Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to report an allegation of abuse
involving one resident (Resident #22) in a review of 19 sampled residents and one
additional resident (Resident #86), to the state agency within two hours of the incident.
The facility census was 91.
1. Review of the facility’s abuse policy from the 2001 MED-PASS revised in (MONTH) of
2014, showed the following:
-All reports of resident abuse, neglect, and injuries of unknown source should be reported
promptly and thoroughly investigated by facility management;
-The Administrator would report alleged abuse or neglect to the state survey and
certification agency and the ombudsman immediately;
-In the events that caused the allegation involved abuse or resulted in serious bodily
injury, it must be reported no later than two hours after the allegation was made;
-The Administrator would report results of all abuse investigations and appropriate action
taken to the state survey and certification agency, the ombudsman, and others as may be
required by state or local laws within five working days of the reported incident.
– The facility did not describe/define what constituted abuse or address situations of
alleged resident to resident abuse.
2. Review of Resident #22’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument, completed by facility staff, dated 7/2/18 showed his/her cognition
was severely impaired and he/she had no behaviors that affected others.
Review of the resident’s monthly summary report dated 9/14/18 showed he/she was friendly,
cooperative, quiet, and had no documented behaviors toward others.
Review of the resident’s nurse’s note dated 9/27/18 at 5:57 A.M. showed a late entry dated
from 9/19/18 showed the resident was in the dining room sleeping in his/her chair when
another resident (Resident #86) came up to him/her and hit him/her (there was no
documentation of where the resident was struck).
3. Review of Resident #86’s quarterly MDS dated [DATE] showed:
-His/her cognition was moderately impaired for daily decision making;
-He/she showed no behaviors toward others.
Review of the resident’s care plan last revised on 8/17/18 showed the following:
-He/she had severe memory impairment, could usually make his/her needs known and he/she
would become distraught at other residents who could not do the same;
-He/she had a history of [REDACTED].
-Staff were to attempt to keep him/her away from other residents when he/she was agitated;
-He/she was taking an antipsychotic medication and staff were to involve his/her
psychiatric physician as needed;
-Hand written notes dated 12/5/17 and 12/27/17 showed the resident was physically
aggressive with other residents and had hit them on the back;
-A hand written note dated 2/13/18 showed he/she yelled and cursed at another resident
(did not list the name of the other resident involved).
Review of the resident’s nurses’ note dated 9/19/18 at 11:57 A.M. showed at 11:40 A.M. the
resident was in the main dining room, walked up to another resident (Resident #22), and
hit the resident on his/her chest.
Review of the resident’s monthly nursing summary dated 9/22/18 showed:
-He/she had [DIAGNOSES REDACTED].
-He/she walked around the facility independently.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
Review of the resident’s Interdisciplinary team (IDT) notes dated 9/19/18 to 9/27/18
showed no documentation of the resident to resident altercation.
During an interview 9/27/18 02:15 P.M., certified nursing assistant (CNA) C said the
following:
-Approximately one week ago he/she witnessed Resident #86 walked up to Resident #22 and
hit him/her pretty significantly on the chest then walk away;
-Resident #86 said something to Resident #22, but he/she did not hear what was said;
-He/she reported the incident to Licensed Practical Nurse (LPN) B;
-Resident #86 had a history of [REDACTED].
-Resident #22 did not have a history of aggressive behaviors toward others.
During an interview on 9/27/18 11:53 A.M., Licensed Practical Nurse (LPN) B said the
following:
-He/she received a report from CNA C stating that Resident #86 walked up and smacked
Resident #22 in the chest then walked away;
-Resident #86 had history of this type of behavior with anybody, not just Resident #22;
-Resident #86 had a [DIAGNOSES REDACTED].
-Resident #22 had no history of aggressive behaviors;
-He/she reported the incident to the Director of Nursing (DON) and completed an incident
report.
4 During interview on 9/27/18 at 1:10 P.M. the DON said the following:
-Staff reported to her a resident to resident altercation when Resident #86 hit Resident
#22’s chest while he/she was reclined in a wheelchair;
-She completed an incident report that day and notified the administrator;
-The previous administrator asked her to tell the nurses not to document in the resident’s
nurses’ notes about the altercation and took the report from the DON;
-The previous administrator should have reported the resident to resident altercation to
the state agency as was the facility policy;
-She left the situation in the previous administrator’s hands and did not report the
resident to resident altercation to the state agency herself;
-The facility policy was to notify the state agency of any resident to resident
altercations for further investigation;
-Resident #86 had hit other residents before. Staff removed Resident #86 from near
Resident #22 at the time of the altercation.
During interview on 9/28/18 at 8:00 A.M. the Social Services Designee said the following:
-He/she learned on 9/27/18 of the resident to resident altercation that occurred on
9/19/18;
-The altercation was 100 percent reportable to the state agency. If the administrator did
not report the altercation other staff should have reported the altercation.
During interview on 9/27/18 at 1:15 P.M. the acting administrator said the following:
-Staff should report any resident to resident altercation to the state agency;
-Staff should notify the DON or the administrator when the altercation occurred and the
administrator should notify the corporate staff;
-He was the current Chief Operating Officer of the facility corporation and was informed
of the resident to resident altercation two days after the occurrence;
-He did not notify the state agency and did not think the altercation was abuse.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 – Potential for minimal harm

Residents Affected – Many

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.

Based on interview and record review, the facility failed to inform residents and
families/legal representatives of their bed hold protocol at the time of transfer to the
hospital for one resident (Resident #72), in a review of 19 sampled residents. The
facility census was 91.
1. Review of the facility policy Bed Reservation revised (YEAR) and located in the facilty
admission packet showed the following:
-All residents were notified upon admission of the Bed Hold Policy;
-During any time period a Private Pay resident’s care was not covered by Medicare or
Medicaid services, the facility would automatically reserve the resident’s bed only if the
resident requested by initialing the form. If the request was initialed on admission, the
facility would reserve the resident’s bed until the resident returned to the facility or
the resident notified the facility in writing of their intentions to terminate the
agreement or it was determined that the resident’s needs could not be met at the facility.
Or, the resident could choose to initial a request the bed not be reserved whenever the
resident was out of the facility. The facility would readmit the resident to the first
available semi-private bed in the facility if the resident continued to require facility
services;
-If the resident’s care was paid for by Medicare, the facility would reserve the
resident’s bed while the resident was on therapeutic leave, for any period that was a
covered service under the program for which the resident was eligible. If the resident’s
absence from the facility exceeded the time period covered or was due to hospitalization ,
the facility would automatically reserve or continue to reserve the bed only if someone
had initialed the request the resident’s bed be automatically reserved. Or, the resident
could choose to initial a request the bed not be reserved whenever the resident was out of
the facility. The facility would readmit the resident to the first available semi-private
bed in the facility if the resident continued to require facility services;
-If the resident’s care was paid for by Medicaid, the resident received temporary leave
days and hospital reserve days as part of the State Medicaid plan. The resident should
initial how the facility should use their hospital reserve days when discharged to the
hospital. Or, the resident could choose to initial a request the bed not be reserved
whenever the resident was out of the facility. The facility would readmit the resident to
the first available semi-private bed in the facility if the resident continued to require
facility services;
-The facility policy did not include at the time of transfer of a resident for
hospitalization or therapeutic leave, a nursing facility must provide to the resident
and/or the resident representative written notice which specifies the duration of the
bed-hold policy.
2. During entrance conference on 9/25/18 at 12:45 A.M. the Director of Nursing said one
resident (Resident #72) was transferred to the hospital and was discharged from the
facility. The facility was not holding the resident’s bed for his/her return.
3. Review of the facility’s Daily Census Sheet dated 9/25/18 showed Resident #72 was in
the hospital.
4. During survey from 9/25/18 through 9/28/18 showed Resident #72’s personal belongings
remained in his/her room.
5. During interview on 9/28/18 at 8:00 A.M. the Social Services Designee said the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 – Potential for minimal harm

Residents Affected – Many

(continued… from page 3)
following:
-On admission residents were given the facility bed hold policy for review. The policy was
only reviewed one time with the resident or resident representative;
-The facility did not contact residents or resident representatives and review the
facility bed hold policy at the time of a resident’s transfer;
-He/she learned about this requirement a week ago and the bed hold policy requirements
were not currently in place.
During interview on 9/28/18 at 2:00 P.M. the Business Office Manager said when a resident
was transferred from the facility, he/she reviewed the resident’s signed bed hold consent
form from admission and if the resident or family had requested the facility hold the
resident’s bed he/she would charge the resident or family for the bed hold. He/she did not
contact the resident or resident’s family at the time of transfer and review or provide
them the facility bed hold policy Resident #72 was transferred to the hospital and
discharged from the facility. He/she did not contact the resident or representative at the
time of transfer regarding holding the resident’s bed.
During interview on 9/28/18 at 4:10 P.M. the acting administrator said he expected staff
to follow the current bed hold/transfer requirements and notify the resident or resident
representative of the facility’s bed hold policy on admission and at the time of transfer
from the facility.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to complete a significant change
in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, for three residents (Residents, #52, #50 and #30)
in a review of 19 sampled residents and one additional resident (Resident #46), within 14
days after the facility determined, or should have determined, there had been a
significant change in the resident’s physical or mental condition (improvement or decline)
which had an impact on more than one area of the resident’s health status and required
interdisciplinary review and/or revision of the care plan. The facility census was 91.
1. During interview on 9/28/18 at 1:10 P.M. the MDS Coordinator said the facility followed
the RAI 3.0 process for completion of the resident’s MDS’ including significant change
MDS’ and resident care plans.
2. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User’s
Manual, version 3.0 showed a significant change is a decline or improvement in a
resident’s status that:
-Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, is not self-limiting;
-Impacts more than one area of the resident’s health status
-Requires interdisciplinary review and/or revision the care plan.
The Manual also showed a Significant Change In Resident Status (SCSA) is appropriate if
there is a consistent pattern of changes, with either two or more areas of decline, or two
or more areas of improvement. This may include two changes within a particular domain
(e.g., two areas of ADL decline or improvement).
Guidelines for determining significant change in resident status included the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-Any decline in an ADL physical functioning area where a resident is newly coded as 3, 4,
or 8;
-Any improvement in an ADL physical functioning area where a resident is newly coded as 0,
1, or 2 since the last assessment;
-Overall improvement or deterioration of the resident’s condition.
3. Review of Resident #30’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument, completed by facility staff, dated 6/18/18, showed the following:
-The resident did not have symptoms of depression on his/her mood assessment;
-The resident required extensive assistance of two staff with bed mobility, transfers, and
toileting;
-The resident required extensive assistance of one staff with eating, personal hygiene,
dressing, and locomotion on and off of the unit.
Review of the resident’s annual MDS, dated [DATE], showed the following:
-The resident had mild depression as evidenced by her/him feeling tired and/or had little
energy 12-14 days (nearly every day), and he/she had a poor appetite
-The resident was dependent on two staff with transfers, toileting, and bathing;
-The resident was dependent on one staff with bed mobility, eating, personal hygiene, and
dressing;
-Locomotion on and off of the unit did not occur.
The quarterly MDS dated [DATE] showed the following when compared to the previous annual
MDS dated [DATE]:
-Staff coded the resident declined in six ADL care areas. He/she declined from extensive
staff assistance to total staff assistance with bed mobility, transfers, eating,
toileting, personal hygiene, and dressing;
-He/she declined from not having depression to having mild depression;
-Met criteria for a SCSA.
Observation on 9/26/18 at 2:29 P.M., showed the resident was totally dependent on
certified nursing assistant (CNA) K and CNA L with transfer, bed positioning, toileting,
and personal hygiene.
During an interview on 09/28/18 2:36 P.M., the MDS coordinator said the resident should
have had a MDS for a significant change but he/she thought it was improperly coded because
the resident could help some with turning, but was mostly dependent on staff with
transfers.
4. Review of Resident #46’s annual MDS dated [DATE] showed the following:
-The resident required limited assistance of one staff member with bed mobility;
-The resident required extensive assistance of two staff members with transfers and
toileting;
-The resident required extensive assistance of one staff member with dressing and personal
hygiene
-The resident was frequently incontinent of bowel.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-The resident required total assistance of one staff member with bed mobility;
-The resident required total assistance of two staff members with transfers;
-The resident required total assistance of one staff member with toileting, dressing and
personal hygiene;
-The resident was always incontinent of bowel.
The quarterly MDS dated [DATE] showed the following when compared to the previous annual
MDS dated [DATE]:
-Staff coded the resident declined in five ADL care areas. He/she declined from limited
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
staff assistance to total staff assistance with bed mobility and declined from extensive
staff assistance to total staff assistance with transfers, toileting, dressing and
personal hygiene;
-Staff coded the resident declined in bowel continence;
-Met criteria for a SCSA.
Observations during survey from 9/25/18 through 9/28/18 showed staff provided total
assistance with incontinence care, bed mobility, dressing and personal hygiene. The
resident was unable to turn self purposefully in bed or participate in self-care. Two
staff members provided total assistance with mechanical lift transfers from bed to a high
back wheelchair. The resident was incontinent of bowel and wore incontinence briefs.
5. Review of Resident #52’s quarterly MDS dated [DATE] showed the following:
-The resident required supervision of one staff member with bed mobility;
-The resident was independent with transfers, walking in room and corridor, and locomotion
on and off the unit;
-The resident required limited assistance of one staff member with dressing, toileting and
personal hygiene.
Review of the resident’s annual MDS dated [DATE] showed the following:
-The resident required limited assistance of one staff member with bed mobility and
transfers;
-The resident required supervision of one staff member while walking in room and corridor
and with locomotion on the unit;
-Locomotion off the unit newly coded as did not occur;
-The resident required extensive assistance of one staff member with dressing, toileting,
and personal hygiene.
The annual MDS dated [DATE] showed the following when compared to the previous quarterly
MDS dated [DATE]:
-Staff coded the resident declined in nine ADL care areas. He/she declined from
supervision to limited assistance of one staff member with bed mobility, declined from
independence to limited staff assistance with transfers, declined from independence to
staff supervision while walking in room and corridor and with locomotion on the unit,
declined from independence to activity did not occur with locomotion off the unit,
declined from limited staff assistance to extensive staff assistance with dressing,
toileting and personal hygiene;
-Met criteria for SCSA.
Observations during the survey from 9/25/18 through 9/28/18 showed staff provided
assistance with transfers from bed to wheelchair or recliner chair. The resident was
unable to walk independently. Staff pushed the resident’s wheelchair back and forth to the
dining area for meals. Staff dressed the resident and provided incontinence care and
personal hygiene. The resident did not assist with cares.
6. Review of Resident #50’s quarterly MDS dated [DATE] showed the following:
-Limited assistance one person assist with bed mobility, transfers, dressing, toileting
and personal hygiene;
-Independent, set up help only with eating;
-Always continent.
Review of the resident’s hospital discharge records dated 6/7/18 showed [MEDICAL
CONDITION] hip.
Review of the resident’s nurses notes dated 7/29/18 showed the resident continued to be a
two-person assist with transfers, toileting, and showers.
Record review of the resident’s quarterly MDS dated [DATE] showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Extensive assistance, two person physical assist with bed mobility and transfers;
-Extensive assistance one-person physical assist with dressing, toileting and personal
hygiene;
-Limited assistance one-person physical assist with eating;
-Occasionally incontinent of bowel.
The quarterly MDS dated [DATE] showed the following when compared to the previous
quarterly MDS dated [DATE]:
Staff coded the resident declined in six ADL care areas. He/she declined from limited
staff assistance to extensive assist with bed mobility, transfers, toileting, dressing and
personal hygiene. He/she declined from independent with eating to limited one-person
assist. He/she declined from always continent to occasionally incontinent of bowel;
-Met criteria for SCSA.
Observation on 9/26/18 at 1:48 P.M. showed the resident sat in his/her wheelchair at the
dining room table. Staff fed the resident lunch.
During interview on 9/27/18 at 2:30 P.M., CNA E said the following:
-At times the resident can be a one-person assist and at other times a two person assist
using the gait belt;
-When the resident has tremors he/she will need assistance with eating;
-At times the resident is a two-person assist with toileting;
-The resident is total assist with dressing, brushing his/her teeth and combing his/her
hair.
7. During interview on 9/28/18 at 1:10 P.M. the MDS Coordinator said the following:
-He/she should complete a significant change in condition assessment when a resident
experienced a decline or improvement in two or more areas of the assessment compared to
the previous assessment or when a change in condition occurred and was sustained for 14
days;
-Resident #46’s quarterly MDS should be a significant change assessment. He/she thought
the previous MDS was coded incorrectly. The resident continued to require total staff
assistance with ADLs and had declined;
-Resident #52’s annual MDS should be a significant change assessment. The resident had
declined in multiple areas of ADLs.
During interview on 9/28/18 at 3:35 P.M. the Director of Nurses said he/she expected staff
to follow the RAI process for completion of MDS’ and complete a significant change in
condition assessment when the resident met the criteria.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 facility
staff provided five of 19 sampled residents (Resident #5, #22, #79, #81, and #83), that
were unable to do their own activities of daily living, the necessary care and services to
maintain good personal hygiene and prevent body odor. The facility census was 91.
1. Review of the facility’s policy for perineal care dated 5/12/17 showed the following:
-The purpose of this procedure was to provide cleanliness and comfort to the resident, to
prevent infections and skin irritation, and to observe the resident’s skin condition;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 – Some

(continued… from page 7)
-Equipment and supplies necessary for performing the procedure included towels, disposable
wipes/washcloths, and personal protective equipment (gloves, gowns, mask, etc.);
-Expose the perineal area;
-With a disposable wipe, wipe the perineal area from front to back and from the center to
the thighs;
-Fold the wipe to use a clean section for each stroke;
-For female residents; separate the labia and wipe the urethral area first, wipe between
the outside of the labia in downward [MEDICAL CONDITION] and alternating from side to side
when moving outward to the thighs. Use a different part of the wipe for each stroke;
-Never wipe upward from the anus;
-For male residents; pull back the resident’s foreskin if the male was circumcised, wipe
the tip of the penis in a circular motion beginning at the urethra, and continue wiping
down the penis to the scrotum and inner thighs. Gently pat the perineal area dry and
reposition the foreskin;
-Turn the resident on their side so they were facing away from you and the buttocks were
exposed;
-Clean the rectum with a clean wipe, wiping in [MEDICAL CONDITION] from the base of the
labia or scrotum and over the buttocks. Use a different part of the wipe each time until
the area was clean;
-Dry the anal area thoroughly, wash and dry hands, put on clean gloves, apply a clean
brief/pull-up/underwear, reapply clothing, and assist the resident back into a comfortable
position;
-Remove gloves and perform hand hygiene.
2. Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual,
showed the purpose of peri-care (perineal) is to clean the peri area for the resident who
is unable to or has difficulty with adequately cleaning self, prevents itching, burning,
and odor, and prevents infections. The manual also showed the resident who is continent
should have peri-care daily with morning care, the resident who is incontinent, after each
voiding or stool, and perineal care was very important in maintaining the resident’s
comfort. More frequent care is required for residents who are incontinent.
Review of the 2001 revision of the Nurse Assistant In A Long Term Care Facility manual,
also showed the procedures staff were to follow when they provided peri-care for a male
(steps 7 through 13) included the following:
-Cover the resident;
-Expose the perineal areas included, wash the penis from the tip downward, rinse, and dry
(specific instructions for uncircumcised);
-Wash and rinse the scrotum;
-Wash and rinse other skin areas between the legs;
-Wash and rinse the anal area;
-Pat the area dry.
For the female resident (steps 7 through 14) included the following:
-Cover the resident;
-Expose the peri area, wash the inner legs and outer peri area along the outside of the
labia (Labia Majora);
-Use a clean area of the washcloth for each wipe of the peri area;
-Wash the outer skin folds from front to back;
-Wash the inner labia (Labia Minora) from front to back;
-Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area)
from front to back;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 – Some

(continued… from page 8)
-Rinse the area well, start from the innermost area and proceed outward;
-Wash and rinse the anal area;
-Pat the peri area dry.
Review of the Nurse Assistant in a Long Term Care Facility manual, Revision (MONTH) 2001,
showed the following:
-Purposes of oral hygiene (mouth care): A clean mouth and properly functioning teeth are
essential for physical and mental well-being of the resident, prevent infections in mouth,
remove food particles and plaque, stimulate circulation of gums, eliminate bad taste in
mouth, thus food is more appetizing.
3. Review of Resident #5’s Minimum Data Set (MDS) a federally mandated assessment
instrument, completed by facility staff, dated 6/22/18 showed the following:
-His/her cognition was severely impaired;
-He/she was always incontinent of bowel and bladder;
-He/she required extensive assistance of one staff with personal hygiene.
Review of his/her care plan last reviewed on 6/22/18 showed staff were to cleanse the
resident’s perineal area with soap and water after each urination and/or bowel movement.
Observation on 9/27/18 at 5:06 A.M. showed the following:
-The resident was incontinent of urine;
-Certified Nursing Assistant (CNA) G removed the resident’s urine soaked incontinence
brief;
-CNA G used one perineal wipe to cleanse the resident’s front perineal area including
bilateral groin areas and the pubic area;
-He/she assisted the resident onto his/her right side and with a one perineal wipe, he/she
cleansed the resident’s entire buttocks and coccyx (tail bone) areas while using the same
surface of the wipe and wiping over with the contaminated surface.
During an interview on 9/27/18 at 6:50 A.M., CNA G said the following:
-He/she wiped until the resident was clean;
-The number of wipes used depended on how soiled the resident was;
-He/she at times performs pericare for the entire peri area with just one wipe.
4. Review of Resident #22’s quarterly MDS dated [DATE] showed the following:
-His/her cognition was severely impaired;
-He/she was always incontinent of bowel and bladder;
-He/she required assistance of one staff with personal hygiene.
Review of the resident’s care plan last reviewed on 7/19/18 showed the following:
-He/she was at risk for pressure ulcers due to frequent bowel and bladder incontinency;
-He/she required extensive assistance for all activities of daily living (ADLs);
-Staff were to provide perineal care when he/she was incontinent;
-He/she had broken and loose teeth;
-No documentation that instructed staff on how/when to provide oral care.
Review of the resident’s Physicians Order Sheet (POS) for (MONTH) (YEAR) showed he/she had
a [DIAGNOSES REDACTED].
Observation on 9/27/18 at 6:00 A.M. showed the following:
-The resident was incontinent of urine;
-CNA C removed the resident’s urine soiled incontinence brief and cleansed the resident’s
front perineal area with one perineal wipe;
-He/she repeatedly wiped the front perineal area with the contaminated surface of the wipe
from back to front;
-He/she assisted the resident onto his/her left side and with one wipe, he/she washed the
resident’s coccyx and buttock areas repeatedly with the contaminated surface.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 – Some

(continued… from page 9)
Observation on 9/27/18 at 6:29 A.M. showed CNA G assisted the resident to the dining room
without performing oral care.
During an interview on 09/27/18 6:50 A.M., CNA G said the following:
-Oral care was usually provided at night, but he/she would provide care in the morning if
the resident had teeth or dentures;
-He/she did not provide oral care if resident did not have teeth;
-Resident #22 did not have teeth therefore he/she did not provide/assist the resident with
oral care.
5. Review of Resident #79’s quarterly MDS dated [DATE] showed:
-His/her cognition was intact;
-He/she required extensive assistance of one staff with transfers and personal hygiene.
Review of the resident’s care plan last updated on 9/20/18 showed the following:
-He/she required the assistance of one staff with ADLs;
-He/she was alert and oriented times three (to person, place, and time);
-Staff were to assist him/her as needed;
-No specific instructions documented that directed staff on providing oral care.
During an interview on 9/27/18 at 12:59 P.M. the resident’s family said the following:
-The resident had an appointment with the dentist on 9/25/18. The dentist noted that the
resident’s teeth had not been brushed in months;
-They were told that the resident’s teeth had lots of food and debris on them and were in
poor shape.
During an interview on 9/27/18 at 1:18 P.M., the resident said that staff did not help
him/her brush his/her teeth.
6. Review of the Resident #81’s annual MDS dated [DATE] showed the following:
-His/her cognition was severely impaired;
-He/she was always incontinent of bowel and bladder;
-He/she required assistance of one staff with personal hygiene.
Review of the resident’s care plan last reviewed on 8/29/18 showed the following:
-He/she required assistance with dressing, toileting, bathing, and mobility;
-He/she was incontinent of bowel and bladder;
-Staff were directed to provide incontinence care every two hours and as needed, assist
him/her with dressing, and to anticipate his/her needs;
-There were no specific instructions documented that directed staff on providing oral
care.
Observation of CNA I performing post-incontinence care and assistance with ADLs on 9/27/18
at 7:16 A.M. showed the following:
-CNA I removed the resident’s urine soiled incontinence brief;
-CNA I repeatedly wiped over the resident’s front perineal area, including his/her left
groin, right groin, and genitalia with one perineal wipe;
-The resident was assisted onto his/her left side and CNA I repeatedly wiped over the
resident’s coccyx and buttock areas with one perineal wipe.
7. Review of Resident #83’s face sheet showed [DIAGNOSES REDACTED].
Review of the resident’s care plan dated 11/20/17 showed the following:
-The resident required staff assistance with all ADLs related to advanced dementia and
stroke. He/she was incontinent of bowel and bladder, required a stand up lift for
transfers and used a wheelchair propelled by staff for mobility. Staff should provide all
skin care, check for incontinence and monitor for skin problems;
-The resident was at risk for skin breakdown due to incontinence of bowel and bladder.
Staff should provide good perineal care after each incontinent episode, provide all skin
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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 – Some

(continued… from page 10)
care and apply house barrier cream to buttocks/perineal area.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Short and long term memory problems;
-Required total assistance of one staff member with bed mobility, transfers, dressing,
toileting and personal hygiene;
-Always incontinent of bowel and bladder.
Observation on 9/27/18 at 10:10 A.M. showed the following:
-CNA O and Licensed Practical Nurse (LPN) P transferred the resident to the toilet with a
mechanical standing lift;
-CNA O removed the resident’s urine saturated incontinence brief, applied a clean
incontinence brief around the resident’s thighs, wiped the resident’s frontal perineal
area with wet wipes, down each side of the perineum and wiped the resident’s buttocks. CNA
O did not wash the resident’s urine soiled inner perineal skin folds, upper thighs, inner
buttock areas or hips, areas which were in contact with the urine saturated incontinence
brief;
-CNA O and Licensed Practical Nurse (LPN) P applied the resident’s pants and transferred
the resident back to the wheelchair.
During interview on 9/27/18 at 10:30 A.M. CNA O said he/she washed the resident’s front
and back while providing perineal care and could not think of any areas he/she missed.
He/she should wash all areas soiled with urine.
8. During interview on 9/28/18 at 3:35 P.M. the Director of Nursing said the following:
-Staff should check resident’s for incontinence and provide incontinence care when needed;
-Staff should provide frontal perineal area incontinence care and then wash the resident’s
buttock areas. Staff should wash from cleanest area to dirtiest area and wash all areas
soiled with urine or feces using multiple wet wipes or wash cloths;
-Staff should provide oral care at least two times daily. Residents with debris on teeth
was not appropriate. Staff should lightly brush resident’s gums if no teeth. Staff should
provide oral care before breakfast with morning cares and provide again at bedtime;
-Staff should change resident’s soiled clothing after meals and not leave soiled clothing
on from breakfast for the remainder of the day.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
used proper technique during gait belt (canvas belt placed around the resident’s waist to
assist with ambulation, transfer, and positioning in a chair) transfers for one resident
(Resident #22) in a review of 19 sampled residents and two additional residents (Resident
#17 and #64). The facility failed to implement new interventions recommended by the
Interdisciplinary team to prevent further falls for one resident (Resident #79) who had a
history of [REDACTED].
1. Review of the facility’s undated protocol for falls showed the following:
-All incidents, including falls were reported using the systems incident report forms;
-Incidents were reported to the Director of Nursing, Physician, and responsible party (if

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
indicated);
-Incidents were discussed, and interventions were reviewed at stand-up meetings weekly at
the interdisciplinary team (IDT) meetings, monthly at QUAPI, and as needed;
-Interventions could include, but were not limited to; follow up assessment and
documentation for 72 hours, Physical and Occupational therapy (PT) (OT) were notified of
the fall and residents were screened when indicated, assessment for mental and/or physical
status changes, follow up review would be completed by nursing, general preventative
measures (monitoring of appropriate interventions), equipment would be checked for proper
function, personal alarms would be used with approval of the resident’s Physician and
family/DPOA, and a physician assessment or emergency room (ER) evaluation would be done if
indicated.
2. Review of the facility policy Safe Lifting and Movement of Residents dated (MONTH)
(YEAR) showed the following:
-The facility used appropriate techniques and devices to lift and move residents in order
to protect the safety and well-being of staff and residents;
-Resident safety, dignity, comfort and medical condition would be incorporated into goals
and decisions regarding the safe lifting and moving of residents;
-Manual lifting of resident should be eliminated when feasible;
-Nursing staff in conjunction with the rehabilitation staff should assess individual
residents’ needs for transfer assistance on an ongoing basis. Staff would document
resident transfer and lifting needs in the care plan;
-Staff responsible for direct resident care would be trained in the use of manual (gait
belts, lateral boards) and mechanical lifting devices;
-Mechanical lifting devices should be used for heavy lifting, including lifting and moving
residents when necessary;
-Only staff with documented training on the safe use and care of the machines and
equipment used in the facility would be allowed to lift or move residents.
3. Review of Resident #79’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/29/18 showed the following:
-Moderately impaired decision making;
-Required extensive assist of one for bed mobility and transfers;
-Surface to surface transfer-not steady only able to stabilize with human assistance;
-One non-injury fall since prior assessment.
Review of the resident’s monthly summary dated 6/19/18 showed the following:
-He/she had [DIAGNOSES REDACTED].
-He/she was alert and oriented, but changed between oriented and confused often;
-He/she was cooperative;
-His/her speech was clear and he/she was always understood;
-He/she required staff guidance/touch to transfer;
-He/she used a wheelchair;
-He/she required staff assistance for toilet use;
-He/she had one to two falls within the past three months;
-Staff were unable to assess the resident’s gait/balance due to he/she was unable to stand
on both feet without holding onto anything, walk straight forward, walk through a doorway,
or make a turn;
-He/she was considered to be at high risk for falls.
Review of the resident’s nurse’s notes dated 7/1/18 at 9:43 A.M. showed the following:
-He/she was found sitting on the floor between the bathroom and the counter in his/her
room:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-He/she had a laceration noted to the back of his/her head approximately three inches long
with a moderate amount of bleeding;
-He/she also had swelling and bruising to the top of his/her left hand near the knuckles;
-He/she was sent to the hospital for evaluation and treatment.
Review of the resident’s nurse’s notes dated 7/1/18 at 12:08 P.M. showed the following:
-He/she returned from the hospital with a non-displaced fracture at the base of the fifth
metacarpal bone (bone located between the wrist and fingers) of the left hand;
-He/she had a splint on the left hand;
-The laceration to the scalp had been closed with four staples.
Review of the resident’s care plan updated on 7/1/18 showed the following:
-A hand written note dated 7/1/18 that showed the resident was found on the floor with a
laceration to the back of his/her head and swelling and bruising to the top of his/her
left hand;
-There was a new order obtained to send him/her to the ER for evaluation and treatment;
-There was an intervention added to remove the grab bars located at the sink.
Review of the resident’s nurse’s note dated 7/3/18 at 12:55 A.M. showed the following:
-He/she was found on the floor by a CNA at 12:30 A.M.;
-The resident had gotten out of bed on his/her own, fell , and struck his/her head on air
conditioner unit;
-There was a large amount of blood on floor and was noted gushing from his/her head;
-The resident had bumped his/her stitches on his/her head from a previous fall and
lacerated the top of his/her head that measured approximately 6 centimeters (cm) by 0.3
cm;
-He/she was sent by ambulance to hospital at 12:45 A.M.
Review of the resident’s nurse’s note dated 7/3/18 at 9:12 A.M. showed the following:
-He/she returned from the hospital at 5:30 A.M.;
-He/she had a bandage to the left occiput (left side of head) and his/her hand was
wrapped.
Review of the interdisciplinary resident screening completed by the therapist dated 7/3/18
showed the following:
-He/she had two recent falls; one on 7/1/18 and one on 7/3/18;
-Fall #1 occurred when he/she attempted to transfer him/herself to the sink;
-Fall #2 occurred when the resident fell from his/her bed at 12:30 (A.M.) while attempting
to transfer him/herself;
-He/she had severe debilitating kyphosis and head drop;
-He/she had [MEDICAL CONDITION] with staples due to the falls;
-He/she was able to make his/her needs known, but was inconsistent with use of his/her
call light;
-Recommended interventions to prevent further falls included; 1) removal of the grab bar
at the sink, 2) foam pad application to the edges of his/her radiator and air conditioner,
3) hang call light from the ceiling over the bed low enough where he/she could reach it
when he/she was reclined, 4) touch pad call light system for use when he/she was in the
recliner, 5) he/she must be out (in the main dining room) for meals, 6) reduce clutter in
his/her room (Tupperware containers and refrigerator), and 7) reduce clothing in his/her
closet in order to close the door and not have clothing outside for resident to organize;
-All recommended interventions were discussed with the Assistant Director of Nursing
(ADON) and the Director of Nursing (DON).
Review of the resident’s care plan showed the following interventions were NOT added as
per the interdisciplinary screening recommendations:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-Placement of a foam pad application to the edges of his/her radiator and air conditioner;
-Hanging the call light from the ceiling over the bed low enough where he/she could reach
it when he/she was reclined;
-He/she must be out (in the main dining room) for meals;
-Placement of a push pad call light system in his/her room;
-Reducing the clothing in his/her closet in order to close the door and not have clothing
outside for him/her to organize.
Review of the resident’s nurse’s note dated 7/5/18 at 11:04 A.M. showed a correction to
the nurse’s note dated 7/1/18; the resident had 16 staples to the back of his/her head
when he/she returned from the ER.
Review of the resident’s quarterly MDS dated [DATE] showed:
-His/her cognition was intact;
-He/she required extensive assistance of one staff with transfers;
-He/she required limited assistance of one staff with walking in room and corridor, and
with locomotion on and off of the corridor;
-He/she used a walker and/or a wheelchair;
-He/she had two falls since prior assessment with injury, but not major injury;
-He/she had one fall since prior assessment with major injury.
Review of the resident’s nurse’s notes dated 8/26/18 at 1:40 P.M. showed the following:
-He/she fell to the floor from the wheelchair at 10:20 A.M. while being pushed to the
front of the facility for church;
-He/she hit her head on the floor, but no injuries were noted.
Review of the facility’s falls committee report dated 8/27/18 showed the resident fell on
[DATE] at 10:20 A.M.
Review of the resident’s Physician’s Order Sheet (POS) dated 9/1/18 to 9/30/18 showed the
following:
-The resident was to have the assistance of one staff for all transfers (start date was
7/14/17);
-The resident was to have gripper socks at bedtime (start date was 7/3/18).
Review of the resident’s nurses’s notes dated 8/31/18 at 4:18 P.M. showed the following:
-Nurse was called to the resident’s room by other staff and found the resident sitting on
the floor in front of his/her wheelchair;
-The resident had raised his/her recliner in high position and slid on to the floor;
-There were no apparent injuries noted.
Review of the resident’s care plan showed that he/she had a fall without injury on
8/31/18. Interventions added to the plan included proper chair positioning.
Review of the resident’s medical record showed there was no further documentation of the
8/31/18 fall, including an event report or incident/accident report.
Review of the facility’s falls committee report dated 9/3/18 showed the resident fell on
[DATE].
Review of the facility’s falls committee report dated 9/10/18 showed the resident fell on
[DATE].
Review of the resident’s nurse’s notes dated 9/20/18 at 2:46 A.M. showed the following:
-The resident was observed lying on the bedside floor mat during rounds;
-The resident said he/she climbed out to get in his/her chair.
Review of the resident’s care plan showed the following:
-He/she was found on the floor mat on 9/20/18;
-He/she said he/she was trying to get into the recliner;
-There were no new interventions added to prevent further falls.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
Review of the resident’s medical record showed there was no further documentation of the
9/20/18 fall, including an event report or incident/accident report.
Review of the resident’s incident log dated 9/26/18 showed the following:
-He/she fell in his/her room on 7/1/18 which resulted in a head injury and localized
tissue [MEDICAL CONDITION]. He/she was sent to the ER for evaluation and treatment;
-He/she fell in his/her room on 7/3/18 which resulted in a head injury and he/she was sent
to the ER for evaluation and treatment;
-He/she fell in the hallway of the unit on 8/26/18 with no head injury;
-He/she fell in his/her room on 8/31/18 with no head or other injuries noted;
-He/she fell in his/her room on 9/20/18 with no head or other injuries noted.
Observation of the resident on 9/27/18 at 7:53 A.M. showed the resident sat in his/her
recliner with regular socks noted on his/her feet.
During an interview, 9/27/18 at 11:53 A.M., LPN B said:
-Interventions such as wedge cushion while in bed to prevent rolling out of bed, bed pad
on the floor, slippy socks, and only nursing to control his/her electric recliner control
had been added to the resident’s care plan;
-The resident is alert and oriented with periods of confusion and hallucinations;
-He/she completed an assessment and an incident report after every fall;
-Charge nurses were responsible for updating the care plan after each fall with meaningful
interventions to prevent further falls;
-Care plans located in the binder at the nurse’s desk were updated and the care plans
documented on the computer may not be updated and accurate.
Interview on 9/27/18 12:59 P.M., the resident’s family said the following:
-The family walked in and noted the call light not within the resident’s reach and was
lying on the floor;
-One of the resident’s falls (7/3/18) resulted in him/her hitting his/her head on the air
conditioner unit, requiring staples to close the wound;
-They were told by facility staff that staff were going to pad the corners of the air/heat
unit, but it was not done.
Observation of the resident’s room on 9/27/18 at 1:00 P.M. showed the following
interventions were NOT completed as per the interdisciplinary screening recommendations:
-No foam pad application noted on the edges of his/her air conditioner;
-No call light hanging from the ceiling over the bed low enough where he/she could reach
it when he/she was reclined;
-No push pad call light placed in the resident’s room.
Interview on 9/27/18 2:24 P.M., showed CNA C said the following:
-The resident used his/her call light, but staff would have to answer quickly or the
resident would attempt to get up on his/her own without help;
-The resident needed a lot of redirection and reminders to use her call light for
assistance;
-The resident did not have a flat call light system;
-Sometimes the resident’s call light would be between his/her legs and the chair, causing
him/her to not be able to locate it.
Observation of the resident on 9/28/18 at 8:00 A.M. showed the resident sat in his/her
recliner located in his/her room with regular socks on his/her feet while eating
breakfast.
During an interview on 10/2/18 at 11:11 A.M. the resident’s family said the following:
-The resident fell on [DATE] with no injury;
-The resident fell on [DATE] in the dining room at approximately 3:00 P.M., as witnessed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
by another resident’s family;
-It was reported that the resident stood up, his/her pants fell down, and he/she fell as
he/she bent over to pull them up;
-The resident suffered a [MEDICAL CONDITION] and was hospitalized ;
-It was reported by the witness that staff were not present at the time the resident fell
;
-He/she reported that the resident’s air conditioner unit was supposed to be padded after
the fall in (MONTH) where he/she suffered from a lacerated scalp as a result of a fall,
but it was not done;
-The resident was supposed to his/her call light hung from the ceiling and over to him/her
where he/she could reach it better when in his/her recliner, but it was not done;
-The resident’s call light was out of his/her reach 80% of the time when they came to
visit.
During an interview on 9/28/18 at 12:00 P.M., the ADON said:
-He/she expected all interventions discussed in the Interdisciplinary team (IDT) meeting
be placed on the resident’s care plan and be followed through;
-He/she expected a re-evaluation to ensure that the interventions were completed.
During an interview on 9/28/18 at 12:00 P.M., the Director of Nursing (DON) said:
-He/she expected all interventions discussed in the Interdisciplinary team (IDT) meeting
be placed on the resident’s care plan and be followed through;
-He/she expected a re-evaluation to ensure that the interventions were completed.
4. Review of Resident #17’s care plan last revised 7/10/18 showed the following:
-Resident requires assist of one with activities of daily living;
-He/she is able to make his/her needs know but has shown an overall decline due to the
advance of dementia;
-Hospice.
Review of the resident’s quarterly MDS dated [DATE] showed extensive assistance one person
physical assist with bed mobility and transfers.
Review of the resident’s physician orders dated 9/18 showed the following:
-Diagnosis, dementia, muscle weakness, pain in [MEDICATION NAME] (vertebrae) spine;
-Difficulty in walking.
Observation on 9/26/18 showed the following:
-Picture of a Bear poster (used to inform caregivers of transfer status for the residents)
posted above his/her bed with an S directing staff to use the Sabina lift (sit to stand
assistive device used for transfers);
-CNA F pulled the resident’s chair to the side of the bed and put his/her hands under the
resident’s legs and arm under the resident’s back pulling him/her up to a sitting
position;
-CNA F told the resident to give him/her a hug and put his/her right arm under the
resident’s right armpit and his/her left arm under the resident’s left armpit;
-CNA F grabbed the resident’s pants and pulled the resident up;
-The resident was slightly bent at the waist, his/her legs were bent at the knees and
bearing no weight;
-CNA F pivoted the resident into his/her wheelchair.
During interview on 9/26/18 at 6:00 A.M., and telephone interview on 10/1/18 4:15 P.M.,
CNA F said the following:
-Normally the resident bears weight,
-He/she had the bed up a little too high for the resident to touch the floor with his/her
feet;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
-He/she is supposed to use the gait belt when transferring a resident.
5. Review of Resident #22’s quarterly MDS dated [DATE] showed his/her cognition was
severely impaired and he/she required extensive assistance of two or more staff with
transfers.
Review of his/her care plan last reviewed on 7/19/18 showed the following:
-He/she required a lot of assistance with transfers and bed mobility;
-Staff were to ensure that they assisted him/her because he/she would not ask for
assistance;
-He/she had an assist handle to help with transfers;
-There was no documentation that directed staff on what type of transfer to use on the
resident.
Review of the resident’s POS dated 9/1/18 to 9/30/18 showed an order for [REDACTED].
Observation on 9/27/18 at 6:29 A.M. showed the following:
-CNA G applied a gait belt around the resident’s waist;
-CNA G and CNA H transferred the resident into his/her wheelchair by placing their arms
under the resident’s arms and grabbing onto the resident’s pants to lift the resident from
the bed to the wheelchair.
During an interview on 9/27/18 at 6:50 A.M., CNA G said the following:
-Transfers should be performed holding on to the gait belt and not by lifting under the
resident’s arms, or by grabbing the resident’s pants;
-He/she had to lift under the resident’s arms and grab the resident’s pants to transfer
him/her because the gait belt was too tight for him/her to get his/her fingers under the
belt.
During an interview on 9/28/18 at 3:34 P.M., the DON said that he/she expected staff to
lift the resident by use of the resident’s gait belt during a transfer. He/she would not
have expected staff to lift the resident by applying pressure under the resident’s arms or
by pulling on the resident’s pants.
6. Review of Resident #64’s care plan revised on 8/15/18 showed the following:
-Assist with one for activities of daily living and mobility;
-Monitor for pain during all activities of daily living;
-Requires assistance with transfers and uses a wheelchair.
Review of resident’s quarterly MDS dated [DATE] showed the following:
-Extensive assistance one-person physical assist transfers;
-Extensive assistance one-person physical assist locomotion.
Review of the resident’s physician orders dated 9/18 showed the following:
-[DIAGNOSES REDACTED].
-Assist times one to wheelchair, may use Sabina lift as needed.
Observation on 9/26/18 at 3:14 P.M., showed the following:
-Picture of a Bear poster above his/her bed with two balloons (two person transfer) and
Sabina lift as needed;
-CNA D wheeled the resident in his/her wheelchair into his/her room from the dining room
and placed him/her by the bed;
-CNA E wrapped the gait belt around the resident’s waist and pulled it tight;
-CNA D and CNA E put their arms under the resident’s armpits and grabbed the back of the
gait belt with their opposite hands;
-CNA D and CNA E lifted the resident up by the resident’s arms and the gait belt at the
same time;
-The resident moaned loudly as CNA D and CNA E lifted him/her from the wheelchair;
-The resident’s knees were bent and he/she was bent at the waist;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-CNA D and CNA E transferred the resident to his/her bed.
During interview on 9/26/18 at 3:16 P.M., CNA D said the resident barely bore weight when
he/she transferred the resident.
During interview on 9/27/18 and 09/27/18 2:30 P.M., CNA E said the following:
-The proper way to transfer someone is to use the gait belt;
-He/she would go tell the nurse if a resident moans during a transfer to find out a
different transfer method;
-The resident could have done a lot more for himself/herself if we would have given
him/her time.
During interview on 9/27/18 at 1:50 P.M., LPN B said the following:
-The facility policy is the resident has to be able to bear some weight in order to
transfer using a gait belt;
-If the resident is not able to bear weight when transferring or is moaning the CNA should
report to the charge nurse for further assessment;
-He/she would not expect staff to lift a resident by putting their arms under the
resident’s armpits and lifting the resident by grabbing onto the resident’s pants;
-He/she would expect staff to use a gait belt to transfer a weight-bearing resident.
During interview on 9/28/18 at 3:50 P.M., the Director of Nursing said the following;
-Staff should be using the gait belt during transfers;
-Staff should be holding onto the gait belt not a resident’s pants during transfers;
-Staff should not put his/her arms under a resident’s armpits during transfers;
-He/she would not expect the CNA to continue to transfer a resident who is moaning;
-He/she expected the CNA to report to the charge nurse the resident moaning during
transfers.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on observation and interview, the facility failed to maintain equipment clean and
free from a build-up of debris, and failed to ensure staff wore hair nets properly in the
kitchen during meal preparation. The facility census was 91.
1. Observations in the kitchen during meal preparation on 9/26/18 from 8:14 A.M. through
11:43 A.M. showed the following:
-At 8:14 A.M., the acting dietary manager was in the kitchen area and did not have her
hair net on properly. Hair in the front and back of her head hung out of the hairnet;
-At 8:50 A.M., the dietician was in the kitchen area and did not have her hair net on
properly. Hair in the front and back of her head hung out of the hairnet;
-At 10:01 A.M., the dietician was in the kitchen area and did not have her hair net on
properly. Hair in the front and back of her head hung out of the hairnet;
-At 10:14 A.M., the acting dietary manager was in the kitchen area and did not have her
hair net on properly. Hair in the front and back of her head hung out of the hairnet;
-At 11:43 A.M., the acting dietary manager was in the kitchen area and did not have her
hair net on properly. Hair in the front and back of her head hung out of the hairnet;
2. Observation on 9/26/18 at 8:23 A.M. showed the window air conditioner in kitchen blew
toward the range. The air condition vent was covered in a thick layer of dust.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
3. During interview on 9/26/18 at 2:43 P.M., the dietician said she expected staff to wear
hairnets properly. The entire head and all hair needed to be covered with the hairnet. She
was not aware she and the acting dietary manager did not have their hairnets on properly.
During interview on 09/26/18 at 2:58 P.M., the acting dietary manager said she expected
staff to wear hairnets properly. The entire head and all hair needed to be covered with
the hairnet. She was not aware she and the dietician did not have their hairnets on
properly.
During interview on 09/26/18 at 3:30 P.M., the acting administrator said he expected any
staff in the kitchen area to have a hairnet on and all hair covered at all times.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
washed their hands after each direct resident contact and when indicated by professional
standards of practice during personal care for seven residents (Residents #79, #83, #81,
#22, #5, #42 and #36) in a review of 19 sampled residents and for one additional resident
(Resident #17). The facility census was 91.
1. Review of the facility policy Handwashing/Hand Hygiene dated (MONTH) (YEAR) showed the
following:
-The facility considered hand hygiene the primary means to prevent the spread of
infections;
-Wash hands with soap and water when hands were visibly soiled and after contact with a
resident with infectious diarrhea;
-Use an alcohol based hand rub or alternatively soap and water before and after coming on
duty, direct contact with residents, handling an invasive device, eating or handling food,
assisting a resident with meals and when entering isolation precaution settings;
-Use an alcohol based hand rub or alternatively soap and water before preparing or
handling medications, performing any invasive procedures, donning gloves, handling clean
or soiled dressings, and when moving from a contaminated body site to a clean body site
during resident care;
-Use an alcohol based hand rub or alternatively soap and water after contact with a
resident’s intact skin, contact with blood or bodily fluids, handling used dressings and
contaminated equipment, contact with objects in the immediate vicinity of the resident and
after removing gloves’
-Hand hygiene was the final step after removing and disposing of personal protective
equipment;
-The use of gloves did not replace hand washing/hand hygiene. Integration of glove use
along with routine hand hygiene was recognized as the best practice for preventing
healthcare-associated infections.
2. Review of the Infection Control Guidelines for Long Term Care Facilities, (MONTH) 2005
edition, Section 3.0, Body Substance Precautions, Subsection 3.2 Implementing the Body
Substance Precautions System, showed the following regarding gloves and handwashing:
-Instructions should be followed by ALL personnel at all times regardless of the
resident’s diagnosis;
-Gloves: Wear gloves when it can be reasonably anticipated that hands will be in contact

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces,
wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these
substances) and/or persons with a rash; gloves must be changed between residents and
between contacts with different body sites of the same resident;
-REMEMBER: Gloves are not a cure-all; they should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects;
dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a
glove easier than to the skin on your hands; and handling medical equipment and devices
with contaminated gloves is not acceptable;
-Handwashing: Handwashing remains the single most effective means of preventing disease
transmission; wash hands often and well, paying particular attention to around and under
fingernails and between the fingers; wash hands whenever they are soiled with body
substances, before food preparation, before eating, after using the toilet, before
performing invasive procedures and when each resident’s care is completed.
3. Review of Resident #5’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument, completed by facility staff, dated 6/22/18 showed the following:
-His/her cognition was severely impaired;
-He/she was always incontinent of bowel and bladder;
-He/she required extensive assistance of one staff with personal hygiene.
Review of his/her care plan last reviewed on 6/22/18 showed staff were to cleanse the
resident’s perineal area with soap and water after each urination and/or bowel movement.
Observation on 9/27/18 at 5:06 A.M. showed:
-Certified nurse assistant (CNA) G entered the resident’s room and applied gloves without
washing his/her hands;
-The resident was incontinent of urine;
-CNA G removed the urine soaked brief with his/her gloved hands;
-He/she cleansed the resident’s front perineal area and with soiled gloves assisted the
resident onto his/her right side to cleanse the buttock area;
-Without removing his/her soiled gloves and his/her washing hands, CNA G pulled the
resident’s gown down, repositioned the resident in bed, pulled up his/her blankets, and
opened the dresser drawer to place perineal wipes in the drawer;
-Without changing gloves or washing his/her hands, CNA G exited the room to discard linens
and trash in the receptacles located down the hall;
-CNA G removed his/her gloves and without washing his/her hands, he/she walked into other
residents’ rooms to adjust blankets and prepare their clothes for the day.
4. Review of Resident #36’s care plan dated 4/20/18 showed the following:
-Required total assistance with activities of daily living;
-9/3/18 pressure ulcer noted to sacrum (located at the intersection of the spine and
pelvic).
Review the resident’s quarterly MDS dated [DATE] showed the following:
-He/she required extensive assistance of one staff with personal hygiene;
-Always incontinent of urine and bowel.
Observation on 9/27/18 at 2:30 P.M. showed the following:
-CNA M and CNA N entered the resident’s room, washed hands and applied gloves;
-CNA N obtained a package of wet wipes and a clean incontinence brief from the resident’s
closet and removed the resident’s blankets;
-CNA M unfastened the resident’s urine soiled incontinence brief;
-CNA M wiped the resident’s front perineal area with wet wipes, removed his/her soiled
gloves and without washing hands applied clean gloves;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-CNA N turned the resident to his/her side and removed the urine soiled incontinence brief
from under the resident’s buttocks;
-CNA N without washing hands or changing gloves, wiped the resident’s buttocks with wet
wipes and changed gloves without washing hands;
-CNA N, with the same soiled gloves and without washing hands placed a clean incontinence
brief under the resident’s buttocks, touched the resident’s arm and thigh and turned the
resident to his/her back;
-CNA M and CNA N with the same soiled gloves and without washing hands fastened the
resident’s clean incontinence brief, repositioned the resident in bed, adjusted the
resident’s pillows under his/her legs and head and replaced the resident’s blankets.
During interview on 9/27/18 at 2:50 P.M. CNA N said he/she did not wash hands or change
gloves as he/she should.
5. Review of Resident #17’s care plan last revised 7/10/18 showed the following:
-Resident requires assist of one with activities of daily living;
-Resident has shown an overall decline due to the advance of dementia;
-Hospice.
Review of resident’s quarterly MDS dated [DATE] showed the following extensive assistance
with personal hygiene with one person assist.
Observation on 9/26/18 5:14 A.M., in the resident’s room showed the following:
-The resident sat in his/her wheelchair;
-CNA F without washing his/ her hands donned gloves and removed the resident’s dentures
from the resident’s mouth;
-CNA F rinsed the resident’s dentures and placed them back into the resident’s mouth;
-CNA F removed his/her gloves,and without washing his/her hands left the resident’s room
and entered another resident’s room touching the doorknob to open the resident’s door;
-Without washing his/her hands, CNA F picked up the resident’s bed remote and started
assisting the resident with his/her activities of daily living.
6. Review of Resident #79’s quarterly MDS dated [DATE] showed the following:
-His/her cognition was intact for daily decision making;
-He/she required extensive assistance of one staff with personal hygiene.
Observation on 9/26/18 at 2:57 P.M., in the resident’s room showed the following:
-The resident sat in a chair watching TV;
-CNA C donned gloves;
-CNA C brushed the resident’s teeth;
-CNA C wiped the resident’s face with a towel;
-CNA C removed his/her gloves and without washing his/her hands, helped the resident make
a phone call with the resident’s telephone, dialing the phone number touching the dial pad
and held the phone (touching the outer area of the phone) to the resident’s ear;
-CNA C without washing his/her hands took the trash and dirty linen items out of the
resident’s room.
During interview on 9/27/18 at 3:10 P.M., CNA C said the following:
-Normally he/she washes his/her hands when entering and leaving a room;
-There was no reason why he/she did not wash his/her hands before starting care on the
resident and after removing his/her gloves;
During interview on 9/27/18 at 1:50 P.M., LPN B said the following:
-The expectation is that staff washes their hands before and after resident care, before
and during meals;
-He/she would expect the staff to wash their hands in between resident care, before
donning gloves and before oral care.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
7. Review of Resident #22’s quarterly MDS dated [DATE] showed the following:
-His/her cognition was severely impaired;
-He/she was always incontinent of bowel and bladder;
-He/she required assistance of one staff with personal hygiene.
Review of the resident’s care plan last reviewed on 7/19/18 showed the following:
-He/she required extensive assistance for all ADLs;
-Staff were to provide perineal care when he/she was incontinent.
Observation on 9/27/18 at 6:00 A.M. showed the following:
-CNA G entered the resident’s room and without washing his/her hands, applied leg
protectors on the resident’s legs;
-CNA G checked the resident’s urine soaked brief by touching the brief with his/her bare
hands;
-CNA G applied gloves without washing his/her hands and obtained perineal wipes;
-He/she removed the urine soaked incontinence brief and washed the urine from the
resident’s front perineal area;
-Without removing his/her contaminated gloves and washing his/her hands, he/she assisted
the resident onto his/her side and cleansed the buttock area;
-With contaminated hands and gloves, CNA G placed a clean incontinence brief, pants, and
shirt on the resident;
-With the same gloved hands, CNA G placed soiled linens in a plastic bag, lowered the bed
by touching the bed control, repositioned the resident, pulled up blankets around the
resident, placed a call light on the resident’s chest, and walked out of room to discard
linens and trash into collection container in hallway with contaminated gloves in place.
During an interview on 9/27/18 6:50 A.M. CNA G said the following:
-He/she washed his/her hands if there was something on his/her hands or served food;
-He/she should have washed his/her hands after he/she provided perineal care;
-He/she should have removed gloves and washed hands before he/she touched any clean items.
8. Review of Resident #83’s care plan dated 8/7/18 showed the following:
-The resident required staff assistance with all ADLs related to advanced dementia and
stroke. He/she was incontinent of bowel and bladder, required a stand up lift for
transfers and used a wheelchair propelled by staff for mobility. Staff should provide all
skin care, check for incontinence and monitor for skin problems;
-The resident was at risk for skin breakdown due to incontinence of bowel and bladder.
Staff should provide good perineal care after each incontinent episode, provide all skin
care and apply house barrier cream to buttocks/perineal area.
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Required total assistance of one staff member with bed mobility, transfers, dressing,
toileting and personal hygiene;
-Always incontinent of bowel and bladder.
Observation on 9/27/18 at 10:10 A.M. showed the following:
-CNA O, without washing hands or applying gloves, touched and adjusted Resident #34’s
urinary catheter bag attached to the side of the resident’s bed frame. The resident’s
urinary catheter bag contained urine;
-CNA O, without washing hands applied gloves, attached a mechanical standing lift cloth
sling around Resident #83’s waist and assisted LPN P transfer the resident from the
wheelchair to the toilet;
-CNA O, without washing hands or changing gloves, removed the resident’s urine saturated
incontinence brief and placed the brief in the trash. CNA O changed gloves without washing
hands;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-CNA O with the same gloves and soiled hands applied a clean incontinence brief around the
resident’s thighs, wiped the resident’s urine soiled front perineal area with wet wipes,
down each side of the resident’s urine soiled perineum and wiped the resident’s urine
soiled buttocks;
-CNA O, without washing hands or changing gloves, pulled up the resident’s clean
incontinence brief and pants and lowered the resident into the wheelchair;
-CNA O removed the soiled gloves and without washing hands removed the resident’s
mechanical lift sling and placed it on the mechanical lift.
During interview on 9/27/18 at 10:30 A.M. CNA O said he/she did not wash hands frequently
enough while providing the resident’s incontinence care. He/she should not touch clean
items and clothing with soiled hands and gloves. He/she should have washed hands after
touching the resident’s urinary catheter bag, before touching the next resident.
9. Review of Resident #42’s quarterly MDS dated [DATE] showed the following:
-[DIAGNOSES REDACTED].
-Cognitively intact;
-Required extensive assistance of one staff member with bed mobility, dressing, toileting
and personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident’s care plan dated 8/1/18 showed the resident was incontinent of
bladder and was a heavy wetter, spent most of time in bed and required assistance with all
ADLs. Staff should provide daily skin care, offer and assist with toileting upon rising,
between meals and at bedtime and provide perineal care and moisture barrier cream after
each toileting or incontinent episode.
Observation on 9/27/18 at 5:50 A.M. showed the following:
-CNA R and CNA S washed hands, applied gloves and removed the resident’s blankets;
-CNA R loosened the resident’s urine soiled incontinence brief and washed the resident’s
front perineal area and skin folds with wet wipes;
-CNA R changed gloves without washing hands and turned the resident on his/her side. The
resident was incontinent of liquid feces. CNA R rolled the urine and feces soiled
incontinence brief and bed pad under the resident’s hip and washed the resident’s urine
and feces soiled buttocks;
-CNA R changed gloves without washing hands, applied a clean incontinence pad and
incontinence brief and turned the resident on top of the pad and brief;
-CNA R and CNA S removed gloves and washed hands.
During interview on 9/27/18 at 6:15 A.M. CNA R said he/she should wash hands as often as
possible.
During interview on 9/28/18 at 3:35 P.M. the Director of Nursing said the following:
-Staff should wash hands every time they touched something or were about to touch
something;
-Staff should wash hands before gloving and after removing gloves and every time gloves
were changed;
-Staff should wash hands and change gloves when gloves were soiled;
-Staff should not touch clean items with soiled hands or soiled gloves;
-Staff should not touch soiled items in a resident’s room and then provide another
resident’s care without washing hands.
Surveyor: [NAME], (NAME)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265589

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

NAME OF PROVIDER OF SUPPLIER

ST PETERS MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

230 SPENCER ROAD
SAINT PETERS, MO 63376

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some