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 TAGSUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0569

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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