six months necessitating hospice services.
Review of the resident’s physician order [REDACTED].>Review of the resident’s care
plan, updated on [DATE], and in use during the survey, showed:
-Problem: Resident has a terminal prognosis related to late effects stroke. Hospice care;
-Goal: Comfort will be maintained;
-Interventions included: Consult with physician and social services to have Hospice care
in the facility.
3. Review of Resident #7’s quarterly MDS, dated [DATE], showed the following:
-Cognitively impaired;
-Ambulatory;
-Vision adequate, can see fine detail, no corrective lenses;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed:
-Problem: At risk for falls due to confusion, gait/balance problems, psychoactive drug
use, unaware of safety needs, and vision/hearing problems due to dementia;
-Approach: Anticipate the resident’s needs. Educate the resident/family/caregivers about
safety reminders and what to do if a fall occurs.
During an observation on [DATE] at 12:36 P.M., Certified Nursing Assistant (CNA) BB
assisted the resident to the small dining room inside the secured unit. As the resident
leaned onto CNA BB’s right side, CNA BB wrapped his/her right arm around the resident’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
waist. CNA BB assisted the resident without the use of a gait belt and the resident leaned
onto the CNA’s right side, as he/she steadied him/herself while he/she ambulated from
his/her room to the dining room.
During an interview on [DATE], at 2:10 P.M., Nurse Z said the resident needed assistance
to ambulate, he/she is visually impaired. He/she can walk but he/she would not see where
he/she was going.
4. During an interview on [DATE] at 11:42 A.M., the DON said the MDS should contain
current and accurate medical [DIAGNOSES REDACTED].

F 0644

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disabilities had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required,
for two of 20 sampled residents (Resident #216 and #116). The census was 96.
Review of the Central Office Medical Review Unit (COMRU) Instructional guide, updated
(MONTH) (YEAR), directs facilities as follows for the PASARR process:
-The DA-124 application will assist in identifying a client that requires a Level II
screening. The DA-124 C form must be completed prior to admitting the client to a nursing
facility to ensure the client does not trigger a Level II screening. A Level II screening
refers to clients with the [DIAGNOSES REDACTED].
-A client that requires a Level II screening cannot be admitted to the nursing facility
prior to the determination of the Level II;
-The triggers for the Level II screening are:
-The client has had inpatient psychiatric treatment in the past two years;
-The client was suicidal or homicidal (includes dementia clients);
-The client has very aggressive behavior (includes dementia clients);
-The client has a [DIAGNOSES REDACTED].
1. Review of Resident #216’s medical record, showed:
-admitted to the facility on [DATE];
-Resided in a Medicaid certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 Level I screen or PASARR Level II screen found.
2. Review of Resident #116’s medical record, showed:
-admitted to the facility on [DATE];
-Resided in a Medicaid certified bed;
-[DIAGNOSES REDACTED].
-No DA 124 Level I screen or PASARR Level II screen found.
3. During an interview on 3/27/19 at 8:05 A.M., the Social Service Designee (SSD) said
they were unable to locate any DA 124 Level I or PASARR Level II screen for either
resident and would need to request a copy.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0644

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a baseline care plan for each resident that includes the instructions needed to
provide effective and person-centered care of the resident that meet professional
standards of quality, by not including the minimum healthcare information for one out of
four newly admitted sampled residents (Resident #320). The census was 96.
Review of Resident #320’s medical record, reviewed on 3/22/19 at 2:05 P.M., showed:
-admitted [DATE];
-Medical [DIAGNOSES REDACTED].
-A health status progress note dated 3/5/19 at 5:03 P.M., showed incontinent of bowel and
bladder. Oxygen at 2 or 3 liters per minute;
-A social service progress note dated 3/6/19 at 12:35 P.M., showed the resident:
-Alert and oriented times two (able to recall person and place), with some confusion and
forgetfulness;
-Required limited assistance of one to two staff for transfers and assistance of one
staff for activities of daily living (ADL’s bathing, toileting, dressing, etc.);
-Propelled self by wheelchair.
Review of the resident’s baseline care plan, dated 3/7/19 and reviewed on 3/25/19 at 3:34
P.M., showed:
-No documented [DIAGNOSES REDACTED].
-No documentation of incontinence of bowel and bladder or assistance required with ADLs
with the corresponding goals and person centered interventions.
Observation on 3/21/19 at 12:48 P.M., showed the Assistant Director of Nursing (ADON) and
the Director of Nursing (DON) transfer the resident from his/her wheelchair with use of a
gait belt. The resident was soaked with urine
Observations on 3/22/19 at 6:50 A.M., showed the resident lay naked in his/her urine
soaked bed, an oxygen nasal cannula was wrapped around the handle bar on the back of the
resident’s wheelchair, there was no oxygen tubing connected to the concentrator located at
the bedside.
During an interview on 3/26/19 at 2:19 P.M., the DON said:
-Base line care plans should include information from the transfer forms and assessments
from the admitting nurses, pertinent medical diagnoses, oxygen therapy, and ADL needs;
-The admitting nurse is responsible for creating the base line care plan;
-The ADON is responsible for checking the base line care plans for accuracy.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
Based on observation, interview and record review, the facility failed to ensure each
resident had a person-centered comprehensive care plan developed and implemented to meet
his or her preferences and goals, and address the resident’s medical, physical, mental and
psychosocial needs, for seven out of 20 sampled residents (Residents #216, #7, #20, #59,
#62, #64, and #122). The census was 96.
1. Review of Resident #216’s (MONTH) 2019 physician order [REDACTED].
-admission date of [DATE];
-an order for [REDACTED].>-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed:
-Problem: Activities of daily living (ADL) self-care performance deficit due to stroke and
abnormalities of gait and mobility:
-Approach: The resident is able to feed self. Requires a bib related to extrapyramidal
movements (continuous spasms and irregular, jerky movements);
Problem: Impaired cognitive function/dementia or impaired thought processes due to
difficulty making decisions:
-Approach: Identify yourself at each interaction. Face the resident when speaking and
make eye contact. Reduce any distractions- turn off the television, radio, close door,
etc. The resident understands consistent, simple, directive sentences. Provide the
resident with necessary cues- stop and return if agitated;
-The care plan did not identify the resident’s puree diet, use of a divided plate, and/or
utensils required to eat.
Observation on [DATE] at 7:53 A.M., showed the resident sat in the small dining room
inside the secured unit. He/she used a knife to scoop portions of his/her pureed meal from
his/her divided plate and placed the knife deeply inside his/her mouth, then with
exaggerated movements of his/her head and arm, removed the knife from his/her mouth.
He/she repeatedly used the knife in his/her puree as staff walked around the dining room
and assisted other residents. The resident continued to use both his/her knife and fork in
the same manner as he/she attempted to eat his/her pureed meal during the entire meal.
During an interview on [DATE] at 2:33 P.M., Nurse Z said the resident is known to grab
food off the table that belongs to other residents and will attempt to grab food from
other resident’s plates. Staff have to watch him/her to keep him/her safe because he/she
is on a puree diet.
During an interview on [DATE] at 8:27 A.M., the physical therapy manager, said the
resident only eats pureed food and should not have a fork or knife. The resident has
ataxic (unsteady, shaky movements or tremor movements) and it would be dangerous for
him/her to try and eat with a knife or fork. He/she has a puree diet and there would be no
need for him/her to have anything other than a spoon. The care plan should be updated to
alert staff in regard to the use of a spoon only and to watch to make sure he/she does not
take other resident’s utensils and regular food.
During an interview on [DATE] at 7:10 A.M., Dietary Aid AA said he/she was responsible for
setting up the meal trays for the residents on the secured unit and staff always provide
all three utensils for every resident on the unit.
During an interview on [DATE] at 9:34 A.M., the Director of Nursing (DON) said some of the
care plans in the computer were not person centered. Care plans should be person centered
and include the resident’s diet and assistance needs.
2. Review of Resident #7’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated [DATE], showed the following:
-Cognitively impaired;
-One staff person assist for toilet use, personal hygiene and dressing;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-Ambulatory;
-Vision adequate, can see fine detail, no corrective lenses;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed:
-Problem: At risk for falls due to confusion, gait/balance problems, psychoactive drug
use, unaware of safety needs, and vision/hearing problems due to dementia. On [DATE], fall
with no injury, he/she leaned over after standing up and lost his/her balance;
-Approach: Anticipate the resident’s needs. Educate the resident/family/caregivers about
safety reminders and what to do if a fall occurs;
-The care plan did not address the resident’s transfer status.
During an observation on [DATE] at 12:36 P.M., Certified Nursing Assistant (CNA) B
assisted the resident to the small dining room inside the secured unit. As the resident
leaned onto CNA B’s right side, CNA B wrapped his/her right arm around the resident’s
waist. CNA B assisted the resident without the use of a gait belt and the resident leaned
onto the CNA’s right side, as he/she steadied him/herself while he/she ambulated from
his/her room to the dining room.
During an interview on [DATE], at 2:10 P.M., Nurse Z said the resident needed assistance
to ambulate, he/she is visually impaired. He/she can walk but he/she would not know where
he/she was going.
During an interview on [DATE], the therapy manager said residents who are assisted with
ambulation should wear a gate belt and should not lean on staff with the staff’s arm
wrapped around the resident’s waist to stabilize them.
During an interview on [DATE] at 9:34 A.M., the DON said some of the care plans in the
computer care were not person centered. The resident required a stand by assist and the
care plans should be person centered and include the resident’s assistance needs.
3. Review of Resident #20’s annual MDS, dated [DATE], showed:
-Brief interview for mental status (BIMS) score of 6 out of 15, indicating severe
cognitive impairment;
-Extensive assistance with one staff assist for bed mobility, locomotion on and off unit,
dressing and personal hygiene;
-Total dependence of two staff assist with transfers;
-Always incontinent of bowel and bladder;
-Medical [DIAGNOSES REDACTED].
-Two or more falls since admission or prior to assessment;
-Therapeutic diet;
-At risk for pressure ulcers (injury to the skin and/or underlying tissue, as a result of
pressure or friction);
-Care area assessment summary (CAAS), showed care areas triggered and the facility
indicated the following would be care planned for:
-ADL function/rehab potential;
-Cognitive loss/dementia;
-Urinary incontinence and indwelling catheter (a sterile tube inserted into the bladder
to drain urine);
-Falls;
-Dental care;
-Nutritional status;
-Pressure ulcer/injury.
Review of the resident’s care plan, dated [DATE] and in use at the time of the survey,
showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
Problem: Falls;
-ADLs function/rehab potential, cognitive loss/dementia, urinary incontinence and
indwelling catheter, dental care, nutrition status, pressure ulcer/injury not care
planned;
-No further problems identified for the resident listed on the care plan.
4. Review of Resident #59’s annual MDS, dated [DATE], showed:
-Short and long term memory issues;
-Locomotion on and off the unit did not occur;
-Total dependence with 2 person assist required for bed mobility, transfers, eating, and
personal hygiene;
-Impairment on one side for upper body and lower body;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s POS, dated (MONTH) 2019, showed:
-An order dated [DATE], for Eliquis (used to prevent blood clots) 5 milligram (mg), give
once a day;
-Physical therapy (PT) and occupational therapy (OT) to evaluate and treat: Right
contracture management and splinting.
Review of physician progress notes [REDACTED].
Review of the resident’s care plan, dated [DATE] and in use at the time of the survey,
showed:
-The care plan did not address the problem, goals or interventions for contracture to the
lower leg and the associated skilled therapies;
-The care plan did not address the use of Eliquis with the associated bleeding
precautions.
5. Review of Resident #62 14 day MDS, dated [DATE], showed:
-BIMs score of 13 out of 15, showed the resident cognitively intact;
-Transferred with extensive, 1 person assist;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 POS, showed:
-An order dated [DATE], for [MEDICATION NAME] (used to treat depression and anxiety) 10 mg
daily;
-An order dated [DATE], for [MEDICATION NAME] 8 mg at bedtime as needed for [MEDICAL
CONDITION];
-An order dated [DATE], for Xarelto (used to prevent blood clots) 15 mg tablet with food
daily;
-An order dated [DATE], for [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 5 mg at
night.
Review of the resident’s care plan, dated [DATE] and in use at the time of the survey,
showed it did not include the problems with goals or interventions for depression,
[MEDICAL CONDITION], or bleeding precautions.
6. Review of Resident #64’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-BIMS score of 13 out of 15, indicates cognitively intact;
-No behaviors;
-Indwelling urinary catheter;
-Required total assistance from the staff for transfers, dressing, eating, hygiene and
bathing.
Review of the resident’s care plan, dated [DATE] and in use during the survey, showed:
-Problem: Indwelling suprapubic catheter (a tube surgically inserted through the abdomen
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
into the bladder for continuous urine drainage) with [DIAGNOSES REDACTED].
-Goal: The resident will be/remain free from catheter related trauma. The resident will
show no signs/symptoms of urinary infection;
-Interventions: Catheter change per nephrologist doctor (physician that specializes in the
kidneys) monthly and as needed at resident bedside. Monitor for signs/symptoms of
discomfort on urination and frequency. Monitor/document for pain/discomfort due to
catheter.
Observation on [DATE] at 8:25 A.M., showed the resident lay in bed. CNA L pulled back the
resident’s covers and revealed a #16 French (size and type) indwelling urinary catheter
inserted into the resident’s bladder through the meatus (opening to the urethra), not
through the abdomen. The CNA said it was not a suprapubic catheter.
During an interview on [DATE] at 10:35 A.M., the DON said she would expect the resident’s
care plan to show the use of an indwelling urinary catheter and not a suprapubic.
7. Review of Resident #122’s (MONTH) 2019 POS, showed the following:
-An order to check gastric tube placement ([DEVICE], a tube surgically inserted into the
stomach to provide food, fluid and medication) every shift and document residual amount
every shift and as needed;
-An order, dated [DATE], to flush [DEVICE] with 150 cubic centimeters (cc) of water every
six hours and at least 30 cc of water before and after each medication every four hours at
6:00 A.M., 10:00 A.M., 2:00 P.M., 6:00 P.M., 10:00 P.M., and 2:00 A.M.;
-Orders dated [DATE], for medications administered per [DEVICE].
Review of the resident’s care plan, in use at the time of the survey, showed staff did not
document the resident’s use of a [DEVICE] or what services or care staff were to provide
for the [DEVICE] with goals and interventions.
During an observation and interview on [DATE] at 7:22 A.M., the resident said he/she
cannot swallow pills so he/she gets them thru the [DEVICE].
During an interview on [DATE] at 10:35 A.M., the DON said she would expect the resident’s
care plan to show the use of a [DEVICE].
8. During an interview on [DATE] at 2:19 P.M., the DON said:
-Comprehensive care plans are person centered and should include medical diagnoses,
catheters, contractures, depression, bleeding precautions, positioning and mobility for
dependent residents;
-Comprehensive care plans should include the MDS triggers for care plans to get true
picture of residents and how to care for them;
-The assistant DON is responsible for checking comprehensive care plans for accuracy.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident who is unable to carry out activities of daily living (ADLs) receives the
necessary services to maintain good nutrition, grooming, and personal hygiene, for four of
four observations of incontinence care (Residents #42, #37, #20 and #320). The sample was
20. The census was 96.
Review of the facility’s perineal (the surface area between the thighs, extending from

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 24)
the pubic bone to the tail bone) care policy, dated 2012, showed:
-Purpose: To cleanse the perineum and to prevent infection and odor;
-Procedure:
-Drape resident for privacy exposing only the perineal area and fold top lined to the
bottom of the bed;
-Discard soiled linen appropriately and change gloves;
-Ask resident to separate their legs and flex knees and wash the perineal area.
1. Review of Resident #42’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/11/19, showed:
-Severe cognitive impairment;
-No behaviors;
-Incontinent of bowel and bladder;
-Required total assistance from staff for transfers, dressing, hygiene and bathing.
Observation on 3/22/19 at 7:20 A.M., showed the resident lay in bed awake. Certified Nurse

Assistant (CNA) Q washed hands, put on gloves and provided the resident with care. CNA Q
removed a half full with urine plastic urinal from between the resident’s legs, wet a wash
cloth with water, applied body wash and shampoo to a cloth, cleaned the central area of
the genitals, from back to front with one swipe of the wash cloth, dried the area, covered
the resident, removed gloves and left the resident’s room. At 7:45 A.M., CNA Q returned to
the room with CNA F. Both CNAs washed hands and put on gloves. CNA F turned the resident
onto his/her right side, washed and dried the resident’s left hip, buttocks and rectal
area and turned the resident onto his/her left side. They washed and dried the resident’s
right hip and buttocks, placed a clean incontinence pad underneath the resident, turned
the resident onto his/her back, placed an empty urinal between his/her legs and covered
the resident. Both CNAs removed their soiled gloves, washed their hands and left the
resident’s room. Neither CNA washed the resident’s entire genital area, or rinsed the soap
off of the resident’s skin prior to leaving the room.
Review of the bottle of Soothe and Cool body wash and shampoo, showed to rinse the skin
thoroughly.
2. Review of Resident #37’s annual MDS, dated [DATE], showed:
-Cognitive status not assessed;
-No behaviors;
-Incontinent of bowel and bladder;
-Required total assistance from staff for transfers, dressing, hygiene and bathing.
Observation on 3/25/19 at 6:15 A.M., showed the resident lay in bed awake. CNA Z washed
hands, put on gloves and provided the resident with care. CNA Z filled a wash basin with
water, placed Smooth and Cool soap into the wash basin, causing the water to become
visibly soapy. CNA Z removed the resident’s urine and stool soiled adult incontinence
brief, turned the resident onto his/her left side, washed and dried the right hip and
rectal area, placed a clean incontinence brief on the resident, dressed and transferred
the resident into his/her wheelchair. He/she removed his/her soiled gloves, washed hands
and left the resident’s room. CNA Z did not wash the resident’s entire genital area, hips
or buttocks to ensure all of the urine and stool had been removed from the resident’s
skin, nor did he/she rinse the soap from the skin prior to dressing and transferring
him/her into the wheelchair.
3. Review of Resident #20’s annual MDS, dated [DATE], showed:
-Brief interview for mental status (BIMS) score of 6 out of 15, indicating severe
cognitive impairment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 25)
-Extensive assistance of one staff assist for bed mobility, locomotion on and off unit,
dressing and personal hygiene;
-Total dependence of two staff assist with transfers;
-Always incontinent of bowel and bladder;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s care plan, in use at the time of the survey, showed it did not
include incontinence of bowel and bladder as a problem or the associated
goals/interventions.
Observation on 3/25/19 at 7:00 A.M., showed CNA E and CNA F performed incontinence care
for the resident:
-The resident lay in bed on urine soaked sheets and chuck pads with his/her pants visibly
soaked with urine all the way up the resident’s back;
-CNA E removed the resident’s urine soaked brief, picked up a soapy washcloth and
proceeded to perform perineal care;
-CNA E did not rinse the soap from the resident’s skin or dry the skin;
-CNA E removed his/her gloves and donned new gloves without cleansing hands;
-CNA E put clean pants on the resident, picked the urine soaked brief off of the bed,
threw it in the trash, rolled the resident to his/her right side by placing his/her dirty
gloves on the resident’s bare legs and shoulders; and folded the urine soaked pad under
the resident;
-CNA E picked up a new soapy washcloth and with his/her dirty gloved hands, swiped the
resident’s buttocks. The CNA did not cleanse the resident’s rectum, back of thighs, or
lower back and hips where he/she was soaked with urine;
-CNA E did not rinse the soap off of the resident’s buttocks, nor dry the resident;
-CNA E threw the urine soaked brief in the trash, rolled the resident back on the
mattress, and put a clean brief on the resident as he/she wore the dirty gloves.
4. Review of Resident #320’s medical record, showed:
-Medical [DIAGNOSES REDACTED].
-A health status progress note dated 3/5/19 at 5:03 P.M., showed Incontinent of bowel and
bladder.
Review of the residents’ care plan, dated 3/7/19, showed it did not include the problem of
incontinence of bowel and bladder or the associated interventions.
Observation on 3/22/19 at 7:32 A.M., showed:
-The resident sat on the edge of his/her bed, naked, with a urine soaked brief on floor at
the resident’s feet, a visible puddle of urine on the resident’s bed and urine soaked
sheets and pads. A strong odor of urine in the room;
-CNA B entered the room with clean clothes and a brief. He/she washed his/her hands and
donned gloves;
-CNA B knelt down in front of the resident, pushed the urine soaked brief away with
his/her foot, put anti-slip socks on the resident, then the clean pants and a clean shirt;
-CNA B offered to put a brief on the resident and the resident refused;
-CNA B and Nurse C helped the resident to his/her feet, pulled up the resident’s pants and
transferred the resident to his/her wheelchair;
-CNA B did not cleanse the resident’s body of the wet urine.
5. During an interview on 3/26/19 at 2:19 P.M., the Director of Nursing (DON) said:
-Staff should cleanse their hands and don gloves before starting incontinence care, when
changing from a dirty to clean task, and after completion of incontinence care;
-Residents who are incontinent of urine should have all areas cleansed that were touched
by urine, including the inner thighs, backside, and abdominal folds;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 26)
-Staff should rinse off the soap from residents’ skin and dry the skin to prevent skin
breakdown;
-Staff are expected to cleanse the perineal area when performing incontinence care;
-Staff are expected to wipe urine away from the urethral passage.

F 0686

Level of harm – Actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with pressure ulcers receive necessary treatment and services, consistent with
professional standards of practice, to promote healing, prevent infection and prevent new
ulcers from developing. This resulted in one resident with a history of pressure ulcers
developing new stage III pressure ulcers and worsening of two stage II pressure ulcers
into an unstageable pressure ulcer when the facility failed to monitor the resident’s
skin, accurately assess and document wound observations, and obtain treatment orders
timely after staff reported to the nurse the resident had new open areas (Resident #267).
In addition, issues were identified with three additional residents who developed new
and/or worsening pressure ulcers when the facility failed to follow physician orders,
accurately assess and document wound observations, report new and deteriorating pressure
ulcers to the physician and use proper technique when treating wounds to prevent infection
(Residents #59, #33 and #116). The facility identified seven residents with pressure
ulcers and all seven were included in the sample of 20. The census was 96.
Review of the facility’s undated Measurement, Assessment of Pressure Ulcers, Wounds and
Other Skin Problems policy, showed:
-At first observation of any skin condition, the charge nurse or treatment nurse is
responsible to measure and describe skin condition in the clinical record;
-All measurements will be recorded in centimeters. All ulcers will be measured weekly and
results recorded;
-Identify the type of ulcer. The medical record should clearly support the clinical basis
for the determination of etiology (cause) of the ulcer;
-Identify the stage or extend of tissue destruction involved;
-Ulcer assessment:
-Obtain length, width and depth;
-Assess wound/skin condition for drainage and record type and amount;
-Assess for presence of necrotic (dead) tissue;
-Assess for presence of granulation tissue (new tissue growth);
-Assess the periwound (skin surrounding the wound) and wound edges;
-Assess odor and pain;
-Describe any problems with adherence to treatment of [REDACTED]. Example: Refuses
treatment or to relieve pressure.
1. Review of Resident #267’s medical record, showed:
-[DIAGNOSES REDACTED].
-A Braden assessment (used for predicting pressure ulcer (injury to the skin and/or
underlying tissue, as a result of pressure or friction) risk), dated 3/4/19, showed a
score of 17, which indicated the resident at risk for pressure ulcers;
-A Braden assessment dated [DATE], showed a score of 14, which indicated the resident at

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 27)
moderate risk for pressure ulcers.
Review of the resident’s care plan, dated 12/1/18 and reviewed on 1/8/19, showed:
-Problem dated 3/8/19: readmitted with left gluteal (buttocks) proximal (situated closer
to the center of the body) and distal (situated further from the center of the body) wound
at a stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with
a red-pink wound bed without slough, may also present as an intact or open/ruptured
blister). Updated 3/18/19, left gluteal fold wounds merged to unable to stage (unstageable
pressure ulcer, obscured full-thickness skin and tissue loss), coccyx (tail bone area)
proximal and distal stage II, right gluteal stage III (full thickness tissue loss,
subcutaneous fat may be visible but the bone, tendon or muscle is not exposed), and
scrotum stage II:
-Goal: The resident’s pressure ulcer will show signs of healing and remain free from
infection;
-Interventions: Assess/record/monitor wound healing. Measure length, width and depth
where possible. Assess and document status of wound perimeter, wound bed and healing
progress. Report improvements and declines to the physician. Updated 3/18/19, low air loss
mattress, consult wound management, heel protectors when in bed;
-Problem: The resident has limited physical mobility related to contractures (a condition
of shortening and hardening of muscles, tendons, or other tissue, often leading to
deformity and rigidity of joints):
-Goal: The resident will remain free of complications related to immobility, including
contractures, thrombus (blood clot) formation, skin-breakdown, fall related injury.
Review of the resident’s care card, located in the resident’s room and updated on 3/11/19,
showed:
-Toileting: Incontinent, needs help with changing;
-Mobility: Assist to bed/chair with one person assist;
-Skin integrity: Preventative care;
-Pressure ulcers: Blank.
Review of the resident’s progress notes, showed:
-On 3/4/19 at 7:46 P.M., Skin/Wound Note: Resident readmitted to the facility on [DATE].
Resident has two open areas to the left gluteal fold (also referred to the ischium, the
back lower portion of the hip, on which the body rests when sitting):
-Area one measures 2.2 centimeters (cm) by 3.4 cm (length by width), 100% pink, minimum
drainage noted, periwound (the tissue surrounding the wound) intact;
-Area two measures 1 cm by 1 cm, 100% pink, scant (small amount) drainage noted,
periwound intact;
-New order for Duoderm (a sterile occlusive dressing) every three days until healed;
-On 3/8/19 at 4:46 P.M., Skin/Wound Note:
-Left gluteal proximal: 2.2 cm by 3.4 cm, 100% pink, minimal drainage noted, periwound
intact, Duoderm every three days;
-Left gluteal distal: 1 cm by 1 cm, 100% pink, scant amount of drainage noted, periwound
intact Duoderm every three days until healed;
-On 3/14/19 at 5:05 P.M., Skin/Wound Note:
-Left gluteal proximal: 2.8 cm by 3.6 cm, 100% pink, minimal drainage noted, periwound
intact, Duoderm every three days;
-Left gluteal distal: 1.2 cm by 1 cm, 100% pink, scant amount of drainage noted,
periwound intact Duoderm every three days until healed;
-On 3/15/19 11:02 P.M., Skin/Wound Note: This writer was notified of and open area located
on the right gluteal area near the fold. Resident denies pain at this present time.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 28)
Resident is incontinent of bowel and bladder, and alert with a disorganized thought
process. On coming charge nurse will be notified of area and treatment nurse will be made
aware of this occurrence for a treatment order to be in place to heal area. Resident is
currently resting in bed positioned on his side for pressure relief;
-On 3/16/19 at 7:41 A.M., responsible party made aware of the resident’s three areas to
both buttocks;
-On 3/17/19 at 3:55 A.M., resident continues on monitoring related to multiple areas to
left buttocks. Dressings remain intact. Pain management medications administered as
scheduled with effectiveness;
-On 3/18/19 at 3:59 P.M., Skin/Wound Note:
-Resident has an unstageable area to the left gluteal fold. Area had two areas that have
now merged to make one area. Left gluteal fold measures 4 cm by 5.5 cm by 0.3 cm (length
by width by depth), wound bed with dark colored slough (moist dead tissue), periwound
pink, moderate serous (clear) drainage noted. treatment of [REDACTED]. No odor present;
-Coccyx has a small stage II, measures 1 cm by 0.5 cm, 100% pink tissue with scant serous
drainage;
-Coccyx distal measures 4 cm by 2 cm, scant drainage, 100% pink tissue. treatment of
[REDACTED].
-Right gluteal stage III, measures 2 cm by 4.5 cm by 0.2 cm, 50% pink, 50% [MEDICATION
NAME] (a tough protein substance that is found in blood plasma. When tissue damage results
in bleeding, [MEDICATION NAME] is converted at the wound into [MEDICATION NAME]), moderate
serous drainage, periwound intact, no odor present. treatment of [REDACTED].
-Scrotum has a stage II present, measures 1.5 cm by 1 cm, 100% pink, scant drainage
noted. Treatment: apply Santyl and leave open to air;
-New orders noted for all open areas, low air loss mattress (LAL) ordered today, heel
protectors to heels when in bed. Orders for Wound Management;
-On 3/19/19 at 1:20 P.M., Health Status Note: Physician here visiting and saw resident.
New order, may have indwelling urinary catheter (a sterile tube inserted into the bladder
to drain urine) till wounds heal;
-On 3/22/19 2:25 P.M, Skin/Wound Note:
-Right Ischial (gluteal): 3.5 cm by 1.5 cm by 0.2 cm, 100% [MEDICATION NAME], moderate
serous drainage, periwound intact, Silver alginate (dressing, works by stopping the growth
of bacteria that may infect an open wound), Santyl, 4×4 gauze, tape, daily;
-Left Ischial (gluteal): 5 cm by 3 cm by 0.3 cm, 100% [MEDICATION NAME], moderate serous
drainage, periwound intact, silver alginate, Santyl, 4×4, tape, daily.
-Coccyx: 5.5 cm by 1 cm by 0.1 cm, moderate serous drainage, periwound intact, silver
alginate, Santyl, 4×4, tape, daily;
-(No documentation of the coccyx proximal wound or scrotal wound).
Review of the facility’s wound reports, showed the following for the resident:
-March 3/2/19 through 3/8/19:
-Left gluteal proximal stage II measured 2.2 cm by 3.4 cm, 100% pink, no drainage,
facility acquired on 3/4/19, Duoderm every three days;
-Left gluteal distal stage II measured 1 cm by 1 cm, 100% pink, no drainage, periwound
intact, facility acquired on 3/4/19, Duoderm every three days;
-March 3/9/19 through 3/15/19:
-Left gluteal proximal stage II measured 2.8 cm by 3.6 cm, 100% pink, no drainage,
periwound intact, facility acquired on 3/4/19;
-Left gluteal distal state II measured 1.2 cm by 1 cm, 100% pink, no drainage, periwound
intact, facility acquired on 3/4/19, Duoderm every three days;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 29)
-March 3/16/19 through 3/22/19:
-Right ischial (gluteal) stage III measured 3.5 cm by 1.5 cm by 0.2 cm, 100% [MEDICATION
NAME], moderate serous drainage, periwound intact, facility acquired on 3/19/19, silver
alginate, Santyl, 4×4, tape daily;
-Left ischial stage III measured 5 cm by 3 cm by 0.3 cm, 100% [MEDICATION NAME], moderate
serous drainage, periwound intact, facility acquired on 3/19/19, silver alginate, Santy,
4×4, tape daily;
-Coccyx stage III measured 5.5 cm by 1 cm by 0.1 cm, 100% [MEDICATION NAME], moderate
serous drainage, periwound intact, facility acquired on 3/19/19, silver alginate, Santyl,
4×4, tape daily;
-(No documentation of the coccyx distal wound or scrotal wound).
Review of the resident’s handwritten and undated physician order [REDACTED].
-An order dated 3/16/19, to apply Duoderm to right gluteal fold every three days and as
needed;
-An order dated 3/18/19:
-Left gluteal fold Santyl, normal saline, calcium alginate, dry dressing and tape daily;
-Right gluteal fold Santyl, normal saline, calcium alginate, dry dressing, and tape
daily;
-Coccyx proximal and distal Santyl, normal saline, dry dressing daily;
-Low air loss mattress;
-Consult for wound management;
-An order dated 3/19/19, may insert 14 French (size) 10 milliliters (ml) indwelling
urinary catheter till wound heals.
During an interview on 3/27/19 at 10:21 A.M., Nurse K said nurses do skin assessments
based on the schedule and the treatment nurse completes his/her own assessments on
residents with major wounds.
Review of the facility’s 400/500 hall skin assessment schedule, showed:
-The resident’s room scheduled to have skin assessments completed on Tuesdays, day shift;
-All skin assessments are to be completed by the end of the shift;
-All skin must be seen by a licensed nurse and documented.
Review of the facility’s undated skin assessment policy, located at the nurse’s station on
400/500, showed:
-Licensed nurse weekly skin assessment: All residents should have their skin assessed
weekly by a licensed nurse. The skin assessment schedule encourages continuity in the
required documentation;
-Certified Nursing Assistant (CNA) shower assessments: This assessment recognizes the
important role CNAs play in pressure ulcer prevention and empowers them to do a regular
skin check. It provides a formal method of communication to the licensed nurse of their
review of resident’s skin which then would be followed up by the licensed staff.
Review of the resident’s Licensed Nurses Weekly Skin Assessment forms, from 1/1/19 through
3/26/19, showed only three assessments completed:
-Dated 2/21/19: Any open ulcers: Not indicated yes or no;
-Dated 3/14/19: Any open ulcers: Yes, Duoderm every three days until healed. Documentation
on the picture of the human body, showed the wound located to the left outer hip/buttocks
area;
-Dated 3/21/19: Any open ulcers: Yes. Documentation on the picture of the human body,
showed a small circle to the left side of the coccyx area, mid left and mid right
buttocks. No documentation on the left gluteal, right gluteal and/or scrotum.
Review of the resident’s Skin Monitoring: Comprehensive CNA Shower Review sheet, from
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 30)
1/1/19 through 3/26/19, showed only two forms completed:
-Dated 1/16/19, showed no open areas;
-Dated 2/27/19, showed the resident at the hospital.
Observation on 3/26/19 at 11:50 A.M., showed the Assistant Director of Nursing (ADON)
obtained the treatment cart and entered the resident’s room. She obtained supplies to
change the resident’s dressing with the treatment administration record (TAR) located on
the treatment cart and open for the ADON to review as she completed the treatments. As the
ADON gathered supplies, CNA P assisted the resident to turn to the left side. The resident
had a wound located to the left ischium (gluteal) with no dressing. The wound appeared to
have depth. The center most, deep part of the wound bed with a white color. A serous
drainage ring visible on the bed pad under the resident. Yellow moist tissue visible in
the wound bed. A dressing located to the coccyx intact. A small open area on the posterior
side of the scrotum with several smaller areas in the surrounding tissue. The CNA assisted
the resident to the far left side and exposed the left ischial (gluteal) wound with no
dressing. The wound bed black and the black tissue pulled away from the wound edge on one
side as CNA P pulled on the resident’s right hip and exposed depth to the wound and
yellow/tan tissue. There were no loose dressings located in the bed or on the pad from the
left and right ischial (gluteal) wounds. The ADON removed the dressing to the coccyx and
exposed two open areas, one distal and one proximal, both the approximate size of a dime
with pink wound beds. The ADON applied the ordered treatment to each wound.
During an interview on 3/26/19 at 12:22 P.M., the ADON said the wound nurse stages the
wounds, but he/she believed the left ischium is unstageable. This wound appeared to be
deteriorating and it looked like it was separating from the wound edge. All of the other
wounds appeared to be improving. The coccyx wounds, she believed to be stage II and the
right ischium a stage III. The small areas to the scrotum were healing well. The last time
she observed the wound was approximately a week earlier. She was not sure why the dressing
was off the left and right ischium (gluteal) when she went in the room to do the
treatment. She was told by the CNA about an hour prior to the treatment that the resident
had to be cleaned, but he/she did not say the treatment came off. If it did, she would
expect the CNA to tell the nurse.
During an interview on 3/26/19 at 12:30 P.M., CNA P said he/she is the CNA assigned to
care for the resident. He/she changed the resident at approximately 10:45 A.M. and he/she
thought the treatments were on at that time. He/she did not remove them and they did not
fall off during care.
During an interview on 3/26/19 at 12:39 P.M., Nurse K said he/she is the nurse assigned to
care for the resident. He/she did not remove the dressings. He/she believed that sometimes
the resident removes them and throws them beside the bed. Observation at this time, with
CNA P and Nurse K, showed no dressings on the floor. CNA P and Nurse K verified the
dressings were not on the floor.
During an interview on 3/27/19 at 10:42 A.M., with the Director of Nursing (DON) and
administrator, the DON said skin assessments are completed weekly and during showers by
CNAs. Nurses complete the licensed nurse weekly skin assessment and CNAs complete the
shower sheets. If new areas are identified; the nurse should call the physician to obtain
orders, asses the wound and document. They then communicate the new area to the wound
nurse so she can follow up. Any nurse can and should get orders for a treatment. It is not
appropriate to wait three days to obtain treatment orders and assess the wound. She was
not sure what preventative measure were in place prior to the development of the new
wounds. The LAL was not ordered until after the new wounds were identified. At 1:47 P.M.,
the DON said it was the responsibility of the wound nurse to review and track the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 31)
completion of weekly skin assessments and the shower sheets. These were not being done for
the resident. The licensed nurse weekly skin assessments and shower sheets that were
provided were the only ones available for the resident from 1/1/19 through current
(3/27/19).
2. Review of Resident #59’s Annual Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 12/19/18, showed:
-Short and long term memory issues;
-Locomotion on and off the unit did not occur;
-Total dependence with two person assist required for bed mobility, transfers, eating and
personal hygiene;
-Incontinent of bladder and bowel;
-Impairment on one side for upper body and lower body;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 2/21/19 and updated on 3/15/19, showed:
-Problem: Remains at risk for pressure areas and skin breakdown related to Stage II to
coccyx and healed pressure areas. On 3/15/19, Right elbow healed, open blister to right
inner thigh and left lower leg left open to air;
-Goal: The resident’s pressure ulcer will show signs of healing and remain free from
infection;
-Interventions: Administer treatments as ordered and monitor for effectiveness; Follow
facility policies/protocols for the prevention/treatment of [REDACTED].
Review of the resident’s electronic medical record skin and wound progress notes, reviewed
on 3/26/19 at 3:46 P.M., showed:
-On 3/14/19 at 4:49 P.M.:
-Right inner thigh: measured 2.5 cm by 4 cm, dark colored area, slightly raised, no
drainage, skin intact, left open to air;
-On 3/21/19 at 4:42 P.M.:
-Right hip proximal: measured 0.8 cm by 0.5 cm by 0.1 cm, 100% pink, no drainage,
periwound intact, border gauze daily;
-Right hip distal measured 1.2 cm by 0.8 cm by 0.1 cm, 100% pink, no drainage, periwound
intact, border gauze daily;
-Left medial leg measured 3.0 cm by 2.4 cm by 0.1 cm, 100% pink, no drainage, periwound
intact, border gauze daily;
-Right medial thigh: 3.0 cm x 2.0 cm x 0.1 cm, 100% pink, no drainage, periwound intact,
border gauze daily.
Review of the resident’s POS, dated (MONTH) 2019 and reviewed on 3/22/19 and 3/25/19,
showed:
-Treatment order dated 11/28/18, Off load area every shift;
-(No treatment orders for the resident’s right hip distal and proximal stage II pressure
ulcers, left medial leg Stage II or right medial thigh Stage II).
Review of the facility’s wound reports, dated (MONTH) 3/16/19 through 3/22/19, showed the
following for the resident:
-Right hip proximal stage II measured 0.8 cm by 0.5 cm by 0.1 cm, 100% pink, minimal
drainage, periwound intact, facility acquired on 3/19/19, border gauze daily;
-Right hip distal stage II measured 1.2 cm by 0.5 cm by 0.1 cm, 100% pink, minimal
drainage, periwound intact, facility acquired on 3/19/19, border gauze daily;
-No documentation of the resident’s left medical leg stage II and right medical thigh
stage II.
Review the resident’s wound clinic wound assessment sheet, dated 3/19/19 at 1:15 P.M.,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 32)
showed:
-Right hip wound proximal measured 0.8 cm by 0.5 cm by 0.1 cm, 100% pink, moderate serous
drainage noted, periwound intact;
-Right hip wound distal measured 1.2 cm by 0.8 cm by 0.1 cm, 100% pink, moderate serous
drainage, periwound intact;
-Left medial leg measured 3.0 cm by 2.4 cm by 0.1 cm, 100% pink, small/moderate serous
drainage, periwound intact;
-Right medial thigh measured 3.0 cm by 2.0 cm by 0.1 cm, 100% pink, small/moderate serous
drainage, periwound intact;
-Treatment ordered (All wounds unless specified): Apply Kerramax border gauze dressing
(super absorbent wound dressing with a soft flexible heat-sealed border) to hip area,
change daily and to inner thigh/medical leg wounds;
-Pillow between legs;
-Off loading, turn schedule.
Observation on 3/22/19 at 7:55 A.M., showed the wound nurse performed wound care for the
resident:
-The TAR on the treatment cart, opened and the wound nurse verified the following orders
listed for the resident:
-Right hip proximal and distal, border gauze every day;
-Right medial thigh, border gauze daily;
-Left medial leg, border gauze daily;
-All three orders dated 3/21/19;
-He/she obtained supplies from the cart, took them into the resident’s room, placed them
on the window sill and went to the sink to wash hands and don gloves;
-He/she removed the pillow from between the resident’s legs, set up a barrier cloth on the
resident’s bed, removed his/her gloves, washed hands at the sink and donned new gloves;
-He/she moved the supplies from the window sill, placed them on the barrier, proceeded to
tear open three gauze sponges and three border gauze dressings;
-He/she removed the resident’s brief, exposing the right hip, took off the dirty undated
dressing and touched the wound bases with his/her right gloved hand. He/she said the wound
consisted of two small areas that are Stage II, 100% pink, scant drainage, periwound
intact;
-Without changing gloves, he/she removed the left medial leg and right medial thigh
bandages, touched both wound bases with the same right gloved hand and described them as:
-Left medial leg, Stage II with 10% slough and 60% necrotic tissue in the center of the
wound, moderate drainage, periwound intact;
-Right medial thigh, Stage II with pink tissue, 10% light yellow slough in the center of
the wound, scant drainage, periwound intact;
-He/she washed his/her hands and donned new gloves;
-He/she measured the residents wounds with the same paper wound measurement tape by
placing the tape inside each wound bed. He/she used the same pair of gloves for all four
of the following wound measurements:
-Right distal hip, Stage II measured 1.0 cm by 0.7 cm;
-Right proximal, stage II measured 0.3 cm by 0.2 cm;
-Left medial leg, Stage II measured 2.8 cm by 2.4 cm;
-Right medial thigh, Stage II measured 2.0 cm by 2.5 cm;
-The wound nurse left the resident on the dirty bed sheets, with his/her right and left
legs rubbing against each other with no dressing to cover the wounds, walked to the
bedroom sink, washed his/her hands and donned new gloves;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 33)
-Without cleansing the wound, he/she took a border gauze dressing and placed it directly
on the resident’s right hip Stage II pressure ulcers;
-Without changing gloves or cleansing the wound, he/she placed a border gauze dressing on
the right medial thigh Stage II pressure ulcer;
– Without changing gloves or cleansing the wound, he/she placed a border gauze dressing on
the left medial leg Stage II pressure ulcer.
Observation on 3/25/19 at 11:30 A.M., showed the resident lay in bed on his/her back with
the right medial thigh without a dressing applied. At 11:35 A.M., the wound nurse
performed wound care for the resident:
-She entered the resident’s room with treatment supplies from the treatment cart,
including a communal bottle of wound cleanser. She placed the supplies on the window sill,
without a barrier;
-She cleansed her hands and donned gloves;
-She examined the resident’s right medial thigh Stage II, touched the wound base with her
right gloved hand and described it as rough, scabbed, dry, 95% yellow, greenish circle in
the middle of the wound, surrounded by pink tissue and has two new small Stage II areas
located above the existing wound, approximately 1 cm wide;
-Without changing gloves, she removed the dirty bandage from the resident’s left medial
leg Stage II, touched the wound base with the same gloved hand and described it as 75%
necrotic tissue, some yellow tissue in the center of the wound surrounded by pink tissue
with bloody scant drainage;
-Without changing gloves, she exposed the resident’s right hip by pulling down the
resident’s brief. There was not a dressing on the right hip or in the brief. The wound
nurse used the same gloved finger and rubbed it over the two wounds on the right hip and
stated the Stage II wounds were healed, with no drainage. (Both the right hip distal and
proximal Stage II wounds presented with bright pink, shiny tissue);
-The wound nurse proceeded to cleanse the wounds by using the communal bottle of wound
cleanser off of the window sill, spraying 4 by 4 gauze sponges with the solution and then
placing the wound cleanser back on the window sill;
-After the wound nurse completed the wound treatments for the residents, she took the
communal wound cleanser bottle off of the window sill and placed it back on the treatment
cart.
Observation on 3/27/19 at 8:15 A.M., showed the resident lay in bed on his/her right side
with a pillow placed between the knees and a dirty, used silicone border dressing wadded
up on the bed near the resident’s legs. The left medial leg Stage II covered with a border
gauze dressing dated 3/26/19, saturated with red, brown drainage. The dressing half off of
the wound. Unable to see right medial thigh wound due to the position of the resident.
During an interview on 3/26/19 at 2:19 P.M., the DON said:
-The wound nurse is expected to recognize slough and necrotic tissue in a wound bed and to
cleanse a wound before applying a new dressing due to infection control;
-The wound nurse is expected to change gloves before the treatment begins, from a dirty to
clean task, to perform hand hygiene every time gloves are removed and should treat each
wound separately;
-It is not acceptable to touch the wound base of several different wounds with the same
dirty gloved hand or to use the same wound measurement tape to measure several different
wounds;
-It is important to maintain sterile technique to avoid cross contamination between
wounds, to prevent further compromising the resident;
-It is not appropriate to use communal items such as wound cleanser, normal saline, or a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 34)
box of gloves without putting the items on a clean barrier in the resident’s room due to
infection control.
3. Review of Resident #33’s POS, dated 3/1/19 through 3/31/19, showed:
-[DIAGNOSES REDACTED].
-An order dated 10/10/18, to cleanse the wound on the top left foot and apply [MEDICATION
NAME] (antiseptic used for skin disinfection), 4×4 gauze and Kling (gauze wrap) once a
day;
-An order dated 1/28/19, to apply Santyl to the left outer foot wound (no frequency
noted);
-No further pressure ulcer treatment orders found as late as 3/25/19 at 12:20 P.M.
Review of the resident’s care plan, in use during the survey, showed:
-Problem: Resident has high risk for pressure ulcer development;
-On 10/17/18 – readmitted with a Stage I (an observable, pressure-related alteration of
intact skin) pressure ulcer on top of left foot;
-On 2/22/19 – Left dorsal (upper side) foot – Stage II. Left lateral (outer side) foot
and left plantar (bottom/heel area) foot – unstageable pressure ulcers;
-On 3/8/19 – All wounds remain;
-On 3/15/19 – Resident is non-compliant with wound care, refuses treatments;
-Goal: Will have intact skin, free of redness, blisters or discoloration;
-Interventions included: Administer treatments as ordered. If resident refuses treatment,
have another nurse attempt treatments. Follow facility policies/protocols for the
prevention/treatment of [REDACTED].
Observation on 3/25/19 at 10:15 A.M., showed the resident lay in bed awake. The wound
nurse took equipment into the resident’s room, washed hands, put on gloves, removed the
dressing dated 3/24/19, from the resident’s wound on the left lateral foot, the left
dorsal foot and left planter area of the left foot. The wound nurse changed gloves,
cleaned each area individually with wound cleanser, applied wet with normal saline 4 by 4
gauze, dry 4 by 4 gauze to each area individually, wrapped the entire foot with
[MEDICATION NAME] gauze, secured with tape, removed gloves, washed hands and left the
resident’s room.
Review of the resident’s TARs, dated 3/1/19 through 3/31/19, showed an order dated 3/5/19,
to cleanse all the areas with wound cleanser, apply a wet to dry dressing and wrap with
[MEDICATION NAME] daily.
During an interview on 3/25/19 at 12:20 P.M., the DON verified there was no order for
staff to clean the areas with wound cleanser, apply a wet to dry dressing and wrap with
[MEDICATION NAME] once a day, on the POS. She would expect staff to obtain an order to
discontinue the previous order and write the current order on the POS and TARs. She
thought the resident had been seen by the specialized wound management company earlier in
the month, they may have changed the treatment orders, but she would expect staff to write
the new orders on the POS and discontinue the old orders, no longer in use. She could not
find any documentation of the resident being seen in March, 2019 by the wound management
company, in the resident’s medical record.
4. Review of Resident #116’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED]. Slough or eschar may be present on some parts of the wound bed.
Often includes undermining and tunneling) pressure ulcer of the sacrum (tailbone area);
-Severe cognitive impairment with short and long term memory problems;
-One Stage III pressure ulcer and two unstageable pressure ulcers;
-Incontinent of bowel and bladder;
-Required total assistance from the staff for transfers, dressing, hygiene and bathing.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0686

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 35)
Review of the resident’s care plan, dated 8/9/18, updated on 11/16/18 and in use during
the survey, showed:
-Problem: Pressure ulcer to the coccyx or potential for pressure ulcer development related
to immobility;
-On 2/22/19 – Coccyx Stage III healing well;
-On 3/8/19 – Coccyx Stage III remains;
-Goal: Pressure ulcer will show signs of healing and remain free from infection. Resident
will have intact skin, free of redness, blisters or discoloration;
-Interventions included: Administer treatments as ordered and monitor for effectiveness.
Monitor dressing during care to ensure it is intact and adhering. Report lose dressing to
treatment nurse.
Review of the resident’s TAR, dated 3/1/19 through 3/31/19, showed an order dated 12/26/18
to apply Santyl, 4 by 4 gauze, ABD (fluffy, surgical dressing) and secure with tape every
day.
Observation and interview on 3/25/19 at 6:10 A.M., showed the resident lay in bed, awake.
CNA Z unfastened the resident’s adult incontinence brief, turned him/her onto his/her side
and revealed a large pressure ulcer on the coccyx. No dressing covered the pressure ulcer,
or was found in the brief, bed or floor. CNA Z said he/ (TRUNCATED)

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with an indwelling urinary catheter (a tube inserted into the bladder for the purpose of
continual urine drainage), received the appropriate care and services to prevent urinary
tract infections to the extent possible by failing to maintain proper placement of
indwelling urinary catheter tubing and obtain orders for catheter use. The facility
identified four residents as having indwelling urinary catheters. Three of those were
chosen for the sample. Of those three, problems were found with one (Resident #10). The
sample was 20. The census was 96.
Review of the Resident #10’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 2/13/19, showed:
-Focus: Resident has suprapubic catheter (a sterile tube inserted into the bladder through
the abdominal wall to drain urine), and [MEDICAL CONDITION] bladder (the bladder does not
empty properly due to a neurological condition);
-Approach:
-Monthly and as needed (PRN), urologist comes to the facility to change catheter;
-Check tubing for kinks each shift;
-Monitor for signs and symptoms of discomfort on urination and frequency;
-Monitor/record/report to MD for signs and symptoms of urinary tract infection: pain,
burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased
pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills,
altered mental status, change in behavior, change in eating patterns;
-Focus: Resident has a urinary tract infection [MEDICAL CONDITION] related suprapubic
catheter and recurrent UTIs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
-Approach:
-Encourage adequate fluid intake;
-Give antibiotic therapy as ordered. Monitor/document for side effects and effectiveness;
-Monitor vital signs every shift. Notify physician of significant abnormalities;
-Obtain and monitor lab/diagnostic work as ordered. Report results to physician and
follow up as indicated.
Review of the resident’s physician order [REDACTED].
Review of the resident’s treatment administration record (TAR), dated 2/1/19 through
2/28/19, showed no order to change supra pubic catheter monthly by urologist and as
needed.
Review of the resident’s progress notes, dated 3/25/19, showed the resident remains in bed
and is afebrile (no elevated temperature). Suprapubic catheter in place, patent and
draining sufficient urine. Urine is observed dark in color with and odor.
Observations on of the resident, showed:
-On 3/21/19 at 9:56 A.M., the resident lay in bed with the catheter on the right side of
the bed, below the bladder. The catheter tubing looped upward. The resident did not have a
privacy drainage bag. There was approximately 600 cubic centimeters (cc) of urine in the
bag. At 12:55 P.M., the catheter tubing was looped upward with approximately 18 inches of
yellow urine that did not drain into the bag. There was 4 inches of sediment inside the
catheter tube. The edges of the drainage bag turned a reddish color;
-On 3/22/19 at 12:03 P.M., the resident lay in bed with the catheter on the right side of
the bed, below the bladder. The catheter tubing looped upward, with yellow urine and
approximately 18 inches of sediment throughout the inside of the tube. There was
approximately 200 cc of urine inside the drainage bag. The edges of the drainage bag
reddish in color;
-On 3/25/19 at 12:00 P.M., the resident lay in bed with the catheter on the right side of
the bed, below the bladder. Approximately 18 inches of cloudy urine inside the catheter
tube that did not drain into the bag. Approximately 600 cc of urine inside the drainage
bag. At 5:55 P.M., the resident lay in bed. The catheter on the right side of the bed,
below the bladder. The catheter tubing was looped upward with yellow, cloudy urine inside
the tube. Approximately 1200 cc of urine inside the resident’s drainage bag;
-On 3/26/19 at 7:01 A.M., the resident said staff recently emptied his/her drainage bag.
Observation, showed the catheter tubing coiled with dried, yellow chunks inside the
tubing. Two, 6 inch areas contained the dried substance. Approximately 100 cc of yellow
urine in the bag;
-On 3/26/19 at 2:16 P.M., the resident lay in bed. The catheter tubing looped upward with
yellow urine inside the tube. Approximately 6 inches of urine in the tube that did not
drain.
During an interview on 3/26/19 at 7:28 A.M., Nurse AA said catheter care is a two party
system. The aides provide the cleaning and empty the bag, but the nurses ensure it is
completed and the catheter is clean.
During an interview on 3/26/19 at 2:15 P.M., Certified Nurse’s Aide (CNA) L said all aides
and nurses provide catheter care.
Observation on 3/26/19 at 12:13 P.M., showed the resident lay in bed. The catheter on the
right side of the bed, below the bladder. The catheter tubing looped upward with dried
sediment inside the catheter tube. The Director of Nursing (DON) confirmed the sediment
inside the catheter tubing. The DON adjusted the tubing and began to loop it around twice
and clip it to the resident’s sheet, parallel to the resident’s waist. Urine flowed
towards the bladder. The DON was asked if the tubing should be above or below the bladder.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
The DON said below the bladder and unclipped the tube from the resident’s sheet and
adjusted it. She clipped the tubing to the bed frame, below the resident’s bladder. The
DON confirmed there was dried, white substance on the outside of the drainage bag and a
dried, yellow substance on the tube that connected the catheter and the drainage bag. The
DON confirmed the reddish tint on the edges of the drainage bag were outside of the
drainage bag. The DON said she saw that on other resident’s drainage bags, but she was
unsure what caused it. She would expect staff to notify her and the urologist to assess
why the bag turned red.
Review of the facility’s undated catheter care policy, showed no direction for staff to
change the catheter tubing and/or appropriate positioning of the catheter tubing and
drainage bag.
During an interview on 3/27/19 at 10:30 A.M., the DON said she would expect the catheter
tubing to be a straight line from the resident’s bladder, below the bladder due to
infection control. The drainage bag should be in a privacy bag or cover. She would also
expect the catheter policy to address the positioning of the catheter.

F 0695

Level of harm – Actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide
necessary respiratory care and services consistent with professional standards of practice
by not following physician orders for oxygen therapy, failing to provide ongoing
assessment and documentation of the resident’s respiratory status and response to oxygen
therapy and failing to care plan interventions for oxygen therapy. As a result, the
resident experienced acute on chronic [MEDICAL CONDITION] (inability to breathe) which
required re-hospitalization , for one resident (Resident #320). In addition, the facility
failed to obtain orders for oxygen usage for one resident (Resident #63). The sample was
20. The census was 96.
1. Review of the Resident #320’s hospital records, dated 3/5/19, showed:
-Hospital admitted [DATE];
-Resident was wheelchair bound and oxygen dependent and was found by nursing home staff
unresponsive, lying on the floor without supplemental oxygen. The resident’s blood oxygen
saturation rate was 77% on room air. Emergency personnel were called for transport to
emergency room ;
-On arrival at emergency room , the resident was intubated (insertion of a tube through
the mouth into the airway) and placed on mechanical ventilation (a machine that helps a
person breathe when they cannot breathe on their own).
Review of the resident’s hospital discharge orders, dated 3/5/19, showed:
-Discharge [DIAGNOSES REDACTED].>-Oxygen Saturation (percentage of oxygen in the
blood), check as needed for respiratory distress (difficulty breathing) or change in
condition per nurse assessment;
-Oxygen instructions: Oxygen at 3 Liters (L) per minute by nasal cannula (a devise for
delivering oxygen by way of two small tubes that are inserted into the nares)
continuously.
Review of the resident’s facility medical record, showed:
-Readmission date of [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 38)
-Medical [DIAGNOSES REDACTED].
-Social service progress note, dated 3/6/19 at 12:35 P.M., showed the resident:
-Alert and oriented times two (able to recall person and place), with some confusion and
forgetfulness;
-Required limited assistance of one to two staff for transfers and assistance of one
person for activities of daily living (ADLs; bathing, toileting, dressing, etc.);
-Propelled self by wheelchair;
-A Health status progress note, dated 3/5/19 at 5:03 P.M., showed:
-Resident admitted to the facility from the hospital;
-Oxygen at 2-3L per minute per nasal cannula;
-A physician order sheet (POS), dated (MONTH) 2019, showed no order for oxygen therapy
and/or to check the resident’s oxygen saturation as needed for respiratory distress or
change in condition per nurse assessment.
Review of the resident’s physician visit note, dated 3/12/19, showed:
-Exam: Not awake, lethargic (lack of energy, sluggish), disorientation, labored breathing
and a decrease of breath sounds heard;
-Order: Acute on chronic hypoxic [MEDICAL CONDITION] with [MEDICAL CONDITION] ([MEDICAL
CONDITION] brain disease), probably hypercarbic carbon [MEDICATION NAME] narcosis
(elevated levels of carbon [MEDICATION NAME] in the blood, causing organ damage). Send
back to hospital for continuous positive airway pressure ([MEDICAL CONDITION])/bi-level
positive airway pressure ([MEDICAL CONDITION]) ([MEDICAL CONDITION] and [MEDICAL
CONDITION] are devices that deliver pressurized air to expand the lungs and assist with
breathing) with oxygen.
Further review of the resident’s POS, showed an order dated 3/12/19, to send the resident
back to the hospital emergency room for acute on chronic hypoxic [MEDICAL CONDITION].
Review of the resident’s progress notes, showed no documentation a nurse assessed the
resident, obtained an oxygen saturation level, or documentation of the resident’s
condition upon transfer to the hospital.
Review of ambulance transport report, dated 3/12/19, showed:
-Resident returning from the hospital to the facility;
-Resident on 3L of oxygen via nasal cannula.
Review of the resident’s progress notes, showed no documentation a nurse assessed the
resident, obtained an oxygen saturation level, or documentation of the resident’s
condition upon return from the hospital.
Further review of the resident’s POS, reviewed on 3/22/19 at 2:05 P.M. and on 3/25/19 at
2:45 P.M., showed no orders for oxygen therapy and/or to check the resident’s oxygen
saturation level.
Review of the resident’s (MONTH) 2019 medication administration record (MAR) and treatment
administration record (TAR), reviewed on 3/22/19 at 2:10 P.M. and on 3/25/19 at 2:50 P.M.,
showed no documentation of the administration of oxygen therapy or oxygen saturation tests
for the resident.
Review of the resident’s care plan, dated 3/7/19 and reviewed on 3/25/19 at 3:34 P.M.,
showed no documented [DIAGNOSES REDACTED].
Observations on 3/21/19, showed:
-At 10:45 A.M., the resident sat in a wheelchair in his/her room. The resident’s chin to
his/her chest and his/her body slumped over the right side of the wheelchair. His/her
right arm dangled down to the wheelbase. He/she rammed the wheelchair into the wall. An
oxygen concentrator unit located alongside the resident’s bed and an empty oxygen tank
attached to the back of the resident’s wheelchair. The resident wore the nasal cannula
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 39)
connected to the empty oxygen tank;
-At 11:01 A.M., the resident used his/her left arm to propel him/herself around his/her
bedroom. The resident’s chin rested on his/her chest and his/her body slumped over the
right side of the wheelchair. The resident’s right arm dangled down to the wheelbase. An
empty oxygen tank attached to the back of his/her wheelchair and the resident wore a nasal
cannula connected to the empty oxygen tank;
-At 11:53 A.M., the resident in his/her room, slumped all the way over onto the right side
of his/her wheelchair. His/her right arm drug on the floor. The resident’s chin rested on
his/her chest and the resident grunted with his/her eyes closed. An empty oxygen tank
attached to the back of his/her wheelchair and the resident wore a nasal cannula connected
to the empty tank. Certified Nurse Aide (CNA) M entered the room and then immediately
exited the room stating he/she needed clean supplies. CNA M did not offer to assist the
resident;
-At 12:43 P.M., the resident propelled him/herself down the hall. He/she used his/her
right arm to pull on the handrails attached to the wall. An empty oxygen tank attached to
the back of his/her wheelchair and the resident wore a nasal cannula connected to the
empty tank. He/she slumped to the right side, head to chest and shouted Help me, please
help me! Clinical Support Staff N in the hall, passed water and ice to residents and
responded, Yep and walked away. A nurse in the hall passed medication from a medication
cart did not respond to the resident. The resident continued to propel him/herself down
the hall towards the nurse’s station, by pulling on the handrails, grunted, cursed and
called for help;
-At 12:47 P.M., the Assistant Director of Nursing (ADON) saw the resident at the nurse’s
station and asked him/her what he/she needed. Without waiting for a response, the ADON
turned the resident around in his/her wheelchair and propelled the resident back down the
100 hall towards his/her room. The resident remained slumped all the way to the right side
of the wheelchair, hung over the arm rest with his/her arm down to the floor. The resident
wore a nasal cannula attached to an empty oxygen tank on the back of his/her wheelchair.
The ADON did not check the oxygen tank’s flow meter or gauge, assess the resident and/or
obtain oxygen saturation levels on the resident;
-At 12:48 P.M., the ADON left the resident in his/her room and said she will get someone
to help. The resident said Damn it! to him/herself. The ADON returned moments later with
the Director of Nursing (DON). The DON removed the resident’s nasal cannula and helped the
ADON transfer the resident to the toilet;
-At 12:58 P.M., CNA M entered the room. The ADON left the room and said she would return
with a new oxygen tank. CNA M finished dressing the resident and propelled the resident
out of the bedroom to the dining room. No staff assessed the resident or obtained an
oxygen saturation on the resident. The resident did not have an oxygen tank on his/her
wheelchair and wore no oxygen. The nasal cannula slung over the resident’s wheelchair, in
between the resident and the back of the wheelchair. The resident slumped to the right
side of the wheelchair and hung over the right arm rest, with his/her head to his/her
chest;
-At 1:19 P.M., the resident sat in the dining room, the DON approached him/her and talked
to him/her at the table. The DON adjusted the resident’s collar and walked away. The
resident still had no oxygen tank and wore no oxygen;
-At 1:26 P.M., CNA O came into the dining room with a full oxygen tank. CNA O locked the
resident’s wheelchair and said to the resident he/she had to stay at the table. The
resident yelled no, take it off and struggled to unlock the wheels of the wheelchair. The
resident could not unlock his/her wheelchair. After placing the oxygen tank on the back of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 40)
the resident’s wheelchair, the CNA attached the nasal cannula. CNA O tried to put the
nasal cannula on the resident, without first explaining to the resident what he/she
prepared to do, and said You have to wear this. The resident screamed back No, I don’t.
The CNA put the nasal cannula back down over the handle of the wheelchair, unlocked the
resident’s wheelchair and walked away.
Observations on 3/22/19, showed:
-At 6:50 A.M., the resident lay in bed in his/her room, a nasal cannula wrapped around the
handle bar on the back of the resident’s wheelchair. No oxygen tubing connected to the
concentrator located at the bedside. The oxygen tank on the wheelchair empty. The resident
wore no oxygen;
-At 7:10 A.M., the resident sat on the edge of his/her bed, slumped over to the right side
and tried to stand up with very shallow breathing. His/her head bowed down, chin to chest.
The resident opened and shut his/her eyes intermittently. The resident did not have oxygen
on;
-At 7:14 A.M., CNA B walked into the resident’s room and saw the resident on the side of
the bed. CNA B said he/she was going to get someone to help the resident and left the room
without doing anything to assist the resident. A few minutes later, CNA B returned again,
walked in the room, repeated he/she will get help and left again. The resident continued
to try to stand by clutching his/her roommate’s wheeled walker for support. The resident
lost his/her balance and fell back onto the bed, with the right side of his/her body
draped over the footboard;
-At 7:27 A.M., CNA B returned with Nurse C. Nurse C and CNA B washed their hands and put
on gloves. The resident sat on the side of the bed, slumped to right side with shallow
breathing. The resident’s eyes closed and his/her head bowed down with his/her chin on
his/her chest. Nurse C did not assess the resident, check the resident’s oxygen saturation
level and/or apply oxygen on the resident;
-At 7:28 A.M., CNA B left the room. Nurse C stood 3 feet away from the resident, with a
curtain partially blocking his/he view of the resident. The resident sat on the edge of
the bed, fidgeted by clasping and unclasping his/her hands, wiped his/her nose and mouth
and crossed his/her legs back and forth on top of each other. The resident struggled to
sit up straight, but kept falling back to the right side. The resident closed his/her eyes
intermittently, with shallow breaths as he/she drooled. The resident grunted and asked for
help. Nurse C responded by telling the resident the CNA will return and to not stand up.
Nurse BB did not assess the resident or place oxygen on the resident;
-At 7:32 A.M., CNA B returned to the room with clean clothes and briefs. CNA B dressed the
resident and transferred the resident to his/her wheelchair with assistance from Nurse BB.
Nurse BB then left the room without assessing the resident, checking the resident’s oxygen
saturation and/or placing oxygen on the resident. CNA B propelled the resident out of the
room to eat breakfast in the dining room. The resident did not wear the nasal cannula and
the oxygen tank on the wheelchair was empty;
-At 7:50 A.M., the resident sat in the dining room, slumped to one side, chin to chest,
eyes closed and drooled, with shallow breathing. No oxygen on the resident;
-At 8:32 A.M., the resident sat in his/her wheelchair in front of the nurse’s station.
Nurse A saw the resident and propelled him/her down the hall to the dining room. Nurse A
bent down and examined the oxygen tank gauge and walked away;
-At 8:38 A.M., Nurse A returned to the resident with a full oxygen tank. Nurse A put a
pulse oximeter (test to show blood oxygen saturation) on the resident’s left hand, index
finger. The oxygen saturation level measured 66% (normal 95% to 100%). The nurse did not
put oxygen on the resident or further assess the resident;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 41)
-At 8:41 A.M., Nurse A propelled the resident down the hall to his/her room. The resident
wore the pulse oximeter that measured 68% oxygen saturation. The resident slumped all the
way to the right side, eyes closed, and did not respond to questions. His/her chin rested
on his/her chest and the resident had shallow breathing;
-At 8:45 A.M., Nurse BB joined Nurse A in the resident’s room. His/her oxygen saturation
measured 63%. The resident wore no oxygen;
-At 8:46 A.M., The resident breathed shallow breaths, did not respond to questions,
slumped all the way to the right side, chin to chest and drooled with his/her eyes shut.
Nurse BB placed an oxygen face mask (a disposable plastic mask worn over the nose and
mouth, used to administer oxygen) on the resident and turned on the oxygen tank. Nurse A
knelt down next to the resident’s wheelchair and held the face mask to the resident’s
face. The resident’s oxygen saturation measured 67% and raised to 69%;
-At 8:49 A.M., the resident’s oxygen saturation measured 82% as he/she continued to
receive oxygen. Nurse BB left the room stating he/she needed to send the resident back to
the hospital. The resident began to open his/her eyes and started to talk. His/her oxygen
saturation raised to 97%;
-At 8:54 A.M., the resident’s oxygen saturation measured steady at 95% as he/she continued
to receive oxygen. Nurse BB returned to the room to get the resident’s blood pressure with
a wrist blood pressure cuff. The nurse’s did not perform a head to toe assessment of the
resident, including counting respirations and/or listening to the resident’s lung sounds;
-At 9:00 A.M., the paramedics arrived to the room with a stretcher. The paramedics asked
Nurse BB for the resident’s medical [DIAGNOSES REDACTED]. Nurse BB told the paramedics the
resident had a physician order for [REDACTED].
-At 9:10 A.M., the paramedics left the building with the resident on a stretcher to take
him/her to the hospital emergency room .
During an interview on 3/22/19 at 9:20 A.M., Nurse BB stated:
-He/she did not know if the resident had oxygen orders;
-Nurse BB looked at the (MONTH) 2019, POS and said there were not any oxygen orders or
respiratory assessment orders listed;
-The resident had a recent [DIAGNOSES REDACTED].>-He/she did not know the last time the
resident had oxygen;
-The resident did not exhibit any behaviors this morning;
-The resident was admitted on [DATE] from the hospital with oxygen. The resident had not
worn oxygen since he/she arrived;
-The resident’s physician sent him/her out to the emergency room last week due to [MEDICAL
CONDITION]. At the time, the physician made the determination. The resident was not on
oxygen.
During an interview on 3/22/19 at 12:40 P.M., the DON said:
-The nurse who admits a resident to the facility is responsible for ensuring all physician
orders from the hospital are reconciled;
-The ADON is responsible to check physician orders to ensure they are correct;
-Nurses are expected to know the [DIAGNOSES REDACTED].
-Resident’s with [MEDICAL CONDITION] and pneumonia [DIAGNOSES REDACTED].
-The DON assumed the resident had a physician order for [REDACTED].
-Signs and symptoms of respiratory distress include lethargy, weakness, confusion,
shortness of breath, anxiety and aggressive behaviors;
-Nurses are expected to recognize signs of respiratory distress;
-Nurses are expected to know how to assess a resident in an emergent situation by
completing a head to assessment including vital signs, respiration count and listening to
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 42)
lung sounds.
During an interview on 3/26/19 at 9:45 A.M., the facility’s Medical Director said:
-If a resident was admitted to the facility following intubation at the hospital, it is
expected they have oxygen therapy orders as needed and respiratory assessment orders as
needed;
-If a resident with a [DIAGNOSES REDACTED].
Review of the resident’s hospital discharge orders, dated 3/26/19, showed:
-Discharge [DIAGNOSES REDACTED].
-Oxygen Saturation – Check as needed for respiratory distress or change in condition per
nurse assessment;
-Oxygen instructions- Oxygen at 3L per nasal cannula continuously.
Review of the resident’s POS, dated (MONTH) 2019 and reviewed on 3/27/19 at 6:20 A.M.,
showed:
-an order for [REDACTED].
-Pulse oximeter (oxygen saturation test) every shift, notify physician if oxygen
saturation less than 90%.
Review of the resident’s (MONTH) 2019 MAR and TAR, reviewed on 3/27/19 at 6:36 A.M. and at
12:10 P.M., showed no orders for oxygen therapy or oxygen saturation tests for the
resident.
During an interview on 3/27/19 at 7:00 A.M., Nurses G and H stated oxygen and pulse
oximeter orders are kept in the nurse’s MAR and TAR binder.
Observation on 3/27/19 at 6:23 A.M., showed the resident in the hall in his/her
wheelchair. He/she called out for help. Nurse H walked down the hall, approached the
resident and asked how he/she could help. Nurse H then propelled the resident to the
nurse’s station. The resident had an oxygen tank on the back of his/her wheelchair, the
gauge read near empty, with the oxygen flowmeter set at 2L per minute and not the 3L as
ordered. The nasal cannula located behind the resident, wrapped around the handle of the
wheelchair. The nasal cannula out of reach of the resident. The resident wore no oxygen.
Observation at 3/27/19 at 8:11 A.M., showed the resident propelled him/herself in his/her
wheelchair on the 200 hall and grunted. The DON approached the resident and said she
needed to get the resident a new oxygen tank because this one is empty. The DON propelled
the resident down the hall, towards the nursing station. The resident was sat upright in
the wheelchair.
Observation on 3/27/19 at 8:22 A.M., showed the resident in his/her room with the nasal
cannula inserted in his/her nostrils. A full oxygen tank hung off of the back of the
resident’s wheelchair with the oxygen tubing attached. The oxygen flow meter was set at 0L
per minute.
Observation on 3/27/19 at 9:45 A.M., showed the resident sat upright in his/her wheelchair
and propelled him/herself down the 200 hall, with a nasal cannula inserted in his/her
nostrils. The oxygen tank full and flow meter set at 2L per minute.
Further review of medical record, reviewed on 3/22/19 at 3:40 P.M., showed:
-Documentation of vital signs obtained on 3/19, 3/20 and 3/22/19, the resident on oxygen
via nasal cannula. The amount of O2 was not listed;
-No respiratory assessments documented in the progress notes.
During an interview on 3/22/19 at 12:40 P.M., the DON said she expects the nursing staff
to accurately document all vital signs including the amount of oxygen administered. Nurses
are expected to document respiratory assessments in the progress notes, especially when
administering oxygen to residents. On 3/26/16 at 10:15 A.M., the DON said care plans are
created collaboratively with the ADON and should include all of the resident’s pertinent
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 43)
medical diagnoses, including [MEDICAL CONDITION] and pneumonia, information found on the
hospital transfer forms and assessments from the admitting nurse. The ADON is responsible
for checking care plans for accuracy.
2. Review of Resident #63’s face sheet, showed:
-Re-admitted on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s POS, dated 2/1/19 through 2/28/19, showed an order, dated
1/30/19, for oxygen at 2L per nasal cannula as needed (PRN).
Review of the resident’s POS, dated 3/1/19 through 3/31/19, showed:
-An order, dated 2/28/19, to check and record PRN oxygen saturation;
-An order, dated 3/2/19, for [MEDICATION NAME] (medication used to treat asthma) treatment
PRN 2.5-0.5 milligram (mg)/3 milliliter (ml) every six hours, inhale 1 vial per nebulizer
(machine used for breathing treatments);
-No order for how many liters of oxygen to administer.
Review of the resident’s care plan, dated 12/26/18, showed:
-Focus: Resident has a [DIAGNOSES REDACTED]. On 1/30/19, resident was readmitted with the
[DIAGNOSES REDACTED].
-Interventions: Advise resident to minimize contact with known offending allergens;
-Focus: Resident has a [DIAGNOSES REDACTED].
-Interventions: Check breath sounds and monitor/document for labored breathing;
-Monitor/document for the use of accessory muscles while breathing;
-Monitor vital signs as ordered/needed. Notify the physician of significant abnormalities;
-Oxygen settings: Oxygen as ordered/needed;
-Check oxygen saturation as ordered/needed.
Observation of the resident, showed:
-On 3/22/19 at 12:04 P.M., the resident’s oxygen tank located on the back the wheelchair.
The oxygen tubing hung around the oxygen tank and the nasal cannula was uncovered hanging
against the tank. The oxygen tubing not dated;
-On 3/22/19 at 1:45 P.M., the resident not in the room. The nebulizer mask uncovered on
the bedside table. The mask not dated;
-On 3/25/19 at 11:06 A.M., the resident not in the room. The nebulizer mask uncovered on
the bedside table. The mask not dated;
-On 3/25/19 at 1:58 P.M., the resident’s oxygen tank on the back the wheelchair. The
oxygen tubing hung around the oxygen tank and the nasal cannula uncovered and hung against
the tank. The oxygen tubing not dated.
During an interview on 3/27/19 at 10:30 A.M., the DON said she would expect the resident’s
oxygen orders to be complete. It should include the amount of liters of oxygen to
administer. She would expect the nasal cannula and the mask to be covered and dated.
3. Review of the facility’s oxygen administration policy, dated 2012, showed:
-Purpose: To administer oxygen to the resident when insufficient oxygen is being carried
by the blood to the tissues;
-Procedure:
-Check the physician’s order for liter flow and method of administration;
-At regular intervals, check liter flow contents of the oxygen cylinder, fluid level in
humidifier and assess resident’s respirations to determine further need for oxygen
therapy;
-Monitor resident’s response to therapy with pulse oximetry as necessary;
-Documentation guidelines:
-Date, time, method of administration and liter flow as ordered;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0695

Level of harm – Actual harm

Residents Affected – Few

(continued… from page 44)
-Condition of the resident before procedure and effectiveness of oxygen therapy;
-Vital signs before oxygen was started and periodically after initiation of therapy;
-Care Plan Guideline:
-Problem: Identify the appropriate problem under which to list oxygen administration as
an approach;
-Goal: List measurable goals to be accomplished with a target date;
-Approaches included: List necessary monitoring and observation of the resident’s
respiratory function.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that
residents who require [MEDICAL TREATMENT] (the process of filtering toxins from the blood
in individuals with kidney failure) receive such services, consistent with professional
standards of practice, by failing to obtain physician orders [REDACTED]. The facility
identified two residents who received [MEDICAL TREATMENT]. Of those two, one was selected
for the sample and issues were identified for this resident (Residents #122). In addition,
the facility failed to provide a [MEDICAL TREATMENT] policy. The sample size was 20. The
census was 96.
Review of Resident 122’s care plan, in use during the survey, showed:
-Check and change [MEDICAL TREATMENT] dressing daily at access site;
-Encourage resident to go for scheduled [MEDICAL TREATMENT] appointments;
-Monitor vital signs. Notify physician of significant abnormalities;
-Monitor/document report to physician as needed any signs or symptoms of infection to
access site: Redness, swelling, warmth, or drainage;
-Monitor/document for [MEDICAL CONDITION] (swelling);
-Monitor/document report as needed for signs or symptoms of renal (kidney) insufficiency:
changes in levels of consciousness, changes in skin turgor, oral mucosa, changes in heart
and lung sounds;
-Monitor/document report as needed any signs or symptoms of the following: bleeding,
hemorrhage (bleed) bacteremia (blood infection), septic shock.
Review of the resident’s physician order [REDACTED].
-No order for the resident to receive [MEDICAL TREATMENT], where or how often;
-No order to check the thrill and bruit (the thrill is the vibration you feel as blood
flows through the fistula. The bruit is the sound you hear, heard with a stethoscope);
-No order to monitor [MEDICAL TREATMENT] site for bleeding.
Review of the resident’s Medication Administration Record [REDACTED]
-No documentation of the [MEDICAL TREATMENT] site monitored for bleeding;
-No documentation staff checked for bruit and thrill.
During interviews on 3/26/19 at 5:43 P.M. and 3/27/19 at 10:30 A.M., the Director of
Nursing (DON) said the facility does not have a [MEDICAL TREATMENT] policy. She would
expect there to be an order for [REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff had
the appropriate competencies and skills sets to provide nursing and related services to
assure resident safety and attain or maintain the highest practicable physical, mental,
and psychosocial well-being for each resident when they failed to demonstrate competency
in symptoms of [MEDICAL CONDITION] (lack of oxygen in the body), oxygen settings and use
when a resident with a history of [MEDICAL CONDITION] and pneumonia had an empty oxygen
tank (Resident #320), failed to demonstrate competency in resident self-determination and
choice (Resident #63) and failed to demonstrate competency on the facility [MEDICAL
CONDITION] (TB) screening policy by not assuring staff had no contact with residents until
after their first step Purified Protein Derivative (PPD). In addition, the facility failed
to ensure each nurse aide had no less than 12 hours of in-service education per year to
address resident care needs and/or deficient areas, as observed during the annual survey,
for five of five certified nursing assistants (CNAs) sampled. The census was 96.
1. Review of the Resident #320’s medical record, on 3/22/19 at 2:05 P.M., showed:
-admitted [DATE];
-Medical [DIAGNOSES REDACTED].
Review of the resident’s hospital discharge orders, dated 3/5/19, showed:
-Discharge [DIAGNOSES REDACTED].>-Oxygen Saturation (O2 sat, amount of oxygen in blood)
– Check as needed for respiratory distress (difficulty breathing) or change in patient’s
condition per nurse assessment;
-Oxygen instructions – Oxygen at 3 Liters (L) per minute by nasal cannula (a devise for
delivering oxygen by way of two small tubes that are inserted into the nares)
continuously.
Review of the physician order [REDACTED].
-No orders for oxygen therapy;
-No orders for oxygen saturation tests.
Observations on 3/21/19, showed:
-At 10:45 A.M., the resident sat in his/her wheelchair in his/her bedroom with his/her
chin to his/her chest and his/her body slumped over the right side of the wheelchair.
His/her right arm dangled down to the wheelbase. An oxygen condenser unit alongside the
resident’s bed, not in use. An empty oxygen tank attached to the back of his/her wheel
chair and the resident wore a nasal cannula connected to the empty oxygen tank. At 11:53
A.M., Certified Nurse Assistant (CNA) M entered the resident’s room and immediately exited
the room and said he/she needed clean supplies. CNA M did not recognize the resident’s
symptoms of possible [MEDICAL CONDITION] and/or offer to assist the resident;
-At 12:43 P.M., the resident propelled him/herself down the hall, with the empty oxygen
tank attached to the back of his/her wheel chair. He/she shouting Help me, please help me!
Clinical Support N was located in the hall and passed water and ice to residents and
responded, Yep and walked away. A nurse in the hall passed medication from a medication
cart. He/she failed to respond to the resident’s pleas for help. The resident continued to
propel him/herself down the hall towards the nurse’s station, by pulling on the handrails,
grunting, cursing and calling for help. There were several nursing staff members at the
nurse’s station within ear shot and view of the resident. No one responded to his/her
shouts for help. No staff recognized the resident’s symptoms of distress;
-At 12:47 P.M., The Assistant Director of Nursing (ADON) saw the resident at the nurse’s

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 46)
station and asked him/her what he/she needed. Without waiting for a response, the ADON
turned the resident around in his/her wheelchair and propelled the resident back down the
100 hall towards his/her room. The resident still slumped all the way to the right side of
the wheelchair, and hung over the arm rest with his/her arm falling down to the floor. The
resident wore a nasal cannula attached to an empty oxygen tank on the back of his/her
wheelchair. The ADON did not check to oxygen tank’s flow meter or gauge. At 12:48 P.M.,
the ADON left the resident in his/her bedroom and said she would get someone to help. The
ADON returned moments later with the Director of Nursing (DON). The DON removed the nasal
cannula from the resident and helped the ADON transfer the resident to the toilet. Neither
the ADON nor DON recognized the resident’s symptoms of distress.
Observations on 3/22/19, showed:
-At 6:50 A.M., the resident was lay in bed with a nasal cannula wrapped around the handle
bar on the back of the resident’s wheelchair. No oxygen tubing connected to the
concentrator, located at bedside, and the oxygen tank on the wheelchair was empty. At 7:10
A.M., the resident sat on the edge of his/her bed, slumped over to the right side, tried
to stand up and had very shallow breathing. The resident opened and shut his/her eyes
intermittently. The resident did not have oxygen on. At 7:14 A.M., CNA B walked into the
resident’s room, saw the resident on the side of the bed and said he/she was going to get
someone to help the resident and left the room without doing anything to assist the
resident. A few minutes later, CNA B returned again, walked in the room, repeated that
he/she will get help and left again. The resident continued to try to stand. The resident
lost his/her balance and fell back onto the bed, with the right side of his/her body
draped over the footboard. At 7:27 A.M., CNA B returned with Nurse C. Nurse C and CNA B
washed their hands and put on gloves. The resident sat on the side of the bed, slumped to
the right side with shallow breathing. The resident’s eyes closed and his/her head bowed
down with his/her chin on his/her chest. Nurse BB and CNA C did not offer any assistance
to the resident and failed to recognize the resident’s symptoms of distress;
-At 7:28 A.M., CNA B left the room. The resident struggled to sit up straight but kept
falling back to the right side. The resident closed his/her eyes intermittently, breathed
shallow and drooled. The resident grunted and asked for help. Nurse BB told the resident
that the CNA will return and to not stand up. Nurse BB did not assess the resident, place
oxygen on the resident and failed to recognize the resident’s symptoms of distress;
-At 7:32 A.M., CNA B returned to the room with clean clothes and briefs. CNA C dressed the
resident and transferred the resident to his wheelchair with assistance from Nurse B.
Nurse BB left the room. CNA B propelled the resident out of the bedroom to eat breakfast
in the dining room. Staff failed to recognize the resident’s symptoms of distress and did
not apply oxygen on the resident;
-At 7:50 A.M., the resident sat in the dining room, slumped to one side, chin to chest,
eyes closed, drooled, with shallow breathing. No oxygen on the resident;
-At 8:32 A.M., the resident sat in a wheelchair in front of the nurse’s station. Nurse A
saw the resident and propelled him/her down the hall to the dining room. Nurse A bent down
and examined the empty oxygen tank gauge and walked away;
-At 8:38 A.M., Nurse A returned to the resident with a full oxygen tank. Nurse A put a
pulse oximeter (test to show blood oxygen saturation, normal 95% through 100%) on the
resident’s left hand, index finger. The oxygen saturation level read 66%. The nurse did
not put oxygen on the resident;
-At 8:41 A.M., Nurse A propelled the resident down the hall to his/her bedroom. The
resident still wore the pulse oximeter and it read 68% oxygen saturation. The resident
slumped all the way to the right side, eyes closed, did not respond to questions, and chin
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 47)
to chest with shallow breathing;
-At 8:45 A.M., Nurse BB joined Nurse A in the resident’s bedroom. His/her oxygen
saturation was 63%. The resident did not wearing oxygen;
-At 8:46 A.M., Nurse BB placed a face mask (a disposable plastic mask worn over the nose
and mouth used to administer oxygen through tubing) on the resident and turned on the
oxygen tank, giving the resident oxygen. Nurse A knelt down next to the resident’s
wheelchair and held the face mask to the resident’s face. The resident’s oxygen saturation
measured at 67% and raised to 69%;
-At 8:49 A.M., the resident’s oxygen saturation measured at 82% as he/she continued to
receive oxygen. Nurse BB left the room stating he/she needed to send the resident back to
the hospital. The resident began opening his/her eyes and started to talk. His/her oxygen
saturation raised up to 97%;
-At 8:54 A.M., the resident’s oxygen saturation measured steady at 95% as he/she continued
to receive oxygen;
-At 9:00 A.M., the paramedics came into the room with a stretcher. The paramedics asked
Nurse BB for the resident’s medical [DIAGNOSES REDACTED]. Nurse BB told the paramedics the
resident had a physician order [REDACTED].>-At 9:10 A.M., the paramedics left the
building with the resident on a stretcher to take him/her to the hospital emergency room .
Further review of the resident’s POS, dated (MONTH) 2019, showed an order dated 3/12/19,
send back to hospital emergency for acute on chronic hypoxic [MEDICAL CONDITION].
During an interview on 3/22/19 at 12:40 P.M., the DON said:
-Resident’s with a [MEDICAL CONDITION] and pneumonia [DIAGNOSES REDACTED].
-Signs and symptoms of respiratory distress include lethargy (extreme drowsiness),
weakness, confusion, shortness of breath, anxiety, and aggressive behaviors;
-Nurses are expected to recognize signs of respiratory distress;
-Nurses are expected to know how to assess a resident in an emergent situation.
During an interview on 3/27/19 at 9:50 A.M., Nurse G said he/she attended the [MEDICAL
CONDITION] (a tube inserted through the throat and into the trachea to provide an airway)
care in-service at the facility last month. He/she has never received respiratory
assessment training at the facility.
Review of the facility’s (MONTH) 2019 [MEDICAL CONDITION] in-service materials, showed:
-Objectives:
-Definition/Rationale for a [MEDICAL CONDITION] including basic anatomy of the trachea
(windpipe);
-Discussion of the most common types of [MEDICAL CONDITION] including ration/function;
-Correctly identify parts of a [MEDICAL CONDITION];
-Discussion of rationale/procedure for [MEDICAL CONDITION] care including suctioning of
the airway;
-Discussion of equipment needed at bedside;
-Tests for administration of oral medications, eye medications, inhalers and patches, and
for medications via gastrostomy tube ([DEVICE], a tube surgically inserted into the
stomach to provide hydration, nutrition and medications);
-The training did not include how to assess for respiratory distress.
During an interview on 3/27/19 at 11:30 A.M., the facility’s nurse educator said during
last month’s (February) [MEDICAL CONDITION] in-service, she did not give an additional
training other than the objectives listed on the All about Tracheostomies presentation and
only tested on skills of administration of oral medications, eye medications, inhalers and
patches, and for medications via tube.
2. Review of Resident #63’s care plan, dated 12/26/18, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 48)
-Focus: Resident is currently involved in an intimate relationship with a resident that is
a resident in the facility;
-Goals: Resident’s decision to be involved in this relationship will be respected and
honored through next review;
-Interventions: Provide/allow privacy as needed/requested. Respect his/her rights.
Review of the resident’s progress notes, showed on 3/11/19, resident had another resident
in bed with him/her. Escorted other resident out of the room.
During an interview on 3/22/19 at 10:21 A.M., the resident said some of the staff respect
his/her choices, but there was one nurse who always escorted his/her partner out of the
room. The nurse found the two of them in bed watching television. The nurse told the
partner to leave the room. They were only watching television. Staff are aware he/she is
in a relationship, and it should be respected.
During an interview on 3/27/19 at 7:31 A.M., Nurse H said he/she wrote in the resident’s
progress notes that he/she found another resident in bed with the resident on 3/11/19.
He/she did not know that the resident had a partner and did not know that the residents
were allowed to have intimate relationships in the facility.
3. Review of facility staff employee files, showed:
-Dietary Aide T’s date of hire 6/6/18. First step PPD administered 6/6/18 and read
negative on 6/9/18;
-CNA U’s date of hire 7/26/18. First step PPD administered 7/26/18 and read negative on
7/29/18;
-Nurse C’s date of hire 10/17/18. First step PPD administered 10/17/18 and read negative
on 10/20/18;
-Dietary Aide V’s date of hire 10/24/18. First step PPD administered 10/24/18 and read
negative on 10/27/18;
-CNA W’s date of hire 11/1/18. First step PPD administered 11/1/18 and read negative on
11/4/18;
-Maintenance Worker X’s date of hire 1/25/19. First step PPD administered 1/25/19 and read
negative on 1/28/19;
-CNA D’s date of hire 3/7/19. First step PPD administered 3/7/19 and read negative on
3/10/19;
-CNA Y’s date of hire 1/25/19. First step PPD administered 1/25/19 and read late on
1/29/19.
During an interview on 3/27/19 at 11:55 A.M., the assistant DON said she is the person
responsible for employee PPDs. She thought she was supposed to administer and read PPDs
before staff have contact with residents, but that is not how it had been done at the
facility. She thought it must be different at every facility.
4. Review of CNA Q’s in-service tracking log, showed:
-He/she received 4 hours and 30 minutes of documented in-service training out of the
required minimum of 12 hours;
-No in-service training provided on emergency protocol, Health Insurance Portability and
Accountability Act (HIPAA)/privacy, dementia care, transfers, activity of daily living
(ADL) care, accidents/safety, range of motion (ROM), turn/reposition, pressure ulcer
prevention, and oxygen use.
Review of CNA B’s in-service tracking log, showed:
-He/she received 7 hours and 30 minutes of documented in-service training out of the
required minimum of 12 hours;
-No in-service training provided on emergency protocol, HIPAA/privacy, dementia care,
transfers, accidents/safety, ROM, turning/repositioning, pressure ulcer prevention, and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 49)
oxygen use.
Review of CNA R’s in-service tracking log, showed:
-He/she received 8 hours and 45 minutes of documented in-service training out of the
required minimum of 12 hours;
-No in-service training provided on emergency protocol, HIPAA/privacy, transfers,
accidents/safety, ROM, turning/repositioning, pressure ulcer prevention, and oxygen use.
Review of CNA S’s in-service tracking log, showed:
-He/she received 2 hours and 45 minutes of documented in-service training out of the
required minimum of 12 hours;
-No in-service training provided on dementia care, HIPAA/privacy, emergency protocol,
transfers, ADL care, accidents/safety, ROM, turning/repositioning, pressure ulcer
prevention, and oxygen use.
Review of CNA O’s in-service tracking log, showed:
-He/she received 9 hours and 30 minutes of documented in-service training out of the
required minimum of 12 hours;
-No in-service training provided on emergency protocol, HIPAA/privacy, transfers,
accidents/safety, ROM, turning/repositioning, pressure ulcer prevention, and oxygen use.
5. During an interview on 3/27/19 at 10:43 A.M., with the DON and administrator, the DON
said she would expect staff to be competent in the care of residents.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Observe each nurse aide’s job performance and give regular training.

Based on observation, interview and record review, the facility failed to ensure each
nurse aide had no less than twelve hours of in-service education per year based on their
individual performance review, calculated by their employment date rather than the
calendar year, for five of five certified nursing assistants (CNAs) employed at the
facility for more than one year. In addition, the facility failed to provide in-service
training on topics identified as deficient during the current annual survey. The census
was 96.
Observation on 3/26/19 at approximately 12:00 P.M., showed a stack of in-service sign in
sheets for a variety of topics provided by the Director of Nursing (DON). Review of the
sign in sheets, showed no indication of how many minutes/hours each in-service included or
a tracking of CNA in-service training hours. On 3/26/19 at 4:57 P.M., the nurse educator
provided additional documentation of CNA in-service training hours tracked since she took
over the position in (MONTH) (YEAR).
1. Review of CNA Q’s employee filed, showed date of hire (DOH) 1/1/99.
Review of the CNA’s in-service tracking log, showed in-service hours tracked annually and
not by DOH:
-An in-service tracking log, dated (YEAR), showed 2 hours of in-service training provided;
-An in-service tracking log, dated 2019, showed 2 hours and 30 minutes of in-service
training provided;
-No in-service training provided on emergency protocol, Health Insurance Portability and
Accountability Act (HIPAA)/privacy, dementia care, transfers, activity of daily living
(ADL) care, accidents/safety, range of motion (ROM), turning/repositioning, pressure ulcer
prevention, and oxygen use.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 50)
2. Review of CNA B’s employee file, showed DOH 1/26/11.
Review of the CNA’s in-service tracking log, showed in-service hours tracked annually and
not by DOH:
-An in-service tracking log, dated (YEAR), showed 2 hours and 30 minutes of in-service
training provided;
-An in-service tracking log, dated 2019, showed 5 hours of in-service training provided;
-No in-service training provided on emergency protocol, HIPAA/privacy, dementia care,
transfers, accidents/safety, ROM, turning/repositioning, pressure ulcer prevention, and
oxygen use.
3. Review of CNA R’s employee file, showed DOH 10/1/13.
Review of the CNA’s in-service tracking log, showed in-service hours tracked annually and
not by DOH:
-An in-service tracking log, dated (YEAR), showed 2 hours and 30 minutes of in-service
training provided;
-An in-service tracking log, dated 2019, showed 6 hours and 15 minutes of in-service
training provided;
-No in-service training provided on emergency protocol, HIPAA/privacy, transfers,
accidents/safety, ROM, turning/repositioning, pressure ulcer prevention, and oxygen use.
4. Review of CNA S’s employee file, showed DOH 3/25/14.
Review of the CNA’s in-service tracking log, showed in-service hours tracked annually and
not by DOH:
-An in-service tracking log, dated (YEAR), showed 30 minutes of in-service training
provided;
-An in-service tracking log, dated 2019, showed 2 hours and 45 minutes of in-service
training provided;
-No in-service training provided on dementia care, HIPAA/privacy, emergency protocol,
transfers, ADL care, accidents/safety, ROM, turning/repositioning, pressure ulcer
prevention, and oxygen use.
5. Review of CNA O’s employee file, showed DOH 10/25/17.
Review of the CNA’s in-service tracking log, showed in-service hours tracked annually and
not by DOH:
-An in-service tracking log, dated (YEAR), showed 3 hours of in-service training provided;
-An in-service tracking log, dated 2019, showed 6 hours and 30 minutes of in-service
training provided;
-No in-service training provided on emergency protocol, HIPAA/privacy, transfers,
accidents/safety, ROM, turning/repositioning, pressure ulcer prevention, and oxygen use.
6. During an interview on 3/26/19 at 4:17 P.M., the nurse educator said she has only been
in her position since (MONTH) (YEAR). Prior to that, the nurse education position was
open. Usually, she tracks staff on their own tracking sheet. That was not being done prior
to her accepting the position. There is a set schedule of trainings for the year. If there
are issues in the building she would provide training on the specific issues. Upper
management completes the performance evaluations for staff, she is not involved in this
process. If there were specific training needs based on performance, management would have
to inform her. When in-services are due, she prefers to do them one on one. She goes to
the staff and provides the information and then has them sign the sign in sheet. She would
expect CNAs to have 12 hours of in-service training per year. CNA in-service training has
only been tracked since (MONTH) (YEAR).

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation and interview, the facility failed to post the number of licensed and
non-licensed nursing staff for each shift that were directly responsible for resident
care, for four of five days of the survey and failed to post the facility census, the
total hours for the licensed and non-licensed nursing staff for each shift and failed to
maintain the daily nurse staffing data for a minimum of 18 months as required. The census
was 96.
Observation on 3/21/19 at 9:50 A.M., showed the facility’s nursing staff information
posted, which contained the name of the facility, date, total number of licensed and
non-licensed nursing staff for the day, evening and night shift, but contained no census
or number of hours worked for licensed and non-licensed nursing staff for each shift
responsible for resident care.
Observation on 3/22/19 at 8:00 A.M., on 3/25/19 at 6:00 A.M., 7:44 A.M., and 3:45 P.M., on
3/26/19 at 6:24 A.M. and at 4:23 P.M., and on 3/27/19 at 8:39 A.M., showed the facility’s
nursing staff information posted, dated 3/21/19, remained posted and had not been changed.
During an interview on 3/27/19 at 11:39 A.M., the staffing coordinator said he/she is
responsible for posting the nursing hours, and had just posted the nursing hours for
3/27/19. He/she started working as the staff coordinator in (MONTH) (YEAR) and is pulled
to work the floor frequently and does not get the hours posted on those days.
During an interview on 3/27/19 at 12:08 P.M., the staffing coordinator said he/she was
unaware he/she had to maintain the posted daily nursing hours for 18 months and had not
been keeping them and was not aware the posted information needed to include the census,
the number of licensed and non-licensed nursing staff as well as the total hours for the
licensed and non-licensed nursing staff responsible for resident care.

F 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide the appropriate treatment and services to a resident who displays or is
diagnosed with dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident who displays or is diagnosed with [REDACTED]. In addition, the facility failed to
develop a personalized plan of care to ensure services to promote the resident’s highest
level of functioning and psychosocial needs, for one out of 20 sampled residents (Resident
#63). The facility census was 97.
Review of Resident #63’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 12/11/18, showed:
-Focus: He/she is verbally aggressive related to ineffective coping skills and poor
impulse control. Resident has a history of using profanity towards staff, residents, and
roommates. He/she had several roommates. He/she does not have a roommate long due to
conflict with the roommate and/or their visitor. He/she is not willing to compromise areas
of the room with others. He/she also has a history of making false allegations against
roommates;
-Interventions: Administer medications as ordered. Monitor/document for side effects and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 52)
effectiveness;
-Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and
document;
-Assess resident’s understanding of the situation. Allow time for the resident to express
self and feelings towards the situation;
-Psychiatric/Psychogeriatric consult as indicated;
-Further review of the resident’s care plan, showed no documentation of a [DIAGNOSES
REDACTED].
Review of the resident’s psychiatric notes, dated 12/14/18, showed:
-Resident seen for depression and anxiety;
-As per staff, resident appears to be depressed and mean at times. As per resident, I am
always in a good mood, people make me mad;
-During the interview today, resident remained calm and cooperative, no apparent distress,
states that mood is mostly good, but can get angry when people make him/her mad;
-Depression: Reports some current symptoms of depression as per criteria;
-Anxiety: Reports some current symptoms of anxiety as per criteria;
-[DIAGNOSES REDACTED].
-Late onset [MEDICAL CONDITION];
-Plan: Increase [MEDICATION NAME] (antidepressant) to 90 milligram (mg) by mouth daily;
-Starter dose of [MEDICATION NAME] (used to treat symptoms of [MEDICAL CONDITION]) 5 mg by
mouth every morning;
-[MEDICATION NAME] 5 mg oral tablet by mouth every morning (start date 12/14/18).
Review of the resident’s medical record, showed:
-A physician’s orders [REDACTED].
-An order, dated 12/14/18, for [MEDICATION NAME] 5 mg, by mouth daily at 9:00 A.M.;
-admitted to the hospital on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED].
-No documentation the [MEDICATION NAME] and [MEDICATION NAME] were discontinued at the
hospital;
-Re-admission POS, dated 12/30/18, showed no orders for [MEDICATION NAME] or [MEDICATION
NAME];
-admitted to the hospital on [DATE] and discharged back to the facility on [DATE] with a
[DIAGNOSES REDACTED].
-Re-admission POS, dated 1/6/19 through 1/31/19, showed no orders for [MEDICATION NAME] or
[MEDICATION NAME];
-admitted to the hospital on [DATE] through 2/28/19, with a [DIAGNOSES REDACTED].
-Re-admission POS, dated 3/1/19 through 3/31/19, showed no orders for [MEDICATION NAME]
and [MEDICATION NAME];
-Review of the Medication Administration Record [REDACTED]
-Orders prior to 12/31/18, not in the medical record;
-January 2019, (MONTH) 2019, and (MONTH) 2019, showed no documentation of [MEDICATION
NAME] or [MEDICATION NAME].
Review of the resident’s progress notes, showed:
-On 2/4/19, Certified Nurse Aide (CNA) stated that resident was rude and mean during care;
-On 2/5/19, plan of care meeting held with resident, social services and Assistant
Director of Nursing (ADON). Explained to resident that he/she cannot speak to staff
related to making vulgar reference to his/her body parts nor cursing at the staff. He/she
sat in his/her wheelchair and appeared to be sleeping, not answering when spoken to. When
his/her name called again, he/she stated rather rudely that he/she heard. Made mention
that if he/she wanted placement elsewhere that social services would assist him/her with
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 53)
this. He/she then stated that he/she wanted to stay here. He/she stated that he/she would
be nicer to staff after being prompted to speak. He/she did not state that he/she was
having any issues with staff but that he/she did not like some people. He/she would not
tell any names, only that he/she did not like certain people;
-On 3/7/19, up in wheelchair. Resident bitter. Constant complaints. No distress noted.
Review of the resident’s social services notes, dated 2/5/19, showed a meeting was held
this morning with the resident, social services, and the ADON. The resident is alert and
oriented and is able to make his/her needs known to nursing staff. He/she is a long term
resident and has been at the facility for almost one year. He/she has [DIAGNOSES
REDACTED]. The meeting was to address the resident’s behavior towards facility staff.
Resident continues to be very rude and use vulgar language towards nursing staff when they
are giving care. When asked why he/she was so hateful towards staff, he/she said that
he/she doesn’t like a couple of them. We asked him/her who he/she did not like and he/she
would not give any names. During our conversation with him/her, he/she kept his/her eye
closed like he/she was sleeping and hardly gave a useful answer to why he/she does not
like some of the staff. We also asked him/her if he/she wanted to transfer to another
facility if he/she was unhappy here, and he/she said no. We explained that if he/she was
not getting along with somebody to let the ADON or social services know so it can be
addressed right away. He/she agreed not to be so vulgar with facility staff. Social
services will continue to follow and monitor him/her for any new concerns or needs that
he/she might have. He/she also agreed to let me know if he/she is having issues with
anybody.
Observation on 3/22/19 at 10:21 A.M., showed the resident sat in his/her wheelchair in
his/her room. The resident said he/she was asked by staff why he/she was so hateful, but
when staff is mean to him/her, the resident cusses at them. It does hurt his/her feelings,
but he/she does not like to be called bitter or hateful by staff. On 3/26/19 at 4:30 P.M.,
the resident said he/she did not have any feelings of sadness; however, staff should not
piss him/her off.
During an interview on 3/26/19 at 4:00 P.M., the Director of Nursing (DON) said the
resident has a [DIAGNOSES REDACTED]. The DON described the resident as hateful. He/she
cusses at the staff. The DON said it is not appropriate for staff to refer to the resident
as bitter or hateful in the progress notes or to his/her face. The DON did not believe the
behaviors were related to the resident’s [DIAGNOSES REDACTED].
During an interview on 3/27/19 at 8:47 A.M., the director of social services said the
resident is very independent, but set in his/her ways. He/she is nice, but people
misunderstand him/her. He/she is told to be mindful that no one likes to be cussed out.
His/her communication is difficult for that reason.
During an interview on 3/27/19 at 7:45 A.M. and 8:42 A.M., the DON said the charge nurse
is responsible for re-capping and ensuring that the resident receives all medications that
were ordered. The resident’s psychiatrist ordered [MEDICATION NAME] back in (MONTH)
(YEAR). The DON confirmed that the resident’s order for [MEDICATION NAME] and [MEDICATION
NAME] were not carried over and there were no orders for it since (MONTH) (YEAR), and
since the MAR indicated [REDACTED]. The DON confirmed that the [MEDICATION NAME] was for
depression and [MEDICATION NAME] for Alzheimer’s. If not given, the behaviors exhibited
are irritability, depression, and isolation. The DON confirmed that the resident displayed
those emotions, except for isolation.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0744

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to establish a system of records
of receipt and disposition of all controlled drugs in sufficient detail to enable an
accurate reconciliation when the controlled substance shift change count check sheets were
missing documentation for six of the six facility medication carts. The facility census
was 96.
Review of the facility’s undated Controlled Substance Storage and Handling policy, showed:
-Policy: Controlled substances (medication in Schedule II, III, IV, V) have high abuse
potential and may be subjected to special handling, storage, and record keeping;
-All Class II controlled substances will be counted each shift or whenever there is an
exchange of keys between off-going and on-coming licensed nurses. The two nurses will:
-Both nurses will count the number of packages of controlled substances that are being
reconciled during the shift/shift count and document on the shift controlled substance
count sheet;
-Two nurses will sign the shift/shift controlled substance count sheets acknowledging
that the actual count of controlled substances and count sheet matches the quantity
documented;
-Any discrepancy in the count of controlled substances shall be reported in writing to
the responsible supervisor and a signed entry shall be recorded on the page where the
discrepancy is found;
-The supervisor shall institute an investigation to determine the reason for the
discrepancy. The record shall then be updated;
-The consultant pharmacist shall make regular checks of the handling, storage, and
recording of controlled substances.
1. Review on 3/25/19 at 6:10 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the nurse’s cart for the 100 hall, showed:
-12 out of 73 shifts with one nurse documented count of narcotics;
-8 out of 73 shifts count of narcotics without nurses documented;
-18 out of 73 shifts without count of narcotics.
2. Review on 3/25/19 at 6:20 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the certified medical technician’s (CMT) cart
for the 100 hall, showed:
-27 out of 73 shifts with one nurse documented count of narcotics;
-13 out of 73 shifts count of narcotics without nurses documented;
-26 out of 73 shifts without count of narcotics count of narcotics.
3. Review on 3/25/19 at 6:30 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the CMT cart for the 300 hall, showed:
-29 out of 73 shifts with one nurse documented count of narcotics;
-12 out of 73 shifts count of narcotics without nurses documented;
-29 out of 73 shifts without count of narcotics.
4. Observation on 3/25/19 at 6:30 A.M., showed Nurse BB pre-signed his/her initials in the
off-going nurse column on the facility’s controlled substance shift change count check
sheet, dated (MONTH) 2019, for the CMT’s cart for the 300 hall.
5. Review on 3/25/19 at 7:45 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the medication cart for the 400/500 hall,
showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 55)
-14 out of 73 shifts with one nurse documented count of narcotics;
-1 out of 73 shifts count of narcotics without nurses documented;
-2 out of 73 shifts without count of narcotics;
-A nurse had pre-signed in the nurse off-going column for the 3 P.M. shift on 3/25/19.
6. Review on 3/26/19 at 6:10 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the CMT cart for the 200 hall, showed:
-21 out of 76 shifts with one nurse documented count of narcotics;
-21 out of 76 shifts count of narcotics without nurses documented;
-32 out of 76 shifts without count of narcotics.
7. Review on 3/26/19 at 6:15 A.M., of the facility’s controlled substance shift change
count check sheet, dated (MONTH) 2019, for the nurse’s cart for the 300 hall, showed:
-16 out of 76 shifts with one nurse documented count of narcotics;
-4 out of 76 shifts count of narcotics without nurses documented;
-5 out of 76 shifts without count of narcotics.
8. During an interview on 3/26/19 at 12:48 P.M., the Director of Nursing (DON) said the
following:
-On going and off going nursing staff are expected to verify narcotics together by
counting the narcotics, verifying the count, documenting their findings on the narcotic
shift change report. It is expected every shift;
-The DON, Assistant to the Director of Nursing (ADON) and the staff educator are
responsible for checking if narcotic logs are filled out correctly;
-The facility does not have a set schedule to conduct an audit of narcotics or the
narcotic shift change reports. She could not say who conducted an audit in previous
months. The last time she checked the shift change narcotic reports was at the beginning
of this month, only looking at the first few days of documentation for this month;
-The pharmacy audits the carts every two months;
-Nurses are to notify the DON if narcotics are missing from shift to shift;
-The DON would use the narcotic shift change report when investigating missing narcotics;
-Given the examples of missing documentation on the narcotic shift change reports, they
are not sufficient to obtain accurate reconciliation of narcotics.

F 0757

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
resident who received hypnotic medications had regularly scheduled evaluations and
assessments. The facility also failed to document a clinical rationale for the use of
hypnotics and failed to ensure staff documented a need or reason that supported the use
for one of 20 sampled residents (Resident #10). The census was 96.
Review of Resident #10’s significant change Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/15/18, showed the following:
-Brief Interview for Mental Status (BIMS) score of 15 out of 15, showed the resident
cognitively intact;
-[DIAGNOSES REDACTED].
-Total dependence for transfers, dressing, eating, and hygiene;
-Antidepressants and opioids administered in the last seven days;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 56)
-No antipsychotics administered;
-No medication follow up.
Review of the resident’s face sheet, showed the following:
-Re-admitted on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
-An order, dated 10/8/18, for [MEDICATION NAME] 3 milligram (mg) at bedtime for [MEDICAL
CONDITION];
-An order, dated 1/17/19, [MEDICATION NAME] mg at bedtime for [MEDICAL CONDITION].
Review of the resident’s Medication Administration Record [REDACTED].
Review of the resident’s care plan, dated 2/13/19, showed:
Focus: The resident has a mood problem related to depression;
Goals: The resident will have improved mood state, happier, calmer appearance, no signs
and symptoms of depression, anxiety or sadness through the review date;
Interventions: Assist the resident in developing/provide the resident with a program of
activities that is meaningful and of interest. Encourage and provide opportunities for
exercise, physical activity;
-Assist the resident, family, caregivers to identify strengths, positive coping skills and
reinforce these;
-Educate the resident/family/caregivers regarding expectations of treatment, concerns with
side effects and potential adverse effects, evaluation, maintenance;
-The resident needs encouragement/assistance/support to maintain as much independence and
control as possible. The resident’s strengths are: Can ask for help and can express
feelings;
-Further review of the resident’s care plan, showed no documentation of [MEDICAL
CONDITION] or the use of Ambien.
Review of the resident’s progress notes, showed no documentation of the resident’s
[MEDICAL CONDITION], the use [MEDICATION NAME], or monitoring the resident for signs and
symptoms of [MEDICAL CONDITION], or the effectiveness of the medications used to treat
[MEDICAL CONDITION].
During an interview on 3/25/19 at 12:00 P.M., the resident said he/she had trouble
sleeping for several months. He/she did not believe the physician or the staff at the
facility addressed his/her [MEDICAL CONDITION]. Prior to being admitted to the facility,
he/she took 11 mg of Ambien. He/she only slept for two hours at night. He/she did not
believe he/she slept during the day, but he/she was told by staff that he/she slept all
day.
During an interview on 3/26/19 at 4:00 P.M., the Director of Nursing (DON) said she was
aware of the resident’s sleep issues. [MEDICATION NAME] decreased at some point last year,
but she was not aware that the resident was also administered [MEDICATION NAME]. If staff
were documenting the resident’s [MEDICAL CONDITION], it would be in the progress notes.
The DON confirmed that there was no documentation of the resident’s [MEDICAL CONDITION] in
the electronic medical record. There was no on-going documentation of interventions staff
have tried. She would expect the care plan to address the resident’s [MEDICAL CONDITION].
[MEDICATION NAME] have been as needed (PRN) if also administered [MEDICATION NAME].

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 57)
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure as needed (PRN) orders
for [MEDICAL CONDITION] drugs are limited to 14 day unless the attending physician or
prescribing practitioner believes that it is appropriate for the PRN order to be extended
beyond 14 days, document their rationale in the resident’s medical record and indicate the
duration for the PRN order, for two out of 20 sampled residents (Residents #59 and #47).
The census was 96.
1. Review of Resident #59’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/19/18, showed:
-Short term and long term memory problems;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s physician orders, dated (MONTH) 2019 and reviewed on 3/22/19,
showed and order dated 3/1/19, for [MEDICATION NAME] (antipsychotic medication used to
treat mental illness, behavior problems, and agitation) 2 milligram (mg), give every 2
hours PRN for agitation or anxiety.
Review of the resident’s medical record, showed no documentation the resident’s physician
evaluated the need for the continued order for the [MEDICATION NAME].
2. Review of Resident # 47’s quarterly MDS, dated [DATE], showed:
-Short term and long term memory problems;
-Medical [DIAGNOSES REDACTED].
Review of the resident’s physician orders, dated (MONTH) 2019 and reviewed on 3/25/19,
showed an order dated 2/25/19, for [MEDICATION NAME] ([MEDICAL CONDITION] medication used
to treat anxiety) 2 mg per milliliter (ml), take 0.5 ml three times a day as needed.
Review of the resident’s medical record, showed no documentation the resident’s physician
evaluated the need for the continued order for the [MEDICATION NAME].
3. During an interview on 3/26/19 at 2:19 P.M., the Director of Nursing (DON) said PRN
[MEDICAL CONDITION] medications should get renewed every 14 days.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 34 opportunities observed, three errors
occurred resulting in an 8.82% medication error rate (Residents #124, #42 and #17). The
census was 96.
1. Review of Resident #124’s physician order [REDACTED].
-Diagnoses included [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease);
-An order dated 3/13/19, to administer [MEDICATION NAME] (used for treatment of
[REDACTED].
Observation on 3/22/19 at 8:58 A.M., showed Certified Medication Tech (CMT) J administered
1 puff of the [MEDICATION NAME] to the resident, waited 30 seconds and administered the
second puff of the inhaler.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 58)
During an interview on 3/22/19 at 9:20 A.M., CMT J said the facility policy is to wait 1
to 2 minutes between puffs of the same inhaler.
2. Review of Resident #42’s POS, dated 3/1 through 3/31/19, showed:
-An order dated 1/11/18, to administer Olopatadine HCL 0.1% eye drops (an [MEDICATION
NAME] used to treat itching and redness in the eyes due to allergies [REDACTED].
-No diagnoses for the use of the eye drop.
Observation on 3/22/19 at 9:12 A.M., showed CMT J put on gloves, administered Olopatadine
HCL 0.1% 1 drop into the left eye and held the resident’s left inner canthus (eye duct)
for only 30 seconds. The resident immediately opened his/her eye. CMT J removed his/her
gloves, washed his/her hands and left the resident’s room.
Review of WebMD instructions for Olopatadine HCL eye drops, showed to apply gentle
pressure on the inner canthus for 1 to 2 minutes before opening the eyes after
administration.
During an interview on 3/22/19 at 9:20 A.M., CMT J said the facility policy is to hold the
inner canthus for 1 minute after administering an eye drop.
3. Review of Resident #17 medical record, showed:
-Medical diagnoses included [MEDICAL CONDITION] (iron poor blood);
-A physician order, dated 9/10/18, for [MEDICATION NAME] (Iron) 300 milligram (mg) per 5
milliliter (ml), take 5 ml (300 mg) via gastronomy ([DEVICE], a tube surgically inserted
into the stomach to provide hydration, nutrition and medications) once daily with
breakfast.
Observation on 3/25/19 at 8:31 A.M., showed Nurse A prepared medications to administer to
the resident. Nurse A poured iron supplement exclir, 220 mg per 5 ml, into a medication
cup. Nurse A verified he/she poured 5 ml of the iron supplement into the medication cup.
After verifying placement of the resident’s [DEVICE], Nurse A poured the 5 ml of iron
supplement into the [DEVICE] via gravity. Nurse A finished administering the remainder of
the resident’s medications and left the room.
During an interview on 3/26/19 at 12:48 P.M., the Director of Nursing (DON) looked at the
bottle of iron supplement and verified the resident received 5 ml of 220 mg per 5 ml, for
a dose of 220 mg instead of 300 mg. She expects nurses give the correct dose of medication
according to the resident’s physician order [REDACTED].
4. During an interview on 3/22/19 at 12:40 P.M., the Assistant Director of Nurses (ADON)
said the facility policy is to wait 1 minute between puffs of the same inhaler to ensure
absorption of the medication and to hold the inner canthus for 1 minute after eye drop
administration to ensure the medication stays in the eye.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure drugs and
biologicals were labeled and stored in accordance with currently accepted professional
standards in two of two medication storage rooms. The census was 96.
Review of the facility’s undated medication storage policy, showed:
-Policy: Medications and biological are stored safely, securely, and properly following

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 59)
the manufacture or supplier recommendations;
-External medications including ointments for skin irritations and medication for
application to wounds should be kept in a treatment cart or in a separate drawer in the
medication cart, which is labeled as such;
-Potentially harmful substances (e.g. urine test reagent tablets, household poisons,
cleaning supplies, disinfectants) are stored in a locked area separately from medications;
-Medication storage areas are kept clean, well lit, and free of clutter;
-The monthly inspection by the consultant Pharmacist and/or Nurse will address all aspects
of drug storage and record keeping, and will be documented for facility follow-up.
1. Observation of the ,[DATE] hall medication storage room, on [DATE] at 7:00 A.M.,
showed:
-On the counter:
-Water bottle and full coffee cup from a local gas station;
-Staff tote, jacket, and used tennis shoes;
-Ketchup packets, and a pile of examination gloves not in a box;
-Medication bottles for current residents;
-Sink contained old, dried French fries and discarded straw wrappers;
-In lower cabinet:
-Dirty cereal bowl;
-Under the sink:
-Container of Lysol and glass cleaner;
-Used bottle of wound cleanser, not labeled;
-Acetic acid (a chemical reagent for the production of chemical compounds) labeled with a
resident’s name, not labeled for the use;
-A nebulizer machine (a machine used for breathing treatments), not in bag, lying amidst
general debris;
-In upper cabinet:
-A nebulizer machine, not in bag;
-In a pull out drawer:
-A urine sample cup labeled with a resident’s name mixed in with other urine sample cups,
swab sticks and a pair of glasses.
2. Observation of the ,[DATE] hall medication storage room, on [DATE] at 7:40 A.M.,
showed:
-The small white refrigerator contained snacks for residents:
-Six expired containers of white milk;
-Seven expired containers of chocolate milk;
-In drawers:
-Oxygen extension tubing, expiration date ,[DATE];
-Intravenous (IV, to give therapies through the vein) administration set, expiration date
[DATE];
-Six sandwich baggies containing cookies, undated;
-A container of Medseptic (skin protectant cream), opened, not labeled, expiration date
of ,[DATE].
3. During an interview with the Director of Nursing (DON) on [DATE] at 12:50 P.M., the
following statements were made:
-Staff are expected to store their personal belongings in their locker or in their car,
not in medication storage rooms;
-Staff should not store their food and drinks in the medication storage rooms, on the
counters or in cabinets;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 60)
-Dishes and soda are not stored in medication storage rooms;
-Clean equipment is stored in the supply room not in medication storage room or in
cabinets;
-Clean equipment is bagged to prevent contamination;
-All expired medical supplies are discarded to prevent possible use on residents;
-Nurses on the ,[DATE] hall are responsible for checking the refrigerator in the
medication storage room and are expected to throw out expired milk;
-Resident snacks of cookies in sandwich baggies should not be in stored in a drawer and
should have a date;
-Staff are expected to send medications that are no longer in use back to the pharmacy or
discard them appropriately;
-Medication storage rooms are expected to maintain cleanliness and organization in order
to control contamination.

F 0770

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide timely, quality laboratory services/tests to meet the needs of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide or obtain laboratory
services to meet the needs of its residents for one of 20 sampled residents (Resident
#167). The census was 96.
Review of Resident #167’s medical record, showed [DIAGNOSES REDACTED].
Review of the resident’s physician’s orders [REDACTED].
-An order, dated 3/20/19, for [MEDICATION NAME] trough (monitor levels of the antibiotic
[MEDICATION NAME] in the blood) twice a week;
-An order, dated 3/20/19, for complete blood count (CBC, screening test to determine
general health status) lab;
-An order, dated 3/20/19, for comprehensive metabolic count, (CMP, a test that provides
information of the body’s chemical balance and metabolism) lab;
-An order, dated 3/20/19, for [MEDICATION NAME] 1250 milligram (mg) /250 milliliter (ml)
infuse 250 ml (1,250 total) intravenous every 12 hours at 9:00 A.M. and 9:00 P.M.
Review of the resident’s lab results, showed the following:
-A lab result, dated 3/21/19, for [MEDICATION NAME] trough, showed normal range;
-No lab result for CMP or CBC.
During an interview on 3/26/19 at 3:13 P.M., the Director of Nursing (DON) said the charge
nurse was responsible for ensuring the labs are completed as ordered. The DON confirmed
that the resident was admitted on [DATE]. She would expect to see a completed CMP, CBC,
and one more [MEDICATION NAME] trough level by this time. The lab for CBC and CMP were not
completed. It is important for the resident’s labs to be completed as ordered to determine
if there are toxic levels or normal levels in the blood.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Some

Based on observation, interview and record review, the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service
safety by not labeling food after opened and not following proper hand washing practices.
This had the potential to affect all residents who ate from the facility kitchen. The
census was 96.
1. Review of the facility’s undated Food Storage policy, showed the following:
-Packaging of food items must be intact and clean and it must protect food from
contamination. Food items must be correctly labeled and contain the correct documentation;
-Identify the food items use by expiration date;
-Store items with the earliest use by or expiration dates in front of items with later
dates;
-Once shelved, use those items stored in front first.
Observation on 3/21/19 at 9:19 A.M., of the dry food storage located in the kitchen,
showed:
-A box of corn starch opened and undated;
-A blue coffee cup, covered with clear plastic wrap, with holes in the plastic wrap, with
what appeared to be sugar inside the cup, located on a shelf in front of a box of sugar
packets;
-A bag of graham cracker crumbs, wrapped with clear wrap, opened, and undated.
Observation on 3/23/19 at 12:06 P.M., of the kitchen, showed:
-Inside the dry storage, a blue coffee cup, covered with clear plastic wrap, with holes
in the plastic wrap, with what appeared to be sugar inside the cup, located on a shelf in
front of a box of sugar packets;
-Inside the refrigerator, four sandwiches, in baggies, not dated;
-A bag of white shredded cheese, wrapped in clear plastic wrap, not dated;
Observation on 3/25/19 at 3:28 P.M., of the dry storage located inside the kitchen, showed
the following;
-A bag of chocolate cake mix, wrapped with clear plastic wrap, opened and undated,
-A bag of yellow mix, wrapped with clear plastic wrap, opened and undated,
-A bag of cocoa mix, opened, uncovered and undated.
2. Review of the facility’s undated Hand Washing policy, showed the following:
-Wet hands with soap and warm water;
-Rub hands for 20 seconds. Get under fingernails and between fingers;
-Rinse under warm running water;
-Dry hands on your own clean towel;
-Turn off water with paper towel and throw towel away.
Observation on 3/25/19 at 10:07 A.M., showed Cook CC prepared baked cod puree. He/she
walked over to the dishwasher, removed a clear plastic container from the dishwasher, and
used the container to blend the cooked zucchini. After he/she pureed the zucchini, he/she
walked over to the dishwasher, not wearing gloves and touched the dishwasher handles.
Without washing his/her hands, he/she removed the clear plastic container from the
dishwasher, and placed the cooked noodles inside and pureed the noodles. With unwashed
hands, he/she touched the inside of the container he/she used to pour the pureed noodles
into.
4. During an interview on 3/27/19 at 7:10 A.M., the dietary manager said dietary staff
were expected to date all food prior to storage and staff were expected to wash their
hands according to the facility policy.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Some

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure all resident records
were complete and accurately documented and failed to ensure three months of medication
and treatment administration records (MARs and TARs) were placed in the residents medical
records, for seven of 20 sampled residents (Residents #216, #7, #272, #18, #15, #33 and
#10). The census was 96.
1. Review of Resident #216’s (MONTH) 2019 physician order [REDACTED].
Further review of the resident’s medical record, showed no MARs or TARs available in the
resident’s medical record for (MONTH) (YEAR), (MONTH) 2019 or (MONTH) 2019.
2. Review of Resident #7’s medical record, showed [DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed no MARs or TARs available in the
resident’s medical record for (MONTH) (YEAR), (MONTH) 2019 or (MONTH) 2019.
3. Review of Resident #272’s medical record, showed [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) 2019 MAR, reviewed on 3/22/19, showed:
-Blood sugar checks: Check and record daily related to diabetes, left blank on 3/5, 3/13,
3/14, and 3/17/19;
-Pain assessment: Check and record every shift, use scale 0-10. Pain assessment documented
four times out of 63 opportunities;
-No reason documented indicating why staff left the boxes for the blood sugar checks and
pain assessments blank.
Further review of the resident’s medical record, showed no MARs and TARs available for the
months of (MONTH) and (MONTH) 2019.
4. Review of Resident #18’s medical record, showed [DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed no MARs or TARs available for
(MONTH) (YEAR), (MONTH) 2019 or (MONTH) 2019.
5. Review of Resident #15’s medical record, showed [DIAGNOSES REDACTED]. Other effects
include [MEDICAL CONDITION] symptoms such as rigid muscles, slow movement and tremors),
[MEDICAL CONDITION], high blood pressure and obesity.
Further review of the resident’s medical record, showed no MARs or TARs available for
(MONTH) (YEAR), (MONTH) 2019 or (MONTH) 2019.
6. Review of Resident #33’s medical record, showed [DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed no MARs or TARs available for
(MONTH) 2019 or (MONTH) 2019.
7. Review of Resident #10’s medical record, showed [DIAGNOSES REDACTED].
Further review of the resident’s medical record, showed no MARs available for (MONTH) 2019
and (MONTH) 2019.
8. During an interview on 3/26/19 at 7:38 A.M., the medical records director said when
MARs and TARs are completed, he/she files them in the chart. It takes approximately two
days to get them filed.
9. During an interview on 3/26/19 at 4:00 P.M., the Director of Nursing (DON) said she was
not sure why the resident’s MARs and TARs were not in the medical record. Medical records
is responsible for ensuring the resident’s medical record was complete. She would expect
at least three months of MARs and TARs to be included in the medical record. Medical
records should be accurate and complete.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Have a plan that describes the process for conducting QAPI and QAA activities.

Based on interview and record review, the facility failed to develop and implement a plan
that describes the process for conducting quality assurance performance improvement
(QAPI)/quality assessment and assurance (QAA) activities, such as identifying and
correcting quality deficiencies as well as opportunities for improvement, which will lead
to improvement in the lives of nursing home residents, through continuous attention to
quality of care, quality of life, and resident safety. This had the potential to affect
all residents at the facility. The census was 96.
Review of the facility’s undated Quality Assessment and Assurance Plan, showed:
-The primary purpose of the QAA plan:
-To provide a means whereby negative outcomes relative to resident care and safety can be
identified and resolved through an interdisciplinary approach and effective system of
services and positive care measures rendered can be reinforced and explained to improve
care given;
-To establish and provide a system whereby a specific process, and the documentation
relative to is, is maintained to support evidence of an ongoing QAA program, encompassing
all aspects of resident care including safety, infection control and quality of life
applicable to nursing home residents;
-To develop monitoring tools that provide an effective mechanism to assure that each
resident receives the necessary care and services to attain or maintain his or her highest
practicable physical, mental and psychosocial well-being;
-To assist departments, consultants and ancillary services that provide direct or
indirect care to residents to delineate lines of authority, responsible and accountability
so that open lines of communication and negative outcome resolutions may be achieved for
optimum resident care on a continuous basis;
-To develop plans of correction and evaluate corrective actions taken to obtain the
desired result;
-To provide a centralized coordinated approach to QAA activities so as to bring out a
comprehensive program of QAA to meet the needs of the facility;
-Meetings are held once a month, usually on the last Tuesday of the month;
-Committee consists of the following individuals: administrator, Director of Nursing
(DON), assistant DON, social services, Minimum Data Set coordinator, dietary manager,
activity director, medical records, maintenance, housekeeping/laundry, business office,
human resources, marketing/admissions, wound nurse, therapy, medical director, and
pharmacy;
-Further review of the facility’s QAA plan, showed the plan failed to:
-Describe how the facility will be tracking and measuring performance;
-Describe how the facility will establish goals and thresholds for performance
measurement;
-Describe how the facility will identify and prioritize quality deficiencies;
-Describe how the facility will systematically analyzing underlying causes of systemic
quality deficiencies;
-Describe how the facility will develop and implement corrective action or performance
improvement activities;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 64)
-Describe how the facility will monitor or evaluate the effectiveness of corrective
action/performance improvement activities, and revise as needed.
During an interview on 3/27/19 at 10:43 A.M., with the DON and administrator, the DON said
all department managers are part of the QAA committee but the medical director has not
been consistent with coming. The committee meets monthly. Floor staff do not attend. The
committee will look at wounds reports, weight loss and fall reports to determine what will
be addressed. The facility addresses individual resident concerns. The facility does not
have a process to address wide spread facility failures or identify potential issues. The
committee addresses concerns once they arise on an individual, case by case basis.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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 follow
acceptable infection control standards by failing to appropriately clean community blood
glucose testing (BGT) machines and community use treatment equipment between use for three
residents observed during BGT (Residents #27, #316, #319). The facility failed to use
acceptable infection control standards for one resident observed during wound care
(Resident #33) and failed to change a peripherally inserted central catheter (PICC line,
an intravenous (IV) line for administering IV medications) for one resident (Resident
#167). The facility failed to follow their respiratory hygiene/cough etiquette policy by
not providing accessible masks, tissues, hand sanitizer and trash receptacles to visitors
and failed to follow their employee [MEDICAL CONDITION] (TB) screening policy by not
assuring staff had no contact with residents until their first step Purified Protein
Derivative (PPD) was read negative for eight of nine sampled employees and reading the
first and second step PPD late for one of nine sampled employees. In addition, the
facility failed to conduct a facility risk assessment to identify where Legionella
(waterborne pathogen) could grow and develop and/or implement a water management program
and policies for testing protocols. This deficient practice has the potential to affect
all residents who reside at the facility. The census was 96.
1. Review of the Centers for Medicare and Medicaid Services (CMS), Center for Clinical
Standards and Quality, Safety and Oversight Group memo QSO-17-30, revised 7/6/18, showed:
-Requirement to reduce Legionella risk in healthcare facility water systems to prevent
cases and outbreaks of Legionnaires’ disease (LD);
-For skilled nursing facilities and nursing facilities: Policies must include a system for
identifying, reporting, investigating and controlling infections and communicable disease
of patients and personnel;
-Medicare and Medicaid certified healthcare facilities are expected to have water
management policies and procedures to reduce the risk of growth and spread of Legionella
and other opportunistic pathogens in building water systems. Facilities must have water
management plans and documentation that, at a minimum, ensure each facility:
-Conducts a facility risk assessment to identify where Legionella and other opportunistic
waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas,
nontuberculous mycobacteria, and fungi) could grow and spread in the facility water
system;
-Develops and implements a water management program that considers the American Society

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Many

(continued… from page 65)
of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard and
the Centers for Disease Control (CDC) toolkit;
-Specifies testing protocols and acceptable ranges for control measures, and document the
results of testing and corrective actions taken when control limits are not maintained;
-Maintains compliance with other applicable Federal, State and local requirements.
During an interview on 3/26/19 at 5:22 P.M., the nurse educator said the facility does not
have a Legionaries policy and procedure. At 5:37 P.M., the Director of Nursing (DON)
verified the facility had no policies or protocols regarding Legionella.
During an interview on 3/27/19 at 10:43 A.M., with the DON and Administrator, the DON said
she was not sure if the facility has conducted a risk assessment to identify where
Legionella and other opportunistic waterborne pathogens could grow and spread in the
facility water system. She did not know if the facility had developed and implemented a
water management program.
2. Review of Resident #27’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/25/19 at 7:20 A.M., showed Nurse K obtained
the BGT equipment, said he/she had already cleaned the BGT machine with an alcohol swab,
put on gloves, took the equipment into the resident’s room and placed the equipment on a
clean barrier on top of the resident’s bedside cabinet. He/she obtained the resident’s
BGT, told the resident the results, removed his/her soiled gloves, picked up the BGT
machine and the barrier, took them out of the resident’s room and placed the now soiled
barrier and equipment directly on top of the medication cart. He/she cleaned the BGT
machine with an alcohol swab and placed the machine in the top drawer of the medication
cart. He/she said the facility policy is to clean the machine before and after use with an
alcohol swab, that is the only thing the facility has to clean the equipment.
3. Review of Resident #316’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/26/19 at 11:00 A.M., showed Nurse G obtain a
BGT from the resident:
-He/she donned gloves without first washing and/or sanitizing his/her hands;
-He/she obtained the BGT machine, supplies and alcohol pads from the top drawer of
medication cart and placed all supplies directly on the resident’s potentially soiled
bedside table;
-He/she obtained the resident’s BGT, reported the results to the resident, and gathered
the dirty supplies to include the lancet (device used to draw blood) and placed them into
the palm of his/her glove, removed the glove and threw it away in the resident’s trash
can;
-He/she placed the BGT machine on the counter of the communal room sink and washed his/her
hands;
-He/she returned the BGT machine to the medication cart and placed it in the first drawer.
During an interview on 3/26/19 at 11:06 A.M., Nurse G said he/she did not have wipes to
clean the BGT machine. The facility seldom had the wipes in stock.
4. Review of Resident #319’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].>Observation on 3/26/19 at 11:08 A.M., showed Nurse G obtained
a BGT on the resident:
-He/she squirted antibacterial gel into a paper towel, took the BGT machine out of the
medication cart and rubbed the antibacterial gel over the surface of the BGT machine;
-He/she cleansed his/her hands, donned gloves, gathered the BGT supplies and walked into
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Many

(continued… from page 66)
resident’s room;
-He/she placed a barrier on the resident’s bedside table and placed the BGT supplies upon
it;
-He/she obtained the resident’s BGT, reported the results to the resident, and gathered
the dirty lancet, and supplies into the palm of his/her glove, removed the glove and threw
it away in the resident’s trash can;
-He/she washed his/her hands and picked up the dirty BGT machine from off the bedside
table with the barrier;
-He/she threw the barrier away, got a new paper towel and squirted antibacterial gel onto
it;
-He/she used the antibacterial gel soaked paper towel to wipe the BGT machine;
-He/she returned the BGT machine into the first drawer of the medication cart.
5. During an interview on 3/26/19 at 10:43 A.M., the Assistant Director of Nurses (ADON)
said the BGT machine is to be cleaned with a bleach wipe before and after each use for
infection control issues. Cleaning the machine with an alcohol swab or hand sanitizer
would not kill all of the germs and you could then have cross contamination between
residents.
6. Review of Resident #33’s medical record, showed:
-[DIAGNOSES REDACTED].
-an order for [REDACTED].
Observation on 3/25/19 at 10:15 A.M., showed the resident lay in bed. The wound nurse
removed a box of gloves, a bottle of wound cleanser, two 4 ounce containers of normal
saline, 4×4 gauze and Kerlix (a stretch gauze dressing) out of the treatment cart, took
them into the resident’s room along with a clean disposable waterproof pad. She placed the
box of gloves directly on the soiled sink top, directly under the paper towel dispenser,
placed the bottle of wound cleanser and the two containers of normal saline directly on
top of the resident’s soiled over the bed table and placed the barrier and dressings on
the resident’s bed. She washed her hands, dried them with a paper towel from the
dispenser, water visibly dripped from her hands down toward the box of gloves, put on
gloves, removed the old dressings, measured the areas and applied the treatment. The wound
nurse changed her soiled gloves and washed her hands at least six times during the
treatment, with water dripping from her hands as she removed paper towels from the
dispenser to dry her hands. After she had finished the resident’s treatment, she took the
box of gloves and placed them directly in the top drawer of the treatment administration
cart, placed the bottle of wound cleanser and one container of normal saline directly into
the metal box on the side of the treatment cart. She did not clean the box of gloves, the
wound cleanser or the normal saline prior to placing them in the cart and moving on to the
next resident.
7. Review of Resident #167’s face sheet, showed [DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 3/21/19, showed the following:
-Focus: The resident has infection of the back. [DIAGNOSES REDACTED].
-Intravenous (IV) antibiotics, no stop date. Continue until further notice;
-Approach: Administer antibiotic as per physician orders;
-Focus: The resident is on IV medications related to wound management;
-IV Dressing: Observe dressing every shift. Change dressing and record observations of
site weekly;
-Monitor/document/report PRN signs and symptoms of leaking at the IV site: [MEDICAL
CONDITION] at the insertion site, shiny or stretched skin, whitening/blanching or coolness
of the skin, slowing or stopping of the infusion, and leaking of IV fluid out of the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Many

(continued… from page 67)
insertion site.
Review of the resident’s physician’s orders [REDACTED].
During an interview on 3/21/19 at 10:36 A.M., the resident said he/she was in the hospital
due to a flesh eating bacteria on his/her back. He/she had a PICC line on the right arm.
It was inserted in the hospital.
Observation on 3/26/19 at 2:43 P.M., showed the resident had a PICC line to the right arm
with a bandage dated 3/18/19.
During an interview on 3/27/19 at 6:55 A.M., Nurse BB confirmed the dressing dated
3/18/19.
During an interview on 3/27/19 at 7:05 A.M., the DON said she would expect staff to follow
physician’s orders [REDACTED].
During an interview on 3/27/19 at 7:19 A.M., Nurse H said he/she was told that the
resident’s PICC line dressing needed to be change changed, but staff had to order the
supplies. They did not have a kit at the facility, and he/she was not IV certified, so
he/she could not change it.
8. Review of the facility’s undated Respiratory Hygiene/Cough Etiquette in Healthcare
Settings policy, showed:
-To prevent the transmission of all respiratory infections in healthcare settings,
including influenza, the following infection control measures should be implemented at the
first point of contact with a potentially infected person. They should be incorporated
into infection control practices as one component of standard precautions;
-Visual alerts: Post visual alerts at the entrance to outpatient facilities instructing
patients and persons who accompany them to inform healthcare personal of symptoms of a
respiratory infection when they first register for care and to practice respiratory
hygiene/cough etiquette:
-Cover your cough;
-Information about persona protective equipment;
-Respiratory hygiene/cough etiquette: The following measures to contain respiratory
secretions are recommended for all individuals with signs and symptoms of a respiratory
infection:
-Cover your mouth and nose with a tissue when coughing or sneezing;
-Use in the nearest waste receptacle to dispose of the tissue after use;
-Perform hand hygiene after having contact with respiratory secretions and contaminated
objects/materials;
-Healthcare facilities should ensure the availability of materials for adhering to
respiratory hygiene/cough etiquette in waiting areas for patient and visitors;
-Provide tissues and no-touch receptacles for used tissue disposal;
-Provide conveniently located dispensers of alcohol-based hand rub;
-During periods of increased respiratory infection activity in the community, offer masks
to persons who are coughing.
Observation in the front entrance to the facility, showed information posted about
influenza, dated 10/1/18:
-Influenza (the flu) is an infectious disease caused by [MEDICAL CONDITION]. Flu can cause
serious illness that may result in hospitalization or death;
-The single best way to protect against influenza is to get vaccinated each year;
-Do not visit the facility if you know you are sick;
-If visiting, wear a mask (no information where to obtain a mask);
-Get a flu shot.
Observation of the facility, on 3/26/19 at 4:31 P.M., showed alcohol gel dispensers’
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Many

(continued… from page 68)
located mid-way down the 100 hall, 200 hall, 300 hall, and two located in the main dining
room. No hand sanitizer available to residents, volunteers or visitors on the 400/500
locked unit and/or front entrance to the facility. No information on cough etiquette,
personal protective equipment (PPE) or respiratory hygiene available to residents,
visitors or volunteers. No masks, tissues and/or no-touch receptacles for used tissue
disposal available to visitors.
During an interview on 3/27/19 at 10:43 A.M., with the DON and administrator, the DON said
the flu season is considered to be (MONTH) through May. She would consider the facility to
currently be in a season with high risk for respiratory infections. Only if there is an
outbreak of a respiratory illness would the facility post information at the front door
telling visitors not to visit. There is hand gel in the halls that can be used by
visitors. There is nothing in the main entrance. She would expect the facility follow
their policy regarding respiratory hygiene.
9. Review of the facility’s Employee [MEDICAL CONDITION] Screening policy, dated 2012,
showed:
-TB screening is a part of the pre-employment medical examination. In general, all
employees who work ten (10) or more hours per week in a long term care facility are to
comply with established TB screening procedures;
-A two-step test is usually given;
-Upon employment, the employee will receive 0.1 milliliter (ml) of the PPD intradermal
(under the skin);
-The employee is then instructed to return in 48 to 72 hours;
-The employee is not to have any patient contact until after the results of the first skin
test have been obtained.
Review of Dietary Aide T’s employee file, showed:
-Date of hire 6/6/18;
-First step PPD administered 6/6/18 and read negative on 6/9/18.
Review of CNA U’s employee file, showed:
-Date of hire 7/26/18;
-First step PPD administered 7/26/18 and read negative on 7/29/18.
Review of Nurse C’s employee file, showed:
-Date of hire 10/17/18;
-First step PPD administered 10/17/18 and read negative on 10/20/18.
Review of Dietary Aide V’s employee file, showed:
-Date of hire 10/24/18;
-First step PPD administered 10/24/18 and read negative on 10/27/18.
Review of CNA W’s employee file, showed:
-Date of hire 11/1/18;
-First step PPD administered 11/1/18 and read negative on 11/4/18.
Review of Maintenance Worker X’s employee file, showed:
-Date of hire 1/25/19;
-First step PPD administered 1/25/19 and read negative on 1/28/19.
Review of CNA D’s employee file, showed:
-Date of hire 3/7/19;
-First step PPD administered 3/7/19 and read negative on 3/10/19.
Review of CNA Y’s employee file, showed:
-Date of hire 1/25/19;
-First step PPD administered 1/25/19 and read late on 1/29/19;
-Second step PPD administered on 2/4/19 and read late on 2/8/19.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265719

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

NAME OF PROVIDER OF SUPPLIER

OAKWOOD ESTATES NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

5303 BERMUDA DRIVE
NORMANDY, MO 63121

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 – Many

(continued… from page 69)
During an interview on 3/27/19 at 7:15 A.M., the dietary manager said new dietary staff
have a day observing the job and the second day is hands on training, serving the
residents.
During an interview on 3/26/19 at 5:29 P.M., the regional maintenance director said newly
hired maintenance staff training consists of getting out on the floor, getting to know
what they can and cannot do with the residents and getting to know the lay out of the
building. It is hands on.
During an interview on 3/26/19 at 4:17 P.M., the nurse educator said the orientation
process for CNA and nurses both consist of a day in the class room from 9:00 A.M. to 11:30
A.M. After that, training is provided on the floor with residents.
During an interview on 3/27/19 at 11:55 A.M., the assistant DON said she is the person
responsible for employee PPDs. She thought she was supposed to administer and read PPDs
before staff have contact with residents, but that is not how it had been done at the
facility. She thought it must be different at every facility.