Original Inspection report

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide dignity
to residents by failing to assist a resident with oral care and sitting the same resident
in a chair soiled with urine, having one resident’s clothing marked with his/her name and
visible to any one who passed by, and not providing a table and chair during meals for
residents who dined on the unit. This affected one of 19 sampled residents and seven
expanded sampled residents (Resident #4, #65, #64, #54, #63, #59, #52 and #13). The census
was 94.
1. Review of Resident #4’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/5/19, showed the following:
-Severe cognitive impairment;
-Total staff assistance needed for toileting, hygiene and transfers;
-Rarely understood or able to make needs known;
-Received nutrition by tube feeding (hollow tube placed into the stomach, provides liquid
nutrition);
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the undated resident’s care plan, showed:
-Focus: Unable to care for him/herself and required total staff assistance with activity
of daily living (ADL’s, ability to perform daily self care tasks);
-Goal: His/her needs will be met;
-Interventions: One staff needed for hygiene and oral care.
Observations of the resident during the survey, showed:
-On 2/3/19 at 8:46 A.M., and 10:25 A.M., he/she sat in his/her room asleep in his/her
geri-chair (G/C, reclining padded wheeled chair). His/her mouth opened and a thick white
sticky substance in his/her mouth with a coated tongue and on his/her teeth;
-On 2/4/19 at 7:45 A.M., the resident sat awake in his/her room in the G/C. He/she
occasionally yelled out and his/her teeth contained a thick white substance;
-On 2/5/19 at 6:45 A.M., and 9:53 A.M., the resident slept with his/her mouth open. A
thick white film was on his/her teeth and corners of his/her mouth.
During an observation and interview on 2/5/19 at 9:53 A.M., showed certified nurses aide
(CNA) E transferred the resident from his/her G/C and placed the resident into his/her
bed. The blanket in the seat of the G/C appeared urine saturated and the seat of the G/C
appeared wet. CNA E provided care to the resident and assisted the resident to get
dressed. CNA E removed the urine saturated blanket from the seat of the G/C and placed a
clean blanket onto the G/C seat. He/she transferred the resident and placed him/her back
into the G/C. CNA E did not clean the G/C seat before he/she placed the resident back into
his/her G/C. CNA E said he/she did not think to wipe off the G/C seat, the blanket had
been urine saturated when he/she had removed it from the resident’s chair. The seat should
have been wiped off with a wet wipe or soapy wash cloth.
Further observations of the resident during the survey, showed:
-On 2/5/19 at 1:15 P.M., the resident asleep with his/her mouth open. A thick, white film
observed on the resident’s teeth and both of the corners of his/her mouth;
-On 2/6/19 at 8:44 A.M., he/she yelled out in his/her room. Nursing staff pushed his/her
G/C into the hallway along the wall. A thick, white film noted to his/her teeth, upper
mouth pallet and both corners of his/her mouth. Multiple nursing staff walked past the
resident and greeted him/her. No staff members attempted to provide oral care to the

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
resident.
During an interview on 2/06/19 at 10:22 A.M., the administrator said staff should wipe
down soiled wheel chair and G/C seats with soap or a disinfecting wipe and allow to dry
before placing a resident back into the chair. Staff should provide oral care at least
every two hours to resident’s that need assistance.
2. Review of Resident #65’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Required extensive assistance from staff with dressing, tilting and personal hygiene.
Required supervision with eating;
-[DIAGNOSES REDACTED].
Observations of the resident on 2/5/19 at 1:15 P.M., showed staff placed the residents
lunch tray on a three tiered wheeled cart by the nurses’ station. Staff sat with the
resident and assisted him/her with eating, taking bites of food to give the resident off
the plate, which sat on the cart.
Further observations of the resident on 2/3/19 at 10:34 A.M., 2/4/19 at 1:15 P.M., 2/5/19
at 8:48 A.M., 2/6/19 at 7:59 A.M., and 2/7/19 at 8:45 A.M., showed the following:
-The resident’s name written in black marker in capital letters across the front of
his/her shirt;
-The resident’s name written in black marker in capital letters on the front of one leg of
his/her pants;
-The resident’s name written in black marker in capital letters on the collars of his/her
shoes.
During an interview on 2/7/19 at 10:05 A.M., the administrator said it is a dignity issue
to have the resident’s name written on the front of his/her clothes and visible on his/her
shoes.
3. Review of Resident #64’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Supervision required for all care;
-[DIAGNOSES REDACTED].
Observations on 2/5/19 at 8:12 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed the
resident sat on the bed and ate from the tray of food that sat on his/her bed.
During an interview on 2/5/19 at 12:55 P.M., the resident said it would be nice to have a
table to eat off of but there was no table available.
4. Review of Resident #54’s annual MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Supervision to limited assistance with all care;
-[DIAGNOSES REDACTED].
Observations on 2/5/19 at 8:12 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed he/she sat
on the side of the bed, staff removed the plates from the food tray and placed them on the
top shelf of a three tiered hard plastic mobile cart where he/she ate his/her meal.
5. Review of Resident #63’s quarterly MDS, dated [DATE], showed the following:-No
cognitive impairment;
-Supervision required for all care;
-[DIAGNOSES REDACTED].
Observations on 2/5 at 8:11 A.M., 12:55 P.M. and 2/6/19 at 7:52 A.M., showed he/she sat on
the side of the bed and ate his/her food from the tray that sat on the bedside table.
6. Review of Resident #59’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Independent with all care;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
-[DIAGNOSES REDACTED].
Observations on 2/5/19 at 8:12 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed the
resident stood next to a side table and ate his/her meal.
During an interview on 2/6/19 at 12:57 P.M., he/she said it would be nice to be able to
sit but there was no room.
7. Review of Resident #52’s annual MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Supervision required with all care;
-[DIAGNOSES REDACTED].
Observations on 2/5/19 at 8:11 A.M., 12:55 P.M. and 2/6/19 at 8:03 A.M., showed the
resident sat on the bed and ate from the food tray that sat on his/her bed.
During an interview on 2/6/19 at 1:00 P.M., he/she said it would be so nice to have a
chair to sit in and a table to hold his/her food.
8. Review of Resident #13’s quarterly MDS, dated [DATE], showed the following:
-Resided in room [ROOM NUMBER];
-Severe cognitive impairment;
-Supervision required for all ADL’s;
-[DIAGNOSES REDACTED].
Observation on 2/6/19 at 8:00 A.M., showed the resident stood at the third floor nurses
station across from room [ROOM NUMBER], held a breakfast tray and said Where am I going to
go? The resident took the tray and entered room [ROOM NUMBER], placed the meal tray on the
bedside table and ate his/her breakfast standing up. At 8:05 A.M., the resident came out
of the room with the meal tray, placed it on the cart and stood at the elevator.
9. During an interview on 2/7/19 at 10:05 A.M., the administrator said the facility does
not have enough tables for residents to use on the second and third floors. It is not
dignified to use over the bed tables and carts and no one should have to eat with their
tray on the bed.

F 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to ensure acceptable general
accounting principles were used when they failed to obtain authorization to spend
resident’s money and ensure the accounts of the resident ledgers and bank statements
reconciled (Residents #37 and #11). The census was 94.
1. Record review of the resident trust account, showed on 12/19/18 the business office
manager ordered seven men’s, two piece sweat pant outfits for Resident #37. The order,
showed an amount of $258.93 and that it would be charged to the resident’s trust account.
Review of the resident’s fund management agreement, did not show that the resident gave
authorization for the facility to spend his/her money. Review of the receipt, showed only
one staff’s initials indicating the clothing was received. Review of the resident’s
personal inventory sheet dated 2/28/11, did not show seven men’s two piece sweat pants on
it.
2. Record review of the resident trust account, showed on 11/9/18 the business office
manager ordered 10, diabetic socks and seven men’s, two piece sweat pant outfits for

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0568

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
Resident #11. The order, showed an amount of $308.92 and that it would be charged to the
resident’s trust account. Review of the resident’s fund management agreement, did not show
that the resident gave authorization for the facility to spend his/her money. Review of
the receipt, showed only one staff’s initials indicating the clothing was received. Review
of the resident’s record, showed no personal inventory sheet.
3. Review of the resident trust account reconciliation for (MONTH) (YEAR), showed a
discrepancy of $5,066.76. There was no explanation for the difference on the form.
4. Review of the resident trust account reconciliation for (MONTH) (YEAR), showed a
discrepancy of $50.00. There was no explanation for the difference on the form.
5. During an interview on 2/7/18 at 9:30 A.M., the business office manager said they have
a shopping program where the nurse initials and she is suppose to initial when they
receive the inventory. They do not have approval from the residents because they are
buying the clothing for residents who can’t speak for themselves. She asks the aides what
the resident needs and then she orders it. She gives the form to social services and they
are suppose to put the items on the inventory sheets. They do not have a written policy or
procedure on the shopping program. The residents do not sign that they receive the items.
The difference in the accounts was before she was in charge of the trust account. She did
not know why there was a descrepancy.

F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to notify the resident or
responsible party when a resident’s money reaches $200 within the SSI limit ($2800) in the
resident trust account. This affected four residents who the facility held funds for. The
census was 94.
1. Record review of Resident #70’s trust account, showed the following:
-On 9/29/18, a balance of $2950.81;
-On 10/30/18, a balance of $4500.15;
-On 11/21/18, a balance of $4546.01;
-On 12/6/18, a balance of $5156.58;
–No record of notification that the resident was within the $200 SSI limit.
2. Record review of Resident #61’s trust account, showed the following:
-On 10/22/18, a balance of $3905.41;
-On 11/21/18, a balance of $3104.91;
-On 12/24/18, a balance of $3226.05;
-No record of notification that the resident was within the $200 SSI limit.
3. Record review of Resident #18’s trust account, showed the following:
-On 12/31/18, a balance of $3482.40;
-No record of notification that the resident was within the $200 SSI limit.
4. Record review of Resident #44’s trust account, showed the following:
-On 12/3/18, a balance of $6817.84;
-On 12/31/18, a balance of $3659.90;
-No record of notification that the resident was within the $200 SSI limit.
5. During an interview on 2/07/19 at 9:30 A.M., the business office manager said she does
not notify the resident or responsible party if a resident is within $200 limit. They are

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
payee for most of the residents so she was told she did not have to send a letter. She has
not notified Medicaid if over the $3,000 amount.

F 0574

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

The resident has the right to receive notices in a format and a language he or she
understands.

Based on observation and interview, the facility failed to provide accessible information
on the location of the State Long-Term Care Ombudsman program, Medicare/Medicaid programs
or the State Survey Agency that was readily available to residents in the facility without
assistance. The census was 94.
Observations throughout the survey on 2/3/19, 2/4/19, 2/5/19, 2/6/19 and 2/7/19 showed:
-A State Long-Term Care Ombudsman sign outside the Administrator’s office and hanging on
the wall of the 300 floor;
-Staff did not provide any contact information regarding the Medicare/Medicaid programs or
the State Survey agency.
During a resident group meeting on 2/5/19 at 10:33 A.M., eight of the residents attended
did not know where contact information for the Medicare/Medicaid programs or the State
Survey agency were kept. Two residents said a sign was posted outside the Administrator’s
office and on the 300 floor for the State Long-Term Care Ombudsman program. There used to
be more signs, but they were taken down when the halls were painted and never replaced.
During an interview on 2/7/19 at 10:05 A.M., the administrator said Ombudsman information
is kept in each resident’s medical chart. He agreed this was not easily accessible to all
residents. The Director of Nursing said information for the Medicaid/Medicare program and
the State Survey agency was posted in the employee break room. She agreed this was not
accessible to residents.

F 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on observation and interview the facility failed to notify residents of the current
availability and location of the most recent survey results and facility plan of
correction. This had the potential to affect all the residents. The facility census was
94.
Observations throughout the survey on 2/3/19, 2/4/19, 2/5/19, 2/6/19 and 2/7/19 showed:
-A survey binder at the receptionist desk at the main entrance;
-One sign at the front entrance indicating the location of the survey result binder across
the hall from the front desk;
-No binder found across the hall from the front desk;
-Staff did not provide easily accessible notice of the location of the survey results to
residents on the 100, 200 and 300 floors.
During a resident group meeting on 2/5/19 at 10:33 A.M., seven of the eight of the
residents attended did not know where to find the survey results. One resident said he/she
knew the binder was at the front desk, but did not know they were allowed to read it. They

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 5)
said they would like to know what the results were.
During an interview on 2/7/19 at 10:05 A.M., the administrator said the survey binder is
kept at the front desk, which has someone at it 24 hours a day, 7 days a week. He said it
is kept there because residents have used it to throw at other residents or staff. He
agreed it was not easily accessible to all residents without having to ask.

F 0578

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to evaluate the cognitive status
of two residents (Resident’s # 22 and #25) prior to them signing the facility code status
form to elect (full code- if the heart stops beating or breathing ceases, all life saving
methods are performed; or no code – do not resuscitate, no life prolonging methods are
performed) and failed to have one resident (Resident #68) sign a facility code status
form. The sample size was 19. The census was 94.
1. Review of Resident #22’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/25/19, showed the following:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the physician’s orders [REDACTED].>Review of the resident’s facility face
sheet, showed the resident had a guardian.
Further review of the medical record, showed a copy of guardianship papers, signed on
4/3/17.
Further review of the medical record, showed the resident signed the facility code status
form on 10/29/18, for the election of full code status. The facility representative
signature line remained blank. The guardian had not signed the form.
2. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following:
-A cognitive score of 0 out of 15, severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance to total dependence on staff care;
-[DIAGNOSES REDACTED].
Further review of the medical record, showed the resident signed the facility code status
form on 5/18/18 for the election of full code status. A facility representative signed the
same form on 5/18/18 as a witness.
Review of the POS [REDACTED]
Review of the resident’s facility face sheet, showed the facility as the responsible party
and a family member as emergency contact.
3. Review of Resident #68’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED]
Review of the medical record, showed no facility code status form or advanced directive in
the record.
During an interview on 2/7/19 at 10:05 A.M., the administrator and Director of Nursing
said a resident should have a BIMS (brief interview of mental status) of at least 10 to be

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
competent enough to sign a code status form. If a resident has a guardian, the guardian
should always be the one to sign and not the resident. They added that the code status
should always be on the POS and a facility code status form signed for every resident.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

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

Based on observations and interviews, the facility failed to provide a clean, safe, and
comfortable homelike environment when staff failed to adequately clean black mold on the
first floor shower room, repair and maintain floors, walls, vents, equipment, vertical
blind slats, ceiling tiles in good repair and ensure electrical wires remained unexposed
above the damaged or missing ceiling tiles. The census was 94.
1. During the entrance conference on 2/3/19 at approximately 8:56 A.M., the administrator
said they have been doing updates on the resident halls. They are in the process of
replacing old ceiling tiles and some are missing.
2. Observations of the 100 unit for all days of the survey 2/3/19 through 2/6/19, showed:
-room [ROOM NUMBER] resident restroom missing six, 1/2 inch floor tiles in front of toilet
and the wall behind the toilet bubbled and the paint peeled and chipped away from wall.
There appeared to be a water leak behind the wall;
-The main 100 unit floor corner shower room located by room [ROOM NUMBER] had chipped
paint on the wall. The corner wall had chipped and damaged, 4 inch by 1 1/2 inch dusty
vents. The shower head leaked and the paint chipped away from wall. There were sections of
black mold near vent in the shower stall, which measured approximately 5 inches by 5
inches;
-Observation on 2/4/19 at 6:52 A.M.,12:10 P.M., and 1:32 P.M., showed the 100 floor shower
room continued to have sections of the black mold that measured approximately 5 inches by
5 inches and remained near vent in shower stall. At one time a male resident exited the
bathroom.
During an interview on 2/5/19 at 6:56 A.M., certified nurse aide (CNA) I said the main 100
unit hallway bathroom is used daily for toileting and showers, he/she worked night shift
and at times residents who can not sleep or want to shower would use the hallway shower
room. Every time he/she had worked residents had used it. He/she had not looked in the
shower for wall damage. If staff find damage to walls or moldy areas, they tell the nurse
and the nurse tells maintenance.
During an interview on 2/3/19 at 9:33 A.M., nurse H said multiple residents used the
hallway bathroom at various times.
During an interview on 2/5/19 at 9:37 A.M., with maintenance employee F and the
administrator in the first floor shower room, employee F identified three areas near the
ceiling in the shower stall as black mold. He was aware of the black mold and first
noticed it a few days ago. He told his manager. The administrator said he was not aware of
the black mold and the shower room needed to be shut down.
Observation on 2/5/19 at 9:50 A.M., showed the director of nursing placed an ‘OUT OF
ORDER’ sign on the outside of the 100 unit main bathroom door.
4. Observation of the 100 hall on all days of the survey from 2/3/19, 2/4/19, 2/5/19,
2/6/19 through 2/7/19, showed two ceiling height exit signs between resident rooms [ROOM

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
NUMBERS]. The tiles around the signs were removed and wires hung down out of the ceiling
approximately 6 inches.
During an interview on 2/07/19 at 8:52 A.M., Employee L said the exit sign tiles on 300
hall have been missing for at least a month.
5. Oservations on 2/05/19 at 1:08 P.M., of 100 unit resident rooms, showed:
-room [ROOM NUMBER]: Wall damaged above base board, paint chipped off and an approximate
area of 1 foot by 4 inch area gouged out of the wall;
-room [ROOM NUMBER]: Gouged and chipped drywall at edge of window ledge;
-room [ROOM NUMBER]: Night stand bottom ledge broken and laying on floor. The window ledge
chipping paint and gouges out of drywall, area measured approximately 1 1/2 feet by 2 1/2
feet.
6. Observations of the 200 unit for all days of the survey 2/3/19 through 2/7/19, showed
the following:
-room [ROOM NUMBER]:
-No head board on bed one and two of three drawers on the bedside table off their tracks;
-Three water spots on the wall over the closet that measured approximately 1 inch round.
A second area measured 1 by 2 inches in round and a third area meaured approximately 5 by
2.5 inches in circumference;
-Shared bathroom that joined rooms [ROOM NUMBERS], showed no working light.
-room [ROOM NUMBER]:
-Wall at the head of the bed, showed an area approximately 1 foot long by 8 feet wide not
painted;
-Broken face plate on electric outlet;
-room [ROOM NUMBER]:
-Missing handle on the third drawer of a three drawer table;
-Wall across from the beds, showed 26 areas of missing paint that measured aprroximately
1 to 1 and 1/2 inches wide by 6 inches long;
-The vertical blinds that covered the window had three slats missing;
-Bathroom that joined rooms [ROOM NUMBERS], showed:
-Left side of the vanity the wall had not been painted;
-Dirty, rusty caulk where the sink joined the wall;
-Vent that measured approximately 10 inches long by 8 inches wide covered in rust;
-room [ROOM NUMBER]:
-No mattress on bed one;
-Second bed foot board chipped in two different places;
-Multiple areas of chipped paint along the wall outside of the bathroom, along the wall
of bed three and around the bathroom door frame.
-room [ROOM NUMBER]:
-Entry wall of the room showed an unpainted area approximately 3 feet by 3 feet;
-Multiple areas of chipped paint;
-Bathroom door nailed shut.
-room [ROOM NUMBER]:
-7 slats missing from the blinds for the window over bed one and no blinds over the
window for bed one;
-No headboard or foot board on bed three;
-Lower 6 inches of the bathroom door chipped.
-room [ROOM NUMBER]:
-Slats on vertical blinds that covered the window all missing except for four blind
slats;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-room [ROOM NUMBER]:
-Ceiling tiles gray and cracked with a large bulge in the tiles over the bed;
-Missing chipped paint on all four walls;
-No curtains or blinds covered the window;
-Vent under the window covered in dust and rust.
-room [ROOM NUMBER]:
-Three blinds missing over the window for bed one and no blinds over the window for bed
two.
-Vertical blinds that covered the window were missing four slats;
-Vent under the window covered in dust and rust.
-room [ROOM NUMBER]:
-Vertical blinds that covered the window missing five blind slats;
-Approximately 20 areas of chipped paint over bed two;
-Ceiling tiles faded in to three different colors and nine tiles, each measured
approximately 2 feet by 18 inches, bulged over bed two;
-Vertical blinds that covered the window were missing five slats.
-room [ROOM NUMBER]:
-Two drawers off the track on the bedside table;
-Tile ceiling bulged in three different areas;
-Multiple areas of chipped paint around the door frame;
-Vertical blinds missing more than half of the slats;
-Missing ceiling tile outside of rooms [ROOM NUMBERS]. A flex metal pipe and an electrical
cord hung from the missing tile outside of room [ROOM NUMBER].
7. During an interview on 2/7/19 at 8:26 A.M., the Maintenance Director said he was made
aware of the black mold when it was shown to the administrator on 2/5/19. He completes
rounds on each resident floor every day. He expects staff to let him know if repairs need
to be made. There are lists on each floor for staff to fill out. He is aware of the
environmental issues and said they repair things, but the residents are very destructive.
He is aware of the missing tiles, but has not replaced them because they have not arrived
yet. He expects they should arrive today. He is aware the tiles by the exit signs are
missing because construction company did work and didn’t replace them. He did not notice
the wires hanging down and agreed it could be a safety issue.
8. During an interview on 2/7/19 at 10:05 A.M., the administrator said he expected
maintenance staff to complete rounds on the resident floors at least weekly. Staff should
also submit work orders for items they noticed needed repaired. The maintenance department
identifies issues and then prioritize what will be addressed. Every window should have
blinds and all slats.

F 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that each resident is free from the use of physical restraints, unless needed
for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow the
facility’s restraint policy and provide timely assessments and documentation including
restraint reduction attempts, failed to position a lap tray as ordered and release the
table tray and ensure repositioning per policy. This affected one of one facility
identified restrained resident (Resident #4). The census was 94.

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
Review of the facility’s physical restraint management policy, revised on 9/2017, showed:
-Guidelines:
-An order has been obtained that includes type of restraint, when to use the restraint
and periodic release of the restraint;
-When the resident’s condition necessitates consideration for a restraint, alternative
interventions should be attempted and fully documented in the nurse notes and the care
plan;
-The resident and/or family member or legal representative will be included in the
decision process and will be informed of how use of the restraint will treat the
resident’s medical condition and promote highest practicable physical and psychosocial
well-being, the benefits and possible negative outcomes of the restraint use and any
alternatives to the restraint;
-During the time the restraint is in place, the restraint is periodically removed and the
resident is assisted with change in position, range of motion and/or stretching;
-Restraints will be assessed on a quarterly basis for appropriateness and attempts for
reductions of the restraint.
Review of Resident #4’s physical restraint assessment, completed on 9/28/18, showed:
-Reason for use of the physical restraint: unsteady gait, agitated behavior, interference
with specific medical treatments, frequent falls, sliding out of wheelchair, attempts to
self transfer and climbs out of bed, one on one certified nurse aide (CNA) observation
uses helmet. The resident had an extremely unsteady gait, and lacked the ability to
maintain proper posture and positioning, he/she is a risk to himself/herself and unable to
be redirected in unsafe situations;
-History: no entry to address what had worked in the past to control/limit behaviors/issue
to prompt the need for the restraint;
-Alternatives used to reduce the risk of harm prior to the use of the restraint: recliner,
family companion, one on one activities, directed ambulation, mattress on the floor,
alternate seating, regular toileting, anticipate hunger, pain, heat and cold, acceptance
of risk, normal schedule/routine, medication review, one to one CNA supervision, helmet
use. The resident lacked the ability to understand and follow simple commands. He/she
continues to be a risk for himself/herself despite alternate interventions;
-Decision to restrain: The resident poses a risk to him/herself if additional
interventions are not put into place to ensure safety. A geri-chair (G/C, reclining,
padded chair) with a lap table (hard plastic table that locks into place in the arms of a
chair) had been encouraged by the family. The family is aware of the benefits and risks of
a G/C with a lap table. The decision to use the geri-chair and lap table had been
determined by the interdisciplinary team with the resident’s physician to ensure the
continued safety of the resident;
-Family notified by phone of decision on 9/18/18;
-Order received from the resident’s physician to clarify restraint parameters and
timeframe’s of appropriate ambulation on 9/28/18;
-No family signed consent for restraint use to include potential risks and benefits.
Review of the resident’s (MONTH) (YEAR) treatment administration record (TAR), dated
11/1/18 through 11/30/18, showed:
-An order dated, 10/24/18 to reposition the resident every two hours and may use a G/C
with a lap tray at all times. Staff initialed every 7:00 A.M. to 3:00 P.M., 3:00 to 11:00
P.M. and 11:00 P.M. to 7:00 A.M., shift daily as completed;
-An order dated, 10/31/18 to release tray table every two hours and place helmet on
his/her head. All dates and every two hour times initialed as completed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
Review of the resident’s (MONTH) (YEAR) TAR, dated 12/1/18 through 12/31/18, showed:
-An order dated, 10/24/18 to reposition the resident every two hours and may use a G/C
with a lap tray at all times. Staff initialed every 7:00 A.M. to 3:00 P.M., 3:00 to 11:00
P.M. and 11:00 P.M. to 7:00 A.M., shift daily as completed;
-An undated order to release the lap tray every two hours at 12:00 A.M., 2:00 A.M., 4:00
A.M., 6:00 A.M., 8:00 A.M., 10:00 A.M., 12:00 P.M., 2:00 P.M., 4:00 P.M., 6:00 P.M., 8:00
P.M., 10:00 P.M. Staff initialed every two hours time slot and daily as completed.
Further review of the medical record, showed no further restraint assessment completed
after 9/28/18.
Review of the resident’s (MONTH) 2019 TAR, dated 1/1/19 through 1/31/19, showed:
-An order dated, 10/24/18 to reposition the resident every two hours and may use a G/C
with a lap tray at all times. Staff initialed 7:00 A.M. to 3:00 P.M., on 1/1/19 through
1/5/19, on the 3:00 P.M. to 11:00 P.M. shift staff initialed on 1/2/19 and 1/3/19 and on
the 11:00 P.M. to 7:00 A.M., shift on 1/1/19 through 1/5/19 as completed;
-No order, tracking or assessment of the table tray released every two hours.
Review of the annual Minimum Data Set (MDS) a federally mandated assessment instrument
completed by facility staff, dated 1/5/19, showed:
-Severe cognitive impairment;
-Total dependence on staff for all care and mobility;
-[DIAGNOSES REDACTED].
-Does not use a trunk or limb restraint;
-Used a chair that prevents rising daily.
-Not involved in a turning and/or repositioning program.
Review of the resident’s care plan updated on 1/20/19, showed:
-Focus: The resident may use a G/C with a tray table for positioning and safety related to
abnormal posture and safety related to stroke and [MEDICAL CONDITION];
-Goal: The resident will remain free of injury, skin break down and other complications
related to use of G/C with tray table;
-Interventions: Education provided to family of risk and benefits of use of G/C such as
skin breakdown and injury, ensure family is in agreement of use of geri chair with the
tray, least restrictive devices used prior to the use of gerichair with tray table was
PT/OT therapy evaluations & 1:1 location monitoring, Fall mats, staff encouraged
him/her to lay down, helmet used during ambulation, staff to monitor and document report
to the physician changes regarding effectiveness of restraint of less restrictive device,
if appropriate; any negative or adverse effects noted including a decline in mood, change
in behavior, decrease in self performance, decline in mood, change in behavior, decline in
cognitive ability or communication, contracture formation, skin breakdown, and falls or
accidents;
-Staff will evaluate the resident quarterly and as needed for the use of G/C with tray
table;
-Staff will release tray table every two hours and as needed;
-Therapy evaluation for seating positioning as needed.
Review of the resident’s (MONTH) 2019 physician order [REDACTED].
Observations of the resident during the survey, showed:
-On 2/3/19 at 8:31 A.M., 9:42 A.M., 10:55 A.M., and 11:24 A.M., he/she sat in his/her room
in his/her G/C and no table tray in place. The resident wore a blue plastic helmet. The
table tray lay against the bedroom wall.
Further observation of the resident, showed:
-On 2/4/19 at 7:21 A.M., 8: 45 A.M., 10:15 A.M., and 1:22 P.M., he/she sat in his/her G/C
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
in his/her room. The bedroom door opened to the hallway. The table tray attached to the
G/C. He/she yelled out go school loudly at times, no staff entered the room. The resident
did not have his/her helmet on;
-On 2/5/19 at 6:48 A.M., 9:27 A.M., 12:33 P.M., and 1:16 P.M., showed he/she sat in
his/her G/C in his/her room and occasionally yelled out loudly go school. No staff entered
his/her room when he/she yelled out. The table tray in place and secured into the arms of
the G/C. He/she wore the blue plastic helmet.
During an interview on 2/5/19 at 10:03 A.M., CNA E said the night shift staff get the
resident up daily around 5:00 A.M., and put the table tray into place on the G/C. The
resident had a fall history and liked to try to get up out of his/her G/C without
assistance and would try to walk. The tray kept him/her in the G/C. He/she thinks the tray
is to be removed every couple hours but is not sure, the resident can not reposition
him/herself. The aides do not document when the table tray is removed.
Observation on 2/6/19 at 6:41 A.M. through 8:58 A.M., showed the resident sat in his/her
G/C in his/her bedroom with the blue plastic helmet on and the table tray in place and
occasionally yelled out go school or banged on the top of the tray. Staff did not enter
the room and check on the resident as he/she yelled out or banged on the tray. Staff did
not remove the tray and did not provide repositioning.
During an interview on 2/05/19 at 12:56 P.M., nurse K said the table tray is used because
the resident is a fall risk and had fallen a few times. Staff are supposed to release the
tray every two hours and then he/she should have his/her helmet on when the tray is off.
The helmet should not be worn if the table tray is used. The two should not be used at the
same time. The restorative aide will ambulate the resident at times, but the restorative
aide is not able to walk the resident daily. He/she did not know of any restraint
assessment that needed to be completed or if one had been completed. The resident’s POS
had orders for the table tray and the G/C. The nurses document in the residents TAR the
removal of the table tray every two hours. He/she verified the resident’s (MONTH) TAR did
not have an order to release the table tray and provide repositioning.
During an interview on 2/06/19 at 7:42 A.M., nurses K and G said they had not completed a
restraint assessment for the lap tray and do not know where to locate the restraint
assessment to complete it. They said the nursing management probably completed the
assessment but they do not know where it is or what the assessment showed. Staff are to
release the tray every two hours and document the table tray release on the resident’s
TAR. Both nurses verified no entry or orders for the release of the tray on the (MONTH)
TAR.
During an interview on 2/6/19 at 7:58 A.M., the administrator said the resident’s charge
nurses complete restraint assessments on him/her quarterly and the assessments should be
in the hard chart and then scanned into the electronic record. Staff should document in
the monthly TAR the removal of the tray every two hours.
Further review of the resident’s medical record on 2/6/19 at 8:29 A.M., showed no
restraint assessment completed after 9/28/18. No orders or documentation to release the
table tray every two hours.
During an interview 2/6/19 at 8:51 A.M., the Director of Nursing said the nurses should
have completed a restraint assessment for December. The restraint form is in the
electronic system and is done quarterly. The staff also should be removing the tray every
two hours and documenting on the TAR that it is being done, provide repositioning and also
offer to walk the resident. The resident could be brought into the hallway for
socialization and monitoring.

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required
for nine of 19 sampled residents (Resident #22, #25, #33, #70, #85, #34, #44, #40 and
#84). The census was 94.
1. Review of Resident #22’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
2. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance to total dependence on staff care;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
3. Review of Resident #33’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Severe cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
4. Review of Resident #70’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance from staff for most activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
5. Review of Resident #85’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required limited assistance from staff with transfers. Required extensive assistance from
staff for dressing, toileting and personal hygiene;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 13)
6. Review of Resident #34’s quarterly MDS, dated [DATE], showed:
-Severe cognitive impairment;
-Experienced delusions;
-Limited staff assistance needed with mobility, toileting, meal set up and transfers;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 completed;
-No PASARR level II screening completed.
7. Review of Resident #44’s quarterly MDS, dated [DATE], showed:
-Cognitively intact;
-Experienced delusions;
-Limited staff assistance needed with toileting, mobility and transfers;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 completed;
-No PASARR level II screening completed.
8. Review of Resident #40’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Inattention and disorganized thinking comes and goes, and changes in severity;
-Independent with most activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
9. Review of Resident #84’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Behaviors exhibited included hallucinations and delusions;
-Alarms: wander/elopement used daily;
-Required extensive assistance from staff for dressing, tilting and personal hygiene;
-Required no assistance for ambulation;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed:
-No DA-124 level I screen found;
-No PASARR level II screen found.
On 2/6/19 at 7:30 A.M., the administrator was requested to provide PASARR documentation
for the above residents.
During an interview on 2/07/19 at 7:37 A.M., the administrator said he is waiting for
PASARRs from a third party. He does not currently have them for any resident in his
possession, but he should. They are aware of the issue and have put processes in place and
its taking time to get documentation back. The forms have to go through their corporate
office before they can get a hard copy. He said he knew they should have them on hand.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

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

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
Based on observation, interview and record review, the facility failed to ensure staff
provided timely updates and revisions to individual resident care plans used to guide
staff to provide resident care to include a resident to resident altercation, a resident
with sexually inappropriate behaviors, a resident with a wanderguard bracelet (a device
worn to alert staff of an attempted elopement) and revise a resident’s continence status.
This practice affected three (Residents #40, #84 and #10) out of 19 sampled residents. The
facility census was 94.
1. Review of Resident #40’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/30/19, showed the following:
-Moderate cognitive impairment;
-Inattention and disorganized thinking comes and goes, and changes in severity;
-Independent with most activities of daily living (ADL’s);
-[DIAGNOSES REDACTED].
Review of the resident’s nurses notes, showed the following:
-1/10/19 at 6:04 A.M., The resident approached staff and residents on floor offering
sexual favors. A resident reported this resident came into his/her room two times during
the night offering sexual favors. This nurse redirected the resident and asked resident to
stay out of other residents room and explained that offering sexual favors is
inappropriate, unwelcomed and requested that the resident stop. Resident verbalized an
understanding of expectations. Staff asked to monitor resident closely and redirect
resident if needed. Staff verbalized an understanding of plan to monitor residents for
safety;
-1/10/19 at 1:37 P.M., Social Services Note, this writer met with resident to see how
he/she was doing and to discuss recent behaviors. Resident stated he/she did not mean to
be disrespectful towards another peer. This writer informed resident that if he/she has
any thoughts or concerns to speak to this writer. Resident was very apologetic and stated
that he/she will not do that again. Resident did not have any other issues or concerns at
this time. Resident will continued to be monitored accordingly;
-1/11/2019 at 8:03 A.M., The resident remains on 15 minute checks for inappropriate
behavior but has not had any episodes thus far and states none will occur. Will continue
to monitor;
-1/11/19 at 11:40 A.M., This writer met with resident to see how he/she was doing and to
discuss recent behaviors. Resident stated that he/she was tired of dealing with dumb ass
people here at the facility. This writer asked resident what was wrong. Resident stated
that he/she did not want to go into details. This writer informed resident that if he/she
needs to talk about anything to find this writer. Resident stated ok just not today.
Resident did not display any fearfulness or have any concerns at this time. Resident will
continued to be monitored accordingly;
-1/13/19 at 11:37 A.M., no behaviors observed, continued close monitoring;
-1/14/19 at 11:46 A.M., no behaviors noted or observed;
-1/14/19 at 1:52 P.M., This writer met with resident to see how he/she was doing and to
discuss recent behaviors. Resident stated that he/she was doing good and was awaiting on
his/her next smoke break. Resident stated that he/she is done trying to get residents to
like him/her, and that he/she will just stick to him/heself for now. This writer informed
resident that it is ok to have friends, and the problem only comes when the issues are
pushed. Resident did not voice any other issues or concerns at this time. Resident will
continued to be monitored accordingly;
-1/29/19 3:00 P.M., This nurse was notified by the Director of Nursing (DON) that the
resident was kicked by another resident in the leg because he/she was upset about how the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
resident talked to a staff member. Spoke to resident, he/she had no comment and stated it
was stupid and he/she ok and had pain of one out of 10. Resident remains alert and
oriented times 3, able to make needs known. Administrator notified and guardian called.
Review of the resident’s care plan, updated 1/21/19, showed the following:
-On 12/5/18, the resident was involved in a physical altercation with another resident,
unprovoked;
-On 1/21/19, the resident was verbally abusive to staff and unable to redirect;
-Goal, the resident will be kept safe in the facility;
-Interventions, 1/21/19 resident sent to hospital for evaluation, keep resident separate
from other resident involved, monitor for 72 hours for signs of fearfulness, obtain x-ray,
provide skin and pain assessments;
-No mention of sexually inappropriate behaviors;
-No mention of the incident of 1/29/19.
During an interview on 2/7/19 at approximately 10:00 A.M., the DON said she expected care
plans to reflect the current needs of the residents. The resident’s sexually inappropriate
behavior should be included on the care plan, as well as the incident of being kicked by
another resident, along with appropriate interventions.
2. Review of Resident #84’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Behaviors exhibited included hallucinations and delusions;
-Alarms: wander/elopement used daily;
-Required extensive assistance from staff for dressing, tilting and personal hygiene;
-Required no assistance for ambulation;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-A (MONTH) 2019 physician order [REDACTED].
-A care plan, last revised on 8/17/18, and in use during the survey, showed the following:
-Focus: Resident wanders on his/her unit. Will roam in other residents’ room due to
cognitive loss. Resident is at risk for elopement related to limited cognition;
-Goal: Resident’s safety will be maintained through the review date (no date listed);
-Interventions: Staff did not include the use of the wanderguard bracelet or how to know
if it was in place or worked.
Observations of the resident on 2/4/19 at 8:21 A.M., 2/5/19 at 7:25 A.M., and 2/6/19 at
7:21 A.M., showed the resident wore a wanderguard bracelet on his/her right wrist.
During an interview on 2/6/19 at 7:37 A.M., nurse G said the resident wanders, but not as
much as he/she used to. The resident wore a wanderguard and it will go off if he/she tries
to go outside. He/she can get on the elevator without it going off. Nurse G was not sure
who checked the placement or function of the wanderguard. He/she thought maybe someone
from social services took the resident to the main entrance to test the function of the
wanderguard.
3. Review of Resident #10’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Independent for activities of daily living;
-Continent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised on 6/24/18 and in use during the survey,
showed the following:
-Focus: Resident is incontinent at night related to cognitive loss;
-Goal: Resident will decrease frequency of urinary incontinence through the next review
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
date (no date given);
-Interventions included: ask resident if he/she would like staff to wake him/her up at
night for toileting needs and ensure resident has unobstructed path to the bathroom.
During an interview on 2/05/19 at 8:13 A.M., the resident said he/she no longer is
incontinent at night. He/She does that at a new place because he/she feels insecure, but
he/she now feels very comfortable at the facility.
During an interview on 2/7/19 at 8:51 A.M., certified nurse aide (CNA) J said the resident
is no longer incontinent at night. It has been a long time since the resident was
incontinent.
Staff failed to update the care plan to reflect the resident’s current continence status.
During an interview on 2/7/19 at 10:05 A.M., the DON said staff should obtain an order for
[REDACTED]. The MDS coordinator is responsible for updating the care plan. The
interdisciplinary team can also update the care plan. The care plan should reflect the
resident’s current status.

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide and
ensure resident’s activity preferences and one to one activity needs had been met. This
practice affected four out of 19 sampled residents (Residents #4, #3, #65 and #25). The
census was 94.
1. Review of Resident #4’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/5/19, showed:
-Severe cognitive impairment;
-Unable to make needs/wants known;
-Needed total staff assistance for care and mobility;
-No activity assessment completed;
-[DIAGNOSES REDACTED].
Review of the resident’s one to one activity visit form, showed:
-On 11/12/18: Staff provided small talk, discussed going to school;
-On 11/14/18: Watched morning news;
-On 11/19/18 and 11/21/18: Small talk;
-On 11/26/18: Played with stress balls;
-On 11/28/18: Listened to the radio;
-On 12/3/18 and 12/12/18: Played with stress balls;
-No further documentation found for (MONTH) (YEAR) one to one activity visits.
Review of the resident’s undated care plan, showed:
-Focus: He/she is at risk for social isolation related to impulsive behavior, cognitive
loss and communication deficit ;
-Goal: He/she will not experience isolation;
-Interventions:Accompany him/her to group activities and encourage participation. If
he/she becomes disruptive provide 1 on 1 activities in his/her room, provide behavioral
health consults as needed, encourage other residents and staff to talk to him/her during
activities, report to the physician mood patterns, staff to provide one on one
socialization with him/her.
Review of the one to one activity visit form, showed:

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-On 1/7/19: Talked about going to school;
-On 1/14/19: Resident asleep;
-On 1/16/19 and 1/21/19: Talked about going to school;
-On 1/29/19: Music therapy;
-On 2/4/19: Talked about going to school;
-No further documentation of one to one visits.
Observations of the resident during the survey, showed:
-On 2/03/19 at 8:43 A.M., and 10:23 A.M., he/she in his/her bedroom facing his/her TV. The
TV was on and the image flickered on the screen and was not clear. He/she yelled out
randomly Go school. Bedroom door opened to hallway;
-On 2/04/19 6:53 A.M., 10:52 A.M., 11:35 A.M., and 2:05 P.M., the resident sat up in
his/her room, the door opened to the hallway, and the TV off. He/she yelled out
occasionally go school. Multiple staff walked past his/her room;
-On 2/06/19 at 7:40 A.M., the resident sat in his/her geri-chair (padded, reclining chair)
in his/her room, the TV on and the image flickered. He/she yelled out multiple times go
school. The bedroom door opened to the hallway. Multiple staff looked into the resident’s
room as they walked past the resident’s room. No staff entered the resident’s room;
-at 8:44 A.M., the resident yelled out in his/her room and banged on the top of his/her
table tray. Nursing staff pushed his/her G/C into the hallway along the wall. He/she
stopped yelling, no staff spoke to him/her or engaged with him/her.
2. Review of Resident #3’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Supervision required with ambulation;
-Extensive assistance to total dependence on staff for all personal care;
-[DIAGNOSES REDACTED].
Review of the care plan, last updated on 8/6/18, showed the following:
-Problem: Resident is dependent on staff for activities, cognitive stimulation, He/she
likes to roam the halls on the unit and required one to one activities related to short
attention span and cognitive loss;
-Goal: Resident will maintain involvement in cognitive stimulation and social activities
as desired through the review date;
-Approaches: one to one bedside-in room visits and activities if unable to attend out of
room events and all staff to converse with resident when providing care.
Review of the activity interview for daily and activity preferences, dated 12/20/18,
showed the following:
-Should interview be conducted? No;
-Activities that are important but resident can not do consistant religious activities,
fresh air, music, books, magazines, keeping up with the news, participating in activities
with groups of people and using the phone in private;
-The resident served as primary respondent to the questionnaire.
Review of the one to one activity visit log, dated 11/1 through 11/30/18, showed the
following:
-11/12 from 10:40 A.M. to 10:45 A.M., small talk and listed to music;
-11/14 from 9:55 A.M. to 10:00 A.M., listen to the radio;
-11/19 from 8:00 A.M. to 8:00 A.M., small talk;
-11/21 from 8:00 A.M. to 8:05 A.M., small talk;
-11/28 from 12:30 P.M. to 12:35 P.M., played with checkers.
Review of the one to one activity log, dated 12/1 through 12/31/18, showed the following:
-12/3 from 12:30 P.M. to 12:35 P.M., small talk;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-12/12 from 8:40 P.M. to 8:50 A.M., combed his/her hair and washed his/her face.
Review of the one to one activity log, dated 1/1 through 1/31/19, showed the following;
-1/7 resident refused;
-1/21 from 11:30 to 11:35 A.M., small talk;
-1/29 from 11:00 to 11:05 A.M., music therapy;
–No other documenttion of activity participation.
Observations on 2/4/19 at 10:00 A.M. and 1:44 P.M., 2/5/19 at 10:36 A.M. and 12:07 P.M.,
2/6/19 at 10:54 A.M., showed he/she sat at the nurse’s desk, alone, no one communicated
with him/her.
3. Review of Resident #65’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance to total dependence on staff for all personal hygiene;
-[DIAGNOSES REDACTED].
Review of the care plan, last updated on 8/15/18, showed the following:
-Problem: Resident has little or no activity involvement related to unspecified
intellectual disabilities and inappropriate social behavior (i.e continuous crying and
yelling out);
-Goal: Resident will participate in activities one to two times by the review date;
-Approach: Allow him/her to have control over activity if possible during one on one
time;
-Preferred activities are one on one activities
-Offer verbal praise to reinforce positive social behavior in group activities

Review of the activity interview for daily and activity preferences, dated 12/8/18, showed
the following;
-Should interview be conducted? YES;
-Activities that are important but resident can not do consisted of religious activities,
fresh air, music, books, magazines, keeping up with the news, participating in activities
with groups of people and using the phone in private;
-The resident served as primary respondent to the questionnaire.
Review of the one to one activity visit log, dated 11/1 through 11/30/18, showed the
following:
-11/12 from 11:25 to 11:30 A.M., small talk and listened to music;
-11/14 from 9:30 to 9:35 A.M., listened to the radio;
-11/19 from 8:30 to 8:35 A.M., small talk;
-11/21 from 8:45 to 8:50 A.M., small talk;
-11/26 from 2:00 to 2:05 P.M., played checkers;
-11/28 from 11:40 to 11:45 A.M., listened to the radio;
Review of the one to one activity log, dated 12/1/ through 12/31/18, showed the following:
-12/3 from 9:15 to 9:20 A.M., small talk;
-12/12 from 10:15 to 10:20 A.M., small talk.
Review of the one to one activity log, dated 1/1 through 1/31/19, showed the following:
-1/7 from 8:30 to 8:35 A.M., watched the morning news;
-1/12 from 11:20 to 11:25 A.M., small talk;
-1/15 from 8:50 to 8:55 A.M., small talk;
-1/17 from 9:50 to 9:55 A.M., played with stress balls;
-No other documentation of activity participation.
Observations on 2/4/19 at 10:00 A.M. and 1:44 P.M., 2/5/19 at 10:36 A.M. and 12:07 P.M.,

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
2/6/19 at 10:54 A.M., showed he/she sat at the nurse’s desk, quiet, no one spoke to
him/her.
4. Review of Resident #25’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Unable to ambulate;
-Extensive assistance to total dependence on staff for all personal care;
-[DIAGNOSES REDACTED].
Review of the care plan, last updated on 1/30/19, showed the following:
-Problem: Resident has memory loss and impaired thought process;
-Will maintain current level of cognitive function through the review date;
-Engage resident in simple, structured activities that avoid overly demanding tasks.

Review of the activity interview for daily and activity preferences, dated 1/26/19, showed
the following;
-Should interview be conducted? Yes;
-Activities very important to him/her included, books, magazines, keep up with the news,
doing things with groups of people, fresh air and religious services;
-The resident served as the primary respondent to the questionnaire.
Review of the one to one activity logs provided by the activity department, showed the
following:
-11/12/18 from 1:45 to 1:50 P.M., small talk while he/she watched TV;
-1/15/19 from 9:50 to 10:00 A.M., played with stress ball;
-1/17/19 from 10:55 to 11:00 A.M., listened to the radio;
-1/24/19 from 8:10 to 8:20 A.M., resident did not want to talk;
-1/29/19 from 11:35 to 11:40 A.M., music therapy;
-2/4/19 from 11:10 to 11:15 A.M., small talk;
-No other documentation for activity participation.
Observations on 2/4 at 9:45 A.M., 10:41 A.M. and 12:06 P.M. and 2/5/19 at 7:33 A.M., 9:40
A.M., 10:55 A.M. and 12:06 A.M., showed the resident sat in a wheelchair in his/her room,
alone, talking out loud.
Observations on 2/6/19 at 9:40 A.M. and 11:00 A.M., showed him/her,lay in bed.
Observation on 2/6/19 at 12:54 P.M., showed him/her seated in a wheelchair across from the
desk. No one spoke to him/her.
During an interview on 2/7/19 at 7:55 A.M., the Activity Director said he has four aides
that work in activities. One to one activity services are provided to most dependent
residents on Monday, Wednesday and Fridays. Each session lasts 5-15 minutes. Small talk,
chit chat. Said difficult to spend time with some individuals because of their behaviors.
Encouraged staff to be specific on their documentation when a resident refuses activity
service. Believed 5 minutes to be sufficient time for an activity.
During an interview on 2/7/19 at 10:05 A.M., the administrator said he does not believe
five minutes is a sufficient amount of time for a one to one activity and his expectation
is that the activity staff spend time working with the residents.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

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

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)

Based on observation, interview and record review, the facility failed to prevent the
development and worsening of moisture associated skin damage wounds, failed to timely
notify the resident’s physician of the discovery and worsening of the wounds, and verify
standing skin care treatment orders to one resident (Resident #4). The facility also
failed to ensure physician ordered fluid restrictions had been implemented and documented
and ensure ordered laboratory testing was completed (Resident #79). The facility also
failed to follow the infection control surveillance policy for antibiotic use and obtain
physician ordered urine testing (Resident #85) prior to administration of antibiotics. The
census was 94.
Review of the facility’s skin management guideline overview revised 7/2017, showed:
-Overview: Residents who are at risk or with wounds and those at risk for skin compromise
are identified, assessed and provided appropriate treatment to encourage healing and
integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident
outcomes.
Review of the facility’s undated standing nursing orders, showed:
-For moisture associated skin damage (MASD, inflammation and breakdown of the skin caused
by prolonged exposure to moisture) the facility should apply barrier cream to the affected
area every shift and after each incontinent episode until the area is healed;
-Wound care for Stage II pressure ulcer (a partial thickness skin loss involving the
epidermis and/or dermis) clean the open area with normal saline or wound cleanser, apply
Medi-honey (helps in managing wounds provides moisture based environment and protection)
nickel thick, cover with dry dressing. Change daily and as needed (PRN) with soilage until
healed.
1. Review of Resident #4’s (MONTH) (YEAR) treatment administration record (TAR) dated
11/1/18 through 11/30/18, showed:
-An order dated 11/2/18 to apply barrier cream to buttocks every shift and PPN, all days
and shifts initialed as completed;
-An order dated 11/22/18 to clean the right buttock and right gluteal fold (skin fold
where the thigh meets the buttock) with normal saline. Apply nickel thick Medi-honey and
cover with dry dressing. Change dressing daily and PRN. Discontinue the treatment when
healed. The treatment initialed as completed daily on 11/22/18 through 11/27/18, and shown
as healed on 11/27/18;
-An order dated 11/27/18 to cleanse the right proximal and distal wound with normal saline
or wound cleanser, apply nickel thick Santyl (sterile enzymatic [MEDICATION NAME] ointment
used to clean wounds of dead tissue), cover the wound with bordered gauze. Change every
three days and PRN. Initialed as completed on the 7:00 A.M. to 3:00 P.M., shift on
11/27/18 and 11/30/18.
Review of the resident’s (MONTH) (YEAR) TAR, dated 12/1/18 through 12/31/18, showed a hand
written undated order to cleanse the right distal and proximal pressure wound with wound
cleanser or normal saline, apply nickel thick Santyl, cover with border gauze and change
every three days and PRN. Initialed as completed on 12/3/18 and 12/6/18 on the 7:00 A.M.,
to 3:00 P.M., shift. The order struck out as discontinued and healed on 12/10/18. No
additional skin care orders.
Review of the resident’s (MONTH) 2019 TAR, dated 1/1/19 through 1/31/19, showed no skin
care treatment orders.
Review of the resident’s annual Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 1/5/19, showed:
-Severe cognitive impairment;

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 21)
-Total dependence on staff for toileting, transfers, hygiene and mobility;
-No skin issues;
-At risk to develop skin ulcers (wounds or damage to skin);
-Always incontinent of bowel and bladder;
-Use pressure reducing device for the bed;
-No pressure reducing device used in the chair;
-Not involved in a turning and/or repositioning program;
-Received no ointments or dressings to areas other than the feet.
Review of the resident’s care plan, updated on 1/20/19, showed:
-Focus: The resident has a pressure ulcer to buttocks refer to the TAR for treatment;
-Goal: The resident will have intact skin, free of redness, blisters or discoloration
by/through review date;
-Interventions: Staff administer treatments as ordered and monitor for effectiveness.
Assess, record and monitor wound healing. Measure length, width and depth where possible.
Assess and document status of wound perimeter, wound bed and healing progress. Report
improvements and declines to the resident’s physician. Monitor nutritional status;
-Focus: The resident is incontinent of bowel and bladder and he/she wears briefs;
-Goal: He/she will remain free of skin breakdown related to incontinence and brief use;
-Interventions: Staff check the resident every two hours and as required for
incontinence, change clothing PRN. He/she to wear briefs while up for incontinence.
Review of the resident’s (MONTH) 2019 TAR and the physician order [REDACTED]. No
additional skin care orders noted.
Observations on 2/3/19 at 8:31 A.M., 9:42 A.M., 10:55 A.M., and 11:24 A.M., showed the
resident was awake in his/her room and sat in his/her geri-chair (G/C, padded reclining
chair). No staff provided or offered perineal (perineal care, cleansing the front of the
hips, between the legs and buttocks and back of the hips) care.
Further observation of the resident, showed:
-On 2/4/19 at 7:21 A.M., 8:45 A.M., 10:15 A.M., and 1:22 P.M., he/she sat in his/her G/C
in his/her room. The bedroom door opened to the hallway. The table tray (locking tray
secured into the arms of a chair) attached to the G/C. He/she yelled out go school loudly
at times, no staff entered the room or provided care;
-On 2/5/19 at 6:48 A.M., through 9:50 A.M., showed he/she sat in his/her G/C in his/her
room and occasionally yelled out loudly go school. No staff entered his/her room when
he/she yelled out or offered or provided incontinence care. The table tray in place and
secured into the arms of the G/C.
Observation and interview on 2/5/19 at 9:53 A.M., showed certified nurse aide (CNA’s) E
and N entered the resident’s room and prepared to provide peri-care. Staff assisted the
resident to stand. The blanket in the seat of the resident’s G/C was urine saturated. The
back of the resident’s pants urine saturated from the top of the waist band to the back of
both knees. Staff placed the resident into bed and unfastened his/her brief. The brief
contained a second thick brief inside and appeared urine saturated and contained a large
amount of bowel movement which oozed from the top front of the brief. CNA’s E and N
cleaned the front of the groin and assisted the resident on to his/her side and exposed
the buttocks. CNA’s E and N cleaned the resident’s hips and buttocks. An open area noted
to the right gluteal fold. The wound appeared red and approximately measured 1.0
centimeters (cm) x 1.5 cm and no depth. CNA E said he/she had not seen the wound before.
The night shift aide did not report anything to him/her about the open area. Night shift
gets the resident up around 4:30 A.M. to 5:00 A.M. CNA N applied vitamin A&D ointment
to the buttocks and the wound. CNA E applied a second thick liner inside the resident’s
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 22)
clean brief and said they always put an extra thick liner in his/her brief, all of the
shifts do, he/she is a heavy wetter. CNA E said he/she had not changed the resident until
this time. He/she will need to tell the nurse about the open area to the buttock. The
CNA’s do not document open areas, aides tell the nurses and the nurses handle the rest of
it;
-Neither CNA’s notified the resident’s nurse to observe the open area prior to completing
care and applying and securing the double brief on to the resident.
During an interview on 2/5/19 at 1:15 P.M., nurse K said that the the resident does not
have any open areas. He/she had not been notified of any skin issues. The resident had a
history of [REDACTED]. When the aides discovered an open area they are to notify the
resident’s nurse immediately so the wound can be assessed and measured. Aides should not
apply ointments or apply briefs until the nurse can assess the wound site. The nurse would
apply the standing wound order to the wound and document in the resident’s record.
Observation on 2/5/19 at 1:23 P.M. through 2:39 P.M., showed the resident up in his/her
room in the G/C. No staff entered the resident’s room to provide or offer care. The charge
nurse did not provide the skin assessment.
Further review of the resident’s care plan and medical record on 2/6/19 at 6:15 A.M.,
showed:
-No care plan updates regarding skin changes or skin care interventions discovered on
2/5/19;
-No nurse notes, wound assessments, no new wound care orders or documentation following
the wound discovered on 2/5/19.
Observation on 2/6/19 from 6:34 A.M. through 7:25 A.M., showed the resident remained in
the G/C in his/her room. The bedroom door opened to the hallway. The lap tray in place
attached to the G/C. The resident yelled out occasionally go school. Multiple staff walked
past his/her room. At 7:31 A.M., the surveyor notified CNA E that he/she wanted to observe
the resident’s skin. CNA E said the resident had been up in his/her G/C since 5:00 A.M.,
and he/she had started his/her shift at 7:00 A.M., that morning. He/she would provide
incontinence care to the resident after breakfast had been served to the other unit
residents around 9:30 A.M. to 10:00 A.M.
During an observation and interview on 2/6/19 at 8:35 A.M., the resident remained in
his/her room in the G/C. The bedroom door opened to the main hallway. He/she yelled loudly
and banged on the lap tray. Staff entered the resident’s room and pushed him/her into the
hallway and placed him/her along the wall. The resident laughed, smiled and sat straighter
in his/her G/C. Nurse G said the night shift gets the resident up daily around 4:30 A.M.
to 5:00 A.M. The resident is always incontinent of bowel and bladder and should be changed
and repositioned every two hours. If aides notice a change in skin they should immediately
tell the charge nurse. He/she had not be notified of any changes in the resident’s skin.
He/she started his/her shift on 2/5/19 at 10:30 P.M. and worked the night shift. None of
the night shift CNA’s had notified him/her of skin issues.
Observation and interview on 2/6/19 at 8:58 A.M., showed CNA E and C applied a gait belt,
removed the lap tray and transferred the resident into his/her bed. The blanket in the G/C
seat was urine saturated and the back of the resident’s pants was urine saturated the
entire area of the buttocks. CNA E pulled down the resident’s pants and removed the double
saturated brief and assisted the resident onto his/her side and exposed the resident’s
buttocks. Two open were wounds observed to the right buttock fold. Both of the wounds
actively bled and blood ran down toward the right buttock toward the groin. The upper
right open wound observed on 2/5/19 bled and a second new wound observed that measured
approximately 0.5 cm x 0.5 cm and no depth. Neither wound had a treatment or dressing in
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 23)
place. CNA E said he/she had notified nurse K on 2/5/19 in the afternoon of the discovered
open area after the resident’s care had been completed. He/she did not provide
incontinence care again before he/she left work on 2/5/19. He/she agreed that on 2/5/19
the resident had one open area and the wound had not been bleeding at that time, a new
second wound had developed and both of the wounds were actively bleeding at the time of
the observation. CNA C exited the room and notified nurse K of the bleeding wounds. CNA E
cleaned the blood off of both wounds and applied pressure to the wounds. Nurse K entered
the resident’s room and measured the two open and bleeding wounds. The upper right wound
measured 1.5 cm x 1.0 cm x 1.0 cm and second wound measured 0.5 cm x 0.5 cm. Nurse K told
the CNAs to leave the areas uncovered and he/she would gather supplies and apply a
treatment to both of the open, bleeding wounds.
During an interview on 2/06/19 at 9:15 A.M., nurse K said CNA E had told him/her on 2/5/19
in the late afternoon that CNA E had discovered the single open area to the resident’s
right upper buttock fold. Nurse K did not document or assess the wound at the time the
aides had already applied the resident’s brief and gotten him/her dressed and placed back
into his/her G/C. He/she called the resident’s physician and received an order to apply
[MEDICATION NAME] (skin barrier) to the area. He/she did not put the [MEDICATION NAME]
order on to the current (MONTH) POS or the resident’s current (MONTH) TAR. He/she could
not recall if he/she notified the change in the resident’s skin condition to the oncoming
shift on 2/5/19. It appeared the resident had developed a secondary open wound below the
first wound discovered on 2/5/19. Both of the wounds had been actively bleeding when
he/she assessed them on 2/6/19. The wounds would need a treatment since the areas are
bleeding and two wounds are now present. The nurses use a standing wound care order and
he/she will put that in place until the resident’s physician can be reached and the order
verified. The resident had a history of [REDACTED]. The resident is always incontinent of
bowel and bladder and should be toileted at least every two hours, double briefing should
not be used. Night shift gets the resident up daily between 4:30 A.M. and 5:00 A.M. He/she
would have to make a late entry note regarding the wound discovered on 2/5/19 and write
the [MEDICATION NAME] order on to the (MONTH) POS and TAR.
During an interview on 2/6/19 at 9:21 A.M., the administrator said that when the CNAs
notice a change in skin, they should immediately get the charge nurse so he/she could
perform a skin assessment and place a treatment on the wound if needed, get physician
orders [REDACTED]. Aides should be checking and changing incontinent residents every two
hours. Residents that have frequent incontinence episodes and a history of skin wounds
should be checked on more frequently than every two hours. Residents should not be double
briefed.
Further review of the resident’s progress notes on 2/6/19 at 10:30 A.M., showed:
-Late entry: on 2/5/19 at 2:57 P.M., The CNA reported skin breakdown after providing care.
Physician notified and order obtained from [MEDICATION NAME].
During an interview 2/6/19 at 11:24 A.M., nurse K said he/she followed the facility’s
standing wound care order for stage II pressure ulcer (partial-thickness skin loss) and
placed the standing order of medi-honey and to covered the areas with a dry dressing onto
both of the open wounds. He/she had not documented the assessment, measurements or
notified the resident’s physician to confirm standing order treatment or let the physician
know of the original wound from 2/5/19 or that the resident had developed a secondary open
wound within 24 hours.
During an interview on 02/06/19 on 12:30 P.M., the resident’s attending nurse practitioner
(NP) said that the resident is totally dependent on staff to meet all of his/her needs.
He/she is not able to make he/she needs or wants clearly known and care or needs are
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
anticipated by the staff. He/she is incontinent of bowel and urine and had a history of
[REDACTED]. Neither he/she or the resident’s physician had been notified of any changes in
the residents skin since 2/5/19 until present. The facility had standing orders for wounds
and skin issues that maybe applied until the physician or himself/herself can be reached
to verify the standing wound orders. He/she and the physician expected the nurse to verify
the standing wound care orders for wound treatments once an issue with the resident’s skin
is determined. The staff should have called him/her or the physician when the original
wound had been discovered on 2/5/19 and then called on 2/6/19 with the discovery of the
second open area and notified of the bleeding. Staff should be providing peri-care and
cleansing every two hours for incontinent residents and more frequently if the skin is
impaired, the resident should probably be lied down in between meals until the wound
heals. Double briefing is not acceptable, the practice exposes the skin to large amounts
of fluid and applies more pressure with the larger amount of brief padding.
Further review of the resident’s medical record and care plan on 2/6/19 at 1:15 P.M.,
showed no contact to the resident’s physician or NP, no wound care orders, no wound
treatments entered onto the resident’s POS or TAR and no nurse note regarding measurements
or wound assessment from 2/6/19 at 8:58 A.M. No updates noted to the resident’s care plan
regarding development of buttock wounds.
During an interview on 2/06/19 on 1:33 P.M., the Assistant Director of Nursing said if the
charge nurse was notified on 2/5/19 of the first wound, then he/she should have called the
physician and obtained an order, documented his/her assessment and updated the care plan.
The resident has a history of pressure ulcers and MASD. The most recent documented buttock
wound had been healed in 12/2018. There were no new orders on the POS or the TAR for skin
treatments as of the time of the interview. The ADON had called the resident’s physician
the afternoon of 2/6/19 after nurse K measured the areas and the resident’s physician gave
an order to administer [MEDICATION NAME]. The facility requested the NP to provide a skin
assessment on 2/6/19. Staff should change incontinent residents at least every two hours
especially if there is history of skin issues and double briefing should not occur. There
should have been a note from the skin measurements from the morning of 2/6/19, however the
ADON requested nurse K not enter the measurements since each nurse preformed wound
measurements differently and the ADON would enter his/her wound findings instead of nurse
K after the resident is seen by the NP later in the day.
Further review of the resident’s progress notes on 2/6/19 at 1:38 P.M., showed:
-On 2/6/19 at 11:00 A.M., two areas of breakdown to right back upper thigh. The upper
wound measured 1.5 cm x 1.0 cm x 0.1 cm. The second lower wound measured 0.5 cm x 0.5 cm x
0.0. The measurements reported to the supervisor. Will continue to monitor;
-On 2/6/19 at 1:04 P.M., the nurse notified the resident’s legal guardian of the wounds;
-On 2/6/19 at 2:50 P.M., the resident’s NP evaluated skin and diagnoses of MASD given. NP
ordered [MEDICATION NAME] and a G/C seat cushion. Treatment administered this shift, and
the resident turned and repositioned every hour.
Further review of the resident’s (MONTH) 2019 POS, dated 2/1/19 through 2/28/19, showed:
-Late entry: 2/5/19 to apply [MEDICATION NAME] to area of skin breakdown on the right
upper thigh. Apply every shift and PRN after each incontinence episode;
-An order dated 2/6/19 to clean areas to the right buttock with wound cleanser, apply
medi-honey, cover with foam dressing, change daily and PRN. The order stuck out and noted
as discontinued on 2/6/19;
-An order dated 2/6/19 to apply [MEDICATION NAME] to wound #2 on the right buttocks for
MASD. Apply each shift and PRN.
Record review of the resident’ medical record, showed a progress note, dated 2/6/19
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
completed by the resident’s NP. The resident had been seen today related to skin breakdown
to right lower buttocks. The area is shallow and superficial. The resident is incontinent,
noncompliant and resistive to care and this placed him/her at high risk for skin breakdown
and further injury. The wounds are reoccurring due to moisture and incontinent MASD and
fragile skin. Continue with current treatment of [REDACTED]. Staff to apply seat cushion
to prevent further breakdown. Therapy evaluation requested for assessment.
Further review of the resident’s care plan, showed an undated entry:
-Focus: The resident has a diagnoses of MASD and has an actual impairment related to
incontinence and impaired mobility. On 2/5/19 he/she had an open area to the right buttock
and right upper thigh;
-Goal: He/she will have no complications due to the open areas to the right buttock;
-Interventions: Avoid scratching and keep the resident’s hands clean, keep excessive
moisture away from the area, educate the family and caregivers of the factors and measures
to prevent skin injury, encourage good nutrition, follow facility policy and protocols for
the treatment of [REDACTED]. The resident has been given a pressure relief cushion in
his/her G/C to facilitate prevention of alteration in skin integrity.
2. Review of Resident #79’s admission MDS, dated [DATE], showed the following:
-Short and long term memory problems;
-Inattention, disorganized thinking and altered level of consciousness always present;
-Supervision required for most activities of daily living (ADL’s, ability to complete
daily self care tasks);
-Occasionally incontinent of bladder;
-No diagnoses listed.
Review of the resident’s progress notes, showed the following:
-12/11/2018, 2:30 P.M., Admission note, the resident arrived at 10:45 A.M., per stretcher
and paramedics. History of dementia, [MEDICAL CONDITION] (chronic and severe mental
disorder that affects how a person thinks, feels, and behaves), [MEDICAL CONDITION], and
chronic [MEDICAL CONDITION] (abnormally low sodium level in the blood, with normal blood
sodium level between 135 and 145 milliequivalents per liter (mEq/L )), fluid restriction
(FR) of 1500 milliliters (ml) per day;
Review of the resident’s initial nutrition assessment, dated 12/19/2018, showed a history
of low sodium, level typically between 130-133mEq/L. On a 1500 ml FR per the hospital and
appears the resident is on FR per the nursing notes. Recommend to add 1500 ml FR to
physician’s orders [REDACTED].
Review of the resident’s care plan, updated on 1/7/19, showed the fluid restriction had
not been included as a problem, with no goals or interventions noted.
Review of the resident’s POS, dated 2/1 through 2/28/19, showed the following:
-1500 ml per day FR, shown on the right hand side of the POS;
-An order, dated 1/17/19 for a comprehensive metabolic panel (CMP-measurement of
substances in the blood, including sodium).
Review of the facility’s staff assignment sheet per shift, kept at the nurse’s station on
the third floor showed the following:
-Resident #79, alert and oriented times three, regular diet mechanical soft texture,
served hall meal trays, takes his/her medications whole. **FLUID RESTRICTION-1500 MG/24
HR**
Review of the resident’s diet slip, showed no mention of the ordered fluid restriction.
Review of the resident’s MAR and TAR, showed no order for a fluid restriction and no
documentation that fluid intake had been monitored by the staff.
During an interview on 2/6/19 at 10:45 A.M., nurse M said there were no residents on the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
third floor with a fluid restriction.
Observation of the resident, showed the following:
-On 2/4/19 at 12:43 P.M., the resident sat at a tray table across from the elevator, ate
lunch and consumed an 8 ounce (oz.) carton of milk, an 8 oz. glass of red liquid and an 8
oz. cup of coffee;
-On 2/5/19 at 10:01 A.M., resident carried an 8 oz. styrofoam cup with a lid onto
elevator, he/she said the cup contained water;
-On 2/6/19 at 12:50 P.M., the resident sat at a table tray across from the elevator, ate
his/her lunch and consumed an 8 oz. carton of milk, 8 oz. glass of clear liquid and an 8
oz. carton of milk.
During an interview on 2/7/19 at 9:36 A.M., the Director of Nursing (DON) said three
residents had fluid restrictions, provided the three resident names, but did not include
Resident #79. She expected staff to document fluid intakes for any residents ordered a FR.
Some residents are noncompliant. She had asked the physician’s to discontinue the fluid
restriction orders but the physicians declined. She expected that staff monitor intake to
not exceed 1500 ml and document in the nurses notes. Noncompliance should also be
documented. All physician’s orders [REDACTED].
During an interview on 2/7/19 at approximately 11:30 A.M., nurse M called the facility’s
laboratory company and asked for results of the ordered CMP, ordered on [DATE]. The
laboratory representative said the only results of laboratory tests for the resident
showed a date of 12/28/18. The laboratory did not have results or a sample received from
the order dated 1/17/19.
3. Review of the facility’s Routine Infection Control Surveillance in Long Term Care
policy, undated, showed the following:
-The primary purpose of infection control surveillance is the collection of information
for action. It is more than just evaluation of laboratory reports, including cultures.
Infection control includes routine surveillance of residents, surveillance of staff, and
surveillance of the environment. This may be accomplished using the following guidelines;
-A facility’s surveillance system should include monitoring for appropriate antibiotic
use. A positive culture in a person without clinical symptoms rarely requires treatment
with antibiotics.
Review of Resident #85’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Required extensive assistance from staff for dressing, toileting and personal hygiene;
-Frequent bladder incontinence;
-Diagnoses included heart failure, diabetes, stroke, overactive bladder and [MEDICAL
CONDITION];
-No urinary tract infections (UTI’s) in the last 30 days.
During an interview on 2/3/19 at 10:12 A.M., the resident said he/she gets frequent UTI’s
and they are very painful.
Review of the resident’s medical record, showed the following:
-A physician’s orders [REDACTED].
-No results of the UA;
-No documentation indicating the resident had any signs or symptoms of a UTI;
-A physician’s orders [REDACTED].
During an interview on 2/7/19 at 10:05 A.M., the administrator said to treat a UTI, they
must follow three criteria, which are to document signs and symptoms of an infection,
notify the resident’s physician and obtain an UA. They did not follow their process to
treat the resident and should have obtained a UA prior to starting antibiotic treatment.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to ensure certified nurse aides
received the required 12 hours of training and have a system to track the hours for four
of the four employees reviewed who worked at the facility for over a year. The census was
97.
Review of the training records provided by the facility, showed:
-Nineteen certified nurse aides (CNAs) worked at the facility for over a year;
-CNA A – received five hours of training;
-CNA B – received four hours of training;
-CNA C – received four hours of training;
-CNA D – received five hours and 15 minutes of training.
During an interview on 2/6/18 at 1:25 P.M., the Director of Nursing and the Assistant
Director of Nursing said they are both aware that the CNA’s have to have 12 hours of
resident care centered training per calendar year beginning on the hire date anniversary.
They said they did not have access to the records prior to (MONTH) (YEAR), and they have
both been at the facility less than six months.

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 the low temperature
dish machine’s chemical sanitizer at 50 parts per million (ppm) of chlorine bleach to
ensure effective sanitizing of dishware. This deficient practice had the potential to
effect all residents who ate at the facility. The census was 94.
During an interview on 2/7/19 at 9:02 A.M., the Dietary Manager (DM) said the dish machine
was low temperature with chemical sanitation and was tested twice daily using chemical
strips. The bucket of sanitizer had to be changed every two weeks or so. The DM took a
strip from a container, and dipped it into the chamber as the sanitizing chemical mixed
with water. The strip did not turn the appropriate color to indicate a sanitizer level of
at least 50 ppm. The DM checked the bucket of sanitizer, followed the tubing from the
bucket to the machine, started another wash cycle and dipped another test strip. Again the
strip did not indicate the proper level of sanitizer. The DM said the machine was tested
earlier in the morning and it was fine. She would call the company that serviced the
machine and have them come to the facility right away.
During an interview on 2/7/19 at 11:38 A.M., the DM said the representative from the
service company came and reset the machine. The representative said each time the bucket
is changed, it must be primed. The DM asked the representative to provide an inservice to
staff on how to prime a new bucket of sanitizer. The DM took another chemical strip,
tested the machine and the strip indicated the proper level of sanitizer.
During an interview on 2/7/19 at 11:45 A.M., Detary Aide O said he/she had changed the
sanitizer bucket before but did know it needed to primed or how to do it.
During an interview on 2/7/19 at 12:35 P.M., the DM said she found out how to prime new

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 28)
sanitizer buckets. Normally, the representative changes it when he/she comes every couple
of weeks. Her staff should know how to prime a new bucket of sanitizer when it is placed
in use.
During an interview on 2/15/19 at 10:25 A.M., the facility’s service representative said
he does not change the sanitizer bucket because he only comes out once a month. If you do
not prime the machine by pressing a button on it’s side after replacing the sanitizer, ten
to fifteen loads will not be sanitized properly due to air in the lines.

F 0914

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide bedrooms that don’t allow residents to see each other when privacy is needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure curtains were placed in
a resident’s room to ensure the resident and their roommate maintained their privacy and
dignity on the first, second and third floors. The sample was 19. The census was 94.
1. Observation of the third floor on all days of the survey from 2/3/19 through 2/7/19,
showed the following:
-room [ROOM NUMBER], equipped with four beds and three privacy curtains;
-room [ROOM NUMBER], equipped with three beds and one privacy curtain;
-room [ROOM NUMBER], equipped with three beds and one privacy curtain;
-room [ROOM NUMBER], equipped with four beds and no privacy curtains;
-room [ROOM NUMBER], equipped with three beds and one privacy curtain.
2. Observations of the second floor on all days of the survey from 2/3/19 through 2/7/19,
showed the following:
-room [ROOM NUMBER], two resident resided in the room. Both privacy curtains, had only the
top 6 inches of netting and no curtains hung down to provide privacy;
-room [ROOM NUMBER], two residents resided in the room, and no privacy curtain for the
resident in bed one, closest to the door;
-room [ROOM NUMBER], three residents resided in the room, and no privacy curtain for the
resident in the third bed.
3. Observations of room [ROOM NUMBER] during all days of the survey from 2/3/19 through
2/7/19, showed three residents resided in the room. No privacy curtain hung between
resident beds one and two.
During an interview on 2/7/19 at approximately 8:00 A.M., the Maintenance Director said he
does rounds on the floors daily to check for items that need repair. Staff also have work
orders on each floor which they can fill out to give to maintenance when they notice
something needed repaired. He was not aware of the missing curtains.
During an interview on 2/7/19 at 10:05 A.M., the administrator said he expected
maintenance staff to complete rounds on the resident floors at least weekly. Staff should
also submit work orders for items they noticed needed repaired. The maintenance department
identifies issues and then prioritize what will be addressed. Every room should have
privacy curtains.

F 0917

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure each resident has 1) at least one window to the outside in a room; 2) a room
at or above ground level; 3) adequate bedding; 4) furniture that meets the resident’s
needs; or 5) adequate closet space.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0917

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide each
resident with functional furniture suitable for the comfort of the resident and visitors
by not providing chairs for residents in his/her room. This deficient practice had the
potential to affect all residents residing in the facility. The sample was 19 and the
census was 94.
1. Review of the facility’s Admission Agreement, undated, showed the following:
-Covered items and services: Payment by the Medicaid/Medicare Program covers room and
board. This includes nursing care, regular meals and snacks, certain equipment, activities
and routine personal hygiene items. Certain items and services are not covered in the
Medicaid/Medicare Program daily rate. There are extra charges for those non-covered items
and services;
-Extra charges for items and services which are not included in the basic daily rate, and
which are not covered by the Medicaid/Medicare program included private room, private
nurse or aide, hair dresser and therapy;
-The Admission Agreement did not state over the bed tables and chairs in residents’ rooms
were considered items not covered by the Medicaid/Medicare Program or residents would need
to purchase these items separately.
2. Review of the Facility Assessment, dated 8/18/17, and provided to the survey team on
2/4/19, showed the facility would provide physical equipment for residents, and included
bed frames, mattresses, room and common space furniture.
3. Observation of the 200 unit on all days of the survey, 2/3 through 2/7/19, showed the
following:
-A total of 16 resident rooms with a capacity of 37 residents;
-30 of 37 beds occupied;
-No room had a chair for a resident or visitor to sit.
4. Observation of the 300 unit on all days of the survey, 2/3/19 through 2/7/19, showed
the following:
-room [ROOM NUMBER] equipped with two beds and no chairs;
-room [ROOM NUMBER] equipped with four beds, no chairs;
-room [ROOM NUMBER] equipped with three beds and no chairs;
-room [ROOM NUMBER] equipped with three beds, no chairs;
-room [ROOM NUMBER] equpped with four beds, no chairs;
-room [ROOM NUMBER] equipped with three beds and no chairs;
-room [ROOM NUMBER] equipped with two beds and no chairs.
5. During the Resident Council interview on 2/5/19 at 10:45 A.M., two of the 8 residents
in attendance said they had chairs in their room. The residents would like to have chairs
in their rooms. They all agreed this would allow them to have a place to sit beside the
bed.

F 0919

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that a working call system is available in each resident’s bathroom and
bathing area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to provide functioning call lights
in two resident rooms on the 200 and 300 floors. Furthermore, the facility failed to
provide functioning call lights in two toilet rooms on the 200 hall, used by residents.

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0919

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
This deficient practice had the potential to affect all residents, staff, and visitors who
might need to use the toilets and would need staff assistance. The facility had a census
of 94.
1. Observation on 2/6/19 at 11:15 A.M., showed two resident bathrooms located in the
hallway of the third floor. Call light boxes were located on the wall of each bathroom.
Neither call light box had a string to activate the call light system.
2. Observation on 2/6/19 at 11:20 A.M., showed resident room [ROOM NUMBER] with four
occupied beds. Call light boxes were located on the wall above the beds. None of the call
light boxes had strings to activated the call light system.
3. Observation on 2/6/19 at 11:20 A.M., showed resident room [ROOM NUMBER] with four
occupied beds. Four call light boxes were located on the wall above the beds. None of the
call light boxes had strings to activate the call light system. Further observation of the
call light outside room [ROOM NUMBER], showed the light detached from the ceiling tile and
hung diagonally from wires.
During an interview on 2/7/19 at 8:26 A.M., the Maintenance Director said he completes
rounds on each floor daily. He was not aware of the malfunctioning call lights.
During an interview on 2/7/19 at 10:05 A.M., the administrator said all call lights should
function.

F 0920

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide at least one room set aside to use as a resident dining room and for
activities, that is a good size, with good lighting, air flow and furniture.

Based on observation, interview and record review, the facility failed to adequately
furnish spaces designated as dining areas with suitable and sufficient tables and chairs.
This deficient practice had the potential to affect all residents who chose to eat in the
common area on the second and third floors. The census was 94.
1. The facility provided a list of dining rooms used by residents for meals, which showed
the following:
-Main dining room on the main ground floor;
-First floor dining room;
-Second floor common area (in front of nursing station);
-Third floor common area (in front of musing station).
2. Observations of the second floor common area on 2/4/19, 2/5/19, 2/6/19 and 2/7/19,
showed approximately 10 residents eating in the common area using over the bed tables and
wheeled carts for tables. The facility did not furnish dining tables and chairs to
accommodate the designated dining space.
3. Observations of the third floor common area on 2/4/19, 2/5/19, 2/6/19 and 2/7/19,
showed the breakfast and lunch food carts contained meal trays for approximately 10
residents, with five over the bed tables available for use at meal times. The facility did
not furnish dining tables and chairs to accommodate the designated dining space.
4. During the Resident Council interview on 2/5/19 at 10:45 A.M., the residents said there
are very few over the bed tables and they are used for meals served on the resident
floors. If a resident has an over the bed table, staff will take it away because they are
used for meal service.
4. During an interview on 2/7/19 at 10:05 A.M., the administrator confirmed the common
areas on the second and third floors are used as dining rooms for residents who prefer to

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0920

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 31)
stay on their floor for meals. He said they do not have enough tables and chairs on those
floors for residents to use during meal times.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

Based on observation and interview, the facility failed to ensure equipment in the kitchen
was in good repair and kept clean and free of greasy build up for five of five days of
observation. The census was 94.
Observation of the kitchen on 2/3/19 at 9:00 A.M., 2/4/19 at 12:17 P.M., 2/5/19 at 11:00
A.M., 2/6/19 at 11:00 A.M. and 2/7/19 at 9:16 A.M., showed the following:
-The front, sides and area around and underneath the stove, grill, deep fat fryer and
convection oven
with stains, streaks and a build up of grease;
-A white towel with grease spots lay on the floor between the deep fat fryer and the
grill;
-A white towel with large dark brown spots stuffed underneath the oven door and below the
grill.
During an interview on 2/3/19 at approximately 9:00 A.M., Cook P said he/she put the towel
under the oven door because the grill pan that caught grease from the grill had a hole in
it. It had been welded back together before but it was leaking again. The towel between
the deep fat fryer and grill was there to catch grease when taking things from the fryer
in order to have less to clean up on the floor.
During an interview on 2/6/19 at 11:16 A.M., the administrator said he was not aware the
drip pan was leaking or that a towel had been placed under the oven. The maintenance
director would be in soon and he would get it taken care of. Staff should let maintenance
know when things need repair and if they are able, they will repair it. An outside company
is used for items maintenance is not able to take care of in the kitchen. At 11;20 A.M.,
the administrator said he removed the towel from under the stove. The maintenance director
said he was aware of the leak two days ago. He told him to order a new drip pan.
During an interview on 2/7/19 at 8:01 A.M., the maintenance director said there are work
order forms on each floor that are picked up daily by the maintenance department. In the
kitchen, staff tell him when something needs to be fixed. He was told a day or two ago
about the drip pan, called the company and a new one should be delivered today.
During an interview on 2/7/19 at 9:16 A.M., Cook P said he told the maintenance director
about the leak a few days ago. He wet the towel before he put it under the oven. He
pointed to the side of the oven, stating the grease dripped down the side of it to the
floor. Cook P opened the oven and pointed to a thick, approximately 1/4 to 1 inch build up
of grease on the inside of the oven door that also came from the leaky grill pan.
During an interview on 2/7/19 at 12:35 P.M., the DM said she did not have a deep cleaning
schedule but did have a daily cleaning list of items she expected to be done. The duties
on the list are not assigned to staff, are not signed off when they are completed and she
does not have a way to know if the tasks have been completed.

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

265578

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

NAME OF PROVIDER OF SUPPLIER

NORMANDY NURSING CENTER

STREET ADDRESS, CITY, STATE, ZIP

7301 ST CHARLES ROCK RD
SAINT LOUIS, MO 63133

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 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some