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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a final accounting of
and/or the remaining funds in the resident trust account were sent to the individual or
probate jurisdiction administering the resident’s estate, in accordance with State and
Federal law (30 days for Federal, 60 days for State), for three of three accounts
reviewed. (Residents #379, #380 and #381) The census was 111.
1. Review of Resident #379’s account, showed he/she expired [DATE], with $995.67, in the
resident trust fund account. The facility did not send the letter to the state regarding
the balance until [DATE].
2. Review of Resident #380’s account, showed he/she expired [DATE], with $664.11, in the
resident trust fund account. The facility did not send the letter to the state regarding
the balance until [DATE].
3. Review of Resident #381’s account, showed he/she expired [DATE], with $85.04, in the
resident trust fund account. The facility did not send the letter to the state regarding
the balance until [DATE].
4. During an interview [DATE], 1:07 P.M., business office manager said it was her fault
the letters were not sent and she had no explanation, why she did not send them. She knew
it should be sent within 30 days.
5. During an interview on [DATE] at 11:00 A.M., the administrator said she was not aware
the letters were not being sent as required.

F 0576

Level of harm – Potential for minimal harm

Residents Affected – Many

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on observation and interview, the facility failed to ensure residents’ mail was
secured until time of delivery and was delivered to residents on Saturdays. The census was
111.
During a resident group interview, in the activity room, on 7/26/18 at 8:30 A.M., 10 of 10
residents said the facility delivers their mail Monday through Friday, but not on
Saturdays. One resident said he/she did not like the facility leaving their mail out on a
table in the activity room prior to delivering it. Anyone could take it or snoop through
it. Observation at that time, showed a table directly behind where the residents sat
during the meeting, with a stack of numerous pieces of mail addressed to numerous
residents.
During an interview on 7/30/18 at 9:32 A.M., the Activity Director said mail is delivered
Monday through Friday by the activity staff. It is not delivered on Saturday because the
business office is closed and they are the ones who receive the mail and give it to them
for delivery. Activity staff are scheduled on the weekends, so if they had it they could
deliver it. Normally the mail is delivered as soon as they receive it. It should not be
left out on tables unsecured.
During an interview on 7/31/18 at 12:41 P.M., the administrator said mail should be
secured until it is delivered and she was not aware the mail was not being delivered on
Saturdays.

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0576

Level of harm – Potential for minimal harm

Residents Affected – Many

F 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

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

Based on observation and interview, the facility failed to post signage indicating where
residents and/or visitors could find the facility’s prior three years of survey results.
The census was 111.
During a resident group interview on 7/26/18 at 8:30 A.M., 10 of 10 residents attending
did not know where the facility kept the survey results from the three previous years and
none of them recalled seeing posted signs regarding the survey results.
Observation on 7/30/18 at 2:18 P.M., showed the receptionist sat at the front desk in the
lobby. There was no posted sign in the lobby showing where residents and/or visitors could
find the survey results from the three previous years. The receptionist did not know where
the survey results were kept. The Chief Operations Officer (COO) approached the
receptionist’s desk and found the survey results at the receptionist’s desk. The COO
pointed to the wall behind the receptionist’s desk and said there used to be a sign
hanging there. She did not know what happened to it. The administrator joined the
conversation and said she had worked at the facility since (MONTH) of (YEAR), and she did
not recall seeing a sign posted since starting at the facility.

F 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Keep residents’ personal and medical records private and confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
incontinence care was provided in a way that minimized resident exposure. Two residents
were observed receiving personal care and problems were identified during both
observations. (Residents #56 and #71) The census was 111.
1. Review of Resident #56’s face sheet, showed the resident was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Review of the resident’s comprehensive care plan updated 5/3/18, showed the following:
-At risk for skin breakdown related to episodes of bowel and bladder incontinence and
his/her inability to toilet or keep himself/herself clean/dry without help;
-Incontinence care after each episode;
-Staff to provide assistance with activities of daily living (ADLs, including perineal
care and dressing).
Observation on 7/27/18 at 6:45 A.M., showed Certified Nurse Aide (CNA) J did the
following:
-Entered the resident room, closed the door;
-Was unable to pull the privacy curtain because it was tied into a knot over the
resident’s bed;
-The resident lay on his/her left side in bed;
-CNA J pulled the covers off of the resident and left them at the end of the bed during
the entire process;
-Cleansed the resident’s perineal area and buttocks;
-Walked away from the bed and got a towel and dried the resident;
-Removed his/her gloves, donned new gloves without washing his/her hands, placed 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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
resident’s brief and pants (on backwards) over feet onto lower legs, woke up the resident
and asked him/her to sit up and stand;
-Assisted the resident to sit up on the side of the bed, and when he/she tried to assist
resident to stand, the resident started crying;
-He/she hugged the resident and rubbed his/her gloved hand over the resident’s back
several times;
-Assisted the resident to stand and pulled up the resident’s pants, leaving them on
him/her backwards;
-Left the same shirt on the resident that he/she had slept in;
-Never covered up the resident’s perineal area or buttocks when he/she walked away from
the resident;
-The resident’s roommate was in his/her bed awake the entire time;
-The privacy curtains was not pulled between the residents.
During an interview on 7/31/18 at 7:01 A.M., CNA J said the following:
-He/she would provide privacy for a resident by closing the door and pulling the curtain;
-When asked about the resident’s curtain being tied up, he/she said that is the way it has
been for a long time because the resident can’t see and could get tangled in it;
-When asked if he/she should have pulled the curtain between the resident and his/her
roommate he/she said, I guess so;
-When asked if he/she should have pulled the sheet over the resident when he/she walked
away he/she said, Maybe, but I don’t do that because the door is closed.
2. Review of Resident #71’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/22/18, showed the following:
-Rarely/never understood/understands;
-Short/long term memory problem;
-Total dependence of one person required for bed mobility, dressing, toilet use and
personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 7/27/18 at 5:47 A.M., showed the resident lay in bed covered with a sheet
and wearing a gown and an incontinence brief. The resident’s privacy curtain had been
pulled half way around the resident’s bed but did not provide full privacy from the room
door. CNA H removed the resident’s cover, incontinence brief and pulled the resident’s
gown up onto the resident’s chest exposing the resident’s lower body, then began washing
the resident. After washing the resident, the CNA walked away from the bed, opened the
room door and went into the hall to discard washcloths and the soiled incontinence brief.
The CNA failed to pull the resident’s gown back down or pull the privacy curtain the full
way around the bed before exiting the room. The door to the room was not shut. The CNA
returned and dressed the resident in the bed without pulling the privacy curtain to
provide full privacy.
3. During an interview on 7/30/18 at 3:22 P.M., Certified Medication Technician (CMT) K
said the following:
-Staff should always close the door and pull the privacy curtain when providing cares for
a resident;
-It is not ok leave the privacy curtain open and provide perineal care with the roommate
in the room;
-Staff should always pull the cover or sheet over the resident before stepping away from
the bed as to not leave the resident exposed.
4. During an interview on 7/31/18 at 12:38 P.M., the Director of Nursing said 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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0583

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
following:
-It is not acceptable to perform perineal care with the privacy curtain open and the
roommate in the room;
-There is no reason for a privacy curtain to be tied up and not able to be used.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Based on interview and record review the facility failed to check the nurse aide (NA)
registry to see if new employees have a Federal Indicator for six of 10 employees
reviewed, hired since the previous survey. The census was 111.
Review of the facility policy dated, (MONTH) 14, 2014, titled Background Record Searches,
showed in accordance with Federal and State law the facility shall require, not later than
two working days from the date an applicant is to have contact with residents is hired .a
check of the CNA Registry on all employees.
1. Review of physical therapist M’s employee file, showed a hire date of 3/12/18, and no
record of the NA registry check.
2. Review of Licensed Practical Nurse N’s employee file, showed a hire date of 4/28/18,
and no record of the NA registry check.
3. Review of Registered Nurse O’s employee file, showed a hire date of 6/7/18, and no
record of the NA registry check.
4. Review of laundry worker P’s employee file, showed a hire date of 6/8/18, and no record
of the NA registry check.
5. Review of food service worker Q’s employee file, showed a hire date of 6/9/18, and no
record of the NA registry check.
6. Review of housekeeper/laundry worker R’s employee file, showed a hire date of 7/9/18,
and no record of the NA registry check.
7. During an interview on 7/26/18 at 10:15 A.M., the human resource person said he only
checked the Federal Register for the nurse aides. He did not know he needed to check it
for all staff.
8. During an interview on 7/26/18 at 1:49 P.M., the administrator said she was not aware
the NA checks were not being done. She thought there was a system to catch that. The check
is required for all employees and is included in their Background check policy.

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to to follow their policy for
abuse and neglect by failing to report to the State Survey Agency, one resident’s
complaint to multiple staff members that $100 had been stolen from his/her wallet by a
current staff member a few months ago. (Resident #108) The census was 111.
Review of the facility’s Abuse Prevention Policy, dated 2/2017, showed the following:
-The facility affirms the right of their residents to be free from abuse, neglect,
exploitation, misappropriation of property or mistreatment. The facility prohibits abuse,

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. The
purpose of the policy is to assure the facility is doing all that is within its control to
prevent occurrences of abuse, neglect, exploitation, misappropriation of property and
mistreatment of [REDACTED].>-Internal Reporting Requirements and Identification of
Allegations: Employees are required to report any incident, allegation or suspicion of
potential abuse, neglect, exploitation, mistreatment or misappropriation of resident
property they observe, hear about, or suspect to the administrator immediately, to an
immediate supervisor who must then immediately report it to the administrator or to a
compliance hotline or compliance officer. In the absence of the administrator, reporting
can be made to an individual who has been designated to act in the administrator’s
absence;
-All residents, visitors, volunteers, family members, or others are encouraged to report
their concerns or suspected incidents of potential abuse, neglect, exploitation,
mistreatment or misappropriation of resident property to the administrator or immediate
supervisor who must then immediately report it to the administrator or designated
individual in the administrators absence. Such reports may be made without fear of
retaliation;
-Reports will be documented and a record keep of the documentation;
-Supervisors shall immediately inform the administrator or person designated to act in the
administrator’s absence of all reports of incidents, allegations or suspicion of potential
abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon
learning of the report, the administrator or designee will initiate an investigation;
-Protection of residents: Residents who allegedly abused another resident shall be
immediately evaluated to determine the most desirable therapy, care approaches, and
placement, considering his or her safety, as well as the safety of other residents and
staff;
-All incidents will be documented, whether or not abuse, neglect, exploitation,
mistreatment or misappropriation of resident property occurred, was alleged or suspected.
Any incident or allegation involving abuse, neglect, exploitation, mistreatment or
misappropriation of resident property will result in a investigation.
The following definitions are based on federal and state law as, regulations and
interpretive guidelines: Misappropriation of resident property means the deliberate
misplacement, exploitation, or wrongful temporary, or permanent use of a resident’s
belongings or money without the resident’s consent.
1. Review of Resident #108’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/3/18, showed the following:
-admission date of [DATE];
-Adequate hearing;
-Highly impaired vision – object identification in question, but eyes appear to follow
objects;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score: 15 of 15 (a score of 13 – 15 indicates the
resident’s cognition is intact);
-No hallucinations or delusions;
-Independent for bed mobility, transfers and walking in room/corridor;
-One person limited assistance required for personal hygiene;
-[DIAGNOSES REDACTED].
During an interview on 7/25/18 at 11:01 A.M., the resident said about three months ago, a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
staff member stole $100 from him/her. He/she did not know the staff member’s name, but
that staff member still worked at the facility. He/she told everyone.
During an interview on 7/30/18 at 7:07 A.M., Nurse L said he/she had heard the resident
was missing some money. He/she had not worked at the facility very long so he/she did not
report the missing money as he/she assumed it had already been investigated.
During an interview on 7/30/18 at 7:09 A.M., Certified Medication Technician (CMT) R said
he/she had been working at the facility since the last week of (MONTH) (YEAR). The
resident did mention to him/her about missing $100. He/she did not recall what day that
happened. The resident accused Certified Nurse Aide (CNA) S of taking the money. CMT R
said he/she asked CNA S if he/she had taken the resident’s money and he/she told him/her
no. He/she told the night shift charge nurse that same day. He/she could not recall the
name of the charge nurse.
During an interview on 7/30/18 at 8:04 A.M., CNA T said he/she had worked at the facility
for five years. For the past few months the resident had said he/she was missing money.
He/she said it on more than one occasion. The first time the resident said the money was
missing, he/she told a charge nurse. The resident has been at the facility for about a
year and he/she had seen the resident with money before.
During an interview on 7/30/18 at 1:41 P.M., the administrator and the Director of Nurses
said they had not been told by staff the resident complained about money being stolen.
Staff should have reported that to both of them immediately. Had they been aware, they
would have followed their abuse and neglect policy and notified the appropriate state
agency.

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow their
policy and thoroughly investigate resident complaints of potential mistreatment and
misappropriation of resident funds. This affected two of 23 sampled residents. (Resident
#69 and #108) The census was 111.
Review of the facility’s Abuse Prevention Policy, dated 2/2017, showed the following:
-The facility affirms the right of their residents to be free from abuse, neglect,
exploitation, misappropriation of property or mistreatment. The facility prohibits abuse,
neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. The
purpose of the policy is to assure the facility is doing all that is within its control to
prevent occurrences of abuse, neglect, exploitation, misappropriation of property and
mistreatment of [REDACTED].>-Internal Reporting Requirements and Identification of
Allegations: Employees are required to report any incident, allegation or suspicion of
potential abuse, neglect, exploitation, mistreatment or misappropriation of resident
property they observe, hear about, or suspect to the administrator immediately, to an
immediate supervisor who must then immediately report it to the administrator or to a
compliance hotline or compliance officer. In the absence of the administrator, reporting
can be made to an individual who has been designated to act in the administrator’s
absence;
-All residents, visitors, volunteers, family members, or others are encouraged to report
their concerns or suspected incidents of potential abuse, neglect, exploitation,
mistreatment or misappropriation of resident property to the administrator or immediate

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
supervisor who must then immediately report it to the administrator or designated
individual in the administrators absence. Such reports may be made without fear of
retaliation;
-Reports will be documented and a record keep of the documentation;
-Supervisors shall immediately inform the administrator or person designated to act in the
administrator’s absence of all reports of incidents, allegations or suspicion of potential
abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon
learning of the report, the administrator or designee will initiate an investigation;
-Protection of residents: Residents who allegedly abused another resident shall be
immediately evaluated to determine the most desirable therapy, care approaches, and
placement, considering his or her safety, as well as the safety of other residents and
staff;
-All incidents will be documented, whether or not abuse, neglect, exploitation,
mistreatment or misappropriation of resident property occurred, was alleged or suspected.
Any incident or allegation involving abuse, neglect, exploitation, mistreatment or
misappropriation of resident property will result in a investigation.
1. Review of Resident #69’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/7/18, showed the following:
-[DIAGNOSES REDACTED].
-No short/long term memory loss;
-No mood or behavior problems;
-Required staff supervision for dressing, eating, personal hygiene and bathing;
-Independent with walking in room and corridor.
During an interview on 7/25/18 at 9:01 A.M., during the tour of the facility, the resident
said he/she hadn’t lived in the facility but a few months. He/she liked living at the
facility for the most part but had a concern about Resident #76. While walking in the
hallway Resident #76 follows him/her too closely and it makes him/her very uncomfortable.
Resident #76 frequently does this while Resident #69 is walking in the hallway and at
times this frightens him/her. He/she doesn’t understand why the other resident does this
and he/she has told him/her to stop. The resident said he/she had not reported this to
anyone, but was agreeable with telling the charge nurse.
During an interview on 7/25/18 at 10:00 A.M., the resident said he/she reported his/her
concerns to the nurse and pointed at Certified Nurse Aid (CNA) F, who instructed him/her
to report his/her concerns to the social worker.
During an interview on 7/25/18 at 1:20 P.M., the resident said the social worker told
him/her to tell Resident #76 not to get into his/her personal space. The resident spoke of
his/her life and said he/she had been assaulted as a child. He/she is afraid of Resident
#76 at times and doesn’t want what happened to him/her in the past to occur now.
During an interview on 7/25/18 at 2:00 P.M., CNA F said the resident reported Resident #76
followed him/her too closely and he/she doesn’t like it. The CNA instructed the resident
to report his/her concerns to the social worker. Resident #76 wanders the halls and in and
out resident rooms.
During an interview on 7/26/18 at 1:45 P.M., Nurse G said staff had not reported the
resident’s concerns regarding Resident #76 following him/her too closely. He/she would
expect staff to report any concerns the residents have. If staff had reported this concern
he/she would have reported it to the Director of Nurses (DON).
During an interview on 7/26/18 at 1:51 P.M., the Social Service Director said she spoke to
the resident, on 7/26/18 at approximately 8:00 A.M. The resident said Resident #76
followed him/her too closely. He/she asked the resident whether Resident #76 had touched
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
him/her inappropriately and the resident said no, but he/she followed him/her too closely.
She told the resident it was very serious to accuse someone of any sexual allegation. She
asked the resident again if Resident #76 had touched him/her or was he/she afraid and the
resident said no. The Social Service Director said she would do an investigation if the
resident had said Resident #76 had touched him/her or if the resident wanted to file a
grievance. She told the resident that Resident #76 would always wander on the floor but
he/she would not hurt anyone. The resident wanted to know why Resident #76 followed
him/her so closely. The Social Service Director had not reported the resident’s concern to
the DON or administrator.
Review of the resident’s social service note, dated 7/26/18 at 5:43 P.M., showed the
following:
-Resident said he/she doesn’t know why Resident #76 talks and walks so close to him/her;
-Asked the resident whether Resident #76 touched him/her or whether he/she was afraid of
him/her. He/she said no;
-Asked if he/she wanted to file a grievance, the resident said no;
-He/she just wanted know why Resident #76 stands so close to him/her;
-The resident said he/she wasn’t afraid but doesn’t want him/her to stand in his/her
personal space.
During an interview on 7/26/18 at 2:25 P.M., the DON said she would have expected staff to
immediately report any concerns to herself or the administrator. It doesn’t matter whether
a sexual allegation occurred or not staff should report residents concerns to
administration. Any concerns reported by a resident should be investigated.
2. Review of Resident #108’s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Adequate hearing;
-Highly impaired vision – object identification in question, but eyes appear to follow
objects;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates the
resident’s cognition is intact);
-No hallucinations or delusions;
-Independent for bed mobility, transfers and walking in room/corridor;
-One person limited assistance required for personal hygiene;
-[DIAGNOSES REDACTED].
During an interview on 7/25/18 at 11:01 A.M., the resident said about three months ago, a
staff member stole $100 from him/her. He/she did not know the staff member’s name, but
that staff member still works at the facility. He/she told everyone.
During an interview on 7/30/18 at 7:07 A.M., Nurse L said he/she had heard the resident
was missing some money. He she had not worked at the facility very long so he/she did not
report the missing money as he/she assumed it had already been investigated.
During an interview on 7/30/18 at 7:09 A.M., Certified Medication Technician (CMT) R said
he/she had been working at the facility since the last week of (MONTH) (YEAR). The
resident did mention to him/her about missing $100. He/she did not recall what day that
happened. The resident accused CNA S of taking the money. CMT R said he/she asked CNA S if
he/she had taken the resident’s money and he/she told him/her no. He/she told the night
shift charge nurse that same day. He/she could not recall the name of the charge nurse.
During an interview on 7/30/18 at 8:04 A.M., CNA T said he/she had worked at the facility
for five years. For the past few months the resident had said he/she was missing money.
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
He/she said it on more than one occasion. The first time the resident said the money was
missing, he/she told a charge nurse. The resident has been at the facility for about a
year and he/she had seen the resident with money before.
During an interview on 7/30/18 at 1:41 P.M., the administrator and DON said they had not
been told by staff the resident complained about money being stolen. Staff should have
reported that to both of them immediately. Had they been aware, they would have followed
their abuse and neglect policy and began their investigation. They would begin the
investigation now.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure resident
care plans were accessible to all staff 24 hours a day, which affected all facility
residents. In addition, the facility failed to ensure one resident’s care plan addressed
the resident’s feeding tube. (Resident #105) The census was 111.
1. During an interview on 7/25/18 at 8:28 A.M., the administrator said on 6/4/18, due to a
billing dispute, the company they used to have for electronic records shut down due to a
billing dispute. That company did not give the facility any way to access the resident
records, including care plans. The only care plans the resident’s have at this time were
printed out prior to 6/4/18. Those care plans are kept in the Care Plan Coordinator’s
(CPC) office. The CPC works Monday through Friday. No staff members have access to the
CPC’s office after hours. If staff wanted access to the care plans after hours, they would
have to contact someone from management to come in and open the CPC’s office.
During an interview on 7/27/18 at 5:47 P.M., Certified Nurse Aide (CNA) H said he/she had
worked at the facility for about six months. If there are resident care plans, he/she had
not seen them or been made aware of them. If he/she wanted to know what type of care a
resident needs he/she would ask other staff.
During an interview on 7/27/18 at 8:59 A.M., Nurse L, working on the 4th floor, said
he/she could not find a care plan book at the nurse’s station. He/she thinks the care
plans were kept in the CPC’s office.
During an interview on 7/31/18 at 12:47 P.M., the CPC said she is the only CPC. She
printed all of the resident’s care plans in (MONTH) and (MONTH) (YEAR) and they had been
in her office since she printed them. She works Monday through Friday. Care plans are
important because they let staff know how to take care of residents and if there is
something they need to pay attention to. They are not useful to staff sitting in her
office. She had no explanation as to why the care plans had not been made available to
nursing staff after business hours. The Director of Nurses, present at that time, said she
was aware the care plans were being kept in the CPC’s office and unavailable to staff
after business hours. She had not discussed that as an issue with the CPC.
2. Review of Resident #105’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/13/18, showed the following:
-admitted : 2/28/18;
-Severe cognitive impairment;
-Total dependence with bed mobility, transfers, locomotion on the unit, dressing, eating
and personal hygiene;

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 – Many

(continued… from page 9)
-[DIAGNOSES REDACTED].
-No swallowing disorder;
-No weight loss or gain;
-Nutritional approach: feeding tube;
-Portion of total calories the resident received through tube feeding: 26-50%.
Review of the resident’s physician’s orders [REDACTED].
Observation on 7/25/18 at 11:08 A.M. and 2:26 P.M., showed the resident sat up in a chair
with his/her tube feeding infusing.
Observation on 7/27/18 at 5:29 A.M., showed the resident lay in bed with his/her tube
feeding infusing.
Review of the resident’s care plan, dated 3/1/18, showed it did not address the tube
feeding.
During an interview on 7/31/18 at 1:24 P.M., the CPC said the resident’s use of a feeding
tube should have been care planned.

F 0660

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Plan the resident’s discharge to meet the resident’s goals and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to provide discharge planning to
two of two resident’s reviewed who left the facility to go to another facility and/or
home. (Residents #103 and #129) The census was 111.
1. Review of Resident #103’s electronic and paper record, showed an admission date of
[DATE]. The record contained no information prior to 6/11/18.
Review of a social service note dated 6/28/18 at 10:45 A.M., showed the resident had been
accepted to another facility and would be transported to the new facility 6/29/18. The
record did not contain a note about the actual date and time the resident left, the
resident’s discharge goals and needs, including caregiver support and referrals to local
contact agencies, or information sent to the new facility.
During an interview on 7/26/18 at 1:49 P.M., the administrator said they had no additional
information about the resident’s discharge plan.
2. Review of Resident #129’s paper and electronic record, showed no information in the
system about the resident.
During an interview on 7/26/18 at 1:49 P.M., the administrator said the resident was
discharged on [DATE], but there is no information in the system about him/her. She thought
he/she went home. They had no discharge plan for the resident.
3. During an interview on 7/25/18 at 8:28 A.M., the administrator said the facility hired
a new electronic medical records company on 6/11/18. Their old company shut down on 6/4/18
due to a billing dispute. The facility used paper documentation from 6/4/18 through
6/11/18. The previous company had not given the facility access to the resident’s
information. Information not accessible included progress notes and assessments from
nursing, social services, activities, care plan summaries and dietary including progress
notes from the Registered Dietician. She was aware the facility was required to maintain
complete and readily accessible records on every resident, but until the billing issues
are resolved the facility was unable to do so.

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0661

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure necessary information is communicated to the resident, and receiving health care
provider at the time of a planned discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to complete a discharge summary
for two of two resident’s reviewed who left the facility to go to another facility and/or
home. (Residents #103 and #129) The census was 111.
1. Review of Resident #103’s electronic and paper record, showed an admission date of
[DATE]. The record contained no information prior to 6/11/18.
Review of a social service note dated 6/28/18 at 10:45 A.M., showed the resident had been
accepted to another facility and would be transported to the new facility 6/29/18. The
record did not contain a note about the actual date and time the resident left, the
resident’s discharge goals and needs, including caregiver support and referrals to local
contact agencies, or information sent to the new facility, what happened to the resident’s
medications and belongings.
During an interview on 7/26/18 at 1:49 P.M., the administrator said they had no additional
information about the resident’s discharge summary.
2. Review of Resident #129’s paper and electronic record, showed no information in the
system about the resident.
During an interview on 7/26/18 at 1:49 P.M., the administrator said the resident was
discharged on [DATE], but there is no information in the system about him/her. She thought
he/she went home. They had no discharge summary for the resident.
3. During an interview on 7/25/18 at 8:28 A.M., the administrator said the facility hired
a new electronic medical records company on 6/11/18. Their old company shut down on 6/4/18
due to a billing dispute. The facility used paper documentation from 6/4/18 through
6/11/18. The previous company had not given the facility access to the resident’s
information. Information not accessible included progress notes and assessments from
nursing, social services, activities, care plan summaries and dietary including progress
notes from the Registered Dietician. She was aware the facility was required to maintain
complete and readily accessible records on every resident, but until the billing issues
are resolved the facility was unable to do so.

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 provide
appropriate perineal care and follow their policy for providing perineal care. During the
survey, facility staff were observed providing perineal care to two residents and problems
were identified during both observations. (Residents #56 and #71). The census was 111.
1. Review of Resident #56’s face sheet, showed the resident was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].
Record review of the resident’s comprehensive care plan updated 5/3/18, showed the
following:
-At risk for skin breakdown related to episodes of bowel and bladder incontinence and
his/her inability to toilet or keep himself/herself clean/dry without help.
-Incontinence care after each episode.
-Staff to provide assistance with activities of daily living (ADLs, including perineal

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 11)
care and dressing).
Observation on 7/27/18 at 6:45 A.M., showed Certified Nursing Assistant (CNA) J did the
following:
-Entered the resident room, closed the door;
-The resident lay on his/her left side in bed;
-CNA J placed a wash basin into the sink and turned on the water to fill the basin;
-Gathered perineal wash and two wash cloths onto sink ledge;
-Placed a wash cloth into the basin, got it wet and added perineal wash;
-Pulled covers off of the resident and left them at the end of the bed during the entire
process;
-Cleansed the resident’s entire buttock area, then back of thighs, then inner perineal and
rectum area;
-Turned wash cloth over and repeated same process;
-Took the wash cloth to the sink and rinsed it in the basin;
-Took the same wash cloth back to the resident, dripping water onto the floor, and rinsed
her buttock area with the same wash cloth using the same procedure as he/she did washing
the resident;
-Got a towel and dried the resident’s buttocks first then thighs;
-Opened a pouch of ointment and squeezed it onto his/her gloves and applied it to the
resident’s buttocks, thighs and then perineal area;
-Opened a second ointment pouch, squeezed onto the same gloves and repeated the process;
-Removed his/her gloves, donned new gloves without washing hands, placed resident’s brief
and pants (on backwards) over his/her feet onto lower legs, woke up resident and asked
him/her to sit up and stand.
During an interview on 7/31/18 at 7:01 A.M., CNA J said the following:
-The procedure for providing perineal care is to clean the front perineal area from the
vagina forward and then the back buttocks area from the vagina back;
-He/she always used just one basin of water for cleaning and rinsing the resident during
perineal care;
-He/she always used just one wash cloth for cleaning and one for rinsing;
-He/she had been in-serviced recently on perineal care and the facility provides
in-services on perineal care at least annually.
During an interview on 7/30/18 at 3:22 P.M., Certified Medication Technician (CMT) K said
the following:
-Staff should use 2 wash basins and 9 wash cloths during perineal care;
-The proper procedure for perineal care is to clean the resident’s perineal area from
front to back. One swipe, fold, swipe again and discard. Never use a wash cloth, rinse and
use again.
During an interview on 7/31/18 at 12:38 P.M., the Director of Nursing (DON) said the
following:
-It is not acceptable to use one basin of water for washing and rinsing;
-It is not acceptable to use just one wash cloth to clean entire perineal area and one
cloth to rinse entire perineal area.
-It is not acceptable to touch the resident or her belongings with dirty gloves.
-She expected staff to follow facility policy and procedures during perineal care.
2. Review of Resident #71’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/22/18, showed the following:
-Rarely/never understood/understands;
-Short/long term memory problem;
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 12)
-Total dependence of one person required for bed mobility, dressing, toilet use and
personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 7/27/18 at 5:47 A.M., showed the resident lay in bed wearing an
incontinence brief. When CNA H removed the brief, a urine odor was noticeable and the CNA
said the resident was wet. With the resident laying on his/her back, the CNA took a wet
soapy washcloth and washed the resident’s genitalia using up and down wiping motions. The
CNA failed to wash the resident’s inner thighs before assisting the resident onto his/her
side to wash the resident’s buttocks. Once on his/her side, the CNA washed down the middle
of the resident’s buttocks, but failed to wash the entire area of the buttocks. During an
interview, the CNA said he/she should have washed the resident’s genitalia using front to
back motions. Failing to wash with front to back motions could cause the resident to get a
urinary tract infection. He/she should have washed the inner thighs and the entire surface
of the buttocks for hygiene.
During an interview on 7/30/18 at 8:46 A.M., the DON said staff should wash the genitalia
using front to back wipes to reduce the risk of urinary tract infection from bacteria. She
would have expected the thighs and buttocks to be thoroughly washed for good hygiene
purposes. The facility has a perineal care policy and she expects staff to follow that
policy.
3. Review of the facility’s undated Perineal Care Policy and Procedure, showed the
following:
-The purposes of this procedure are to provide the resident assistance with activities of
daily living, provide cleanliness and comfort to the resident, to prevent infections and
skin irritation, and to observe the residents skin condition;
-Place the equipment on the bedside stand. Arrange the supplies so they can be easily
reached;
-Wash and dry hands thoroughly;
-Fill the wash basin one-half full of warm water. Place the wash basin on the bedside
stand within easy reach;
-Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident’s body;
-Put on gloves.
-For female residents:
-Wet washcloth and apply soap or skin cleansing agent;
-Wash perineal area, wiping from front to back;
-Separate the labia and wash area downward from front to back;
-Continue to wash the perineum moving from inside outward including thighs, alternating
from side to side and using downward [MEDICAL CONDITION]. Do not use the same washcloth or
water to the clean the urethra or labia;
-Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth;
-Gently dry perineum;
-Wet washcloth and apply soap or skin cleansing agent;
-Wash the rectal area thoroughly, wiping from the base of the labia towards and extending
over the buttocks. Do not reuse the same washcloth or water to clean the labia;
-Rinse rectal area thoroughly in the same direction, using fresh water and a clean
washcloth;
-Dry area thoroughly;
-Discard disposable items into designated containers;
-Remove gloves and discard into designated container. Wash and dry your hands thoroughly;
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 13)
-Reposition the bed covers. Make the resident comfortable.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 provide
oversight and develop a plan of care for one resident who’s spouse had a history of
[REDACTED]. (Residents #126 and #48) The census was 111.
1. Review of Resident #126’s care plan, dated [DATE], showed the following:
-Primary language is not English, utilize the resident’s spouse for communication;
-Oxygen therapy related to [MEDICAL CONDITION] (a tube is surgically inserted through the
trachea creating an opening to deliver oxygen to the lungs) which is related to [MEDICAL
CONDITION];
-At risk for pulling out gastrostomy tube ([DEVICE], a tube is inserted through a surgical
incision in the abdominal wall to administer medication, hydration and nutrition);
-The care plan did not identify a problem, goal or interventions regarding the resident’s
spouse administering tube feeding independently without staff knowledge or a physician’s
orders [REDACTED].>-The care plan did not identify a problem, goal or intervention
regarding the resident’s spouse removing the resident’s [MEDICAL CONDITION];
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-No speech;
-Sometimes understood/understands;
-Short/long term memory problem;
-Total dependence of one person required for bed mobility, dressing and personal hygiene;
-Shortness of breath or trouble breathing when lying down;
-Oxygen therapy, suctioning and [MEDICAL CONDITION] care not identified.
During an interview at the entrance conference on [DATE] at 8:28 A.M., the administrator
and Director of Nurses (DON) said they had a concern regarding the resident. His/her
spouse removed the resident’s [MEDICAL CONDITION] last night and the resident had to be
sent to the hospital for it to be replaced. This is the first time this has happened,
however the spouse has a history of giving the resident additional cans of tube feeding
through his/her gastrostomy tube without the physician or staff authorization. The spouse
thinks the resident is hungry. He/she had not been trained to give the feeding to the
resident. They had to remove the resident’s tube feeding supplies from his/her room which
seemed to have stopped the problem. The resident’s weights are stable. The resident and
the spouse are of a different ethnic background and both are difficult to communicate
with. Another family member assists with translation with the spouse.
During an interview on [DATE] at 12:34 P.M., Nurse L said he/she was working the day the
spouse removed the resident’s [MEDICAL CONDITION]. The resident had just returned from the
hospital with the spouse in attendance. He/she left the room for just a couple of minutes
before returning to find the resident’s [MEDICAL CONDITION] in the trash can. He/she did
not see the spouse remove the [MEDICAL CONDITION], but since it was in the trash can it
had to be him/her. He/she had also seen the spouse giving the resident tube feeding. They
had to take the tube feeding supplies out of the room. The spouse visits a couple of times

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 – Few

(continued… from page 14)
a day, usually for about 15 minutes. He/she tries to keep a close watch as to what the
spouse is doing when he/she visits. Since removing the tube feeding supplies from the
resident’s room, he/she had caught the spouse in the storage room closet. That’s where
tube feedings supplies are kept. The spouse was looking for cans of tube feeding to give
the resident.
During an interview on [DATE] at 1:09 P.M., the administrator and DON said they had a
meeting with the resident’s spouse a few months ago regarding the problem with the spouse
administering the tube feeding. The Care Plan Coordinator had not updated the resident’s
care plan. They had instructed staff to go in and check what the spouse was doing
periodically when he/she visits the resident. The DON said since the meeting, there had
been no problems with the spouse trying to administer tube feeding she was aware of. She
did not know the resident’s spouse had been trying to get tube feeding from the storage
closet. She should have been informed of that. The Care Plan Coordinator, present at the
interview said the resident’s care plan had been in her office since (MONTH) or (MONTH) of
(YEAR). She had not updated the resident’s care plan regarding the problems the facility
had with the spouse. Care plans should reflect the resident’s current status.
2. Review of Resident #48’s care plan, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Staff to assist with activities of daily living;
-The care plan did not identify a problem, goal or interventions related to the resident’s
[MEDICAL CONDITION];
-Full code status (CPR to be initiated).
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Brief Interview for Mental Status score of 14 (13 – 15 indicates the resident is
cognitively intact);
-Supervision – oversight, encouragement or cueing required for eating;
-Shortness of breath or trouble breathing with exertion and while lying flat;
-Oxygen therapy, suctioning, swallowing disorder and [MEDICAL CONDITION] care not
indicated.
Review of the resident’s physician’s orders [REDACTED].
-Mechanical soft (ground meat/soft foods) diet;
-Supervised meals;
-Use speaking valve (a cap that fits over the [MEDICAL CONDITION]) during all meals.
-A handwritten order dated [DATE], for the resident to have a speech therapy evaluation;
-A handwritten order dated [DATE], and written by speech therapist V change the resident’s
diet to regular consistency and the resident must use speaking valve during meals.
Observation on [DATE] at 8:49 A.M., showed the resident sat alone in his/her room eating
breakfast and without a speaking valve covering his/her [MEDICAL CONDITION].
Observation on [DATE] at 12:17 P.M., showed the resident sat alone in his/her room eating
lunch and without a speaking valve covering his/her [MEDICAL CONDITION].
Observation on [DATE] 8:41 A.M., showed the resident sat in a wheelchair in his/her room.
Certified Nurse Aide (CNA) S took the resident breakfast and left the room. The resident
began eating. The speaking valve for the resident’s [MEDICAL CONDITION] sat in a container
on top of the resident’s night stand.
During an interview on [DATE] at 8:50 A.M., CNA S said he/she had worked at the facility
for a few months. He/she was not aware the resident had an order for [REDACTED].
During an interview on [DATE] at 9:17 A.M., nurse L said he/she did not know the resident
should be supervised
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 – Few

(continued… from page 15)
during meals or wear the speaking valve during meals.
During an interview on [DATE] at 9:56 A.M., speech therapist V said he/she evaluated the
resident on [DATE] and wrote the order on the POS dated [DATE]. At the time of the new
order, he/she spoke to nursing and told them the resident must wear the speaking valve
during meals. He/she thinks that was nothing new as the speaking valve order had been a
part of previous orders as well. He/she instructed the resident to wear the speaking valve
during meals but the resident is occasionally forgetful. If the resident does not wear the
speaking valve, he/she could be at a greater risk to aspirate (food or fluids go into the
lungs). Based on her recent evaluation, the resident still required supervision during
meals. The resident should be in the dining room were staff are present.
During an interview on [DATE] at 12:59 P.M., the DON said she was not aware of the
resident’s orders for supervision during meals and the speaking valve. She expects staff
to follow the orders.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain
acceptable parameters of nutritional status by not providing supplements as ordered and
not completing dietary recommendations for two residents who experienced weight loss. The
sample was 23. (Residents #83 and #179) The census was 111.
1. Review of Resident #83’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 3/10/18, showed the following:
-[DIAGNOSES REDACTED].
-Short term memory loss;
-Required staff supervision for bed mobility, transfers, walking in room and corridor,
eating and toilet use;
-Required limited staff assistance for dressing and personal hygiene;
-Required extensive staff assistance for bathing;
-Weight 192 pounds;
-Not on a weight loss regimen.
Review of the resident’s care plan, updated 4/2/18, showed the following:
-Problem: High risk of malnutrition and weight loss related to [DIAGNOSES REDACTED].
-Approach: Encourage diet compliance and activity as tolerated. Encourage good food and
fluid intake. Monitor progress. Monitor for weight fluctuations. Weights as per
physician’s orders [REDACTED].
Review of the resident’s monthly weight sheet for (MONTH) (YEAR), showed a weight of 187.4
pounds.
Review of the resident’s undated physician’s orders [REDACTED].
Review of the resident’s weekly weight sheet, completed by the restorative aide, dated
5/15/18, showed the following:
-Reason for weekly monitoring: weight loss checked;
-admitted [DATE];
-Admit weight of 162.0;
-Week 1: 152.4, 9.6 pound loss;
-Week 2: 145.0, 7.4 pound loss;

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
-Week 3: 142.0, 3 pound loss;
-Week 4: 138.2, 3.8 pound loss;
-Comments: 6/14/18: Resident had a loss of 23.8 pounds in four weeks;
-No documentation whether staff notified the physician of the weight loss.
Review of the resident’s dietary recommendations, dated 6/1/18, showed the following:
-Quarterly assessment;
-Recommendation for Resource 2.0 (nutritional supplement used to provide high calories and
protein) three times per day with medication pass;
-Date completed 6/6/18.
Review of the resident’s progress notes, showed there were none available, due to
inability of the facility to access electronic records prior to 6/4/18.
Review of the resident’s POS, dated 6/6/18 through 6/30/18, showed an order dated 6/6/18,
start Resource 2.0 three times per day with medication pass per dietary recommendation.
Review of the resident’s medication administration record (MAR), dated 6/6/18 through
6/30/18, showed an order dated 6/6/18, for Resource 2.0 three times per day with
medication pass.
Review of the resident’s written nurse’s notes, dated 6/12/18, showed the following:
-The resident’s physician visited;
-New orders for laboratory test;
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes, completed by the dietitian, dated 6/19/18, showed
the following:
-Triggered for severe weight loss over past two months;
-Weight: 142 pounds, down 45.4 pounds over two months;
-Had a major decline;
-Had to be assisted by staff with feeding;
-Resident receives a fortified shake with meals;
-Resource 2.0 three times per day ordered on [DATE];
-Will recommend an appetite stimulant if appropriate and continue to monitor.
Review of the resident’s dietary recommendations, dated 6/19/18, showed the following:
-Weight loss assessment;
-Recommendation for appetite stimulant if appropriate
-Resident’s physician to review when he/she visits;
-Date completed: blank.
Review of the resident’s weekly weight sheet, completed by restorative aide dated 6/20/18,
showed the following:
-Reason for weekly monitoring: weight loss checked;
-Weight of 138.2 pounds;
-Week 1: 135.0, 3.2 pound loss;
-Week 2: 131.6, 3.4 pound loss;
-Week 3: 126.6, 5 pound loss;
-Week 4: 124.2, 2.4 pound loss;
-Comments: 6/20/18: Resident continued on weekly weights due to losing excess weight.
7/18/18 Resident had weight loss of 14.0 pounds in four weeks;
-No documentation whether staff notified the physician of the weight loss.
Review of the resident’s POS, dated 7/1/18 through 7/31/18, showed an order dated 7/7/18,
for [MEDICATION NAME] (medication used for depression and weight gain) 7.5 milligram (mg)
at bedtime.
Review of the resident’s physician’s progress noted, dated 7/7/18, showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-Chief complaint: Was asked to see resident, not eating, losing weight;
-Assessment/Plan: Try [MEDICATION NAME] 7.5 mg. Failure to thrive, recommend hospice.
Review of the resident’s nurse’s notes, dated 7/7/18, showed the following:
-Physician in to see resident;
-New orders noted;
-Pharmacy faxed;
-No further notes regarding the resident’s weight loss until 7/16/18.
Review of the resident’s progress note, completed by the dietitian, dated 7/16/18, showed
the following:
-Resident has triggered for significant weight loss in one month, 7.3% and 29.8% in three
months;
-Weight 131.6 pounds;
-Resident had a overall major decline probably related to advancing disease process;
-Remains on a mechanical soft diet with fortified shakes with meals and Resource 2.0 three
times per day with medication pass;
-Recommend resident be added to the weekly weight list until he/she goes on hospice;
-Staff to continue to offer/encourage whatever items resident will eat or drink within the
restrictions of his/her diet.
Review of the resident’s nurse’s notes, dated 7/19/18, showed the following:
-Physician in to see resident;
-New order to send to the hospital;
-[DIAGNOSES REDACTED].
-Resident transferred to hospital per ambulance.
Review of the resident’s POS, dated 7/1/18 through 7/31/18, showed an order dated 7/19/18,
to send to the emergency room with a [DIAGNOSES REDACTED].
Review of the resident’s nurse’s notes, dated 7/24/18 at 12:28 A.M., showed the following:
-Readmit to the facility;
-Alert and oriented to person and place;
-Physician verified all orders.
Review of the resident’s POS, dated 7/23/18, showed the following:
-Regular diet;
-Resource 2.0, 120 ml by mouth with meals;
-No documentation regarding pureed diet, fortified health shake or thickened liquids.
Review of the resident’s MAR, dated 7/23/18 through 7/31/18, showed the following:
-No documentation regarding the Resource 2.0 three times per day with meals;
-No documentation regarding pureed diet, fortified health shake or thickened liquids.
Observation on 7/25/18 at 9:40 A.M., during the tour of the facility, showed the resident
lay in bed eating a pureed breakfast of scrambled eggs, grits and meat. Thickened liquids
of water and orange juice, no fortified shake or Resource 2.0 sat on tray. The resident
talked about his/her life at the facility, complained the food wasn’t good and tasted
bitter.
Observation on 7/27/18 at 8:02 A.M., during medication pass, showed no supplements of any
kind on the medication cart.
Observations showed the following:
-7/27/18 at 9:07 A.M.:Staff served the resident breakfast, in a divided plate, of pureed
french toast, scrambled eggs, oatmeal and thickened water. Certified Nurse Aide (CNA) U
called dietary for thickened juice and milk. No fortified health shake or Resource 2.0 sat
on the tray;
-7/30/18 at 12:54 P.M.: Served meal tray per staff. Pureed meat, rice, vegetables,
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
thickened orange juice and water. No fortified shake or Resource 2.0 sat on the tray.
Review of the resident’s dietary slip on his/her tray showed regular diet and fortified
shake with meals;
-Observation of the meal cart used to serve resident trays from dietary, showed no health
shakes or Resource 2.0 on the cart.
During an interview on 7/30/18 at 1:34 P.M., the resident said he/she hasn’t received a
shake and doesn’t remember whether he/she has ever gotten one.
During an interview on 7/30/18 at 11:13 A.M., the dietitian said she has no access to her
dietary notes prior to 6/4/18. She was unaware the resident hadn’t received Resource 2.0.
She wasn’t aware the resident wasn’t receiving his/her fortified shake on the tray. The
facility had not made her aware the resident was a recent readmit from the hospital. She
would have reviewed the resident’s readmit orders and given recommendations.
During an interview on 7/31/18 at 12:35 P.M., the Director of Nurses (DON) said staff
failed to transcribe the order for Resource 2.0 three times per day on the MAR. In
addition, she would want staff to document the amount of Resource supplement the resident
consumes. She would have expected the staff to clarify previous orders of pureed diet,
thickened liquids and fortified health shake with meals. She will have staff to call and
verify orders.
During an interview on 7/31/18 at 1:30 P.M., the DON said the physician gave orders to
restart the pureed diet with thickened liquids and fortified health shake with meals.
2. Review of Resident #179’s quarterly MDS, dated [DATE], showed the following:
-Understood/understands;
-Supervision – oversight, encouragement or cueing required for eating;
-[DIAGNOSES REDACTED].
-Weight of 229 pounds;
-No weight loss or gain of 5% or more in the past six months.
Review of the resident’s monthly weight review, showed the following:
-4/2018: 228.6 pounds;
-5/2018: 222.8 pounds;
-6/2018: 211.2 pounds;
-7/2018: 206.4 pounds. This represents a three month weight loss of 22.2 pounds or 9.71%.
Review of the dietician’s progress note, dated 7/16/18 at 12:32 P.M., showed the resident
had triggered for a significant three month weight loss at 9.7%. Weight 206.4 pounds,
height 66 inches. Body Mass Index 33.3 obese. Resident is probably not eating well when
he/she goes out of the facility. Staff state resident often goes right to bed after
returning to facility. Regular diet. Will receive multivitamin daily and health shakes two
times a day.
Review of the resident’s medical record (paper chart), showed a diet order communication
form, dated 7/18/18, for the resident to receive health shakes two times a day.
Review of the resident’s care plan, dated 4/17/18, showed no update regarding house
supplements two time a day.
Review of the resident’s POS and MAR, dated 7/1/18 through 7/31/18, showed no order for
health shakes two times a day.
Observation on 7/27/18 at 12:23 P.M., showed the resident sat in the dining room eating
lunch. Staff did not serve a health shake with lunch.
During an interview on 7/31/18 at 8:50 A.M., Certified Medication Technician R said when a
health shake is ordered it is written on the MAR. That is how he/she knows to give it.
He/she looked at the resident’s MAR and said there was not an order to give the resident
health shakes two times a day. He/she had not been giving the resident health shakes. At
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
8:55 A.M., CNA T said he/she had worked at the facility for five years. Part of his/her
duties includes passing meal trays to the residents. He/she could not recall giving the
resident a health shake.
During an interview on 7/31/18 at 9:00 A.M., Nurse L said he/she did not know the resident
had an order for [REDACTED]. The nurse that takes the order is responsible to write the
order on the POS and MAR. He/she could not find an order for [REDACTED]. (This represents
a severe three month weight loss of 29 pounds or 12.79% since 4/2018).
During an interview on 7/31/18 at 1:04 P.M., the DON said the nurse that completed the
diet order communication form was responsible to place the order on the POS and MAR. If it
is not on the MAR, staff would not know to give the health shakes.

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure two of
two residents with [MEDICAL CONDITION] and humidified oxygen received the humidified
oxygen as ordered and failed to ensure one resident’s continuous positive airway pressure
mask was in good working order. (Resident’s #48, #126 and #37) The census was 111.
1. Review of Resident #48’s care plan, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Staff to assist with activities of daily living;
-The care plan did not identify a problem, goal or interventions related to the resident’s
[MEDICAL CONDITION] or humidified oxygen;
-Full code status (CPR to be initiated).
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated [DATE], showed the following:
-admission date of [DATE];
-Understood/understands;
-Extensive assistance of one person required for bed mobility, transfers and dressing;
-[DIAGNOSES REDACTED].
-Shortness of breath with exertion and while lying flat;
-Oxygen therapy and [MEDICAL CONDITION] care not identified.
Review of the resident’s physician’s orders [REDACTED].
-Oxygen, 4 liters as needed (PRN) with HHTC (high humidity [MEDICAL CONDITION] collar);
-HHTC 28% humidity (the percent of humidification to be used to keep secretions thin to
avoid mucus plugs) PRN;
-(Humidified oxygen is delivered by a compressor. The compressor has a humidity bottle
attached to it. An oxygen concentrator is used to deliver (bleed) oxygen into the
corrugated oxygen tubing via an oxygen cannula. The humdified oxygen is forced from the
humidity bottle through corrugated tubing to the [MEDICAL CONDITION] collar).
Observation on [DATE] at 5:37 A.M., showed the resident lay in bed. The compressor was on
and a humidity bottle was attached. The humidity was set at 98%. No oxygen concentrator
was in the room. Certified Nurse Aide (CNA) H was in the room assisting the resident. The
CNA said he/she had worked with the resident all night. The compressor and the [MEDICAL
CONDITION] collar had been on all night long. He/she had not seen an oxygen concentrator
in the room all night. The resident had been complaining of there being too much water in
the tube.

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
During an interview on [DATE] at 6:33 A.M., Nurse X said he/she worked all night and had
been in the resident’s room a couple of times. The resident’s compressor was on when
he/she arrived. He/she had not noticed the humidity was set on 98%. It should be on 28%.
The resident did not need and did not have an order for [REDACTED].
During an interview on [DATE] at 8:46 A.M., the Director of Nurses (DON) said she had
never seen oxygen not being used when a resident was on humidified oxygen. The nurse
should have checked the resident’s orders and started the oxygen. She has never seen just
a compressor used for humidified O2. When resident returned from hospital, the admitting
nurse is responsible for checking for orders, including oxygen. The nurses are responsible
for ensuring the humidity bottle is full and the humidity setting is as ordered.
2. Review of Resident #126’s care plan, dated [DATE], showed the following:
-Oxygen as ordered related to [MEDICAL CONDITION] which he/she has related to [MEDICAL
CONDITION];
-Administer oxygen, HHTC, and perform oxygen saturation levels (a device clipped onto the
finger that reads the oxygen level) as ordered and PRN;
-[DIAGNOSES REDACTED].
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-Sometimes understood/understands;
-Total dependence of one person required for bed mobility and dressing;
-Total dependence of two (+) persons required for transfers;
-Oxygen therapy and [MEDICAL CONDITION] care not identified.
Review of the resident’s handwritten POS, dated [DATE] through [DATE], showed the
following:
-May discontinue [MEDICAL CONDITION] device;
-Check oxygen every four hours;
-[MEDICAL CONDITION] care every shift;
-HHTC PRN;
-No order for the rate of oxygen or the HHTC %.
Observation on [DATE] at 10:51 A.M., showed the resident lay in bed as the wound care
company nurse completed a wound treatment. The resident had humidified oxygen infusing to
a [MEDICAL CONDITION] collar via a compressor and oxygen concentrator. The humidity bottle
was set on 28% and the oxygen concentrator was set on 2 liters.
Review of the resident’s POS, showed a handwritten order, dated [DATE], for HHTC to be set
a 28% at all times.
Observation on [DATE] at 6:19 A.M., showed the resident lay in bed. The HHTC was set on 0%
and the oxygen concentrator was set at 2 liters. The oxygen cannula was bent at the site
of insertion into the humidity bottle. At 6:41 A.M., Nurse X said he/she had worked all
night. He/she had not noticed the HHTC was set at 0%. He/she noticed the bent oxygen
tubing and said it was unlikely the correct amount of oxygen was getting through. He/she
changed the oxygen cannula. He/she did not know how many liters of oxygen the resident
should be receiving. He/she said he/she thought the resident was receiving two or three
liters prior to going to the hospital and being readmitted on [DATE]. He/she could not
find an order for [REDACTED].
Review of the resident’s POS, showed a undated handwritten order clarification for oxygen
at 4 liters to bleed into HHTC at 28%.
During an interview on [DATE] at 8:46 A.M., the DON said the nurse in charge of the
resident at the time of his/her readmission, should have checked for the resident’s oxygen
and HHTC orders. If they were not present on admission, the nurse should have contacted
the physician at the time of the readmission.
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
3. Review of Resident #37’s care plan, updated [DATE], showed no documentation regarding
the C-Pap (Continuous positive airway pressure, a form of positive airway pressure
ventilator, which applies mild air pressure on a continuous basis to keep the airways
continuously open in people who are able to breathe spontaneously on their own).
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].
-No short/long term memory loss;
-Required no staff assistance with bed mobility, transfers, walking, locomotion on and off
unit and toileting;
-Required staff supervision for dressing eating, personal hygiene and bathing;
-No respiratory treatments documented.
Review of the resident’s POS, dated [DATE] through [DATE], showed the following:
-[DIAGNOSES REDACTED].
-Order dated [DATE], for an C-Pap at night and while sleeping;
-Oxygen at four liters per minute continually per nasal cannula (flexible plastic tubing
used to deliver supplemental oxygen or increased airflow to a patient);
-Change oxygen tubing, humidifier every Sunday.
Review of the resident’s MAR, dated [DATE] through [DATE], showed the following:
-C-Pap at night and while sleeping. No staff initials (indicating application of the
C-Pap);
-Change oxygen tubing, humidifier, and clean filter every Sunday, 7:00 P.M. – 7:00 A.M.:
blank.
Observation on [DATE] at 9:00 A.M., during the tour of the facility showed a C-Pap machine
sat on the bedside table. The mask to the C-Pap machine lay on the table broken. An oxygen
mask was attached to tubing connected to the C-Pap machine. The oxygen tubing lay on the
bed, with no date, and appeared brown and dirty. The resident was not in the room during
the tour.
During an interview on [DATE] at 7:37 A.M., the resident said the C-Pap machine mask has
been broken for about a week. He/she’s been using an oxygen mask in place of the C-Pap
mask. He/she said the oxygen mask doesn’t work as well as the other mask. Someone was
supposed to come yesterday, [DATE], to fix it but they never came.
During an interview on [DATE] at 6:38 A.M., the resident said no one has come to fix
his/her C-Pap mask.
Observation on [DATE] at 8:26 A.M., showed a oxygen mask connected to the tubing on the
C-Pap machine. The oxygen nasal cannula lay on the floor broken and dirty.
During an interview on [DATE] at 7:22 A.M., the resident said his/her C-Pap mask remained
broken. He/she woke frequently at night because he/she can’t breath well. No one came to
his/her room to check C-Pap machine.
Review of the resident’s nurse’s notes, dated [DATE] through [DATE], showed no
documentation regarding the resident’s C-Pap machine mask being broken.
During an interview on [DATE] at 12:35 P.M., the DON said she was not aware the resident
C-Pap mask was broken. She would expect the staff to contact respiratory company to order
a replacement. This normally would take 24 hours at the most. Staff should have documented
this in the medical record and in report for follow up.
4. Review of the facility’s policy regarding C-Pap Support, dated ,[DATE], showed the
following:
-Purpose: To provide the spontaneous breathing resident with continuous positive airway
pressure with or without supplemental oxygen;
-To improve arterial oxygenation in residents with respiratory insufficiency, obstructive
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
sleep apnea or [MEDICAL CONDITION];
-To promote resident comfort and safety.

F 0756

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to forward monthly pharmacy
recommendations to residents physicians for their review for two of two months reveiwed.
The census was 111.
During an interview on 7/30/18 at 12:00 P.M., the survey team requested the facility
monthly pharmacy recommendations for (MONTH) and (MONTH) of (YEAR).
During an interview on 7/31/18, the Director of Nurses (DON) said she did not have the
pharmacy recommendations from (MONTH) and (MONTH) (YEAR) until the day before, when she
contacted the pharmacy and they received them via e-mail. She realized there was a problem
receiving the recommendations timely a few months ago and she spoke to the pharmacist at
that time. The pharmacist’s solution was to e-mail the recommendations to her within one
week of the review date. She did not follow up with the pharmacist after speaking to him.
It is her responsibility to ensure the recommendations were being received. Ideally, after
the facility received the recommendations, the facility should forward them to the
residents’ physicians for review within 24 to 48 hours after receiving them from the
pharmacist.
Review of the recommendations presented by the DON on 7/31/18, showed 12 residents had
recommendations completed on 5/23/18, and 22 residents had recommendations completed on
6/30/18. The DON said none of the 34 recommendations had been forwarded to the residents’
physicians for review.

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 it was
free from significant medication errors during insulin administration via insulin pen for
one resident. (Residents #74) The census was 111.
Review of Resident #74’s admission face sheet, showed the resident was admitted to the
facility on [DATE] with a [DIAGNOSES REDACTED].
Review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-Accuchecks (blood sugar level check) three times daily (TID – AM, Lunch, Supper).
-[MEDICATION NAME] (fast acting insulin) [MEDICATION NAME] (prefilled insulin device)
Inject sub-cutaneous (SQ) per sliding scale:
–150-200 = 1 unit;
–201-250 = 2 units;
–251-300 = 3 units;
–351-400 = 4 units.
Observation on 7/27/18 at 5:35 A.M., showed Certified Medication Technician (CMT) I did

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 23)
the following:
-Obtained a blood sugar level of 245 for the resident;
-Dialed up two units of [MEDICATION NAME] insulin;
-Cleaned the resident’s right upper arm with an alcohol pad and injected two units of
[MEDICATION NAME] insulin. He/she did not prime (remove air from the needle and cartridge)
the [MEDICATION NAME] prior to administering the insulin;
-Documented the insulin administration and left the unit without providing the resident
with a drink or food and nothing was available on the locked unit the resident resided on
for the resident to eat or drink.
During an interview on 7/27/18 at 5:43 A.M., CMT I said the following:
-He/she performs accuchecks for four residents on the third floor;
-Only two residents receive sliding scale insulin;
-Resident #74 was the only resident that required sliding scale insulin that day;
-He/she always administers the sliding scale insulin when he/she checked the resident’s
blood sugar level.
Observation and interview during medication administration on 7/27/18 at 8:08 A.M., showed
the following:
-CMT P provided the resident with a cup of juice with his/her medications;
-The resident said he/she had not received anything else to drink or eat prior to the cup
of juice he had just received;
-The resident had not received breakfast yet;
-This was approximately two hours and 25 minutes after the resident received his/her
insulin.
During an interview on 7/30/18 at 3:54 P.M., Nurse L said the following:
-CMTs do the accuchecks and insulin administration;
-He/she would expect staff to prime the [MEDICATION NAME] prior to administering insulin.
During an interview on 7/31/18 at 6:53 A.M., CMT I said the following:
-He/she is a fairly new CMT, just certified last year and this is his/her first CMT job;
-He/she was not aware he/she was required to prime the [MEDICATION NAME] with two units of
insulin prior to dialing up the amount of insulin the resident was to receive and
injecting the insulin.
During an interview on 7/31/18 at 12:38 P.M., the Director of Nursing said the following:
-He/she expected staff to follow facility policy;
-He/she expected staff to prime the insulin pen prior to administering insulin to the
resident;
-It is not acceptable to inject insulin without first priming the insulin pen because the
resident will not get the correct dosage of insulin.
-It was not acceptable for a resident to wait over 2 hours to receive food after insulin
administration.
-He/she expcted staff to provide food to the resident within a few minutes of receiving
insulin.
Review of the facility’s Insulin Administration Policy and Procedure updated (MONTH) 2007,
showed it did not address the use of the [MEDICATION NAME].
Review of the [MEDICATION NAME] package insert, showed the following:
-Subcutaneous injection: [MEDICATION NAME] should be given immediately (within 5-10
minutes) prior to the start of a meal
-Before each injection small amounts of air may collect in the cartridge during normal
use. To avoid injecting air and to ensure proper dosing:
–Turn the dose selector to select 2 units;
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 24)
–Hold your [MEDICATION NAME] with the needle pointing up. Tap the cartridge gently with
your finger a few times to make any air bubbles collect at the top of the cartridge;
–Keep the needle pointing upwards, press the push-button all the way in. The dose
selector returns to 0;
–A drop of insulin should appear at the needle tip. If not, change the needle and repeat
the procedure no more than 6 times;
–If you do not see a drop of insulin after 6 times, do not use the [MEDICATION NAME].

F 0803

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be
followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, interview and record review, the facility failed to ensure menus
were followed for 10 of 10 prepared pureed diets. The census was 111.
1. Observation on 7/30/18 at 7:01 A.M., showed Cook A prepared pureed 10 servings of pork
sausage. The cook said he/she used 10 three ounce scoops of ground pork sausage. He/she
blended them and added 8 ounces of chicken broth. Cook A said he/she was looking for a
thick consistency. A test taste at that time, showed the mixture had a gritty rough taste
and was not smooth or thick.
Review of the pureed recipes used by the facility, showed the following for cooked pureed
sausage patty:
-For 10 servings of meat, use 1 patty which equals one ounce serving and 10 tablespoons of
chicken broth. Place portion of prepared meat in a food processor with hot broth and blend
to a smooth consistency.
2. Observation on 7/30/18 at 1:03 P.M., showed Cook B prepared pureed 10 servings of green
peas. The cook said he/she used 10, 1/2 cups of green peas. He/she added 10, 1/2 cups of
2% milk and blended for approximately two minutes. The mixture had a liquid consistency.
During an interview at that time, the cook said he/she realized he/she used too much milk
because the consistency was liquid.
Review of the pureed recipes used by the facility, showed the following for cooked pureed
green peas:
-For 10 servings of green peas use 1/2 cup of peas per serving and 10 ounces of 2% milk.
Place green peas and milk in a blender and blend until smooth.
3. During an interview on 7/30/18 at 1:34 P.M., the Dietary Manager said she expected the
recipes to be followed as written.

F 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure food and drink is palatable, attractive, and at a safe and appetizing
temperature.

Based on observation and interview, the facility failed to ensure the meal service tray
temperatures were maintained at least at 120 degrees Fahrenheit (F). This potentially
could effect residents who received hall trays or ate in their rooms. The census was 111.
1. During the resident group interview on 7/26/18 at 8:30 A.M., 10 of 10 residents
attending said the food temperatures are fine if you eat in the dining room, but if you

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0804

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
eat in your room, the food is often served cold.
2. Observation on 7/30/18 at 8:10 A.M., the unheated cart arrived to the first floor. At
8:30 A.M., a temperature of a breakfast tray was taken and recorded at:
-Scrambled eggs: 110 degrees F;
-Mechanical Meat: 105 degrees F;
-French Toast: 100 degrees F.
3. Observation on 7/30/18 at 8:17 A.M., the unheated cart arrived to the fourth floor. At
8:40 A.M., staff served the last resident and temperatures were taken from a test tray and
recorded at:
-Scrambled eggs: 116 degrees F;
-Sausage link: 107 degrees F;
-French Toast: 104 degrees F.
4. During an interview on 7/30/18 at 1:29 P.M., the Dietary Manager said the meal service
trays should be at least 120 degrees F so the food is palatable to the residents. They
have used hot carts for food delivery but there was an electrical problem so they stopped
using them.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on observation and interview, the facility failed to keep kitchen walls, baseboards
and sinks clean and free of grease, dirt and grime on four of four days of observation. In
addition, the facility failed ensure tray lids used for meal service were dry. This had
the potential to affect residents who ate from the facility’s kitchen. The census was 111.
1. Observation on 7/25/18 at 8:38 A.M., 7/26/18 at 7:06 A.M., 7/27/18 at 6:00 A.M. and
7/30/18 at 7:01 A.M., showed the following:
-The wall near the convection oven was stained with black marks and the baseboards under
the convection oven were peeling;
-The walls under the hand sink near the dishwasher area had dirt and grime;
-The baseboards were peeling along side the refrigerators near the bread rack. The dump
sink near the dishwasher area was covered inside with black grime;
-The column wall near the dishwasher was covered the dirt, grease and missing
approximately eight tiles;
-The wall behind the fryer, flat grill top, stove and convection was covered with grease
and grime.
2. Observation on 7/27/18 at 12:10 P.M., showed a Dietary Aide dried approximately 20 wet
lids with the same cloth towel used during the meal service and used the lids for meal
service.
3. During an interview on 7/30/18 at 1:20 P.M., the Dietary Manager (DM) the porters have
a daily cleaning schedule. The schedule does include walls, floors and equipment. She just
hired two new porters a week ago and has been working with them. It is important to keep
the kitchen clean because the residents eat food from the kitchen. Wet dishes should not
be used and should not be dried off with a towel. The dishes should air dry to prevent
cross contamination.

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

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

Based on interview, the facility failed to maintain the ability to access resident’s
electronic records. On 6/4/18, the previous electronic record company shut down their
system and blocked the facility from accessing the resident’s electronic records. The
census on 6/4/18 was 114. The census at the time of the survey was 111 and 110 of those
residents resided at the facility prior to 6/4/18. Twenty eight of those 110 residents
were sampled during the survey and all 28 had electronic records prior to 6/4/18 that were
inaccessible to the facility, residents, ancillary services and the survey team.
During an interview on 7/25/18 at 8:28 A.M., the administrator said the facility hired a
new electronic medical records company on 6/11/18. Their old company shut down their
system on 6/4/18 due to a billing dispute. The facility used paper documentation from
6/4/18 through 6/11/18. The previous company had not given the facility access to the
residents’ information. Information not accessible included progress notes and assessments
from nursing, social services, activities, care plan summaries and dietary including
progress notes from the Registered Dietician. She was aware the facility was required to
maintain complete and readily accessible records on every resident, but until the billing
issues are resolved the facility was unable to do so.

F 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Have the Quality Assessment and Assurance group have the required members and meet at
least quarterly

Based on interview and record record review, the facility failed to conduct ongoing
quarterly quality assurance and assessment (QAA) meetings for the previous 12 months. The
census was 111.
1. During an interview on 7/30/18 at 9:58 A.M., the Medical Director (MD) said he had not
been notified and had not attended a QAA meeting in several months.
2. During an interview on 7/30/18 at 10:30 A.M., the administrator said she began working
at the facility at the end of (MONTH) (YEAR). She looked for proof of QAA meetings for the
past 12 months and could only find the one that she had been a part of on 6/21/18. The
Medical Director did not attend that meeting. She thought the DON had notified the Medical
Director of that meeting.
3. Review of the facility Agenda for Quality Improvement Committee Meeting, undated,
showed the following:
-Determine the quality improvement issues on gathered information, opportunity for
improvement and severity of the issue as related to risk. For example: Falls, weight loss,
hydration, incontinence, pain management, restraints, activities, mobility, wounds,
medication errors, meal pass and results reflected on the quality indicators report;
-Each month the QA team determines which indicators are impacting the quality of care and
rank indicator to be brought before the committee;
-Keeping in mind the focus of the committee is to identify issues, plan interventions and
measure the effectiveness of the interventions
4. Review of the Medical Director Description of Services policy, signed by a facility
representative on 1/29/16 and the Medical Director on 3/31/16, 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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0868

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 27)
-Be responsible for coordination of medical care and implementation of resident care
policies in accordance with applicable federal Medicare and Medicaid requirements and
state law governing health care facilities;
-Provide general oversight and supervision of physician services and the medical care of
residents in the facility, implement methods of identifying and intervening in cases in
which medical care may be inadequate or otherwise not in compliance with stat and federal
requirements and maintain effective liaisons with attending physicians in furtherance of
the goal of assuring quality medical care of residents of the facility;
-Serve on the following committees in the facility: QAA, Infection Control, Pharmaceutical
Services, Utilization Review, Interdisciplinary Care Planning, Discharge Planning and
other committees as deemed necessary or appropriate.

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 and interview, the facility failed to ensure staff completed personal
care, during two of two observations, and blood glucose monitoring, during two of two
observations, using acceptable infection control nursing practices and standards.
(Residents #56, #71, #74 and #73) The census was 111.
1. Review of Resident #56’s face sheet, showed the resident was admitted to the facility
on [DATE] with [DIAGNOSES REDACTED].
Review of the resident’s comprehensive care plan updated 5/3/18, showed the following:
-At risk for skin breakdown related to episodes of bowel and bladder incontinence and
his/her inability to toilet or keep himself/herself clean/dry without help.
-Incontinence care after each episode.
-Staff to provide assistance with activities of daily living (ADLs, including perineal
care and dressing).
During perineal care observation on 7/27/18 at 6:45 A.M., Certified Nurse Aide (CNA) J did
the following:
-Entered the resident room, closed the door;
-The resident lay on his/her left side in bed;
-CNA J placed a wash basin into the sink and turned on the water to fill the basin;
-Gathered perineal wash and two wash cloths onto sink ledge;
-Placed a wash cloth into the basin, got it wet and added perineal wash;
-Pulled covers off of the resident and left them at the end of the bed during the entire
process;
-Cleansed the resident’s entire buttock area, then back of thighs, then inner perineal
area and rectum area;
-Turned wash cloth over and repeated same process;
-Took the wash cloth to the sink and rinsed it in the basin;
-Took the same wash cloth back to the resident, dripping water onto the floor, and rinsed
his/her buttock area with the same wash cloth using the same procedure as he/she did
washing the resident;
-Got a towel and dried the resident’s buttocks first then thighs;
-Opened a pouch of ointment and squeezed it onto his/her gloves and applied it to the
resident’s buttocks, thighs, and then perineal area;
-Opened a second ointment pouch and squeezed onto same gloves and repeated the process;

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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 28)
-Removed his/her gloves, donned new gloves without washing hands, placed the resident’s
brief and pants (on backwards) over feet onto lower legs, woke up the resident and asked
him/her to sit up and stand;
-Assisted the resident to sit up on the side of the bed, and when he/she tried to assist
resident to stand, the resident started crying;
-He/she hugged the resident and rubbed his/her gloved hand over the resident back several
times;
-Assisted the resident to stand and pulled up the resident’s pants.
During an interview on 7/31/18 at 7:01 A.M., CNA J said the following:
-He/she always uses just one basin of water for cleaning and rinsing the resident during
perineal care;
-He/she always uses just one wash cloth for cleaning and one for rinsing;
-Staff should wash hands and change gloves before and after care with each resident;
-He/she does not change gloves during care because it is the same person;
-He/she had been in-serviced recently on infection control and the facility provides
in-services on infection control at least annually.
During an interview on 7/30/18 at 3:22 P.M., Certified Medication Technician (CMT) K said
the following:
-Staff should use 2 wash basins and 9 wash cloths during perineal care;
-One swipe, fold, swipe again and discard. Never use a wash cloth, rinse and use again;
-Never use the same water, washing the cloth in the water and reusing cloth;
-Wash hands and change gloves after each area for example .after cleaning the front,
cleaning the back, drying and putting on cream. Don’t want to cross contaminate;
-Staff must change gloves before touching the resident, his/her bedding and clothing.
During an interview on 7/31/18 at 12:38 P.M., the Director of Nursing (DON) said the
following:
-It is not acceptable to use one basin of water for washing and rinsing;
-It is not acceptable to use just one wash cloth to clean entire peri area and one cloth
to rinse entire perineal area;
-It is not acceptable to touch the resident or her belongings with dirty gloves;
-He/she expected staff to follow facility policy and procedures for proper infection
control during perineal care.
2. Review of Resident #71’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/22/18, showed the following:
-Rarely/never understood/understands;
-Short/long term memory problem;
-Total dependence of one person required for bed mobility, dressing, toilet use and
personal hygiene;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 7/27/18 at 5:47 A.M., showed the resident lay in bed wearing an
incontinence brief. CNA H donned a pair of gloves and removed the resident’s wet brief.
After washing the resident’s genitalia and buttocks, but before removing his/her gloves,
the CNA touched the resident’s room door handle, pants, shoes, shirt and gait belt
(applied around the waist to aid in a transfer). During an interview the CNA said after
cleaning the resident’s genitalia and buttocks, his/her gloves were soiled and should have
been removed before touching clean objects. Failure to remove the soiled gloves could
spread infection.
During an interview on 7/30/18 at 8:46 A.M., the DON said staff should remove soiled
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 29)
gloves prior to touching anything clean for infection control purposes. The facility has a
policy for infection control practices during care and she expects staff to follow that
policy.
3. Record review of Resident #74’s admission face sheet showed the resident was admitted
to the facility on [DATE] with a [DIAGNOSES REDACTED].
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-Accuchecks (blood glucose level) three times daily (TID – AM, Lunch, Supper).
– [MEDICATION NAME] Inject sub-cutaneous (SQ) per sliding scale:
–150-200 = 1 unit;
–201-250 = 2 units;
–251-300 = 3 units;
–351-400 = 4 units.
During an observation on 7/27/18 at 5:35 A.M., CMT I did the following:
-Removed the glucometer, lancets and strips from the top drawer of the medication cart;
-Placed the supplies on the medication cart top without first cleaning/sanitizing the top
of the cart or placing a barrier;
-Gathered the supplies into his/her hand, walked into the dining area, and placed the
supplies on top of the table with no barrier;
-Donned gloves and then asked the resident to go to his/her room;
-The resident already had his/her hand held out and asked the CMT why he/she had to go to
his/her room, he/she always gets it done in the dining area and said to just do it there;
-CMT I gathered the supplies, placed all the supplies inside the top drawer of the cart
and locked it;
-Walked into a resident’s room and washed his/her hands;
-Returned to the cart and gathered supplies onto the cart top without sanitizing the top
of the cart or placing barrier;
-Carried all the supplies to the resident and placed them onto the dining room table
without using barrier;
-Used the lancet, placed it onto the table top, tried to get blood from finger with no
results;
-Used a second lancet and placed it on top of the table next to the first lancet;
-Got blood onto the test strip in glucometer and placed the glucometer with the bloody,
used test strip onto the table top;
-CMT I gathered the used supplies into his/her gloved hand and removed his/her gloves,
throwing all into trash can on the treatment cart;
-Placed the soiled glucometer onto the treatment cart top with using a barrier;
-Entered a resident’s room and washed his/her hands;
-Returned to the treatment cart and without cleaning, placed the soiled glucometer into
the top drawer of the treatment cart;
-Removed the [MEDICATION NAME] (fast acting insulin) [MEDICATION NAME] (prefilled insulin
device) from the top drawer of the treatment cart;
-Removed the [MEDICATION NAME] cap;
-Dialed up two units of [MEDICATION NAME] insulin;
-Placed the needle onto the [MEDICATION NAME] without cleaning [MEDICATION NAME] with
alcohol;
-Cleaned the resident’s right upper arm with an alcohol pad and injected two units of
[MEDICATION NAME] insulin;
-Removed the needle and placed it in sharps container;
-Sanitized his/her hands.
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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 30)
During an interview on 7/27/18 at 5:43 A.M., CMT I said the following:
-He/she performed accuchecks for four residents on the third floor;
-This was the same procedure he/she used every morning.
During an interview on 7/30/18 at 3:54 P.M., Nurse L said the following:
-CMTs do the accuchecks and insulin administration;
-He/she would expect staff to cleanse the top of the [MEDICATION NAME] prior to attaching
the needle.
During an interview on 7/31/18 at 6:53 A.M., CMT I said the following:
-He/she is a fairly new CMT, just certified last year and this is his/her first CMT job;
-He/she should have sanitized the top of the treatment cart and placed a clean barrier;
-He/she should have sanitized the top of the dining table and placed a barrier;
-He/she should have sanitized the glucometer before and after use;
-He/she should have used facility approved sanitizing wipes to sanitize all items used;
-He/she should have cleansed the rubber top of the [MEDICATION NAME] with an alcohol pad
prior to placing the needle.
4. Review of Resident #73’s POS, dated 7/1/18 through 7/31/18, showed an order for
[REDACTED].
Observation on 7/27/18 at 6:33 A.M., showed Nurse W washed his/her hands, applied gloves
and cleaned the blood glucose machine with an alcohol wipe. After obtaining the resident’s
blood glucose reading, Nurse W cleaned the blood glucose machine with a alcohol wipe and
placed it in the medication cart drawer.
During an interview on 7/27/18 at 6:45 A.M., Nurse W said his/her sanitizing wipes were on
the other medication cart. He/she said it should be alright to clean the blood glucose
machine with alcohol as long as it has been cleaned.
5. During an interview on 7/31/18 at 12:38 P.M., the DON said the following:
-He/she expected staff to follow facility policy;
-He/she expected staff to clean the rubber [MEDICATION NAME] on the top of the insulin pen
prior to attaching the needle to maintain infection control standards;
-It is not acceptable to place a needle on a [MEDICATION NAME] prior to cleaning the top
rubber [MEDICATION NAME] because it could introduce foreign substances into the insulin.
6. Record review of the facility’s undated Infection Control Policy, showed the following:
-This facility’s infection control policies and practices are intended to facilitate
maintaining a safe, sanitary and comfortable environment and to help prevent and manage
transmission of diseases and infections;
-All personnel will be trained on our infection control policies and practices upon hire
and periodically thereafter, including where and how to find and use pertinent procedures
and equipment related to infection control. The depth of employee training shall be
appropriate to the degree of direct resident contact and job responsibilities.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to establish an antibiotic
stewardship program that included antibiotic use protocols and a system to monitor
antibiotic use. The census was 111.
1. During an interview on 7/31/18 at 8:05 A.M., the Director of Nurses (DON) said she 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:

265378

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

NAME OF PROVIDER OF SUPPLIER

ROYAL OAK NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

4960 LACLEDE AVENUE
SAINT LOUIS, MO 63108

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 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 31)
aware the facility should have developed an Antibiotic Stewardship Program, but they had
not. She was aware of the policy and the facility should follow that policy.
2. Review of the facility Antibiotic Stewardship Policy, dated 2/2017, showed the
following:
1. Policy: It is the policy of this facility to maintain an Antibiotic Stewardship Program
with the mission of promoting the appropriate use of antibiotics to treat infections and
reduce possible adverse events associated with antibiotic use. Components of this policy
were developed by using evidence based practice guidelines and are aligned with the core
elements of Antibiotic Stewardship for Nursing Homes, published by the Center for Disease
Control (CDC) and the State Operations Manual: Guidance to Surveyors of Long Term Care
Facilities, published by the Centers for Medicare/Medicaid;
-Responsibility: DON/Leadership Team;
-The The facility will incorporate all seven core elements outlined by the CDC:
A} Leadership Commitment: The facility leadership is committed to provide necessary
resources;
B} Accountability: The physician, nursing, and pharmacy are the leads responsible for
promoting and overseeing antibiotic stewardship activities;
C} Drug Expertise: The facility maintains a consultant pharmacist/other individual with
antibiotic-specific drug expertise;
D} Action: The facility will implement policies and procedures to improve antibiotic use;
E} Tracking: The facility will monitor antibiotic use and outcomes from antibiotic use;
F} Reporting: The facility will provide regular feedback on antibiotic use and resistance
to prescribing clinicians, nursing staff, and other relevant staff;
G} Education: The facility will provide resources to clinicians, nursing staff, residents,
and families about resistance and appropriate antibiotic use;
2. The facility will utilize the McGeer’s criteria (infection surveillance definitions for
long-term care facilities) when considering initiation of antibiotics;
3. The facility will work with the hospital and the attending physician for new residents
that are admitted to the facility with a physician’s orders [REDACTED].