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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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 TAGSUMMARY 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;