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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to be treated with respect and dignity and to retain and use
personal possessions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure the
admission policy did not limit the facility’s responsibility for resident’s personal
property, and failed to provide completed personal inventory lists for seven of 20 sampled
residents (Resident #245, #69, #20, #14, #66, #69 and #59). The census was 96.
1. Review of the facility’s undated resident admission agreement, showed the following:
-Personal items and services: Any personal items such as TV; radios, cell phones, books,
gifts, dentures and hearing aids are not the responsibility of the community if stolen,
lost or damaged.
During an interview on 12/11/18 at 10:30 A.M., the administrator said he would take the
language out of the admission agreeement removing the facility’s responsibility for
resident’s personal items. He was not aware the agreement included that language.
2. Review of Resident #245’s medical record, showed:
-admitted to the facility on [DATE];
-admitted to hospice services on 11/17/18:
-[DIAGNOSES REDACTED].
Observation on 12/7/18 at 8:32 A.M., showed the resident asleep in bed and covered with a
purple and white afgan. The resident’s closet contained five pair of pants, four shirts
and two pairs of shoes.
Review of the resident’s medical rcord, showed a blank facility property inventory sheet.
3. Review of Resident #69’s medical record, showed:
-admitted on [DATE];
-[DIAGNOSES REDACTED].
Observation of the resident’s closet on 12/7/18 at 10:15 A.M., showed multiple pants,
shirts and shoes. The items had been labeled with the resident’s name.
Review of the resident’s medical record, showed a blank inventory sheet.
4. Review of Resident #20’s quarterly Minimum Data Set (MDS), a federally mandated
asssessment instrument completed by facility staff, dated 9/9/18, showed the following:
-admitted to the facility on [DATE];
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
During an interview on 12/6/18 at 9:32 A.M., the resident said his/her spouse gave him/her
a blanket and it disappeared. He/she said the facility made no offer to replace it.
Review of the resident’s medical record, showed a blank personal belongings inventory
sheet.
Observation of the resident’s room on 12/6/18 at 9:32 A.M., 12/7/18 at 6:50 A.M., 12/10/18
at 10:21A.M. and 12/11/18 at 7:03 A.M., showed pictures, a TV and other personal items.
5. Review of Resident #14’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
During an interview on 12/5/18 at 11:30 A.M., the resident said a staff member broke one
of his/her hand held speakers and the facility refused to replace it.
Review of the medical record, showed a blank personal belongings inventory sheet.
Observation of the resident’s room on 12/5/18 at 11:30 A.M., 12/7/18 at 11:45 A.M. and
12/11/18 at 8:56 A.M., showed a stereo system, computer, clothing and multiple other
personal items.

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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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 0557

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
6. Review of Resident #66’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the medical record, showed a blank personal belongings inventory sheet.
Observation of the resident’s room on 12/5/18 at 10:49 A.M., 12/6/18 at 1:32 P.M. and
12/17/18 at 1:51 P.M., showed a TV and clothing.
7. Review of Resident #49’s face sheet, showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed no inventory of personal items.
Observation of the resident’s room on 12/5/18 at 1:52 P.M., 12/6/18 at 1:32 P.M. and
12/7/18 at 7:10 A.M., showed the resident had a recliner and personal items including
pictures, as well as clothing.
8. Review of Resident #59’s face sheet, showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed no inventory of personal items.
Observation of the resident’s room on 12/5/18 at 2:11 P.M., 12/6/18 at 7:11 A.M. and 1:50
P.M., 12/7/18 at 7:10 A.M., and 12/10/18 at 8:13 A.M., showed a wood bedroom set, a
recliner, and other miscellaneous decor items and photographs.
9. During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing said the nurses
completed the personal inventory sheets when residents are admitted . Any additions to the
inventories would be added at the time the resident aquired something new. The inventory
sheets are kept in the resident’s medical record.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to ensure their abuse and
neglect policy identified when, how and by whom determination of capacity to consent to
sexual contact will be made and where this documentation will be maintained. The census
was 96.
Review of the facility’s Abuse Policy and Procedures, dated (MONTH) (YEAR), showed the
following:
-This facility affirms the right of our residents to be free from abuse, neglect,
misappropriation of resident property, corporal punishment and involuntary seclusion;
-Abuse means any physical or mental injury, or sexual assault inflicted upon a resident
other than by accidental means in a facility. Abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or
mental anguish. This also includes the deprivation by an individual, including a
caretaker, of goods or services that are necessary to attain and/or maintain physical,
mental and psychosocial well-being. This assumes that all instances of abuse of residents,
even those in a coma, cause physical harm or pain or mental anguish;
-The policy failed to identify when, how and by whom determination of capacity to consent

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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
to sexual contact will be made and where this documentation will be maintained.
During an interview on 12/11/18 at 10:30 A.M., the administrator said he would see that
the policy was updated to include it.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
had complete, accurate and individualized care plans, to address the nutritional status
and pain control for two of 20 sampled residents (Residents #42 and #14). The census was
96.
1. Review of Resident #42’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 7/7/18, showed the following:
-Severe cognitive impairment;
-Extensive to total dependence on staff for all mobility and personal care;
-[DIAGNOSES REDACTED].
-Care area assessment prompted nutritional status to be care planned.
Review of the care plan, dated 7/7/18 and last reviewed and updated on 10/24/18, showed no
documentation regarding nutritional status.
Review of the resident’s weights from 6/18/18 through 11/18/18, showed a weight loss of
15.57%.
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said the care
plan should have included the resident’s nutritional status and updated as needed.
2. Review of Resident #14’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
-Frequent moderate pain.
Review of the care plan, dated 6/22/18, showed no documentation regarding the resident’s
pain.
Review of the POS [REDACTED]
-An order, dated 10/24/18, to apply a [MEDICATION NAME] (narcotic [MEDICATION NAME]) 25
microgram (mcg) patch and change every three days;
-An order, dated 11/16/18, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME]) 30
milligrams (mg) one tablet daily at bedtime;
-An order, dated 11/16/18 to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
5/325 mg every six hours PRN (as needed) for pain relief.
During an interview on 12/11/18 at 10:30 A.M., the DON said pain should have been
addressed on his/her care plan because that was an ongoing issue from the beginning of
his/her stay.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure ordered
antibiotics had a reason and frequency for administration, ensure treatment orders
included the location for the application, ensure there were physician orders
[REDACTED].#66, #42, #59, #69, #20, #61 and #92). The census was 96.
1. Review of Resident #66’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/23/18, showed the following:
-No cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s physician order [REDACTED].
-An order dated 10/17/18, to administer Fluconazole (antibiotic) 100 milligram (mg) for
three days;
-No [DIAGNOSES REDACTED].
Review of the POS [REDACTED]
-An order dated 11/18/18, to administer [MEDICATION NAME] (antibiotic) 500 mg one tablet
by mouth twice a day for seven days. No [DIAGNOSES REDACTED].
-An order dated 11/18/18 to administer [MEDICATION NAME] (antibiotic) one gram (gm) one
time NOW. No [DIAGNOSES REDACTED].
-An order dated 11/18/18, to administer Ceftraxone (antibiotic) 500 mg intramuscularly
(IM, injection in to the muscle) one time NOW. No [DIAGNOSES REDACTED].
-An order dated 11/29/18, to administer [MEDICATION NAME] 500 mg one tablet by mouth twice
a day for seven days. No [DIAGNOSES REDACTED].
Review of the POS [REDACTED]
-An order dated 12/7/18, to administer [MEDICATION NAME] 500 mg by mouth twice a day for
seven days;
-No [DIAGNOSES REDACTED].
2. Review of Resident #42’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive to total assistance required from staff for all mobility and personal care;
-Diagnoses included heart failure and dementia.
Review of the resident’s POS, dated 10/26/18 through 10/31/18, showed the following:
-An order, dated 10/31/18, to administer [MEDICATION NAME] (antibiotic) 100 mg by mouth
twice a day for seven days;
-No [DIAGNOSES REDACTED].
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said that
when an antibiotic is ordered it should include the route of administration, the frequency
of administration, the number of days to be administered and the [DIAGNOSES REDACTED].
3. Review of Resident #59’s significant change MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADL’s);
-Total assistance required for toilet use;
-Incontinent of bowel and bladder;
-At risk for pressure ulcers (injuries to skin and underlying tissue resulting from
prolonged pressure on the skin);
-Diagnoses included heart failure, high blood pressure, [MEDICAL CONDITION] (inability to
speak), stroke, dementia, anxiety and depression.
Review of the resident’s care plan, dated 10/24/18, showed the 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-Problem: Pressure ulcer- no noted breakdown at this time and utilize approaches to help
limit risk of skin breakdown;
-Approach: Do treatments as ordered by physician, provide diet as ordered;
-Problem: Nutritional status, received mechanical soft diet and weight would remain stable
with good hydration and skin intact;
-Approach: Monitor and encourage consumption, monitor hydration, assist with tray setup
and monitor weights.
Review of the resident’s POS, dated 12/1/18 through 12/31/18, showed the following:
-An order dated 10/8/18, for [MEDICATION NAME] (protective skin ointment) cream, apply to
affected area four times daily as needed (no area specified);
-An order dated 10/8/18, for [MEDICATION NAME] (topical medication used to treat
inflammation) ointment 0.1 percent (%), apply to affected area every day as needed (no
area specified);
-An order, dated 10/19/18, for [MEDICATION NAME] (anti-anxiety medication) [MEDICATION
NAME], 2 mg per (/)1 milliliter (ml), 0.5 mg equals 0.25 ml sublingual (SL- under the
tongue) every three hours as needed. No [DIAGNOSES REDACTED].
-No diet order listed on the POS.
During an interview on 12/11/18 at 10:30 A.M., the DON said orders for treatments should
contain the location where medication is to be applied. A [DIAGNOSES REDACTED].
4. Review of Resident #69’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Extensive staff assistance needed for bed mobility, transfers, dressing and hygiene;
-Received oxygen therapy.
Review of the admission nurse note, dated 10/28/18 at 6:23 P.M., showed the resident
admitted to the facility and used oxygen at 2 liters per minute (LPM) per nasal cannula
(NC, thin two pronged tubing inserted into the opening of the nose).
Review of the resident’s POS, dated 10/28/18 through 10/31/18 and 11/1/18 through
11/31/18, showed no orders for oxygen use.
Review of the resident’s care plan, updated on 11/23/18, showed:
-Problem: Continuous use of oxygen;
-Goal: Limit the potential of side effects;
-Approach: Label oxygen setting on the outside of concentrator or tank and ensure of the
appropriate setting.
Observation of the resident, showed he/she used oxygen at 3 LPM per NC on 12/6/18 at 10:09
A.M., and 1:00 P.M., 12/11/18 at 7:30 A.M. and 12:45 P.M.
Review of the resident’s POS, dated 12/1/18 through 12/31/18, showed no orders for oxygen
use.
During an interview on 12/11/18 at 12:15 P.M., the resident said he/she wore the oxygen
constantly. He/she has breathing issues and the oxygen helped the issue. Staff supply
him/her with the oxygen and set the amount on the machine in his/her room or to the back
of the oxygen tank when he/she is in the wheelchair.
During an interview on 12/11/18 at 10:30 A.M., the DON said all oxygen use should have a
physician’s orders [REDACTED]. If the amount of oxygen administered is changed, a
physicians order needs to be obtained and a new order written on the POS. The resident’s
care plan should be updated to show the oxygen change.
5. Review of Resident #20’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Diagnoses included diabetes and [MEDICAL TREATMENT] (a treatment to remove waste, salt
and extra water to prevent them from building up in the body keeping a safe level 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
certain chemicals in the blood).
Review of the resident’s POS, dated 12/1/18 through 12/31/18, showed an order, dated
2/28/18, to obtain and record a weight every Friday.
Review of the treatment administration record’s (TAR), dated 10/1/18 through 10/31/18,
11/1/18 through 11/30/18 and 12/1/18 through 12/31/18, showed no recorded weekly weights.
Review of the monthly weight form, dated (MONTH) (YEAR) through (MONTH) (YEAR), showed the
resident weighed monthly, not weekly.
During an interview on 12/11/18 at 10:30 A.M., the DON said weekly weights should be
recorded on the monthly weight record or on the resident’s TAR.
6. Review of Resident #61’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Diagnoses included [MEDICAL CONDITION], heart failure and a stroke.
Review of the POS [REDACTED].
Review of the POS [REDACTED].
Review of the medical record, showed no results of the Vitamin D or HgbA1c levels.
During an interview on 12/11/18 at 10:30 A.M., the DON said after the blood is drawn the
results are available within 24 to 48 hours on the laboratories web site. It is the
responsibility of the nurse to check that information. The DON later provided the proof
that the lab work was completed however the staff had not obtained that information.
7. Review of Resident #92’s quarterly MDS, dated [DATE], showed:
-admitted [DATE];
-Cognitive impairment;
-[DIAGNOSES REDACTED].
-Staff assistance needed with set up and supervision for dressing, toileting and hygiene.
Review of the resident’s care plan dated 9/10/18, showed:
-Problem: Activity of Daily Living: the resident is limited in ability to shower and
bathe. He/she will dress himself/herself;
-Goal: He/she will receive showers with staff assistance;
-Approach: Staff to provide full assistance with showering, notify the nurse of any
irregularities.
During a family interview on 12/6/18 at 11:30 A.M., the resident’s family member said
he/she had requested the resident to be been seen by the facility podiatrist. The
resident’s toe nails were long and needed professional attention. He/she did not know how
the resident could wear his/her shoes because of the toe nail length. The family had
filled out a consent sheet for the resident to be seen by the podiatrist in 8/2018, but
the resident had not been seen and he/she did not know why.
Observation and interview on 12/10/18 at 7:06 A.M., showed the resident in his/her room.
The resident wore socks and shoes on his/her feet and said sometimes his/her toes hurt and
the shoes hurt his/her toe tips and he/she received a shower earlier in the morning. The
resident removed his/her socks and shoes. The resident’s right and left second and third
toe nails appeared long. The left second and third toe nails had begun to curl upward.
During an interview on 12/11/18 at 10:30 A.M., the DON said the aides need to let the
nurse know of any irregular nails or skin issues. The aides are not allowed to cut or clip
long toe nails and should tell the nurse so the nails can be assessed. Once a consult is
recommended the family signs a consent and the social worker makes the appointment. A
Podiatrist comes to the facility to see the residents. The resident had not been seen by
the Podiatrist. The DON had been unaware of the family signed consent and of the existing
long toe nails.

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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that one
resident received treatment and care in accordance with professional standards of practice
by failing to document the administration of as needed (PRN) pain medication. The failure
prevented the resident from experiencing effective pain control (Resident #14). The sample
size was 20. The census was 96.
Review of Resident #14’s admission Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 6/15/18, showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
-Frequent moderate pain.
Review of the care plan, dated 6/22/18, showed no documentation regarding the resident’s
pain or the ordered PRN pain medications.
Review of the physician’s orders [REDACTED].
-An order, dated 9/7/18 to apply a [MEDICATION NAME] (narcotic [MEDICATION NAME]) patch 25
micrograms (mcg) and change every three days;
-An order, dated 10/11/18, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
5/325 milligrams (mg) one tablet by mouth twice a day PRN;
-An order, dated 10/11/18, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME]) ER
(extended release) 30 mg twice a day.
Review of the individual controlled substance record, dated 10/14/18 through 10/31/18,
showed the following administrations of [MEDICATION NAME]:
-10/14/18 at 10:00 A.M., 4:00 P.M. and 11:00 P.M.;
-10/15/18, at 6:00 A.M., 1:00 P.M. and 6:45 P.M.;
-10/16/18, at 6:10 P.M. and 11:00 P.M.;
-10/17/18, two handwritten signed out illegible times;
-10/18/18, at 6:10 P.M.;
-10/19/18, at 6:00 A.M., 4:00 .P.M and 10:00 P.M.;
-10/20/18, at 6:00 A.M. and 6:00 P.M.;
-10/21/18, at 11:00 A.M. and 7:00 P.M.;
-10/22/18, at 4:00 A.M. and 6:00 P.M.;
-10/23/18, at 6:00 A.M. and 5:00 P.M.;
-10/24/18 at 6:00 A.M.;
-10/25/18 at 12;00 P.M. and 5:00 P.M.;
-10/26/18 at 10:00 A.M. and 7:30 P.M.;
-10/27/18 at 6:00 A.M. and 8:00 P.M.;
-10/28/18 at 5:00 A.M. and 4:00 P.M.;
-10/29/18 at 5:00 A.M. and 4:00 P.M.;
-10/30/18 at 5:00 A.M., one illegible hand written time and 6:00 P.M.;
-10/31/18 at 7:00 A.M
Review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED].
Observation of the individual controlled substance record, dated 11/1/18 through 11/30/18,
showed the following administrations of [MEDICATION NAME]:

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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
-11/1/18 at 11:00 A.M. and 6:00 P.M.;
-11/2/18 at 1:00 A.M. and 9:00 P.M.;
-11/3/18 at 10:00 A.M. and 5:00 P.M.;
-11/4/18 at 1:00 A.M., 7:00 A.M., 12:00 P.M. 7:00 P.M. and 11:00 P.M.;
Review of the POS [REDACTED]
-An order to administer [MEDICATION NAME] 5/325 mg one tablet every six hours PRN;
-Decrease [MEDICATION NAME] ER 30 mg to once a day at bedtime.
Further review of the individual controlled substance record, dated 11/1/18 through
11/30/18, showed the following administration of the [MEDICATION NAME].
-11/15/18 at 6:00 A.M., 12:00 P.M., and 6:45 P.M.;
-11/16/18 at 6:00 A.M., 12:00 P.M. and 6:50 P.M.;
-11/17/18 at 10:00 A.M., 4:00 P.M. and 9:00 P.M.;
-11/18/18 at 6:00 A.M., 12:10 P.M. and 6:00 P.M.;
-11/191/8 at 7:30 A.M., 5:00 P.M. and 11:00 P.M.;
-11/20/18 at 8:00 A.M., and 5:30 P.M.;
-No administrations recorded for 11/21/18;
-11/22/18 at 8:15 A.M. and 12:30 P.M.;
-11/23/18 at 6:30 A.M., 2:00 P.M. and 10:00 P.M.;
-11/24/18 at 6:00 A.M. and 7:00 P.M.;
-11/25/18 at 1:30 A.M., 6:45 A.M. and 8:00 P.M.;
-11/26/18 at 6:00 A.M.;
-11/27/18 at 5:00 A.M. and 1:30 P.M.;
-11/28/18 at 5:00 A.M.;
-11/29/18 at 5:00 A.M., 3:00 P.M. and 11:00 P.M.;
-11/30/18 6:00 A.M.
Review of the resident’s (MONTH) MAR, dated 11/1/18 through 11/30/18, showed no
documentation of [MEDICATION NAME] administration, no documentation of the resident’s
level of pain and no documentation regarding the effectiveness of the medication.
Review of the resident’s individual controlled substance record, dated 12/1/18 through
12/7/18, showed the following administrations of [MEDICATION NAME]:
-12/1/18 at 6:00 A.M. and 6:20 P.M.;
-12/2/18 at 6:00 A.M., 12:00 P.M. and 10:00 P.M.;
-12/3/18 at 6:00 A.M. and 12:00 P.M.;
-12/4/18 at 8:30 A.M., 2:00 P.M. and 10:30 P.M.;
-12/5/18 at 6:00 A.M. and 6:15 P.M.;
-12/6/18 at 5:00 A.M.;
-12/7/18 at 5:00 A.M.
Review of the resident’s (MONTH) MAR, dated 12/1/18 through 12/7/18, showed no
documentation of [MEDICATION NAME] administration, no documentation of the resident’s
level of pain and no documentation regarding the effectiveness of the medication.
During an interview on 2/10/18 at 7:16 A.M., Licensed Practical Nurse (LPN) A said there’s
no need to write down every time staff give the resident a pain pill. He/she will always
ask the resident if the medication was effective but he/she does not record that either.
He/she said the resident always has pain and the resident had seen pain management and
that is when the resident started on the [MEDICATION NAME]. The resident started to refuse
for pain management to see him/her. LPN A said he/she should have recorded when the
medication is administered and if the medication had been effective in relieving the pain.
He/she continued to say that he/she needed to improve on documenting in the MAR but added
the resident is always in pain and only wants what the resident wants.
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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
During an interview on 12/11/18 at 8:15 A.M., the Director of Nursing (DON) said every
time a narcotic is given it needs to be signed out on the narcotic sheet and the MAR, no
exceptions. The pain level needs to be recorded and the effectiveness of the medication.
She said it makes me a little nervous and hoped the resident really received the
medication as ordered. Nurses failing to record the medication administration and faililng
to follow up on the medication effectiveness is very inappropriate.
During an interview with the DON present on 2/11/18 at 8:56 A.M., the resident said he/she
does not want to become addicted to any opiates and has not taken a [MEDICATION NAME] in
about a week. He/she said the nurse just brings it to him/her and sometimes he/she takes
it and sometimes does not.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a timely
response to the registered dietician’s recommendation regarding weight loss of 15.57 %
over a six month period for one of 20 sampled residents (Resident #42). The census was 96.
Review of Resident #42’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/8/18, showed the following:
-Severe cognitive impairment;
-Extensive to total dependence on staff for all mobility and personal care;
-[DIAGNOSES REDACTED].
Review of the resident’s weights, showed the following:
-Weighed 190 pounds (lbs) on 6/18/18;
-Weighed 191.4 lbs on 7/18/18;
-Weighed 190.6 lbs on 8/18/18;
-Weighed 181.8 lbs on 9/18/18;
-Weighed 170 lbs on 10/18/18;
-Weighed 160.4 lbs on 11/18/18.
Review of the resident’s care plan, dated 7/7/18, showed no documentation regarding weight
loss.
Review of the physician’s orders [REDACTED].
Review of the dietician’s progress note, dated 10/16/18, showed he/she recommended to
increase the Med Pass to 90 cc’s three times a day.
Review of the nurse’s notes, dated 10/16/18, showed no documentation regarding the
dietician’s recommendation or notification to the physician.
Review of the dietician’s progress note, dated 11/16/18, showed he/she recommended to
increase Med Pass to 90cc’s three times a day.
Review of the nurse’s notes, dated 11/16/18, showed no documentation regarding the
dietician’s recommendation or notification to the physician.
Review of the physician’s orders [REDACTED].
-An order, dated 9/14/18, to administer Med Pass 2.0 (medicated nutrition supplement) 60
cubic centimeters (cc) twice a day;
Observation on 12/6/18 at 1:08 P.M., showed the resident sat at the dining room table. A
Certified Nurse Aide (CNA) fed him/her and he/she consumed approximately 10% of the meal.
Observation on 12/7/18 at 9:05 A.M., showed the resident sat at the dining room table. 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
CNA fed him/her and he/she consumed approximately 5% of the meal.
Observation on 12/10/18 at 9:18 A.M., showed the resident sat at the dining room table. A
CNA fed him/her and he/she consumed approximately 5-10% of the meal.
Observation on 12/10/8 at 1:18 AM., showed the resident sat at the dining room table. A
CNA fed him/her and he/she consumed approximately 5-10% of the meal.
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing said when a
dietician makes a recommendation, he/she writes that information on a requisition form and
gives it to the nurse. The nurse is then responsible to contact the physician to obtain an
order. She said the order to increase Med Pass should have been obtained before now.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 residents
who recieved dalysis services had current [MEDICAL TREATMENT] orders and also failed to
ensure the dialyisis services had been addressed on the resident’s individual care plans.
The facility also failed to ensure individual [MEDICAL TREATMENT] contracts had been
secured from out sourced [MEDICAL TREATMENT] care centers. This affected two of three
sampled [MEDICAL TREATMENT] residents (Resident #69 and #44). The census was 96.
1. Review of Resident #69’s physician order [REDACTED].M.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facilty staff, dated 8/24/18, showed:
-Cognitively intact;
-Received [MEDICAL TREATMENT] therapy;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated on 11/23/18, showed:
-Problem: Received [MEDICAL TREATMENT] three days a week;
-Goal: Limit the risk of side effects for [MEDICAL TREATMENT] treatments;
-Approaches: Allow the resident to rest after return from [MEDICAL TREATMENT], follow
renal diet, obtain ordered labs, monitor [MEDICAL TREATMENT] for infection and bleeding.
Review of the POS [REDACTED].
During an interview on 12/6/18 at 1:15 P.M., the resident said he/she had gone to [MEDICAL
TREATMENT] for several years. He/she goes three times a week. The facility takes him/her
to the [MEDICAL TREATMENT] center and brings him/her back to the faciliy after [MEDICAL
TREATMENT] therapy. He/she usually eats breakfast and lunch at the facility and when
he/she gets back, staff will provide him/her a late dinner.
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said all
[MEDICAL TREATMENT] resident’s should have current [MEDICAL TREATMENT] orders. The orders
should include when and where the resident attends [MEDICAL TREATMENT]. The [MEDICAL
TREATMENT] site contact information should be included on the order sheet. The care plan
should match the [MEDICAL TREATMENT] orders and include post and pre [MEDICAL TREATMENT]
therapy care.
During an interview on 12/11/18 at 12:18 P.M., the DON said the care plans of the [MEDICAL
TREATMENT] patients should have the [MEDICAL TREATMENT] contact information, the [MEDICAL
TREATMENT] treatment schedule and post treatment care at the facility. The resident’s care
plan did not have the specific [MEDICAL TREATMENT] information on the care plan and 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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 – Some

(continued… from page 10)
facility created the care plan addendum. The facility had employeed a new MDS coordinator
and the management had been working on updating the facility care plans for accuracy
2.Review of Resident #44’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-[DIAGNOSES REDACTED].
-Received [MEDICAL TREATMENT] therapy.
Review of the resident’s care plan updated on 10/16/18, showed:
-Problem: Requires [MEDICAL TREATMENT] outside of the facility;
-Goal: Limit risk of side effects from [MEDICAL TREATMENT] treatments;
-Approach: Allow to rest upon return from [MEDICAL TREATMENT], assess [MEDICAL TREATMENT]
site for bruit and thrill, encourage the resident to follow renal diet, obtain ordered
labs or copies of labs from [MEDICAL TREATMENT] center, monitor shunt site for signs of
infection and bleeding, assist to attend [MEDICAL TREATMENT] treatments;
-The care plan did not contain [MEDICAL TREATMENT] center contact information or address
and did not provide the resident individual [MEDICAL TREATMENT] treatment days.
Review of the (MONTH) POS, dated 12/1/18 through 12/31/18, showed:
-Additional order: End stage [MEDICAL CONDITION]/ [MEDICAL TREATMENT] (HD, filtering of
the body’s blood to remove impurities and toxins) Monday, Wednesday and Friday by right
[MEDICATION NAME];
-An order dated 2/3/18 to assess right [MEDICATION NAME] every shift for signs or symptoms
of infection and report site bleeding. Apply direct pressure, call 911;
-[MEDICAL TREATMENT] orders did not include [MEDICAL TREATMENT] center contact
information.
During an interview on 12/6/18 at 9:08 A.M., the resident said he/she had lived at the
facility for a year and attended [MEDICAL TREATMENT] since he/she came into the facility.
He/she went to the [MEDICAL TREATMENT] center three times a week and the facility takes
him/her to the [MEDICAL TREATMENT] center appointments.
On 12/10/18 at 1:15 P.M., the surveyor requested copies of [MEDICAL TREATMENT] contracts
from the [MEDICAL TREATMENT] centers from the DON and the Administrator.
During an interview on 12/10/18 at 1:45 P.M., the Administrator said he could not locate
the [MEDICAL TREATMENT] contracts for the requested [MEDICAL TREATMENT] providers. He
contacted the [MEDICAL TREATMENT] providers and was getting signed contracts from the
[MEDICAL TREATMENT] providers at the time of the interview. The facility should have
already had the [MEDICAL TREATMENT] contracts implemented when the resident was admitted
into the facility and receiving [MEDICAL TREATMENT].

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure resident monthly
pharmacy drug regimen recommendations (MRRs) were reviewed and notify the physician or
medical director of irregularities, for eight of 20 sampled residents (Residents #59,
#152, #6, #30, #61, #14, #52 and #63). The census was 96.
1. Review of Resident #59’s significant change Minimum Data Set (MDS), a federally

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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
mandated assessment instrument completed by facility staff, dated 10/19/18, showed the
following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the following:
-Pharmacy medication regimen review (MRR) completed on 10/11/18 with noted irregularities;
-No documentation in the record regarding what the irregularities were, or if the
physician reviewed the irregularity and if action had been taken.
2. Review of Resident #152’s face sheet, showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the following:
-Pharmacy MRR completed on 11/8/18 with noted irregularities;
-No documentation in the record regarding what the irregularity was, if the physician
reviewed the irregularity and if action had been taken.
3. Review of Resident #6’s admission MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the following:
-Pharmacy MRR completed on 11/8/18 with noted irregularities;
-No documentation in the record regarding what the irregularity was, if the physician
reviewed the irregularity and if action had been taken.
4, Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the following:
-Pharmacy MRR completed In May, June, (MONTH) and (MONTH) (YEAR), with noted
irregularities;
-No documentation in the record regarding what the irregularities were, if the physician
reviewed the irregularities and if action had been taken.
5. Review of Resident #61’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the following:-Pharmacy MRR’s completed on
8/9/18, 10/10/18 and 11/7/18 with noted irregularities;
-No documentation in the record regarding what the irregularities were, if the physician
reviewed the irregularities and if action had been taken.
6. Review of Resident #14’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the following:
-Pharmacy MRR completed on 11/7/18 with noted irregularities;
-No documentation in the record regarding what the irregularities were, if the physician
reviewed the irregularities and if action had been taken.
7. Review of Resident #52’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Received daily administration of antidepressants, antianxiety and pain medications.
Review of the resident’s physician’s orders [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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-[MEDICATION NAME] (used to treat depression) 5 milligrams (mg) three times a day, started
on 7/21/18;
-[MEDICATION NAME] (used to treat Alzheimers behaviors) 5 mg daily, started on 5/7/18.
Further review of the medical record, showed no monthly pharmacy reviews had been located.
On 12/11/18 at 10:30 A.M., the resident’s monthly pharmacy review sheets were requested.
The facility was unable to produce the resident’s monthly pharmacy reivew forms.
8. Review of Resident #63’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the long term psychiatric managment visit note, dated 10/5/18, showed the
resident received the following medications: [REDACTED]
-[MEDICATION NAME] (used to treat depression) 50 mg daily, started on 11/17/16;
-[MEDICATION NAME] (used to treat psychotic behaviors) 25 mg twice a day, started on
2/20/18;
-[MEDICATION NAME] 5 mg daily, started on 2/2/18;
-[MEDICATION NAME] (used to treat anxiety) 10 mg daily, started on 8/31/18.
Further review of the medical record, showed the following:
-10/10/18 see report for recommendation;
-Pharmacy MRR completed on 11/7/18 with noted irregularities;
-No documentation in the record regarding what the irregularities were, if the physician
reviewed the irregularities and if action had been taken
9. During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing said the
facility had lost the medical records staff person and a new medical records staff member
had been hired and was in training. The facility had been having difficulity in finding
some of the prior pharmacy recommendations and follow up with the physicians.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 29 opportunities for error, two errors
occurred resulting in a 6.89% medication error rate (Residents #37 and #42). The census
was 96.
Review of the facility’s undated Medication Administration Policy, last revised on
12/7/18, showed the following:
-Purpose: To provide general guidelines to ensure safe and effective administration of
medication to accommodate resident’s awake times;
-Medications should be administered to accommodate residents’ awake times and within
facilities medication time guidelines. Time critical medications such as those that
require periods of time: Before, after or with meals, will be given with in 30 minutes
before or after meal times and have specified times on the Medication Administration
Record [REDACTED].
Review of the facility’s Policy and Procedure Using and Insulin Flex Pen (pre-filled
insulin pen), dated 5/19/17, showed the following:
-Step one-preparing the flex-pen:
-Wash hands, check the label to ensure you are using the right type of insulin;

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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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 – Some

(continued… from page 13)
-Pull off the pen cap and wipe the rubber [MEDICATION NAME] with an alcohol swab;
-Remove the protective cap from the needle and screw it to the flex pen tightly. It is
important that the needle is on straight;
-Never place a disposable needle on the flex pen until you are ready to administer the
injection;
-Pull off the big outer needle cap and then pull off the inner needle cap. Throw away the
inner needle cap right away;
-Always use a new needle for each injection;
-Be careful not to bend or damage the needle before use;
-To reduce the risk of needle stick, never put the inner needle ca back on the needle;
-Step two-doing the air shot before each injection:
-Small amounts of air may collect in the cartridge during normal use. To avoid injecting
air and ensure proper dosing;
-Turn the dose selector to two units;
-Hold your flex pen with the needle pointing up and tap the cartridge gently a few times,
which moves the air bubbles to the top;
-Press the push-button all the way until the dose selector is back to zero. A drop of
insulin should appear at the tip of the needle;
-If no insulin appears, change the needle and repeat.
1. Review of Resident #37’s physician order [REDACTED].
-[DIAGNOSES REDACTED].>-An order, dated 12/7/18, to administer [MEDICATION NAME] (long
acting insulin) 1.8 milligrams (mg) subcutaneous (sc, an injection administered under the
skin) every morning.
Observation on 12/6/18 at 8:15 A.M., showed Licensed Practical Nurse (LPN) A removed an
unused [MEDICATION NAME] flex pen from the medication drawer, removed the protective
packaging, attached a needle to the end of the pen, dialed 1.8 mg on the pen, entered the
resident’s room and administered the medication.
During an interview on 122/6/18 at 8:18 A.M., LPN A said he/she should have wasted two
units prior to the administration of the medication but he/she was nervous and forgot.
2. Review of Resident #42’s POS, dated 12/1/18 through 12/31/18, showed the following:
-[DIAGNOSES REDACTED].>-An order, dated 10/22/17, to administer [MEDICATION NAME] eye
drops (used to treat itching, burning, redness and watering of the eyes) one drop to each
eye twice a day.
Observation on 12/6/18 at 8:22 A.M., showed Certified Medication Technician (CMT) B
administered one drop of [MEDICATION NAME] to the resident’s left eye, held the inner
canthus for 10 seconds and then repeated the same process in the right eye.
During an interview on 12/6/18 at 8:25 A.M., CMT B said he/she administers the eye drop
then holds the inner canthus for a count of 10.
3. During an interview on 12/10/18 at 9:30 A.M., the Director of Nursing said whenever
insulin is given by a flex pen it is important to dial the pen to 2 units, waste that
amount, cleanse the tip of the pen with alcohol and then administer the dose. She added
that when administering eye drops the inner canthus should be held for at least one minute
if not two minutes to ensure the medication has been absorbed.

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
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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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 14)
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 eight of
26 insulin pens (pre-filled) were labeled and dated correctly. The facility census was 96.
Review of the facility’s insulin storage, expiration and disposal policy, revised on
[DATE], showed:
-Dating: upon accessing vial it is dated with the current date;
-Expiration: Insulin is considered viable for 28 days after opening. This is a guideline
from the pharmacy. The date on the vial or pen should be checked before each use and upon
expiration the insulin should be taken to the nursing office.
Observation on [DATE] at 6:50 A.M., of the Terrace nurse medication cart showed:
-Three [MEDICATION NAME] (short acting) insulin [MEDICATION NAME] opened and in use,
undated;
-One Levimer (long acting) insulin flextouch pen opened, undated and in use;
-One [MEDICATION NAME] (long acting) insulin [MEDICATION NAME] pen open, undated and in
use.
Observation on [DATE] at 7:16 A.M., of the Garden nurse medication cart showed:
-One [MEDICATION NAME][MEDICATION NAME] opened, in use and handwritten expiration date
[DATE] written on the pen;
-One [MEDICATION NAME]vial opened, in use and undated;
-One [MEDICATION NAME] (long acting) insulin pen opened, in use and undated.
During an interview on [DATE] at 1:30 P.M., the Director of Nursing said that she expected
the nurses to date the insulins when removed from the medication room refrigerators with
the date the insulin had been removed and the expiration date. Insulin expires 28 days
after it is opened. The nurses should check the insulin date before administering the
insulin to the resident. If an insulin is found undated, the insulin should be disposed
and a new insulin obtained and dated. Undated insulin could be expired and may affect the
effect of the insulin.

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.

Based on observation and interview, the facility failed to ensure pans and serving
utensils were sanitized by not properly using the three compartment sink. This deficient
practice had the potential to affect all residents who ate at the facility. The census was
96.
1. Observation of the kitchen, showed the following:
-On 12/10/18 at 1:32 P.M., Cook E stood at the three compartment sink and washed a large
metal pan in the first compartment filled with soapy water and labeled ‘wash’. Cook E
dipped the pan in the second compartment filled with dingy water, labeled ‘rinse’, turned
the faucet on in the third compartment, labeled ‘sanitize’, and ran the pan underneath the
running water and rinsed off the soap. The third compartment did not contain water or
sanitizer. A tube ran from a bottle of pink sanitizer under the sink into a dispenser on
the wall. A larger tube, tinted with a light pink residue, came out of the dispenser 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

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

(continued… from page 15)
was placed inside the second compartment. No tube from the dispenser was inside the
sanitize compartment. Cook E placed the wet pan on the counter to the left of the third
compartment, and said the pans are not washed in the dishwasher. They are washed by hand
in the three compartment sink. Next Cook E washed at least five serving utensils in the
wash compartment, swished them around in the rinse compartment, rinsed them under the
water running into the sanitize compartment and placed them on the counter to the left of
the third compartment. Cook E continued this process with the dirty pans from lunch.
2. During an interview on 12/11/18 at approximately 12:00 P.M., the dietary manager (DM)
said the three compartment sink is used to wash pans and serving utensils. The DM took the
tube that rested in the second compartment and moved it over to the third compartment
labeled ‘sanitize’, and said the sanitizer ran into the sink from the tube. Pans were
washed in the wash compartment, then rinsed in the second compartment and sanitized in the
third compartment. It was not acceptable for the pans and serving utensils to be rinsed
under running water and not sanitized.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to practice
appropriate hand hygiene during personal care and failed to provide a two step [MEDICATION
NAME] skin test (skin test used to check if a person has been infected with [MEDICAL
CONDITION]). This affected two of 20 sampled residents (Residents #84 and #245). The
census was 96.
Review of the facility’s undated Infection Control and Prevention Policy, showed the
following:
Guidelines:
-Observe standard precautions;
-Wash your hands before and after procedures;
-Wash your hands before and after resident contact;
-Wear gloves when appropriate.
-Handwashing:
-Before, during and after food preparation;
-Before eating;
-Before and after resident contact;
-After handling garbage;
-Whenever visibly soiled;
– After blowing nose, coughing, sneezing or using the toilet.
-Glove Usage:
-Gloves should be used in addition to not as a substitute for hand hygiene;
-Contamination is still possible;
-Wear gloves when contact with blood or other potential infectious materials are
possible;
-Do not wear the same pair of gloves for more than one resident;
-Do not wash gloves;
-Remove gloves after caring for a resident;
-Wash hands after removing 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:

265523

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

NAME OF PROVIDER OF SUPPLIER

PARKWOOD SKILLED NURSING AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

3201 PARKWOOD LANE
MARYLAND HEIGHTS, MO 63043

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
1. Review of Resident #84’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/25/18, showed the following:
-Severely impaired cognition;
-Required extensive assistance with mobility and personal hygiene;
-Occasionally incontinent of bladder and frequently incontinent of bowel;
-[DIAGNOSES REDACTED].
Observation on 12/6/18 at 7:20 A.M., showed Certified Nurses Aide (CNA) C entered the
resident’s room and donned gloves without washing his/her hands. The resident had urinated
and had a bowel movement (BM). CNA C provided incontinence care. After cleansing the
buttocks of stool he/she rolled the linens, soiled with urine and BM, under the resident
and then lay a clean brief under the resident’s right hip. CNA C then rolled the resident
to his/her left side, removed the soiled linens from the bed, pulled the clean brief under
the resident, turned the resident to his/her back and secured the brief. Without changing
gloves or washing his/her hands, CNA C dressed the resident in slacks and a shirt. He/she
placed the wheelchair next to the bed, removed his/her gloves, did not wash his/her hands
and left the room to get assistance. CNA’s C and D returned to the room, donned gloves
without washing hands and transferred the resident to the wheelchair. Both CNA’s removed
their gloves and CNA C washed the resident’s face, combed his/her hair, then rummaged
through the drawers of personal belongings to find the resident’s glasses. CNA’s C and D
left the room with the resident and wheeled him/her to the dining room for breakfast. A
walker was in the path of the wheelchair so CNA C moved the walker out of the way. CNA’s C
nor D had yet to wash their hands.
During an interview on 12/6/18 at 7:30 A.M., CNA’s C and D said they always wash their
hands before and after care of a resident. They added that sometimes if the resident had a
BM they may change their gloves.
During an interview on 12/11/18 at 10:30 A.M., the Director of Nursing (DON) said staff
should always wash their hands before and after contact with a resident. They should wash
their hands when going from dirty to clean, before touching any personal items and before
leaving the room and should always wash their hands after cleaning BM.
2. Review of Resident #245’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s test/immunization record, showed [MEDICATION NAME] skin test
administered on 11/5/18 to the resident’s left forearm (lower arm). No results provided
and no second testing administered.
During an interview on 12/11/18, the DON said when a resident is admitted into the
facility, the resident should receive a two step TB testing. The admission nurse is
responsible to administer the first admission TB test, document the administration and
note in the Medication Administration Record [REDACTED]. The second administration should
be scheduled into the resident’s MAR indicated [REDACTED]. All residents receive an annual
sign and symptom assessment for TB after the two step testing is completed.