Original Inspection report

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0554

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Allow residents to self-administer drugs if determined clinically appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
residents’ right to self-administer medications had been determined as clinically
appropriate for one of 15 sampled residents (Resident #54). The census was 58.
Review of Resident #54’s medical record, showed the following:
-An admission Minimum Data Set (MDS), a federally required assessment instrument completed
by facility staff, dated 11/8/18, showed [DIAGNOSES REDACTED].
-No order to self-administer medications;
-No assessment for the ability to self-administer medications.
Review of the resident’s care plan, dated 11/2/18, showed no documentation for the ability
to self-administer medication.
Observation and interview on 12/11/18 at 8:22 A.M., showed a medicine cup on the
resident’s bedside table with four white pills inside the cup. The resident said that
he/she needed his/her cup of water refreshed, so he/she will wait to take his/her
medications until he/she receives his/her food. The resident said he/she did not know the
name of the staff that administered his/her medication. At 8:25 A.M., staff went into the
resident’s room with beverages and his/her meal. At 8:35 A.M., the medicine cup was empty.
During an interview on 12/13/18 at 9:45 A.M., the Director of Nursing (DON) said the
resident had not been assessed to administer his/her own medications. If the physician is
okay with the resident self-administering medications, the facility will still need to
assess the resident for their ability to do so and educate the resident. If it is
determined the resident can self-administer medications, it is care planned. Then facility
does not have a policy used for determining a resident’s ability to self-administer
medications. Staff should stay in the room with residents until they take their
medications.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a clean
and comfortable environment when the facility failed to repair a resident’s heater and
failed to ensure floors and a tube feeding stand were clean and free of debris for two of
15 sampled residents (Residents #107 and #6). The census was 58.
1. Observation and interview on 12/10/18 at 10:09 A.M., showed Resident #107 in bed with
the blanket covering his/her body. The resident said he/she was cold. The air temperature
was noticeably cooler inside the resident’s room than the hallway. The resident said
he/she was shivering. The heater did not work and it had not been working for a couple of
days. The heater blew out cold air. Staff did not offer to move him/her to another room.
He/she reported to staff that the heater was not working, but he/she did not remember who
he/she spoke to.
Review of the maintenance work order book, showed no work order for the resident’s heater.
Further review, showed no work orders after 11/17/18.
Observation on 12/10/18 at 10:16 A.M., showed the heater was turned on and the control
knob was turned to hot. Cold air blew out of the heater. At 10:22 A.M., the air from the

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
heater did not heat up. The temperature of the air blowing from the heater, measured with
a digital thermometer, was 61.2 degrees Fahrenheit (F).
Observation on 12/10/18 at 12:13 P.M., showed staff had entered room. The resident and
his/her roommate were not in the room. The residents’ beds were made. The room felt cold.
During an interview on 12/12/18 at 1:06 P.M., the resident said the heater was still
broken and no one came in to fix it.
During an interview on 12/12/18 at 3:59 P.M., the maintenance supervisor said there is a
work order log book at the nurse’s station that is checked every morning. The residents
inform the nurses and Certified Nurse Aides (CNAs) if there is something that needs to be
repaired and then they will write it in the work order log book. Staff write the
resident’s name, room number and what needs to be repaired, including the date and time.
He was not aware the heater was not working. If it is not documented, then he would not
know about it. At 4:10 P.M., the surveyor and maintenance supervisor went into the
resident’s room. The maintenance supervisor said the heater was not working because it was
not turned on. He turned the heater on and confirmed the control knob was already turned
to heat. He said it would only take approximately 45 seconds for the air to heat up. The
heater was on for approximately one minute and the cold air continued to blow from the
heater. He turned off the heater and confirmed it did not work and he would try to reset
it. He removed the cover from the heater and pressed a button to reset it. He placed the
cover back on and turned the heater on. The air from the heater became warmer within 10 to
15 seconds.
During an interview on 12/13/18 at 9:45 A.M., the administrator said if something needed
to be repaired, staff are to report it and document in the maintenance communication
binder at the nurse’s station. If the repair cannot wait, they can contact the
administrator, DON or the maintenance supervisor for instructions. The administrator would
expect staff to contact the maintenance supervisor and document any repairs in the work
order log. She would also expect staff to assess the resident’s rooms during rounds to
determine if it was at a comfortable temperature.
2. Observation on 12/10/18 at 8:56 A.M., and 12/11/18 at 7:58 A.M., showed Resident #6’s
tube feeding machine located next to the his/her bed. The machine was turned off. There
was a dried brown substance on the tube feeding machine stand and on the floor under the
stand.
Observation on 12/12/18 at 11:02 A.M., showed the tube feeding machine pushed to the other
side of the room. There was a dried, brown substance on the bottom of the stand. There was
dried, brown substance on the floor on the right side of the resident’s bed, where the
stand was previously.
Observation on 12/13/18 at 7:08 A.M., showed the tube feeding machine next to the
resident’s bed. The machine was turned off. There was a dried brown substance on the stand
and on the floor under the stand.
During an interview on 12/13/18 at 7:52 A.M., License Practical Nurse (LPN) O said if
there was a recent spill of the tube feeding formula, he/she would try to clean it up
his/herself. If it was already dried, he/she would alert housekeeping.
During an interview on 12/13/18 at 9:45 A.M., the administrator said floors in the
resident rooms are expected to be cleaned daily. If nursing staff see dried formula on the
floor and the tube feeding stand, she would expect staff to notify housekeeping and
address the spill on the floor. All facility staff are responsible for creating a homelike
environment and to promptly address all cleaning needs.
Review of the facility’s enteral feeding policy, revised (MONTH) 2011, showed housekeeping
will wipe off pumps and poles with disinfectant daily and as needed.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
3. Observation on 12/10/18 at 2:00 P.M., showed a pink, gum like substance stuck to the
floor in the hall outside room [ROOM NUMBER]. CNA B said watch your step and pointed to
the spot on the floor. On 12/11/18 at 9:01 A.M., the pink, gum like substance remained on
the floor. A housekeeping staff walked past the spot on the floor with his/her
housekeeping cart. On 12/12/18 at 7:29 A.M., the bulk of the pink, gum like substance had
been removed from the floor. A pink ring with a sticky residue remained.
4. During an interview on 12/13/18 at 9:45 P.M., with the administrator and DON, the DON
said there is a maintenance communication binder at each nurse’s station to report
maintenance needs. Staff can also immediately contact maintenance, the DON or
administrator if there is something that requires immediate attention. All staff in the
facility are responsible to create a home like environment and address cleaning needs.

F 0585

Level of harm – Potential for minimal harm

Residents Affected – Many

Honor the resident’s right to voice grievances without discrimination or reprisal and
the facility must establish a grievance policy and make prompt efforts to resolve
grievances.

Based on interview and record review, the facility failed to establish a grievance policy
that allowed residents/visitors to file grievances orally or anonymously, identified a
grievance official and/or that required the facility to maintain evidence demonstrating
the result of all grievances for a period of no less than three years from the issuance of
the grievance decision. The census was 58.
Review of the facility’s grievance policy, revised (MONTH) 1999, showed:
-Grievances must be reduced to writing and signed by the resident or legal representative
before submission to the administrator. The Compliment/Complaint procedure and form will
be utilized for this purpose;
-Upon receipt of a written grievance, the administrator will investigate the grievance;
-If the administrator is unable to resolve the grievance, it will go to the Corporate
Section 504 Coordinator who will have a period of thirty (30) days to make a decision or
otherwise resolve the grievance;
-The policy failed to state residents have the right to file grievances orally or
anonymously, identify the grievance official and does not require the facility to maintain
evidence demonstrating the result of all grievances for no less than three years from the
issuance of the grievance decision.
During a group interview on 12/11/18 at 1:39 P.M., eight out of eight residents said they
did not know how to file a formal grievance at the facility. The eight residents did not
know if the facility had a grievance form and/or where to find one, or if the facility had
a grievance official.
During an interview on 12/13/18 at 8:15 A.M., Licensed Practical Nurse (LPN) M said if a
resident expressed the desire to file a grievance or complaint, he/she would fill out an
incident report and give it to the Director of Nursing (DON). He/she would have the
resident fill out a statement to provide to social services. No one has formally explained
to him/her what the facility’s grievance process is.
During an interview on 12/13/18 at 8:27 A.M., Certified Nurse Aide (CNA) E said if a
resident expressed the desire to file a grievance or complaint, he/she would refer the
resident to social services. Social services handles resident grievances.

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0585

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 3)
During an interview on 12/13/18 at 8:28 A.M., Receptionist N said if he/she was approached
by a resident who wanted to file a grievance, he/she would walk the resident over to
social services, where all grievances are filed.
During an interview on 12/13/18 at 9:40 A.M., the administrator said the facility has a
form for residents to complete if they choose to file a grievance. The grievance forms are
available at every nurse’s station and at the receptionist’s desk. If they would feel more
comfortable, residents can file a grievance with social services or ask to speak to the
administrator. If the resident wishes to remain anonymous when filing a grievance, they
have the right to do so. The facility retains resident-specific grievances for one year.
The administrator said she was aware of the regulations to retain grievances for three
years.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to assure their abuse and
neglect policies and procedures identified when, how and by whom determination of capacity
to consent to sexual contact will be made and where this documentation will be recorded.
The census was 58.
Review of the facility’s Abuse, Neglect, Mistreatment and Misappropriation of Resident
Property policy, dated (YEAR), showed:
-It is the policy of this center to encourage and support all residents, team member,
families, visitors, volunteers and resident representatives in preventing and reporting
any suspected acts of abuse, neglect, exploitation, involuntary seclusion or
misappropriation of resident property;
-The policy failed to identify when, how and by whom determination of capacity to consent
to sexual contact will be made and where this documentation will be recorded.
During an interview on 12/12/18 at 12:25 P.M., the administrator said she thought the
policy regarding capacity to consent was included in the abuse and neglect policy. She
will look for it. On 12/13/18 at 9:45 A.M., the administrator said she was unable to
locate a policy to address capacity to consent to sexual activity.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to issue written transfer
notices to residents and/or their representative upon discharge to a hospital when their
return to the facility was expected. Of the 15 sampled residents, one had been recently
discharged to a hospital for various medical reasons, he/she was expected to return, and
he/she had not been issued a written transfer notice upon leaving the facility (Resident
#108). The census was 58.
Review of Resident #108’s medical record, showed:

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident was provided a notice upon discharge.
During an interview on 12/10/18 at 7:45 A.M., the resident said he/she did not remember
getting any discharge notice when sent to the hospital.
During an interview on 12/12/18 at 10:02 A.M., the Director of Nurses (DON) said nursing
had not been issuing any discharge notices to the residents on discharge to the hospital
with return anticipated. The Marketing/Admission staff would be responsible to provide the
notices.
During an interview on 12/12/18 at 10:15 A.M., the Marketing/Admissions staff said she is
not responsible for issuing any discharge notice for residents who were discharged to the
hospital.
During an interview on 12/12/18 at 10:23 A.M., both Social Worker I and Social Worker J
said they do not issue any discharge notices to any resident discharge to the hospital
with a return anticipated. The Marketing/Admissions staff would be issuing the notices.
During an interview on 12/13/18 at 9:45 A.M., the DON said he was aware they should be
issuing a discharge notice upon discharge to the hospital with return anticipated, they do
not have any policy to address this and they had not been issuing any discharge notices
whenever a resident was discharged to the hospital with return anticipated.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident or their
legal representative of the facility bed hold policy at the time of transfer to the
hospital, for one of one resident who was recently transferred to a hospital for various
medical reasons (Resident #108) of 15 sampled residents. The census was 58.
Review of Resident #108’s medical record showed:
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No documentation the resident or the resident’s representative received information in
writing of the facility’s bed hold policy at the time of transfer.
During an interview on 12/10/18 at 7:45 A.M., the resident said he/she did not remember
getting any written bed hold policy when sent to the hospital.
During an interview on 12/12/18 at 10:02 A.M., the Director of Nurses (DON) said nursing
had not been issuing any written bed hold policy to the residents or legal representatives
on discharge to the hospital with return anticipated. The Marketing/Admission staff would
provide the written policy.
During an interview on 12/12/18 at 10:15 A.M., the Marketing/Admissions staff said she is
not responsible for issuing any written bed hold policy to the residents or their legal
representative when they were discharged to the hospital and their return was anticipated.
During an interview on 12/12/18 at 10:23 A.M., both Social Worker I and Social Worker J
said they do not issue any written bed hold policy to any resident or their legal
representative upon discharge to the hospital with a return anticipated. The

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
Marketing/Admissions staff would be issuing the written bed hold policy.
During an interview on 12/13/18 at 9:45 A.M., the DON said he was aware the facility
should be issuing a written bed hold policy to the residents or their legal representative
upon discharge to the hospital with return anticipated, they do not have any policy to
address this and they had not been issuing any written bed hold policy, whenever a
resident was discharged to the hospital with return anticipated.

F 0636

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the failed to assure comprehensive assessments were
completed not less than every 12 months, for two of 16 residents reviewed for resident
assessment completion (Residents #8 and #16). The census was 58.
1. Review of Resident #8’s medical record, showed:
-An admission date of [DATE];
-An admission Minimum Data Set (MDS, a federally required resident assessment completed by
facility staff), dated 10/31/17;
-No comprehensive assessment completed since 10/31/17.
2. Review of Resident #16’s medical record, showed:
-An admission date of [DATE];
-An annual MDS, dated [DATE];
-No comprehensive assessment completed since 11/8/17.
3. During an interview on 12/12/18 at 2:35 P.M., the MDS coordinator said comprehensive
MDS’s are to be completed on admission and annually. She is aware the facility is behind
on completion of MDS.

F 0638

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to assure quarterly Minimum Data
Set (MDS, a federally required resident assessment completed by facility staff) were
completed not less than every three months, between comprehensive assessments, for 11 of
16 residents reviewed for resident assessment completion (Residents #2, #14, #7, #5, #4,
#3, #15, #13, #11, #9 and #10). The census was 58.
1. Review of Resident #2’s medical record, showed:
-An original admission date of [DATE];
-An admission MDS, dated [DATE];
-Quarterly MDS’s, dated 4/1/18 and 6/29/18;
-No quarterly MDS completed for (MONTH) (YEAR).
2. Review of Resident #14’s medical record, showed:
-An original admission date of [DATE];
-A significant change MDS, dated [DATE];

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-No quarterly MDS completed for (MONTH) (YEAR).
3. Review of Resident #7’s medical record, showed:
-An original admission date of [DATE];
-An admission MDS, dated [DATE];
-Quarterly MDS’s, dated 4/15/18 and 7/13/18;
-No quarterly MDS completed for (MONTH) (YEAR).
4. Review of Resident #5’s medical record, showed:
-An original admission date of [DATE];
-An annual MDS, dated [DATE];
-No quarterly MDS completed for (MONTH) (YEAR).
5. Review of Resident #4’s medical record, showed:
-An admission date of [DATE];
-An annual MDS, dated [DATE];
-No quarterly MDS completed for (MONTH) (YEAR).
6. Review of Resident #3’s medical record, showed:
-An admission date of [DATE];
-An annual MDS, dated [DATE];
-Quarterly MDS’s, dated 4/8/18 and 7/6/18;
-No quarterly MDS completed for (MONTH) (YEAR).
7. Review of Resident #15’s medical record, showed:
-An original admission date of [DATE];
-An annual MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed for (MONTH) (YEAR).
8. Review of Resident #13’s medical record, showed:
-An admission date of [DATE];
-An annual MDS, dated [DATE];
-No quarterly MDS completed for (MONTH) (YEAR).
9. Review of Resident #11’s medical record, showed:
-An original admission date of [DATE];
-An admission MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed for (MONTH) (YEAR).
10. Review of Resident #9’s medical record, showed:
-An original admission date of [DATE];
-An annual MDS, dated [DATE];
-A quarterly MDS, dated [DATE];
-No quarterly MDS completed for (MONTH) (YEAR).
11. Review of Resident #10’s medical record, showed:
-An original admission date of [DATE];
-An annual MDS, dated [DATE];
-Quarterly MDS’s, dated 4/16/18 and 7/14/18;
-No quarterly MDS completed for (MONTH) (YEAR).
12. During an interview on 12/12/18 at 2:35 P.M., the MDS coordinator said quarterly MDS’s
are to be completed every 90 days between the comprehensive assessments. She is aware the
facility is behind on completion of MDS’s.

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to electronically transmit
encoded, accurate, and complete Minimum Data Set (MDS, a federally required resident
assessment completed by facility staff) data to the Centers for Medicare and Medicaid
(CMS) System within 14 days after a facility completes a resident’s assessment. In
addition, the facility failed to complete and transmit a discharge assessment for one of
four discharged residents sampled and one of 15 sampled residents (Residents #17 and
#108). The census was 58.
1. Review of the facility’s MDS submission reports for the prior six months, showed:
-CMS Submission Report, dated 6/15/18, showed five records submitted. Of those five, two
submitted late;
-CMS Submission Report, dated 6/20/18, showed seven records submitted. Of those seven, one
submitted late;
-CMS Submission Report, dated 6/21/18, showed six records submitted. Of those six, three
submitted late;
-CMS Submission Report, dated 6/27/18, showed two records submitted. Of those two, one
submitted late;
-CMS Submission Report, dated 6/27/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 6/29/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 6/29/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 6/29/18, showed four records submitted. Of those four, four
submitted late;
-CMS Submission Report, dated 7/5/18, showed six records submitted. Of those six, two
submitted late;
-CMS Submission Report, dated 7/5/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 7/5/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 7/9/18, showed five records submitted. Of those five, two
submitted late;
-CMS Submission Report, dated 7/1018, showed four records submitted. Of those four, two
submitted late;
-CMS Submission Report, dated 7/10/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 7/11/18, showed eight records submitted. Of those eight,
five submitted late;
-CMS Submission Report, dated 7/11/18, showed two records submitted. Of those two, two
submitted late;
-CMS Submission Report, dated 7/13/18, showed three records submitted. Of those three, one
submitted late;
-CMS Submission Report, dated 7/16/18, showed eight records submitted. Of those eight,
five submitted late;
-CMS Submission Report, dated 7/16/18, showed five records submitted. Of those five, one

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
submitted late;
-CMS Submission Report, dated 7/19/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 7/20/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 7/24/18, showed nine records submitted. Of those nine, two
submitted late;
-CMS Submission Report, dated 7/30/18, showed six records submitted. Of those six, two
submitted late;
-CMS Submission Report, dated 9/6/18, showed four records submitted. Of those four, three
submitted late;
-CMS Submission Report, dated 9/13/18, showed nine records submitted. Of those nine, eight
submitted late;
-CMS Submission Report, dated 9/14/18, showed three records submitted. Of those three, two
submitted late;
-CMS Submission Report, dated 9/17/18, showed four records submitted. Of those four, three
submitted late;
-CMS Submission Report, dated 9/17/18, showed four records submitted. Of those four, three
submitted late;
-CMS Submission Report, dated 9/17/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 9/17/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 9/19/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 9/25/18, showed nine records submitted. Of those nine, nine
submitted late;
-CMS Submission Report, dated 9/26/19, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 10/4/18, showed nine records submitted. Of those nine, three
submitted late;
-CMS Submission Report, dated 10/8/18, showed three records submitted. Of those three, two
submitted late;
-CMS Submission Report, dated 10/8/18, showed three records submitted. Of those three, two
submitted late;
-CMS Submission Report, dated 10/8/18, showed three records submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 10/9/18, showed five records submitted. Of those five, one
submitted late;
-CMS Submission Report, dated 10/10/18, showed one record submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 10/15/18, showed two records submitted. Of those two, one
submitted late;
-CMS Submission Report, dated 10/15/18, showed four records submitted. Of those four, one
submitted late;
-CMS Submission Report, dated 10/16/18, showed four records submitted. Of those four, one
submitted late;
-CMS Submission Report, dated 10/16/18, showed one report submitted. Of the one, one
submitted late;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-CMS Submission Report, dated 10/16/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 10/16/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 10/18/18, showed five reports submitted. Of those five,
three submitted late;
-CMS Submission Report, dated 10/18/18, showed five reports submitted. Of those five, two
submitted late;
-CMS Submission Report, dated 10/22/18, showed three reports submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 10/24/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 10/25/18, showed three reports submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 10/26/18, showed two reports submitted. Of those two, one
submitted late;
-CMS Submission Report, dated 10/29/18, showed three reports submitted. Of those three,
one submitted late;
-CMS Submission Report, dated 10/30/18, showed two reports submitted. Of those two, two
submitted late;
-CMS Submission Report, dated 11/6/18, showed four reports submitted. Of those four, three
submitted late;
-CMS Submission Report, dated 11/7/18, showed two reports submitted. Of those two, two
submitted late;
-CMS Submission Report, dated 11/8/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 11/8/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 11/8/18, showed two reports submitted. Of those two, two
submitted late;
-CMS Submission Report, dated 11/12/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 11/13/18, showed two reports submitted. Of those two, two
submitted late;
-CMS Submission Report, dated 11/13/18, showed five reports submitted. Of those five, five
submitted late;
-CMS Submission Report, dated 11/19/18, showed nine reports submitted. Of those nine,
seven submitted late;
-CMS Submission Report, dated 11/21/18, showed two reports submitted. Of those two, one
submitted late;
-CMS Submission Report, dated 11/26/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 11/26/18, showed four reports submitted. Of those four, one
submitted late;
-CMS Submission Report, dated 11/27/18, showed one report submitted. Of the one, one
submitted late;
-CMS Submission Report, dated 11/28/18, showed four reports submitted. Of those four, four
submitted late;
-CMS Submission Report, dated 11/28/18, showed four reports submitted. Of those four, four
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
submitted late;
-CMS Submission Report, dated 12/4/18, showed three reports submitted. Of those three,
three submitted late;
-CMS Submission Report, dated 12/6/18, showed two reports submitted. Of those two, one
submitted late;
-CMS Submission Report, dated 12/7/18, showed two reports submitted. Of those two, one
submitted late.
2. Review of Resident #17 medical record, showed:
-admitted to the facility on [DATE];
-A discharge date of [DATE];
-No discharge MDS assess completed.
3. Review of Resident #108’s medical record, showed:
-Originally admitted to the facility on [DATE];
-discharged to the hospital on [DATE];
-Returned to the facility from the hospital on [DATE];
-No discharge with return anticipated MDS or entry MDS as late as 12/12/18 at 3:09 P.M.
During an interview on 12/12/18 at 3:09 P.M., the MDS coordinator said she had done a
discharge MDS with return anticipated on 12/3/18, had not submitted the MDS as of that
time and had not started or completed the entry MDS for 12/6/18.
4. During an interview on 12/11/18 at 10:44 A.M., the MDS coordinator said she has only
been in her position for approximately one month. Prior to that, the position was vacant.
She has one additional MDS staff to assist her. On 12/12/18 at 8:08 A.M., the MDS
coordinator said there is no specific process for transmission of completed MDS data, she
transmits them when she has a batch completed and ready to be sent. She would expect MDS
data be submitted timely. She was not sure of the specific time frames in which a
completed MDS data must be transmitted. On 12/12/18 at 2:35 P.M., the MDS coordinator said
she would expect discharge MDS’s be completed within a week of a resident’s discharge from
the facility. She is aware the facility is behind on completion of MDS’s.

F 0641

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure each resident receives an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure that each
resident receives an accurate assessment, reflective of the resident’s status, for two of
15 sampled residents (Residents #30 and #32). The census was 58.
1. Review of Resident #30’s quarterly Minimum Data Set (MDS), a federally required
resident assessment completed by facility staff, dated 9/30/18, showed:
-[DIAGNOSES REDACTED].
-Resident rarely/never understood;
-Total dependence for transfers and toilet use, full staff performance. One person
physical assist.
Review of the resident’s undated certified nurse’s aide (CNA) care plan guide, located in
the care plan binder, showed for mobility: Right sided weakness, full weight bearing,
transfer assist times 2 staff with mechanical lift.
Review of the resident’s care plan, dated 10/16/18 and in use at the time of the survey,
showed:

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
-Problem: At risk for injury related to falls and self-harm as evidenced by [DIAGNOSES
REDACTED].
-Goal: No injury from fall through next review;
-Interventions: Hoyer (mechanical lift) for all transfers. If the resident becomes
aggressive or agitated, return to bed or chair (whichever is closer) in a safe manor.
Observation on 12/10/18 at 1:57 P.M., showed CNA B obtained the Hoyer lift. CNA B,
Licensed Practical Nurse (LPN) A and Restorative Aide C transferred the resident to bed
with the use of the Hoyer lift.
2. Review of Resident #32’s quarterly MDS, dated [DATE], showed total dependence, full
staff performance of one person physical assist required for transfers.
Review of the resident’s care plan, dated 10/16/18 and in use at the time of the survey,
showed:
-Problem: Assistance required for activities of daily living (ADLs) related to history of
tibia (long bone in lower leg) fracture, [MEDICAL CONDITIONS], weakness and [MEDICAL
CONDITION] (neurological disease);
-Goal: Not experience decline in ADL function;
-Approach: Provide proper assistance for transfers. Resident is a Hoyer lift.
3. During an interview on 12/12/18 at 8:08 A.M., the MDS coordinator said she would expect
residents who use a Hoyer lift have their MDS reflect they require total assist of two
persons to transfer. MDS should be accurate.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a baseline care plan consistent with the resident’s specific conditions, needs
and risks within 48 hours of admission to properly care for two out of three newly
admitted sampled residents and one closed record (Residents #56, #255 and #108). The
sample was 15. The facility census was 58.
1. Review of Resident #56’s medical record, showed:
-admitted to the facility on [DATE] under hospice care;
-expired on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, undated and in use at the time of survey,
showed no documentation of the resident’s hospice care or [DIAGNOSES REDACTED].
During an interview on [DATE] at 8:00 A.M., the Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, coordinator said if a resident
was admitted to hospice when he/she was admitted , it should be documented on the baseline
care plan.
During an interview on [DATE] at 9:45 A.M., the Director of Nursing (DON) said he would
expect the resident’s care plan to include hospice care. He would expect all baseline care
plans to be person centered.
2. Review of Resident #255’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-No orders for side rails.
Review of the resident’s baseline care plan, undated and in use at the time of survey,
showed:
-Marked for pressure ulcers (location left blank);
-No use of safety devices, including side rails.
Observation on [DATE] at 9:39 A.M., [DATE] at 2:00 P.M., [DATE] at 12:04 P.M. and [DATE]
at 7:38 A.M. and 10:11 A.M., showed the resident lay in bed, with half side rails up on
each side of his/her bed.
During an interview on [DATE] at 9:40 A.M., the DON said all baseline care plans should be
dated. The use of assistive or safety devices should be indicated on the baseline care
plan, including the size and type of side rails used, if any. Pressure ulcers should be
noted on the baseline care plan, as well as their location on the resident. Care plans
should be person-centered.
3. Review of Resident #108’s medical record, showed:
-admitted to the facility on [DATE], and readmitted from a local hospital on [DATE];
-[DIAGNOSES REDACTED]. Can be caused by [MEDICAL CONDITION]);
-No orders for [MEDICAL TREATMENT] (the process of filtering toxins from the blood for
individuals with kidney failure).
Observation and interview on [DATE] at 7:45 A.M., showed a dressing on his/her left upper
arm. The resident said the dressing covered his/her [MEDICAL TREATMENT] shunt, he/she goes
out to [MEDICAL TREATMENT] every Monday, Wednesday and Friday.
Observation of the daily transport schedule sheet at the nurse’s station, dated [DATE],
showed:
-Resident’s pick up time – 7:30 A.M.;
-Appointment time – 8:30 A.M., family will take to [MEDICAL TREATMENT];
-Scheduled [MEDICAL TREATMENT] goes M/W/F;
-[MEDICAL TREATMENT] center makes appointments;
-Needs a breakfast.
Review of the resident’s undated baseline care plan, showed staff had not care planned the
resident for [MEDICAL TREATMENT] or for the [MEDICAL TREATMENT] shunt.
During an interview on [DATE] at 10:02 A.M., the DON verified the resident’s baseline care
plan did not address [MEDICAL TREATMENT] or the [MEDICAL TREATMENT] shunt and it should be
addressed on the baseline care plan.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop a care
plan to thoroughly address the use of a gastrostomy tube ([DEVICE], a feeding tube placed
into the abdomen of the stomach) and indwelling urinary catheter (a sterile tube inserted
into the bladder to drain urine) for two of 15 sampled residents (Residents #19 and #6).
The census was 58.
1. Review of the Resident #19’s physician’s orders [REDACTED].
-An order, dated 12/15/18, for [MEDICATION NAME] 1.2 (high protein tube feeding formula),

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
continuous at 50 milliliters (ml) per hour;
-An order, undated, to flush the [DEVICE] with 200 ml of water every 6 hours;
-A standing order for nothing by mouth (NPO).
Review of the resident’s care plan, dated 9/6/18, showed:
-Problem: Eating; resident is totally dependent on the staff;
-Interventions: Provide resident tube feeding and flushes per orders;
-Weigh resident per resident orders;
-Further review of the care plan, showed no documentation of the resident’s [DIAGNOSES
REDACTED].
Observations of the resident on 12/10/18 at 9:08 A.M., 12:10 P.M. and 2:55 P.M., 12/11/18
at 8:11 A.M., 3:13 P.M. and 4:35 P.M. and 12/12/18 at 1:20 P.M. and 4:46 P.M., showed the
[DEVICE] infused at 50 ml/hour.
2. Review of the Resident #6’s POS, dated 12/1/18 through 12/31/18, showed:
-An order, undated, for an indwelling urinary catheter, 16 French (fr, size) 30 cubic
centimeter (cc) balloon;
-An order, undated, to change the catheter as needed (PRN) for blockage or obstruction;
-An order, dated 12/3/18, to record urine output every shift;
-An order, dated 12/3/18, to provide catheter care per facility protocol every shift;
Review of the resident’s care plan, dated 1/18/18, showed no documentation of the
resident’s use of a urinary catheter or [DIAGNOSES REDACTED].
Observations of the resident on 12/10/18 at 8:56 A.M., 9:45 A.M. and 2:01 P.M., 12/11/18
at 7:58 A.M., 10:03 A.M., 12:16 P.M. and 3:17 P.M., 12/12/18 at 1:30 P.M. and 12/13/18 at
7:08 A.M., showed the resident in bed with catheter tubing and a drainage bag that hung on
the right side of the bed.
3. During an interview on 12/13/18 at 8:00 A.M., the Minimum Data Set (MDS), a federally
mandated assessment instrument completed by facility staff, coordinator said there are two
care plan coordinators in the facility. He/she is responsible for the 100 and 200 unit. If
he/she noticed something during an observation of the resident, he/she would update the
care plan. If changes are discussed during the morning clinical meeting, the care plan is
updated. When there is a care plan meeting, all information is updated and reviewed to
ensure that it reflects the resident’s goals and needs. She would expect a resident’s use
of [DEVICE] and catheter to be on the care plan.
4. During an interview on 12/13/18 at 9:45 A.M., the Director of Nursing (DON) said the
nurse is able to update the care plan during the shift. It is reviewed in clinical morning
meeting and discussed for appropriateness of interventions and care. He would expect the
resident’s care plan to be person centered and reflect the resident’s goals for admission
and desired outcomes. The resident’s use of a [DEVICE] and catheter are expected to be
included in the care plan.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure residents
who were unable to carry out activities of daily living (ADLs) receive the necessary
services to maintain good nutrition, grooming, and personal and oral hygiene, for two of

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
two observations of incontinence care and for one of 15 sampled residents who was observed
to be left wet for an extended period of time and did not have care provided per physician
orders [REDACTED].#30 and #20). The census was 58.
1. Review of Resident #30’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 9/30/18, showed:
-[DIAGNOSES REDACTED].
-Resident rarely/never understood;
-Total dependence for transfers and toilet use, full staff performance. One person
physical assist;
-Extensive assistance required for personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident’s physician order [REDACTED].
-An order dated 11/6/18, for a Broda chair (medical reclining chair) for positioning;
-Moisture barrier ointment after each incontinence and as needed;
-Please lay own in between meals.
Review of the resident’s undated Certified Nursing Assistant (CNA) are plan guide, located
in the care plan binder, showed:
-Bladder: Total;
-Bowel: Incontinent;
-Mobility: Right sided weakness, full weight bearing, and transfer assist times 2 with
mechanical lift.
Review of the resident’s care plan, dated 10/16/18, showed:
-Problem: Requires assistance with ADLs due to [DIAGNOSES REDACTED].
-Goal: Will maintain/increase ADL skills;
-Interventions: Encourage independence with bathing, dressing, grooming and oral hygiene.
Shave daily as required;
-Problem: Incontinent of bowel and bladder:
-Goal: Experience no skin conditions related to incontinence;
-Interventions: Check for incontinence, change if wet/soiled. Apply moisture barrier,
reapply after each incontinence episode.
Observation on 12/10/18 at 7:55 A.M., showed the resident not in his/her room.
Observation on 12/10/18 at 9:45 A.M. through 12:06 P.M., showed the resident sat in a
Broda chair in the television room near the 200 hall. A Hoyer (mechanical lift) pad
located under the resident. At 12:06 P.M., the resident continued to sit in the television
area. The resident’s head tilted down and to the left and his/her eyes closed. A staff
person propelled the resident in his/her Broda chair from the television room to the
assist dining room near the 400 hall. At 12:30 P.M., staff sat at the resident’s side and
assisted the resident with lunch. At 12:33 P.M., Licensed Practical Nurse (LPN) A
propelled the resident in his/her Broda chair from the assist dining room to the
television area near the 200 hall. At 12:42 P.M., a staff person propelled the resident
from the television area to the hallway outside the main dining room. At 12:45 P.M., staff
propelled the resident back up the hall to the television area near the 200 hall. He/she
positioned the resident in front of the television. The resident remained in the
television area.
During an interview on 12/10/18 at 1:54 P.M., LPN A said CNA B is assigned to care for the
resident.
During an interview on 12/10/18 at 1:57 P.M., CNA B said he/she was assigned to care for
the resident. He/she and another staff person got the resident up in the morning. He/she
could not remember what time in the morning the resident got up. The resident had not been
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
back to bed since. Observation at this time, showed CNA B obtained the Hoyer lift. CNA B,
LPN A and Restorative Aide C transferred the resident to bed with the use of the Hoyer
lift. After the staff transferred the resident to bed, Restorative Aide C left room. CNA B
and LPN A remained in the room. CNA B obtained supplies, assisted the resident to pull
his/her pants down and assisted the resident to his/her right side. An undated dressing
was observed on the resident’s coccyx. The resident’s brief was wet. CNA B unsecured the
resident’s brief, LPN A assisted the resident to turn to the other side and unsecured the
resident’s brief on the right side. CNA B rolled up and removed the resident’s brief. LPN
A and CNA B assisted the resident to turn to the right side. CNA B placed a clean brief
under resident’s soiled buttocks, obtained a disposable wipe and wiped the inside of the
gluteal fold several wipes, folding the disposable wipe between each wipe. A small amount
of stool was observed on the resident’s bottom. CNA B failed to wipe the resident’s left
and right buttocks. Without changing his/her gloves or sanitizing his/her hands, CNA B
dried the resident’s buttocks with a towel and applied protective ointment, obtained from
the resident’s dresser with the soiled gloves, to the resident’s buttocks. LPN A
positioned the resident to his/her back. CNA B removed his/her gloves, washed his/her
hands and placed new gloves on. CNA B cleansed the resident’s genitals, secure the
resident’s brief and assisted the resident onto his/her back. CNA B failed to cleanse the
resident’s groin, inner thighs or pubic area. While wearing the same gloves, CNA B removed
the resident’s pants, placed a wedge cushion behind the resident’s back, and covered the
resident with a sheet and blanket. He/she used the bed controllers to elevate the head of
the bed and lower the bed to the floor before removing his/her soiled gloves and washing
his/her hands.
During an observation on 12/11/18 at 7:57 A.M., CNA E propelled the resident in his/her
wheelchair down the hall and into the dining room. The resident sat on a mechanical lift
transfer pad and did not appear shaved. At 8:16 A.M., the resident continued to sit in the
dining room as a staff member fed the resident a breakfast of ground sausage, scrambled
eggs, oatmeal, toast with butter and jelly, with glasses of orange juice and water. At
8:25 A.M., the resident sat in his/her wheelchair in the 100/200 television room and faced
the T.V. with the T.V. tuned to a news station. The resident slept in his/her wheelchair
with his/her head bent over his/her chest and continued to sit on his/her mechanical lift
pad. This surveyor sat in the same living room with the resident from 8:25 A.M. until
11:34 A.M., at which time CNA E propelled the resident down the hall to the dining room.
At 12:45 P.M., CNA E propelled the resident back from the dining room into the television
room where the T.V. was on. The resident’s head slumped to his/chest. The resident
received no personal hygiene care during the times of the observation.
During an interview on 12/13/18 at 9:45 P.M., with the administrator and Director of
Nursing (DON), the DON said staff should check incontinent residents at minimum, every two
hours. He would expect physician orders [REDACTED]. If a resident had orders to lay down
between meals, he would expect staff to offer to lay the resident down.
2. Review of Resident #20’s significant change MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-No behaviors;
-Incontinent of bowel and bladder;
-Required total assistance from the staff for transfers, dressing, eating, hygiene and
bathing.
Observation on 12/11/18 at 3:40 P.M., showed the resident lay in bed awake. CNA K and CNA
L brought supplies into the resident’s room, washed hands and put on gloves. CNA K removed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
the covers from the resident, removed a wet with urine and soiled with stool adult
incontinence brief from the resident and turned the resident onto his/her right side. CNA
K cleaned the resident’s rectal area with perineal wipes in a front to back motion to
remove the stool. After the stool had been removed from the resident’s rectal area, he/she
washed the resident’s rectal area with derma vera skin and hair cleaner soap in a front to
back motion. CNA K placed a clean adult incontinence brief under the resident, turned
him/her onto his/her back, fastened the brief, covered the resident with a blanket,
removed his/her soiled gloves, washed his/her hands and left the resident’s room. Neither
CNA K nor CNA L washed the resident’s perineal area, genitals or left and right buttocks
to ensure all of the urine and stool had been removed from the resident’s skin. Neither
CNA rinsed or dried the resident’s skin to ensure all of the soap had been removed from
the resident’s skin prior to placing the clean incontinence brief on him/her.
Observation of the derma vera skin and hair cleaner soap bottle, showed directions to
rinse the skin thoroughly.
During an interview on 12/13/18 at 9:45 A.M., the DON said he would expect staff to wash a
resident’s perineal area, genitals and the entire buttocks, to ensure all urine and stool
have been removed from the resident’s skin. He would expect staff to rinse the soap off
the resident’s skin and to dry the skin prior to placing a clean incontinence brief on the
resident. If urine, stool and soap are left on the skin, it can cause skin breakdown.
3. Review of the facility’s Incontinence Assessment and Management policy, dated 9/2005,
showed:
-The facility will ensure each resident, who is incontinent, will be identified, assessed
and provided appropriate treatment and services to prevent urinary tract infections and
restore as much normal urinary function as possible;
-The policy failed to identify the protocol and steps involved in providing incontinence
care, that all areas potentially contaminated with urine or stool will be cleaned, and
soap must be rinsed.
MO 547
MO 009

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide appropriate care for a resident to maintain and/or improve range of motion
(ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
with limited mobility received appropriate services, equipment and assistance to maintain
or improve mobility with maximum practicable independence by failing to provide
restorative services for five of nine residents investigated for positioning/mobility,
restorative and/or activities of daily living (Resident #31, #30, #32, #1, and #27). The
facility census was 58.
Record review of the facility’s restorative nursing program, dated 9/21/07, showed:
-Policy: The facility will assure that all Restorative Nursing Programs follow the
Resident Assessment Instrument (a comprehensive, standardized tool used by facilities to
assess residents in long term care settings, (RAI) guideline established by Center of
Medicaid and Medicare Services (CMS) and State requirements);
-RAI-Restorative nursing guidelines requirements:

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-Addressed in the plan of care and clinical record with measurable objectives and
interventions;
-Evidence of periodic evaluation by a nurse in the clinical record;
-Each restorative service delivered at a minimum of 15 minutes in 24 hours;
-The Rehab/Restorative Nurse will:
-Initiate programs, through the certified nurse aides (CNAs), using the appropriate
restorative nursing program forms which include resident’s name, date initiated,
strengths, weaknesses, measurable goals, steps that will be carried out, nurses signature
and date;
-Initiate Restorative Program Documentation Log;
-Complete monthly documentation on appropriate restorative nursing program forms;
-Place restorative nursing program forms and program documentation logs in the binder
provided;
-Audit documentation logs frequently to assure CNAs are completing documentation as
required.
1. Review of Resident #31’s medical record, showed:
-admitted to the facility on [DATE];
-A quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed
by facility staff, dated 6/29/18, showed:
-Extensive assistance with two-person physical assist required for bed mobility,
transfers, locomotion on and off unit, dressing and toilet use;
-No rehabilitation or therapy received;
-[DIAGNOSES REDACTED].
-A medical progress note, dated 1/31/18, showed primary assessment/plan as,
weakness-unable to get therapy;
-A social services progress note, dated 2/1/18, showed a care plan meeting held and
resident will be put on restorative therapy three days a week;
-A medical progress note, dated 2/28/18, showed assessment/plan for weakness as, continue
restorative therapy;
-A physician order [REDACTED].
-A care plan, printed 10/18/18, showed:
-Problem: History of falls within past 31-180 days;
-Intervention: Restorative therapy as ordered;
-A POS from (MONTH) and (MONTH) (YEAR), showed undated orders for restorative therapy;
-Further review of the medical record, showed no documentation restorative therapy
occurred.
Review of the Restorative Binder, showed no documentation of restorative services provided
to the resident from (MONTH) (YEAR) through (MONTH) (YEAR).
Observation on 12/11/18 at 8:17 A.M., showed the resident lay in his/her bed. The resident
was receiving his/her medications from Certified Medical Technician (CMT) H. The resident
did not lift his/her upper body off of the bed when reaching for his/her medication cup,
handed to him/her from the CMT. The resident lifted his/her head a few inches off of the
pillow in order to take a drink from a cup full of water, handed to the resident by the
CMT.
During an interview on 12/10/18 at 10:10 A.M., the resident said he/she received therapy
upon first admission to the facility. The service discontinued and he/she did not know
why, but the resident wanted to continue therapy. He/she could not stand on his/her own
anymore and he/she relied more on staff to assist him/her in and out of bed and in
completing basic tasks. He/she stayed in bed most of the time because he/she did not want
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
to bother staff by asking them to get him/her out of bed and then asking staff to return
him/her to bed only a few hours later.
During an interview on 12/12/18 at 10:50 A.M., Restorative Aide (RA) C said all
documentation of the residents’ restorative services should be located in the Restorative
Binder. All residents at the facility are eligible for restorative therapy. Residents who
do not qualify for physical therapy because of their insurance would be appropriate
referrals for restorative. A physician order [REDACTED]. He/she knew the resident from
weighing him/her monthly, but was not aware of the resident’s interest in receiving
restorative therapy. He/she has had relatively the same caseload for the past several
months.
During an interview on 12/13/18 at 9:40 A.M., the DON said all residents in the facility
are eligible for restorative therapy. Nursing and therapy staff are responsible for making
referrals to restorative. If a resident is care-planned to receive restorative, they
should receive the service. If a resident refuses restorative or if the therapy is
discontinued, this should be reflected on the resident’s care plan.
2. Record review of Resident #30’s quarterly MDS, dated [DATE], showed:
-Transfers, bathing, and toilet use required total dependence;
-Use of wheelchair for mobility;
-Walking in the room or the corridor did not occur;
-Impairment on one side of the upper and lower extremities;
-No restorative nursing services provided in the previous seven days.
Record review of the resident’s medical record, showed:
-Medical [DIAGNOSES REDACTED].
-A POS, dated 12/1/18 through 12/31/18, showed an order to provide restorative nursing
services per facility protocol;
-A Care plan, dated 10/16/18, showed:
-Problem: The resident requires assistance with activities of daily living (ADLs) due to
[DIAGNOSES REDACTED].
-Goal: The resident will maintain/increase ADL skills;
-Interventions: Allow the resident to complete as much of the task as possible. Assist as
needed;
-No documentation for restorative nursing.
Observation on 12/10/18 at 1:53 P.M., showed the resident sitting slumped in his/her wheel
chair in the communal living room in front of the T.V. The resident’s head was dropped
down to his/her chest and his/her arm hung loosely with the hand caught in between the
resident’s side and the wheel chair. The resident grunted from time to time during time of
the observation.
3. Record review of Resident #32’s quarterly MDS, dated [DATE], showed:
-Extensive assist of one person required for bed mobility, dressing, and personal hygiene;
-Total dependence, full staff performance every time, for transfers, toilet use and
bathing;
-Walking in room and in corridor did not occur;
-Wheelchair for mobility;
-Impairment on both sides of lower extremities;
-No restorative nursing services provided in the previous seven days.
Record review of the resident’s medical record, showed:
-Medical [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] neurological disease);
-A Care plan, dated 10/16/18, showed:
-Problem: The resident requires assistance with ADLs related to history of tibia fracture
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
(a break in a bone found in the lower leg), [MEDICAL CONDITION], weakness and [MEDICAL
CONDITION];
-Goal: The resident will not experience a decline in ADL function through next review;
-Interventions: Assist with mobility as necessary or as requested by the resident;
-A POS, dated 12/1/18 through 12/31/18, showed an undated order to provide restorative
nursing services per facility protocol;
-No documentation for restorative nursing.
Observation on 12/11/18 at 10:15 A.M., showed the resident lay in his/her bed, with legs
outstretched in front of him/her, watching T.V. The resident’s bedside table was pulled up
over the resident’s lap and the resident had his/her remote control on the table.
4. Record review Resident #1’s annual MDS, dated [DATE], showed:
-Total dependence two + person physical assist for bed mobility and transfers;
-Walking in room and corridor did not occur;
-Wheelchair for mobility;
-Impairment on both sides of upper and lower extremities;
-No restorative nursing services provided in the previous seven days.
Record review of the resident’s medical record, showed:
-Medical [DIAGNOSES REDACTED]. These non-bony tissues include muscles, ligaments and
tendons.), muscle spasm, osteo[DIAGNOSES REDACTED] (inflammation of bone and bone marrow),
chronic pain and [MEDICAL CONDITION] (paralysis of all four limbs);
-A Care plan, dated 11/15/18, showed:
-Problem: The resident requires extensive assistance with ADLs related to medical
[DIAGNOSES REDACTED].
-Goal: The resident will not experience a decline in ADL function through next review;
-Intervention: Allow the resident to complete as much of the task as possible. Assist as
needed;
-A POS, dated 12/1/18 through 12/31/18, showed an undated order to provide restorative
nursing services per facility protocol;
-No documentation for restorative nursing.
Observation on 12/10/18 at 11:26 A.M., showed the resident lay in bed with his/her left
arm contracted up to his/her chest. The resident’s feet were twisted in towards the center
of his/her body and had on protective soft boots. Both side rails of the bed were up and
the bed was in the highest position. The resident’s hair appeared greasy, unwashed and
he/she wore a sweatshirt with visible signs of soil. The resident had body odor.
5. Review of Resident #27’s quarterly MDS, dated [DATE], showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-Extensive assistance with one personal physical assist required for bed mobility,
transfers, dressing and toilet use;
-No rehabilitation or therapy received during assessment period.
Review of the resident’s POS for September, October, (MONTH) and (MONTH) (YEAR), showed a
treatment order as follows: Apply ankle-foot orthosis (AFO, a brace) to left foot each
day, on in the morning (6-2), off at bedtime (2-10) as tolerated. Dorsal carpal tunnel
splint left wrist on in the morning (6-2), off at bedtime (2-10) as tolerated. Apply left
resting hand splint to left hand-on during the day (6-2), off at night (2-10) as
tolerated.
Review of the resident’s Treatment Administration Record (TAR), for (MONTH) (YEAR),
showed:
-An order, dated 7/29/16, to apply the AFO to left foot each day, on in the morning (6-2);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
-Charting not completed on 10/3, 10/4, 10/5, 10/6, 10/7, 10/11, 10/20, 10/21, 10/25,
10/29 and 10/30/18, to show treatment administered;
-No documentation on the back of the TAR to show why the treatments not administered;
-an order for [REDACTED].> -Charting not completed on 10/3, 10/4, 10/5, 10/6, 10/7,
10/11, 10/21, 10/25, 10/29 and 10/30/18 to show the treatments administered;
-No documentation on back of the TAR to show why the treatments not administered.
Review of the resident’s TAR for (MONTH) (YEAR), showed:
-An order, dated 7/29/16, to apply the AFO to left foot each day, on in the morning (6-2);
-Staff documented the AFO treatment administered as ordered on [DATE].
Observation on 12/10/18 at 10:03 A.M. and 1:58 P.M., showed the resident wore a brace on
his/her left wrist. The resident did not wear a brace on his/her left foot.
During an observation and interview on 12/11/18 at 7:55 A.M., the resident wore a brace on
his/her left wrist and on his/her left foot. The resident said he/she was supposed to wear
the left foot brace every day, but sometimes staff was too busy to put it on him/her.
During an interview on 12/12/18 at 10:16 A.M., the DON said the charge nurse is ultimately
responsible for ensuring splints are applied to residents as ordered. On 12/13/18 at 9:40
A.M., the DON said a resident’s records should accurately reflect what treatments have
been administered. Staff should not document administration of a treatment, including
splints, unless the resident received the treatment. If a resident refuses a treatment,
staff should document the refusal in the resident’s record.
6. During an interview on 12/12/18 at 10:50 A.M., RA C stated he/she started working at
the facility in (MONTH) (YEAR). His/her referrals for restorative therapy are supposed to
come from the DON and his/her supervisor, the restorative nurse. There is no communication
between restorative and the therapy department. He/she has had several supervisors since
starting his/her position at the facility. All documentation of his/her restorative
services should be in the binder. Any documentation prior to the RA working at the
facility may not be in the binder; he/she doesn’t know where it might be. A physician
order [REDACTED]. He/she has had pretty much the same residents on his/her caseload since
he/she started, with the exception of a few residents who discharged from the facility.
7. During an interview on 12/12/18 at 11:16 A.M., the DON stated if a resident is admitted
and needs restorative nursing therapy, he will communicate the order to the RA. If the
resident has contractures, the therapy department will assess the resident and then
dictate what services the residents will receive on the program. The DON oversees the
restorative nursing program and expects a physician’s orders [REDACTED]. The DON also
expects the care plan to address the resident’s order for restorative nursing therapy as
per the facility’s restorative nursing program policy requirements.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
residents’ environment remains as free of accident hazards as possible and each resident
receives adequate supervision and assistive devices to prevent accidents, for three of
three residents observed during a mechanical lift transfer who were transferred with a
broken lift (Residents #1, #32, #30). In addition, the facility failed to assure safely

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
functioning mechanical lifts were in use in the facility when two of two mechanical lifts
were identified by staff as being broken. This had the potential to affect all residents
who transfer with the use of a mechanical lift. The census was 58.
1. Record review of Resident #1’s annual Minimum Data Set (MDS), a federally required
resident assessment completed by facility staff, dated 6/25/18, showed:
-Total dependence two + person physical assist for bed mobility and transfers;
-Walk in room and walk in corridor, activity did not occur;
-Wheelchair for mobility;
-Impairment on both sides of upper and lower extremities.
During an observation on 12/10/18 at 11:57 AM, Certified Nurse Aide (CNA) B and CNA G
transferred the resident from his/her bed to his/her wheelchair using a Hoyer lift
(mechanical lift). CNA G moved the mechanical lift into position over the resident’s bed
in order to lift the resident up to transfer him/her to his/her wheelchair. CNA G used the
hand held controller to open the mechanical lift’s legs to approximately 50% wide. To move
the positioning bar of the mechanical lift up and down, CNA G took a pen and inserted the
tip of the pen into small holes on the operating pad located on the main support bar on
the mechanical lift. After the transfer was completed, CNA G was asked to open the
mechanical’s lifts legs to 100%. CNA G used the hand held controller to open the
mechanical lift’s legs and when he/she pressed the buttons the legs did not work. CNA G
said the mechanical lift shorted out. CNA G confirmed the battery attached to the machine
had battery life left. Further observation, showed the area where the CNA inserted his/her
pen had several pen marks around the holes.
2. Record review of Resident #32’s quarterly MDS, dated [DATE], showed:
-Extensive assist of one person required for bed mobility, dressing, and personal hygiene;
-Total dependence, full staff performance every time, for transfers, toilet use, and
bathing;
-Walk in room and walk in corridor, activity did not occur;
-Wheelchair for mobility;
-Impairment on both sides of lower extremities.
During an observation on 12/11/18 at 11:40 A.M., CNA C and CNA F transferred Resident #32
from his/her bed to his/her wheelchair. CNA C maneuvered the Hoyer mechanical lift over to
the resident’s bed and opened the legs of the mechanical lift to 50%. CNA C then used the
tip of his/her pen to insert it into a hole on the mechanical lift’s main support bar to
move the arm up to lift the resident off the bed. CNA C then moved the mechanical lift
such that it was positioned sideways over the resident’s wheel chair and lowered the
resident down, again by inserting the pen tip into the hole located on the arm of the
mechanical lift. CNA C stated he/she was not able to open the mechanical lifts legs wide
enough to straddle the wheel chair and so, positioned the mechanical lift to the side of
the wheel chair to lower the resident into it.
3. Review of Resident #30’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].
-Resident rarely/never understood;
-Total dependence for transfers and toilet use, full staff performance. One person
physical assist.
Review of the resident’s POS, dated 2/1/18 through 12/31/18, showed:
-An order dated 11/6/18, for a Broda chair (reclining wheeled chair) for positioning;
-No order for transfer status.
Review of the resident’s undated CNA care plan guide, located in the care plan binder,
showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-Mobility: Right sided weakness, full weight bearing and transfer assist times 2 with
mechanical lift;
-Type: Blank.
Review of the resident’s care plan, dated 10/16/18, showed:
-Problem: At risk for injury related to falls and self-harm as evidenced by [DIAGNOSES
REDACTED].
-Goal: No injury from fall through next review;
-Interventions: Hoyer for all transfers. If the resident becomes aggressive or agitated,
return to bed or chair (whichever is closer) in a safe manor.
Observation on 12/10/18 at 1:57 P.M., showed CNA B obtained the Hoyer lift. CNA B, LPN A
and Restorative Aide C transferred the resident to bed with the use of the Hoyer lift.
Staff connected the lift to the Hoyer pad as the resident sat in his/her Broda chair.
Staff lifted the resident up and out of the chair and positioned the resident over his/her
bed. Restorative Aide C used a pen connected to a lanyard around his/her neck and pressed
into the control panel of the mechanical lift until the lift lowered the resident to the
bed.
4. During an interview on 12/11/18 at 11:45 A.M., CNA C stated the legs on the mechanical
lift used when transferring Resident #1 and #32 would not open all the way, they only open
maybe 50%. The remote would not move the mechanical arm up and down, and he/she inserted
the tip of his/her pen into two different emergency holes located on the mechanical lift’s
main support bar to make it go up and down in order to lift and lower the residents. The
second mechanical lift, located in the facility, operates the same, I use a pen to make it
go up and down you have to kick the legs open and shut. CNA C said both mechanical lifts
had been broken for at least a couple of weeks. Broken equipment is reported to
maintenance by writing the issue down in a maintenance log located at the nurse’s station.
He/she did not report the broken mechanical lifts because he/she assumed someone else had
as Everyone knows they don’t work.
5. During an interview on 12/11/18 at 2:42 P.M., the Director of Nursing (DON) stated
maintenance does equipment checks to ensure proper functioning which is then documented in
a log. The DON was not sure how often maintenance performs the checks. If a mechanical
lift was not working properly, the DON expects nursing staff to tell him, the
administrator and the maintenance staff immediately so that it can be addressed.
6. During an interview on 12/13/18 at 9:45 P.M., with the administrator and DON, the DON
said there is a maintenance communication binder at each nurse’s station. Staff should
fill out a maintenance request if they have maintenance issues. Staff should immediately
contact maintenance, the DON or administrator if there is something that requires
immediate attention. Staff should not use a broken Hoyer lift on residents. If a lift is
broken, he would expect staff to immediately report it. The lift should be put out of
commission until it is fixed.
7. Review of the facility’s Total Resident Transfer Using Mechanical Lifts policy, dated
3/31/08, showed:
-Staff members will ensure resident safety during total transfers of residents;
-Total mechanical lifts require a minimum of 2 trained staff members;
-Trained employees must follow manufacturer’s directions when using the lifts;
-The policy failed to identify the steps for staff to take when transferring a resident
with the use of a mechanical lift.
8. Review of Resident Transfers Policy, dated 1/13/06, showed:
-The facility will assess the resident to determine the safest method of physical transfer
as component of activities of daily living (ADLs);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
-Protocol: Only those staff members who have been trained in resident handling techniques
are permitted to transfer residents;
-Safety with transfers must be a priority.
9. During an interview on 12/13/18 at approximately 8:30 A.M., the DON stated the facility
does not have a policy outlining the proper steps on how to safely transfer a resident
using a mechanical lift. When asked for mechanical lift training documentation for staff,
the DON provided sign in sheets labeled Nursing/Gait belt/Transfer in service education
dated 3/27/18 with the Total Resident Transfer Using Mechanical Lifts policy attached.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
appropriate treatment and services to prevent urinary tract infections by failing to
provide appropriate indwelling urinary catheter positioning for one of three residents
sampled with an indwelling urinary catheter (Resident #6). The facility identified three
residents with a urinary catheter, Resident #6 was not identified by the facility as
having an indwelling urinary catheter. The census was 58.
Review of the facility’s undated Catheter policy, showed:
-Policy: In order to ensure proper technique is utilized to reduce the possibility of
infection with the insertion and maintenance of a Foley (brand of indwelling urinary
catheter) catheter, to relieve bladder distention, to determine amount of residual urine
and to uphold resident dignity, facility will follow specific procedures;
-Maintenance: Precede any entry into the drainage system by thoroughly cleansing with an
alcohol sponge to prevent bacterial contamination;
-To avoid urinary back flow never elevate the drainage bag to or above the bladder level;
-Empty the bag through the distal value into a receptacle and close it appropriately
afterward;
-Measure urinary output at the end of each 8 hour shift;
-Maintain input and output;
-Change the catheter as ordered by the physician and per facility policy;
-Cleanse the urinary meatus and adjacent catheter each shift to minimize [MEDICAL
CONDITION] discharge (the emission or secretion of fluid containing mucus and pus).
Review of Resident #6’s significant change Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/1/18, showed:
-[DIAGNOSES REDACTED].
-Brief interview for mental status (BIMS) score of 10 out of 15, which showed the resident
is cognitively impaired;
-Always incontinent of urine.
Review of the resident’s physician’s orders [REDACTED].
-An order, undated, for a Foley catheter, 16 French (fr, size) 30 cubic centimeter (cc)
balloon;
-An order, undated, to change Foley catheter as needed (PRN) for blockage or obstruction;
-An order, dated 12/3/18, to record urine output every shift;

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 24)
-An order, dated 12/3/18, to provide catheter care per facility protocol every shift.
Review of the resident’s care plan, dated 1/18/18, showed no documentation of the
resident’s use of a Foley catheter or a [DIAGNOSES REDACTED].
Observations of the resident during the survey, showed:
-On 12/10/18 at 9:45 A.M. and 2:01 P.M., the resident lay in the bed. The catheter tubing
looped/coiled down approximately 18 inches and back up towards the resident’s bladder. The
urine inside the tube did not drain into the drainage bag and there was no privacy bag.
The catheter tubing contained bright yellow urine;
-On 12/11/18 at 7:58 A.M., 10:03 A.M., 12:16 P.M. and 3:17 P.M., the resident lay in the
bed. The catheter tubing looped/coiled approximately 18 inches and back up towards the
resident’s bladder. The urine inside the tube did not drain into the drainage bag and
there was no privacy bag. The catheter tubing contained yellow urine;
-On 12/12/18 at 1:44 P.M., the resident was transferred from his/her wheelchair to the bed
with the use of a Hoyer lift (mechanical lift). During the transfer, Certified Nurse Aide
(CNA) E removed the resident’s catheter drainage bag and placed it on top of the
resident’s lap. There was approximately 5 inches of tubing on the resident’s lap. Urine
was observed moving back towards the bladder. CNA E used the drawstring of the resident’s
pants to wrap around the tubing. The drainage bag was tied to the resident’s pants during
the entire transfer. When the bed was lowered, License Practical Nurse (LPN) A untied the
catheter bag and hooked it to the bottom of the bed frame. LPN A left the room and CNA P
removed the drainage bag from the bed frame and placed it back onto the resident’s lap to
reposition him/her and remove the Hoyer pad from underneath him/her. Urine was observed
moving back towards the bladder. Staff removed the Hoyer pad and removed the drainage bag
from the resident’s lap and hooked onto the bed frame.
During an interview on 12/13/18 at 9:45 A.M., the Director of Nursing (DON) said the
catheter tubing and drainage bag should always be below the bladder. If the resident is in
bed, the tubing should not be looped, kinked or coiled. It should be hanging on the bed
frame, below the bladder and not in a position to obstruct the bladder. The CNAs and the
nurse are responsible for checking the position of the catheter to ensure its proper
position. There should be a privacy bag due to dignity for the resident. It is not
appropriate for staff to hook the resident’s pants to the catheter bag because urine could
flow back into the bladder. Any urine in the catheter tube could flow back into the
bladder and cause an infection. During a Hoyer transfer, staff are expected to have the
catheter tube and drainage bag below the bladder.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide thorough
assessments, orders, monitoring and ongoing communication with the [MEDICAL TREATMENT]
center. The facility identified three residents who received [MEDICAL TREATMENT]. Of those
three, two were selected for the sample of 15 and issues were found with one resident
(Resident #108). The census was 58.
Review of Resident #108’s medical record, showed:
-admitted to the facility on [DATE], and readmitted from a local hospital on [DATE];
-[DIAGNOSES REDACTED]. Can be caused by [MEDICAL CONDITION]);

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 25)
-No orders to send the resident to [MEDICAL TREATMENT] (the process of filtering toxins
from the blood in individuals with kidney failure);
-No order for the frequency of the [MEDICAL TREATMENT];
-No order to check the arteriovenous (AV), fistula (connection or passageway between an
artery and a vein, surgically created for [MEDICAL TREATMENT] treatments) for bruit/thrill
(the thrill is the vibration you feel as blood flows through the fistula. The bruit is the
sound you hear, heard with a stethoscope);
-No order to check the AV fistula for signs/symptoms of infection and bleeding.
Review of the resident’s progress notes, showed:
-No documentation of assessment and/or monitoring of the fistula;
-No documentation of assessing the fistula for bruit and thrill;
-No documentation of assessing for signs and symptoms of infection and bleeding;
-No documentation of assessing the resident for pain before and after [MEDICAL TREATMENT];
-No documentation of communication between the [MEDICAL TREATMENT] center and facility.
Observation and interview on 12/10/18 at 7:45 A.M., showed a dressing on the resident’s
left upper arm. The resident said the dressing covered his/her [MEDICAL TREATMENT]
fistula, he/she goes out to [MEDICAL TREATMENT] every Monday, Wednesday and Friday.
Observation of the daily transport schedule sheet at the nurses station, dated 12/12/18,
showed:
-Resident’s pick up time – 7:30 A.M.;
-Appointment time – 8:30 A.M., family will take to [MEDICAL TREATMENT];
-Scheduled [MEDICAL TREATMENT] M/W/F;
-[MEDICAL TREATMENT] center makes appointments;
-Needs a breakfast.
During an interview on 12/12/18 at 10:02 A.M., the Director of Nurses (DON) verified there
were no orders for the resident to receive [MEDICAL TREATMENT], where, how often, time of
appointment, or for any assessments of the AV fistula site which would include
thrill/bruit, pain, bleeding and swelling of the site. He would expect staff to document
the assessment on the treatment administration record (TAR). He looked for the TARs and
said there he could not find any TARs for the resident and the assessments were not on the
resident’s medication administration records (MARs). He would expect staff to obtain
orders for the resident to receive [MEDICAL TREATMENT], where, how often and assessments
for the AV fistula, to follow those orders and to document any communication between
facility and [MEDICAL TREATMENT] center.

F 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Try different approaches before using a bed rail. If a bed rail is needed, the
facility must (1) assess a resident for safety risk; (2) review these risks and benefits
with the resident/representative; (3) get informed consent; and (4) Correctly install and
maintain the bed rail.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure side
rails were assessed as a necessary device and failed to ensure side rails fit properly to
reduce the risk of entrapment, for one of 15 sampled residents (Resident #255). The census
was 58.
Review of Resident #255’s medical record, showed the following:

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0700

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
-A physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Mobility: Bed rest;
-No order for side rails;
-A POS, dated (MONTH) (YEAR), showed:
-Mobility: Up as tolerated;
-No order for side rails;
-An Assistive Device/Restraint Review, dated 11/28/18, showed:
-All sections of the assessment left blank;
-No documentation regarding assistive device benefits, risks, or recommendations;
-Document signed by the assessing nurse;
-A Contracture Assessment, dated 11/28/18, showed:
-Left hand mobility, no limitation/within normal limits;
-Right hand mobility, full limitation/closed fisted;
-A care plan, undated and in use at the time of survey, showed;
-Paralysis/contractures in both arms and legs;
-No use of safety devices identified.
Observation of the resident, showed:
-On 12/10/18 at 9:39 A.M. and 2:00 P.M., the resident lay in bed, with half side rails up
on each side of the bed;
-On 12/11/18 at 12:04 P.M., the resident lay in bed, with both half side rails up. When
touched, the side rails moved loosely. The right side rail easily moved 1.5 inches (in)
away from the resident’s bed, and the left side rail moved 1 in away from the bed;
-On 12/12/18 at 7:38 A.M., the resident lay in bed, with both half side rails up and a
fall mat on the floor to his/her left side. Both side rails wiggled loosely, moving side
to side and back and forth, approximately 4 to 5 inches away from the resident’s mattress.
During interview and observation on 12/12/18 at 10:11 A.M., the Director of Nursing (DON)
said residents are assessed for side rails upon admission. The assessment should be filled
out completely and accurately and should indicate what type of assistive device will be
used. It is not acceptable for the assessment to be signed and dated by staff, but left
blank. The DON observed both side rails of the resident’s bed, moved them, and said the
side rails were loose. He said the side rails are supposed to give a little. The DON said
the loose side rails created a gap between the side rails and the bed; this creates a risk
for entrapment. Nursing is responsible for ensuring side rails are secure. If a side rail
is loose, nursing staff is expected to report the issue to maintenance.

F 0726

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to assure nursing
staff with appropriate competencies and skill sets to assure resident safety and attain or
maintain the highest practicable physical, mental and psychosocial well-being of each
resident by failing to assure nursing staff were competent in the use of insulin pens for
two of two residents observed to receive insulin via an insulin pen (Residents #32 and
#28). The census was 58.

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
1. Review of Resident #32’s physician order [REDACTED].
-[DIAGNOSES REDACTED].>-An order, dated 8/30/18, for [MEDICATION NAME] (long acting
insulin) 50 units subcutaneous (SQ, under the skin) two times a day;
-An order, dated 9/5/18, for Humalog (short acting insulin) 12 units SQ three times a day
with meals routine;
-An order, dated 9/5/18, for Humalog per sliding scale. For a blood sugar of 181 through
220, administer 2 units of Humalog.
Observation on 12/10/18 at 8:32 A.M., showed Licensed Practical Nurse (LPN) A administered
insulin to the resident. LPN A obtained the residents blood sugar level of 201, dialed 14
units on the resident’s Humalog insulin pen and placed a needle on the pen. He/she then
dialed 50 units on the resident’s [MEDICATION NAME] pen and placed a needle on the pen.
He/she then entered the resident’s room, wiped off the left and right side of the
resident’s abdomen with alcohol wipes and administered the Humalog into the resident’s
right abdomen and [MEDICATION NAME] to the left abdomen. LPN A failed to prime the pens
prior to administration of the insulin via insulin pens.
During an interview on 12/10/18 at 9:00 A.M., LPN A said staff have a resource binder
located at the nurse’s station that has a lot of information, but he/she is not sure if it
has resident care policies. He/she would have to ask management if he/she needed a
specific policy. Staff know how to care for residents by looking at the care plan located
at the nurses station.
2. Review of Resident #28’s POS, dated 12/1/18 through 12/31/18, showed an order dated
4/13/18, for Humalog insulin pen per sliding scale insulin. For a blood sugar of 221
through 280, administer 3 units of Humalog.
Observation on 12/11/18 at 12:23 P.M., showed LPN D administered insulin to the resident.
LPN D obtained the resident’s blood sugar level of 229, dialed 3 units of the resident’s
Humalog insulin pen and placed a needle on the pen. He/she entered the resident’s room,
wiped off the residents left arm and administered the Humalog insulin to the resident. LPN
D failed to prime the insulin pen prior to administration of the insulin via insulin pen.
3. Review of the resource binder, located at the 100/200 hall nurse’s station and 300/400
hall nurse’s station, showed no policy and procedure for blood sugar checks or insulin pen
administration.
4. During an interview on 12/12/18 at 12:45 P.M., the administrator said the Director of
Nursing (DON) is responsible for staff training and education.
5. During an interview on 12/12/18 at 1:29 P.M., the DON said policies for resident care
are located on the intranet and available to all staff. He would expect staff to follow
the facility policies regarding insulin administration via an insulin pen. Staff should
prime insulin pens prior to the administration of insulin. He was not sure when the most
recent training was provided to staff on administration of insulin via insulin pen.
6. Review of the facility’s Safe Medication Administration policy, dated 9/2018, showed:
-All injectable medications must be prepared and administered in accordance with safe
injection practices;
-The policy failed to direct staff on the procedure of administration of insulin via a pen
and/or direct staff to prime the pen prior to administration of insulin.
7. Review of the facility’s most recent in-service training on blood sugar machines and
insulin administration, provided by the DON on 12/13/18 at 9:45 A.M., showed:
-Completed on 10/23/18 from 2:00 P.M. through 2:30 P.M.;
-Eight staff attended;
-Insulin administration training did not include direction to prime insulin pens prior to
the administration of insulin.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview, and record review, the facility failed to establish a system of
records of receipt and disposition of all controlled drugs in sufficient detail to enable
an accurate reconciliation. The facility census was 58.
Review of the facility’s Controlled Substance policy, dated 5/11/12, showed:
-A master narcotic count record will be maintained in a binder on each medication cart;
-At shift change, the oncoming and off going nurses will:
-Count controlled substances;
-Sign the master narcotic count record to verify the count is accurate for all controlled
substances;
-Notify the Director of Nursing (DON) or the Assistant Director of Nursing (ADON)
immediately if a discrepancy cannot be resolved.
1. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) (YEAR), for the 300 and 400 halls, showed:
-For the 300 cart, 9 out of 90 shifts the same nurse (and only nurse) documented for both
the on and the off shift narcotic count, and 9 out of 90 shifts only one nurse documented;
-For the 400 cart, 10 out of 90 shifts the same nurse (and only nurse) documented for both
the on and the off shift narcotic count, and 3 out of 90 shifts only one nurse documented;
-For the 300/400 nurses station, 80 out of 90 shifts the same nurse (and only nurse)
documented for both the on and the off shift narcotic count, and 1 out of 90 shifts only
one nurse documented.
Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) (YEAR) and reviewed on 12/12/18, for the 300 and 400 halls, showed:
-For 300/400 nurse’s cart, 7 out of 35 shifts, one nurse documented, and 3 out of 35
shifts without count of narcotics;
-For the 300/400 nurse’s station, 16 outof 35 shifts with one nurse documented, and 10 out
of 35 shifts without count of narcotics;
-For the 300/400 certified medication technician (CMT) cart, 19 out 35 shifts with one
nurse documented, and 8 out 35 shifts without count of narcotics.
2. Review of the facility’s controlled substance shift change count check sheet, dated
(MONTH) (YEAR), for the 100 and 200 halls, showed:
-For the 100/200 nurses station, 1 out of 90 shifts, the same nurse (and only nurse)
documented for both the on and the off shift narcotic count, and 7 out of 90 shifts with
one nurse documented;
-For the 100/200 CMT cart, 23 out of 35 shifts, one nurse documented for both the on and
the off going shift, and 4 out 35 shifts without count of narcotics.
3. Review of the facility’s controlled substance shift change count check sheet with an
illegible label, dated (MONTH) (YEAR), showed 5 out of 90 shifts with the same nursing
staff documenting for both the on and the off shift narcotic count, and 11 out of 90
shifts with one nurse documented.
4. During an interview on 12/12/18 at 11:16 A.M., the DON said he expects the oncoming and
off going nursing staff to count the narcotics together before starting and ending their
shifts, and to document their findings on the controlled substance shift change count

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
check sheet found in the narcotic binder on each medication cart.
5. During an interview on 12/12/18 at 2:13 P.M., the Administrator and the DON stated:
-The facility completes an audit of the controlled substance shift change count check
sheets on a monthly basis. It consists of looking if overall packages match the count and
if the narcotic count is being done on the medication carts;
-The pharmacy conducts quarterly audits of the facility’s controlled substances;
-If narcotics were missing in the facility and the controlled substance count sheets were
incomplete, the DON would default to the last count listed on the master count sheet. He
would also look at the package log, and the pharmacy log to ascertain which residents were
receiving narcotics routinely. The DON would then verify who worked on the shift in which
the narcotics went missing;
-Due to the missing information on the controlled substance shift change count check
sheets, they are not sufficient to obtain accurate reconciliation of the facility’s
controlled substances.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 25 opportunities observed, 4 errors occurred
resulting in a 16% error rate (Residents #32, #28 and #31). The census was 58.
1. Review of Resident #32’s physician order [REDACTED].
-[DIAGNOSES REDACTED].>-An order dated 8/30/18, for [MEDICATION NAME] (long acting
insulin) 50 units subcutaneous (SQ, under the skin) two times a day;
-An order dated 9/5/18, for Humalog (short acting insulin) 12 units SQ three times a day
with meals routine;
-An order dated 9/5/18, for Humalog per sliding scale. For a blood sugar of 181 through
220, administer 2 units of Humalog.
Observation on 12/10/18 at 8:32 A.M., showed Licensed Practical Nurse (LPN) A administered
insulin to the resident. LPN A obtained the residents blood sugar level of 201, dialed 14
units on the residents Humalog insulin pen and placed a needle on the pen. He/she then
dialed 50 units on the residents [MEDICATION NAME] pen and placed a needle on the pen.
He/she entered the residents room, wiped off the left and right side of the resident’s
abdomen with alcohol wipes and administered the Humalog into the right abdomen and
[MEDICATION NAME] to the left abdomen. LPN A failed to prime the pens prior to
administration of the insulin via insulin pens.
2. Review of Resident #28’s POS, dated 12/1/18 through 12/31/18, showed an order dated
4/13/18, for Humalog insulin pen per sliding scale insulin. For a blood sugar of 221
through 280, administer 3 units of Humalog.
Observation on 12/11/18 at 12:23 P.M., showed LPN D administered insulin to the resident.
LPN D obtained the resident’s blood sugar level of 229, dialed 3 units of the resident’s
Humalog insulin pen and placed a needle on the pen. He/she entered the resident’s room,
wiped off the residents left arm and administered the Humalog insulin to the resident. LPN
D failed to prime the insulin pen prior to administration of the insulin via insulin pen.
3. Review of the facility’s Safe Medication Administration policy, dated 9/2018, showed:
-All injectable medications must be prepared and administered in accordance with safe

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
injection practices;
-The policy failed to direct staff on the procedure of administration of insulin via a pen
and/or direct staff to prime the pen prior to administration of insulin.
4. Review of Resident #31’s POS, dated 12/1/18 to 12/31/18, showed an order dated
12/28/17, for Aspercreme 4% patch ([MEDICATION NAME], pain medication), apply 1 patch to
left knee once daily.
During an observation on 12/11/18 at 8:17 A.M., showed Certified Medical Technician (CMT)
H, sanitized his/her hands, placed gloves on and applied a [MEDICATION NAME] onto the
resident’s right knee. The CMT stated the [MEDICATION NAME] was on the resident’s right
knee when asked.
During an interview on 12/12/18 at 11:16 A.M., the Director of Nursing (DON) said he
expected medications to be used as ordered on the POS. If a [MEDICATION NAME] was ordered
to be placed on a resident’s left knee, he expected it nursing staff to put it on the
resident’s left knee.
5. During an interview on 12/12/18 at 1:29 P.M., the DON said policies for resident care
are located on the intranet and available to all staff. He would expect staff to follow
the facility policies regarding insulin administration via an insulin pen. Staff should
prime insulin pens prior to the administration of insulin.
MO 813

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
are free of any significant medication errors by failing to prime insulin pens before use
to assure the correct does of the medication was administered, for two of two residents
observed to receive insulin via an insulin pen (Residents #32 and #28). The census was 58.
1. Review of Resident #32’s physician order [REDACTED].
-[DIAGNOSES REDACTED].>-An order dated 8/30/18, for [MEDICATION NAME] (long acting
insulin) 50 units (subcutaneous SQ, under the skin) two times a day;
-An order dated 9/5/18, for Humalog (short acting insulin) 12 units SQ three times a day
with meals routine;
-An order dated 9/5/18, for Humalog per sliding scale. For a blood sugar of 181 through
220, administer 2 units of Humalog.
Observation on 12/10/18 at 8:32 A.M., showed Licensed Practical Nurse (LPN) A administered
insulin to the resident. LPN A obtained the residents blood sugar level of 201, dialed 14
units on the residents Humalog insulin pen and placed a needle on the pen. He/she then
dialed 50 units on the residents [MEDICATION NAME] pen and placed a needle on the pen.
He/she entered the residents room, wiped off the left and right side of the resident’s
abdomen with alcohol wipes and administered the Humalog into the right abdomen and
[MEDICATION NAME] to the left abdomen. LPN A failed to prime the pens prior to
administration of the insulin via insulin pens.
2. Review of Resident #28’s POS, dated 12/1/18 through 12/31/18, showed an order dated
4/13/18, for Humalog insulin pen per sliding scale insulin. For a blood sugar of 221
through 280, administer 3 units of Humalog.
Observation on 12/11/18 at 12:23 P.M., showed LPN D administered insulin to the resident.

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
LPN D obtained the resident’s blood sugar level of 229, dialed 3 units of the resident’s
Humalog insulin pen and placed a needle on the pen. He/she entered the resident’s room,
wiped off the residents left arm and administered the Humalog insulin to the resident. LPN
D failed to prime the insulin pen prior to administration of the insulin via insulin pen.
3. Review of the facility’s Safe Medication Administration policy, dated 9/2018, showed:
-All injectable medications must be prepared and administered in accordance with safe
injection practices;
-The policy failed to direct staff on the procedure of administration of insulin via a pen
and/or direct staff to prime the pen prior to administration of insulin.
4. During an interview on 12/12/18 at 1:29 P.M., the Director of Nursing (DON) said
policies for resident care are located on the intranet and available to all staff. He
would expect staff to follow the facility policies regarding insulin administration via an
insulin pen. Staff should prime insulin pens prior to the administration of insulin.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure drugs
and biologicals were labeled in accordance with currently accepted professional principles
and facility policy and failed to discard expired medications for three of five medication
carts checked. The facility census was 58.
Review of the facility’s storage of medications policy, undated, showed:
-The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.
All such drugs shall be returned to the dispensing facility or destroy;
-Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be
stored separately from other medications;
-Antiseptics, disinfectants, and germicides used in any aspect of resident care must have
legible, distinctive labels that identify the contents and the directions for use, and
shall be stored separately from regular medications.
1. Observation on 12/10/18 at 9:53 A.M., of the certified medical technician (CMT)
medication cart on 300 hall, showed a Breo Ellipta medication delivery device ([MEDICATION
NAME][MEDICATION NAME], medication used to open the lung airways by inhalation), unlabeled
with a resident’s name and stored loose in the top drawer of the cart.
2. Observation on 12/10/18 at 10:01 A.M., of the CMT cart on 400 hall, showed one tube of
barrier cream (used to prevent skin breakdown on an incontinent resident), opened,
unlabeled with a resident’s name, and stored in a compartment with packaged oral
medications.
3. Observation on 12/13/18 at 7:30 A.M., of the nurse’s medication cart on 300 hall,
showed:
-One opened bottle of Liquid Iron, expired 10/2018;
-One bottle of rubbing alcohol, opened, unlabeled with a resident’s name and stored with
packaged oral medications;
-One bottle of [MEDICATION NAME] (cleansing solution usually used on wounds), opened,
unlabeled with a resident’s name and stored with 4 containers of nutritional liquid

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
supplements and an opened box of [MEDICATION NAME] and [MEDICATION NAME] sulfate
([MEDICATION NAME][MEDICATION NAME], medications used to open the lung airways) duo
nebulizer vials (delivery device used to administer medication in the form of a mist
inhaled into the lungs);
-One box of [MEDICATION NAME] and [MEDICATION NAME] sulfate duo nebulizer vials, expired
9/2018;
-One tube of Derma Cream (moisture barrier cream used to help prevent skin breakdown on
incontinent residents), open, unlabeled with a resident’s name, and stored with auto
shield pen needles (small needles used with insulin pens to administer insulin beneath the
skin) and lancets (a small device with sharp pointed surgical instrument used to prick a
resident’s finger to draw blood to test amount of sugar (glucose) in the body);
-Eight tubes of Santyl (enzymatic debridement ointment used to treat wounds and/or
pressure ulcers), all opened, appeared used, unlabeled with a resident’s name, and stored
in a Ziploc bag.
4. During an interview on 12/12/18 at 11:16 A.M., the Director of Nursing (DON) stated:
-Staff should discard all medications that are expired or discontinued. There is a system
in place for nursing staff to put discontinued medications in a bin in the medication
rooms so they can be sent back to the pharmacy;
-Half used tubes of Santyl should not be saved on medication carts;
-Ointments should be labeled and stored in the medication cart so there is not an
infection or cross contamination issue.

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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to store, prepare,
distribute and serve food in accordance with professional standards for food service
safety by failing to store food in sanitary conditions, properly label food and beverages,
and dispose of expired thawed food. The facility also failed to keep the floors free of
food and debris and/or ensure staff covered their hair with restraints when preparing
food. These deficient practices had the potential to affect all residents who ate at the
facility. The census was 58.
Review of the facility’s food preparation policy, dated (MONTH) (YEAR), showed all foods
that are to be held for more than 2 hours at a temperature of 41 degrees Fahrenheit or
less will be labeled and dated with a prepared date (day one) and a use by date (day
seven).
1. Observation of the walk in cooler on [DATE] at 8:05 A.M., showed a bag of thawed, raw
chicken on a metal pan, dated [DATE]. The bag of thawed chicken lay on top of pinkish
liquid inside the metal pan. There was a wrapped, undated piece of thawed meat on the
metal pan and lay in the reddish liquid.
2. Observation on [DATE] at 8:31 A.M., showed:
-Two partially thawed bags of chicken inside the walk in cooler without a date, one
partially thawed bag of chicken dated [DATE], and one thawed bag of chicken dated [DATE].
The bags were on top of each other with the bag dated [DATE] on the bottom;
-Crinkled French fries on the floor in front of the stove;

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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 33)
-Food crumbs and debris under the three sink sanitizer;
-Dirt and debris under the stove, sink, and food warmer;
-Dried grease stains on the back splash and side of the fryer.
3. Observation on [DATE] at 5:43 P.M., showed:
-Uncovered bowls of fruit on a cart inside the walk in cooler;
-Two, opened lemon flavored thickened liquid cartons, labeled [DATE] inside the walk in
cooler. Cartons were labeled, once opened store at ambient temperature for up to 8 hours
or refrigerate for up to 7 days;
-Food crumbs, dirt and debris under the stove, sink, and food warmer;
-Dried grease stains on the back splash and side of the fryer.
4. Observation on [DATE] at 6:00 P.M., showed Dietary Aide Q prepared food with
approximately 2 to 3 inches of hair outside of the hair restraint. Dietary Aide R poured
beverages. He/she had approximately 4 inches of hair outside of the hair restraint.
5. During an interview on [DATE] at 11:07 A.M., the dietary manager said thawed meat
should be dated and inside the cooler for up to seven days. It is dated when it goes from
the freezer to the walk in cooler. He would expect staff to clean spilled liquids in the
cooler thus preventing cross contamination. He would expect staff to check the dates on
the food on a daily basis. The thawed chicken, dated [DATE], was not served. The district
manager found it and threw it out. Staff are expected to prepare the food within the
required time frame and should place the oldest in front so it is used first. He would
expect staff to cover all hair when in the kitchen. The cooks are responsible for cleaning
the floors and underneath the equipment at the end of the day. It is unlikely French fries
were served in the morning, so it was there from the night before. The thickened liquids
should have a date when it was placed in the cooler and another date when it was opened.
The dietary manager is responsible for dating the food that was delivered, and dietary
aides are responsible for dating it once opened and wrapped.

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure all resident records
were complete and accurate by failing to ensure documentation of care provided was
documented at the time it was provided and/or available, by not documenting daily, weekly
and monthly weights and not having laboratory results in the resident’s medical records
for eight of 15 sampled residents (Residents #108, #49, #36, #1, #105, #28, #32 and #45,).
The census was 58.
1. Review of Resident #108’s medical record, showed:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
-No order to check the arteriovenous (AV), fistula (connection or passageway between an
artery and a vein, surgically created for [MEDICAL TREATMENT] treatments) for bruit/thrill
(the thrill is the vibration you feel as blood flows through the fistula. The bruit is the
sound you hear, heard with a stethoscope);
-No order to check the AV fistula for signs/symptoms of infection and bleeding.
Review of the resident’s medical record, showed:

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 34)
-No documentation of assessment and/or monitoring of the fistula;
-No documentation of assessing the fistula for bruit and thrill;
-No documentation of assessing for signs and symptoms of infection and bleeding;
-No documentation of assessing the resident for pain before and after [MEDICAL TREATMENT].
Review of the facility’s treatment administration record (TAR), showed no TARs for the
resident as late as [DATE] at 10:00 A.M.
Observation and interview on [DATE] at 7:45 A.M., showed a dressing on his/her left upper
arm. The resident said the dressing covered his/her [MEDICAL TREATMENT] fistula, he/she
goes out to [MEDICAL TREATMENT] every Monday, Wednesday and Friday.
During an interview on [DATE] at 10:02 A.M., the Director of Nurses (DON) said he would
expect staff to document the assessment on the treatment administration record (TAR). He
looked for the TARs and said there he could not find any TARs for the resident and the
assessments were not on the resident’s medication administration records (MARs). He would
expect staff to document the assessments for the AV fistula on the resident’s TARs. The
DON then approached a charge nurse and told him/her to obtain the orders for the [MEDICAL
TREATMENT] and AV fistula assessments, place the orders on the POS and the TARS.
On [DATE] at approximately 2:30 P.M., the medical records person provided a copy of the
resident’s handwritten TARs, dated [DATE] through [DATE]. The handwritten TARs showed:
-Assess AV fistula for position, bruit/thrill, signs/symptoms of infection, redness to
site, active bleeding;
-All were initialed for [DATE] through [DATE].
During an interview on [DATE] at 9:45 A.M., the DON said the resident’s admission was not
done properly. Staff only filled out the MAR and not any TARs, on [DATE], after brought to
his attention, staff went back and wrote orders from the resident’s original admission on
[DATE]. He would expect staff to obtain orders from the physician if the physician wants
to continue previous medications or treatments. He was not sure where the TARs provided on
[DATE] at approximately 2:30 P.M., came from.
2. Review of Resident #49’s physician order [REDACTED].
-An order dated [DATE], for daily weights at 6:00 A.M.;
-An order dated [DATE], to obtain a [MEDICAL CONDITION] stimulating hormone (TSH, blood
test to monitor treatment of [REDACTED].M.
Review of the resident’s medical record, showed:
-The last documented monthly weight done in (MONTH) (YEAR);
-No further weights documented in the medical record;
-No laboratory test results for the TSH, lipid panel, or the CMP ordered on [DATE].
Review of the resident’s MARs and TARs, dated [DATE] through [DATE], and [DATE] through
[DATE], showed no documentation of any daily weights.
3. Review of Resident #36’s medical record, showed;
-Physician order [REDACTED].
-The last documented monthly weight done in (MONTH) (YEAR);
-No further weights documented in the medical record.
4. Review of Resident #1’s medical record, showed:
-POS, dated [DATE] through [DATE], showed an undated order to obtain weekly weights for
four weeks and then monthly;
-No weights documented in the medical record.
5. Review of Resident #105’s medical record, showed:
-admitted on [DATE];
-expired on [DATE];
-[DIAGNOSES REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 35)
-An order, dated [DATE] to change trachea tubing every week on Tuesday.
Review of the resident’s Treatment Administration Record (TAR), dated [DATE] through
[DATE], showed:
-On [DATE]: No documentation;
-On [DATE]: No documentation;
-On [DATE]: No documentation;
-Further review of the TAR, showed staff documented the changing of the trachea tube on
Sunday, [DATE] and Tuesday, [DATE].
During an interview on [DATE] at 9:45 A.M., the Director of Nursing (DON) said he would
expect staff to document that treatments had been completed per physician’s orders
[REDACTED].
6. Review of Resident #28’s medical record, showed:
-POS, dated [DATE] through [DATE], showed an undated order to obtain monthly weights;
-The last documented monthly weight done in (MONTH) (YEAR);
-No further weights documented in the medical record.
7. Review of Resident #32’s medical record, showed:
-POS, dated [DATE] through [DATE], showed an undated order to obtain weekly weights;
-No weights documented in the medical record.
8. Review of Resident #45’s medical record, showed:
-POS, dated [DATE] through [DATE], showed an undated order to obtain weekly weights for
four weeks and then only monthly;
-No weights documented in the medical record.
9. During an interview on [DATE] at 9:55 A.M., the DON said the Restorative Therapy Aide
is responsible for obtaining the daily, weekly and monthly weights and the CNAs are
responsible for obtaining the weights on the weekends or when the Restorative Aide is not
in the building. Daily weights should be recorded on the MAR. He verified no daily weights
had been documented on the resident’s (MONTH) and (MONTH) MARs or TARs. He verified the
laboratory test results for the laboratory test ordered on [DATE] were not in the
resident’s medical record. He had a staff member to make sure the laboratory test were
drawn as ordered and to print the results. He would expect the results to be in the
resident’s medical record.
10. During an interview on [DATE] at 10:40 A.M., the Restorative Therapy Aide said he/she
obtains the daily, weekly and monthly weights, keeps them in a binder in his/her office
since (MONTH) (YEAR). He/she was placing the weights in a binder at the nurses stations
but they were going missing so now they are not placed in the residents medical records.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain an
infection prevention and control program designed to provide a safe, sanitary and
comfortable environment and to help prevent the development and transmission of
communicable diseases and infections by failing to follow infection control standards of
practice during incontinence care and during the transfer of a resident with an indwelling
urinary catheter, for two of 15 sampled residents (Resident #30 and #1). The census was

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 36)
58.
1. Review of Resident #30’s quarterly Minimum Data Set (MDS), a federally required
assessment instrument, dated 9/30/18, showed:
-[DIAGNOSES REDACTED].
-Rarely/never understood;
-Total dependence for transfers and toilet use, full staff performance. One person
physical assist;
-Extensive assistance required for personal hygiene;
-Always incontinent of bowel and bladder.
Review of the resident’s undated Certified Nurses Aide (CNA) care plan guide, located in
the care plan binder, showed:
-Bladder: Total;
-Bowel: Incontinent.
Review of the resident’s care plan, dated 10/16/18, showed:
-Problem: Required assistance with activities of daily living (ADLs) due to [DIAGNOSES
REDACTED].
-Goal: Will maintain/increase ADL skills;
-Interventions: Encourage independence with bathing, dressing, grooming and oral hygiene;

-Problem: Incontinent of bowel and bladder:
-Goal: Experience no skin conditions related to incontinence;
-Interventions: Check or incontinence, change if wet/soiled. Apply moisture barrier,
reapply after each incontinence episode.
Observation on 12/10/18 at 1:57 P.M., showed CNA B obtained the Hoyer lift (mechanical
lift). CNA B, Licensed Practical Nurse (LPN) A and Restorative Aide C transferred the
resident to bed with the use of the Hoyer lift. After the staff transferred the resident
to bed, Restorative Aide C left room. CNA and LPN A remained in the room. CNA B obtained
supplies, assisted the resident to pull his/her pants down, and assisted the resident to
his/her right side. An undated dressing observed on the resident’s coccyx (tail bone). The
resident’s brief was wet with urine. CNA B unsecured the resident’s brief, LPN A assisted
the resident to turn to the other side and unsecured the resident’s brief on the right
side. CNA B rolled up and removed the resident’s brief. LPN A and CNA B assisted the
resident to turn to the right side. CNA B placed a clean brief under resident’s soiled
buttocks, obtained a disposable wipe and wiped the inside of the gluteal fold with several
wipes, folding the disposable wipe between each wipe. A small amount of stool was visible
in the resident’s gluteal fold. Without changing his/her gloves or sanitizing his/her
hands, CNA B dried the resident’s buttocks with a towel and applied protective ointment to
the resident’s buttocks that he/she obtained from the resident’s dresser while still
wearing the soiled gloves. LPN A positioned the resident to his/her back. CNA B removed
his/her gloves, washed his/her hands and placed new gloves on. CNA B cleansed the
resident’s genitals, dried the resident’s genitals with the towel used with the soiled
gloves to dry the buttocks, secure the resident’s brief and assisted the resident onto
his/her back. While wearing the same gloves, CNA B removed the resident’s pants, placed a
wedge cushion behind the resident’s back, and covered the resident with a sheet and
blanket. He/she used the bed controllers to elevate the head of the bed and lower the bed
to the floor before removing his/her soiled gloves and washing is/her hands.
Review of the facility’s Incontinence Assessment and Management policy, dated 9/2005,
showed:
-The facility will ensure each resident, who is incontinent, will be identified, assessed

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

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 37)
and provided appropriate treatment and services to prevent urinary tract investigations
and restore as much normal urinary function as possible;
-The policy failed to identify the protocol and steps involved in providing incontinence
care, which all areas potentially contaminated with urine or stool will be cleaned, and/or
non-rinse soap must be rinsed.
During an interview on 12/13/18 at 9:45 P.M., with the administrator and Director of
Nursing (DON), the DON said he would expect staff change their gloves and sanitize their
hands any time they go from a dirty to clean area. Staff should not touch the resident or
resident surfaces with potentially soiled gloves. Staff should not place a clean brief
under the resident before cleansing the resident’s skin.
2. Record review Resident #1’s annual MDS, dated [DATE], showed:
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Total dependence two + person physical assist for bed mobility and transfer;
-Wheelchair for mobility;
-Impairment on both sides of upper and lower extremities.
Record review of the resident’s medical record, showed:
-Medical [DIAGNOSES REDACTED].
-Physicians order sheet (POS), dated 12/1/18 through 12/31/18, showed an undated order for
indwelling catheter size 16 French (FR, indicates the size) with 10 cubic centimeter (CC)
balloon for use due to [MEDICAL CONDITION] bladder.
Review of the resident’s care plan, dated 11/15/18, showed:
-Problem: The resident is at risk for infection related to indwelling catheter:
-Goal: The resident will remain free of urinary tract infection during the period of
catheterization;
-Intervention: Keep tubing below level of bladder and free of kinks or twists.
Observation on 12/10/18 at 11:57 A.M., showed CNA B and CNA G transferred the resident
from his/her bed to his/her wheelchair using a mechanical lift. CNA B and CNA G stood on
either side of the resident’s bed and asked the resident to roll onto his/her left side
and then onto his/her right side as they put the mechanical lift pad underneath the
resident. Once the resident was lying on the mechanical lift pad, CNA G unhooked the
resident’s catheter bag from its place, hanging underneath the resident’s bed, and placed
the catheter bag on the resident’s bed and in between his/her legs. CNA Q then secured the
hooks of the resident’s lift pad to the arm of the mechanical lift machine. CNA B used the
remote control to activate the arm of the mechanical lift and raised the resident off of
the bed. CNA G took the resident’s catheter bag and placed it on the resident’s lap, above
the resident’s bladder level, as he/she was suspended in the air with the use of the
mechanical lift. The resident was transferred from his/her bed and lowered into his/her
wheelchair. CNA B and CNA G unhooked the resident’s lift pad from the machine and CNA G
removed the catheter bag from the resident’s lap and hung it on the bottom of the
resident’s wheelchair.
During an interview on 12/12/18 at 11:16 A.M., the Director of Nursing (DON) said he
expected staff to keep a catheter bag below the level of the resident’s bladder when
transferring a resident from the bed to his/her wheelchair. When transferring a resident
using a mechanical lift, the catheter bag would be hung on the lift pad below the level of
the bladder, and staff would then move the catheter bag before the resident is lowered
into place. The catheter bag should be placed in a position in which it cannot be crushed
or sat on.
3. Review of the facility’s Infection Control: Hand Washing policy, dated 9/2014, showed:
-The facility recognizes proper hand hygiene to be one of the most important elements of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265457

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

NAME OF PROVIDER OF SUPPLIER

ROSEWOOD CARE CENTER OF ST LOUIS

STREET ADDRESS, CITY, STATE, ZIP

11278 SCHUETZ ROAD
SAINT LOUIS, MO 63146

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 38)
an effective infection control program and one of the best ways to prevent the spread of
infection and illness;
-Times to perform hand hygiene: before putting on gloves and after removing gloves; before
and after providing resident care; after handling soiled or used linens, bedpans,
catheters and urinals; after handling garbage, trash, soiled linen or any equipment that
may be contaminated.
MO 823