Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure residents
have the right to choose schedules, including sleeping and waking times, consistent with
their interests, assessments, and plan of care, for one resident who voiced the desire to
sleep in (Resident #6). The sample size was 15. The census was 60.
Review of Resident #6’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/5/17, showed:
-[DIAGNOSES REDACTED].
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 7 out
of a possible score of 15, showed the resident had severe cognitive impairment;
-Makes self-understood;
-Understands- clear comprehension;
-Total dependence for bed mobility and transfer;
-How important is it to choose your own bed time: Very important.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-[DIAGNOSES REDACTED].>-A BIMS score of 8, showed the resident had moderately impaired
cognition;
-Makes self-understood;
-Understands- clear comprehension;
-Total dependence for bed mobility and transfer.
Review of the resident’s care plan, last updated 8/9/18, showed:
-Problem: Activities of Daily Living (ADL) Function/Rehabilitation Potential: The resident
needs extensive to total assist for ADLs related to having a [DIAGNOSES REDACTED].
-Goal: To be dressed and clean, season-appropriate clothing. Needs will be met;
-Approach: Bed mobility, assist of one extensive. Transfer, assist of one extensive, use
sit to stand (mechanical lift). Allow to participate in choosing what clothing to wear;
-Problem: Cognitive Loss/Dementia: Memory recall problem related to dementia. Impaired
insight and judgement:
-Goal: Improved memory/recall ability;
-Approach: Engage in conversation that is meaningful;
-The care plan did not address the resident’s preference regarding when to go to bed or
get up in the morning.
Review of the facility get up list, found at the nurse’s station in the staffing binder,
showed 10 residents on the get up list. Resident #6 included as one of the residents.
During an interview on 8/28/18 at 7:00 A.M., Certified Nursing Assistant (CNA) N said
there are set residents that night shift staff are responsible to get up. They use the get
up list and he/she pointed to the get up list at the nurse’s station.
Observation on 8/28/18 at 7:28 A.M., showed the resident sat in the assist dining room in
a wheelchair. He/she said staff got him/her up real early this morning. They always do
that. They do not ask if he/she wanted to get up, they just get him/her up. He/she would
rather sleep in.
Observation on 8/30/18 at 7:32 A.M., showed the resident sat in a wheelchair in the assist
dining room, asleep. Staff came in and woke the resident. During an interview at this
time, the resident said staff got him/her up early again today without asking. They just
come in and get him/her up.
During an interview on 8/30/18 at 1:00 P.M., with the administrator and Director of
Nursing (DON), the DON said residents who want to get up early or who require a lot of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
assistance are the residents on the get up list. Staff should provide the residents a
choice to get up or sleep in. If a resident would prefer to sleep in, staff should
communicate this to management. Staff are taught it is always the resident’s choice. If a
resident did not want to be on the get up list, this is something that should be addressed
on the care plan.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

Based on observation, interview and record review, the facility failed to ensure residents
had access to personal funds on the weekend. This had the potential to affect all
residents who have funds held by the facility. The census was 60.
During an interview on 8/28/18 at 10:08 A.M., the facility bookkeeper said the residents
are unable to request funds on the weekend because the office is closed.
During an interview on 8/28/18 at 1:20 P.M., Resident #4 said residents are unable to get
their funds on the weekend because the office is closed.
During an interview on 8/28/18 at 1:30 P.M., Resident #57 said the office is closed on the
weekend.
During an interview on 8/28/18 at the facility Administrator said no one is available on
the weekends to provide resident funds. The residents know to get any funds they need on
Friday before the office closes.

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 interview and record review, the facility failed to ensure residents had access
to mail delivered on Saturday. This failure has the potential to affect all facility
residents. The census was 60.
During the group interview on 8/28/18 at 11:00 A.M., residents said they don’t receive
mail on Saturday.
During an interview on 8/28/18 at 1:20 P.M., Resident #4 said he/she watches the mailman
delivery mail on Saturday. There is no one available to pass the mail out until Monday.
During an interview on 8/28/18 at 2:07 P.M., the Activity Director said mail is delivered
to the facility on Saturday. The charge nurse will lock it in the medication room until
Monday.
During an interview on 8/28/18 at 2:15 P.M., the Administrator said she thought staff was
distributing the mail on Saturday. The facility has a activity aid on the weekend who
could pass out mail to the residents.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to have a system in place to
ensure an annual review of each resident’s code status and facility policies regarding
provision of emergency and life-sustaining care, was conducted with the resident and/or
the responsible party, to ensure full understanding and determine if they wanted to make
changes to their code status. This affected one resident and all residents living in the
facility for over a year. (Resident #49) The census was 60.
Review of Resident #49’s medical record, showed the following:
-A green FULL CODE sheet in the very front of the chart;
-An admit of 5/13/16;
-[DIAGNOSES REDACTED].
-A physician’s orders [REDACTED].
-No further information to indicate that the code status/emergency and life-sustaining
care had been reviewed annually with the resident.
During an interview on 8/30/18 at 10:00 A.M., the social service director said she did not
have any roll in updating resident code statuses periodically or during care plan
meetings.
During an interview on 8/30/18 at 11:22 A.M., the marketing/admissions director said she
is not involved in annual code status review/update.
During an interview on 8/30/18 at 11:37 A.M., the care plan coordinator said the social
service director was responsible for doing resident code status reviews/updates, at least
that’s how it was with the prior social service director.
During an interview on 8/30/18 at 2:05 P.M., the administrator said the code status annual
update was always the responsibility of the social service director, but the current one,
who has only been there fore four months, had not been made aware.

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain a clean, comfortable
and homelike environment by not maintaining four resident rooms and one shower room clean
and in good repair. (Rooms 308, 309, 314, 102 and the 300A central shower room). The
census was 90.
1. Observation from 8/27/18 through 8/30/18 during the survey, in the 300A central shower
room, showed the following:
-The 100 hall entrance door to the central bath had horizontal dark colored scrapes
measuring 34 inches across the entire door;
-A 6 inch, 2 inch and 1 inch circular scraped areas on the drywall between the 100 hall
entrance door and the sink;
-The corner wall between the 100 hall entrance door and the sink had a 7 inch by 7 inch
hole/gash along with multiple small gashes/holes on the wall near the floor.
2. Observation from 8/27/18 through 8/30/18 during the survey, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-room [ROOM NUMBER]: Three dresser drawers missing from the bottom of the closet. The wall
between the sink and the bathroom door had a 9 inch by 3 inch gash, 3 inch by 2 inch gash
and 4 1/2 inch by 2 inch gash exposing white chalk material. The inside of the bathroom
door had a 1/2 inch by 30 inch horizontal dark scrape and a 3 inch by 2 inch hole in the
door;
3. Observation from 8/27/18 through 8/30/18 during the survey, showed the following:
-room [ROOM NUMBER] had one drawer missing from the bottom of the closet, one broken
drawer underneath the TV, two thin black lines approximately 3 feet long between the
closet and entrance door, approximately 3 1/2 feet of missing basedboard between the
entrance door and bathroom door. The floor tiles underneath the bed had a 4 foot long
black scuff mark;
4. Observation from 8/27/18 through 8/30/18 during the survey, showed the following:
-room [ROOM NUMBER] had a 17 inch by 17 inch white patched area on the wall next to the
bathroom door. During an interview at that time, the resident that lived in that room said
he/she moved to the room two months ago and it had been that way since he/she had been
there.
5. Observation from 8/27/18 through 8/30/18, during the survey, showed the following:
-room [ROOM NUMBER] had a dull, sticky floor, areas of missing wall paint to the left of
the sink; one just above cove base, approximately 6 inches by 2-3 inches wide, four inches
above that was an approximately 2 inch by 1 inch area and 6 inches above it was a 2 by 1/2
inch area. To the left of the air conditioning unit and approximately 8 inches above the
cove base, was an approximately 3 foot long by 1 inch wide black scuffed area on the wall.
An approximately 8 inch by 1 inch section of missing floor linoleum just before the
bathroom entrance. In the bathroom, there was no cove base from door to the back wall and
1/3 of the way behind the toilet. The raised toilet seat had an approximately 8 inch by 1
inch area of rust on the front of the frame and silver electrical tape silver on back bar
of the seat. The wall in front of the toilet had a 4 inch round hole, with a capped off
pipe.
6. During an interview on 8/30/18 at 12:15 P.M., the Maintenance Director said he is the
only person in the maintenance department. He has to prioritize his time. He does not do
routine walking rounds of the facility. He relies on staff to complete work orders so he
will know what needs repaired. Most of the time, staff tell him about something that needs
repaired rather than to record it on a work order which does not work out well because he
may forget it. He observed the areas identified and located in the 300 Hall Central Bath,
room [ROOM NUMBER] and room [ROOM NUMBER]. He was not aware of the gashes, holes or
missing drawers.
7. During an interview on 8/30/18 at 12:25 P.m., the Housekeeping Supervisor said he is
the only one that works on the floors. He started at the facility in (MONTH) (YEAR). There
was not a schedule for floor stripping. He has been trying to get the floors stripped a
few rooms at a time. He had not been able to get to room [ROOM NUMBER]. He said the black
scuff marks cannot be mopped up, the floor has to be stripped and waxed.

F 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
Based on observation, interview and record review, the facility failed to ensure one
resident remained free from restraints, conduct a restraint assessment and ensure it was
care planned. The facility identified no residents with restraints. (Resident #6). The
facility census was 60 residents.
Record review of the facility’s Restraint Policy dated revised on 1/20/17, showed:
-Restraints will not be used unless the facility’s Interdisciplinary Team had completed an
assessment and evaluation to identify the causative medical or environmental factors and
has considered less restrictive alternatives, except in case of an emergency;
-Medical symptoms that warrant the use of restraints will be documented in the resident’s
medical record, ongoing assessments and care plan;
-The physician’s orders [REDACTED].
-Procedures: New Restraint Orders:
-Complete Restraint Assessment;
-Obtain order for:
-Type of restraint;
-Duration to be utilized;
-Medical [DIAGNOSES REDACTED].
-Parameters for use (including release schedule);
-Frequency of checking; and
-Removal schedule;
-Obtain consent from the resident, family, surrogate or healthcare representative if the
resident lacks medical decision making capacity;
-Apply restraint per manufacturer’s guidelines;
-Update care plan with the problem, goal and approaches, which must include:
-Observation;
-Release;
-Repositioning, at least every two hours;
-Document in the medical record, including:
-Alternative tried prior to use of physical restraint; and
-Resident response to restraint;
-Documentation of resident and family/responsible party education and/or notification;
-Documented therapy evaluation;
-Completion of CAA/off-cycle evaluation;
-The Interdisciplinary Team meets as soon as possible to review the assessment and to
consider if all alternatives and interventions have been selected and implemented for how
each resident can attain or maintain the highest level of functioning with the lease
restrictive measures;
-Ongoing restraint use;
-Review each resident currently using a restraint device, at least monthly and for any
change of condition;
-Attempt gradual reduction of restraint use by implementing interventions which may serve
as enablers and reminders. Reduction attempts should be documented, including the resident
response to the interventions;
-The Plan of Care should be updated at least quarterly and with any significant change,
including the medical symptoms which continue to warrant the need for a restraint.
1. Record review of Resident #6’s Admission Face Sheet, showed he/she was admitted to the
facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (a potentially
disabling disease of the brain and spinal cord);
-[DIAGNOSES REDACTED] (a movement disorder in which your muscles contract involuntarily);
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
-Cauda Equina Syndrome (the nerve roots in the lumbar spine are compressed, cutting off
sensation and movement);
-Dementia (a chronic disorder marked by memory disorders, personality changes, and
impaired reasoning);
-[MEDICAL CONDITION] (causes bones to become weak and brittle);
-Muscle weakness; and
-Lack of coordination.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].>-No order
for the use and type of a self-release belt.
-No order pertaining to the parameters of use including: release, checking, repositioning
and removal of the self-release belt.
-No order for duration of use of the self-release belt.
Record review of the resident’s quarterly Nursing Data Collection Tool dated 8/10/18,
showed:
-The resident did not have any upper or lower extremity limitations that would interfere
with daily functions or places the resident at a risk of injury;
-The resident uses a Broda chair (tilt-in-space chair) for mobility;
-The resident does not use any devices or restraints.
Record review of the resident’s Fall Risk Evaluation dated 8/10/18, showed the resident
scored a 16 indicating the resident is at risk for falls.
Observation on 8/27/18 at 12:33 P.M., showed:
-Staff pushed the resident’s Broda chair to the table in the assist dining room (ADR) and
the resident had a self-release belt left in place across the resident’s lap;
-The self-release belt remained in place the entire time the resident was in the ADR
during the meal.
Observation on 8/28/18 at 7:26 A.M., showed:
-The resident sat in his/her Broda chair in the ADR with self-release belt in place. Staff
pushed him/her to the table with the self-release belt left in place across the resident’s
lap.
-The self-release belt remained in place the entire time the resident was in the ADR.
Observation on 8/29/18 at 5:58 P.M., showed the resident sat in the ADR with his/her Broda
chair pushed up to the table and the resident’s self-release belt in place.
Record review of the resident’s comprehensive care plan, showed no care plan for a
self-release belt/restraint.
Review of the resident’s medical record, showed no restraint assessment.
During an interview on 8/30/18 at 9:27 A.M., the resident said:
-He/she is not sure how long the Broda chair had a self-release belt on it just that it
has been on there for a long time;
-Staff always buckled the self-release when he/she is up in his/her Broda chair;
-The self-release buckle stays in place at all the time and is never released while he/she
is in the chair;
-He/she does not know if he/she can release the self-release belt because he/she had never
tried;
-He/she thought the self-release belt was placed on him/her for safety.
During an interview on 8/30/18 at 10:20 A.M certified nurses aide (CNA) J said:
-The resident always has the self-release belt on when he/she is up in his/her Broda
chair;
-The self-release belt is never released and the resident is not repositioned until he/she
is placed in bed;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0604

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
-He/she is not aware if an assessment was performed on the resident prior to placement of
the self-release belt;
-He/she is not sure when the self-release belt was placed, but it has been on the Broda
chair as long as he/she can remember;
-He/she had never seen the resident release the self-release belt by him/herself;
-Staff always has to release the self-release belt as far as he/she knows.
During an interview on 8/30/18 at 10:22 A.M., CNA M said that he/she is not sure when the
resident’s self-release belt was put in place, but he/she wears it every day when he/she
is up in his/her Broda chair.
During an interview on 8/30/18 at 10:24 A.M., CNA E said:
-He/she knows the self-release belt is on the broad chair, but has never known the
resident to need it;
-He/she assumed the self-release belt was on there for safety reasons;
-He/she believed therapy does the evaluations for self-releasing belts;
-He/she had never monitored the self-release belt, released the self-release belt, or
reposition the resident while the self-release belt was in place;
-He/she was never educated to monitor, release the belt, or reposition the resident while
the self-release belt was in place.
During an interview on 8/30/18 at 12:58 P.M. the Administrator said:
-He/she was not aware the resident had a self-releasing belt on his/her Broda chair;
-Restraint assessments are performed through therapy;
-A restraint assessment was not completed for the resident;
-He/she would expect to have an order for [REDACTED].>-Care Plans should accurately
reflect the resident’s current medical status;
During an interview on 8/30/18 at 12:58 P.M. the Director of Nursing said:
-He/she was not aware the resident had a self-releasing belt on his/her Broda chair;
-Restraint assessments are performed through therapy;
-A restraint assessment was not completed for the resident;
-He/she would expect to have an order for [REDACTED].>-Care Plans should accurately
reflect the resident’s current medical status.

F 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility’s abuse and neglect policies,
procedures and protocols, failed to identify when, how, and by whom determinations of
capacity to consent to a sexual contact will be made and where this documentation will be
recorded. The census was 60.
Review of the facility’s Abuse, Neglect, Exploitation or Mistreatment policy, dated
5/1/15, showed:
-Sexual abuse is non-consensual sexual contact of any kind with a resident;
-No requirement specified for the facility to identify when, how, and by whom
determinations of capacity to consent to sexual contact will be made and where this
documentation will be recorded.
During an interview on 8/30/18 at 7:41 A.M., the administrator said she was not sure if
the facility had a policy that addressed a resident’s capacity to consent to sexual

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0607

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
activity. The facility determines a resident’s capacity to consent based on their
cognitive orientation. This is the responsibility of the nurses. She is not sure if this
is documented anywhere, but the residents level of orientation is documented throughout
the medical record. At 7:54 A.M., the administrator verified the facility did not have a
policy regarding a resident’s capacity to consent to sexual activity.

F 0608

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures to ensure (1) employees report any
suspicion of a crime against any resident, according to timelines; (2) post the notice of
employee rights; and (3) prohibit and prevent retaliation for reporting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow their policy for
reporting a suspicion of a crime by failing to contact local law enforcement and the State
Agency regarding one resident’s stolen video game component, game controllers and video
games. The resident had been hospitalized and noticed the items missing upon readmission.
(Resident #26). The census was 60.
Review of the facility Reporting Reasonable Suspicion of a Crime policy, dated 5/1/2013,
showed the following:
-Pursuant to the requirements of section 1150B of the Social Security Act, covered
individuals will timely report any reasonable suspicion of a crime committed against a
resident of the facility to the appropriate State Agency and at least one local law
enforcement entity;
-The facility will notify covered individuals of their reporting requirements annually and
will not retaliate against any individual who makes a report regarding the suspicion of a
crime;
-If the events that cause the suspicion do not result in serious bodily injury, the
individual shall report the suspicion not later than twenty-four (24) hours after forming
the suspicion;
-A covered individual is anyone who is an owner, operator, employee, manager, agent or
contractor of the facility. Covered individuals are subject to a civil money penalty and
exclusion sanctions for failure to meet reporting obligations described herein;
-A crime is defined by law of the applicable political subdivision where the facility is
located. The facility must coordinate with local law enforcement entities to determine
what actions are considered crimes within their political subdivision;
-Individuals reporting suspicion of a crime must call, fax, or e-mail both local law
enforcement and the State Agency;
-All suspicions of a crime are reported verbally immediately to the
administrator/Designee, in addition to the reporting obligations stated above. Failure to
report in the required time frames may result in disciplinary action, including up to
termination.
Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/21/18, showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0608

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Extensive assistance of one person required for bed mobility, transfers, dressing and
personal hygiene;
-Walking in room/corridor: Activity did not occur;
-Physical impairment of both lower extremities;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the resident was admitted to a local
hospital on [DATE] and returned on 7/11/18.
Review of a Complaint/Grievance Report, dated 7/13/18 and completed by the Social Service
Director (SSD), showed the following:
-Communicated verbally by the resident;
-Communicated to the administrator or Director of Nurses (DON): Blank;
-Describe concerns in detail: Playstation 3 and 2 hand controllers and 1 game;
-Findings of investigation: None;
-Complaint/grievance solved? No. Items stolen while away in hospital;
-Is complainant satisfied? No;
-Complainant remarks: Wants to be compensated.
Review of a Complainant/Grievance Report, dated 8/9/17, and completed by the SSD, showed
the following:
-Communicated verbally by the resident;
-Concerned about: Playstation 3;
-Describe concern in detail: He/she had a total of 17 games and they took 11 of them and
left 6. They also took the other controller.
During an interview on 8/29/18 at 8:11 A.M., the resident said he/she was admitted to the
hospital last month for a few days. When he/she returned, he/she noticed someone had
stolen his/her Playstation 3 video game, three controllers and 11 games. He/she told the
staff about the stolen items, including the DON and administrator, the day he/she
returned.
During an interview on 8/29/18 at 8:21 A.M., Certified Nursing Assistant (CNA) I said
he/she had worked at the facility for several years. He/she had taken care of the resident
several times. He/she confirmed the resident had the Playstation 3, controllers and games
prior to going to the hospital. He/she was working when the resident returned from the
hospital. He/she was in the resident’s room when the resident told him/her the items had
been stolen.
During an interview on 8/29/18 at 8:25 A.M., CNA O said he/she had worked at the facility
about 5 years and is familiar with the resident. He/she knows the resident had the
Playstation 3, controllers and video games prior to going to the hospital. The resident
told him/her about those things being stolen when he/she returned from the hospital.
He/she told the charge nurse and the administrator.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she is the designated
Facility Abuse Coordinator. She is responsible to investigate allegations of theft. She
was aware the resident was missing a video game, but not all of the other things the
resident said was missing. Someone told her when the resident returned from the hospital
something was missing. She recalled asking some staff about it, but she did not document
her findings. She did not follow the policy and notify local law enforcement or the State
Agency because she did not have a reason to believe a staff member stole the items. She
acknowledged she failed to follow the policy.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0608

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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 Abuse,
Neglect, Exploitation or Mistreatment Policy by failing to report to the State Survey
Agency, one resident’s missing video component and video accessories and two additional
resident’s complaints of missing money. (Residents #26, #43 and #29). The census was 60.
1. Review of the facility Abuse, Neglect, Exploitation, or Mistreatment policy, dated
9/13/17, showed the following:
-The facility’s leadership prohibits neglect, mental, physical and/or verbal abuse, use of
a physical and/or chemical restraint not required to treat a medical condition,
involuntary seclusion, corporal punishment and misappropriation of a patient’s/resident’s
property and/or funds and ensures that alleged violations involving abuse, neglect,
exploitation or mistreatment, including injuries of unknown source and misappropriation of
resident property, and are reported immediately;
-The facility shall report immediately, but not later than 2 hours after the allegation is
made, if the events that cause the allegation involve abuse or result in serious bodily
injury, or not later than 24 hours if the events that cause the allegation do not result
in serious bodily injury to the administrator of the facility and to other officials
(including to the State Survey Agency and adult protective services where state law
provides for jurisdiction in long-term care facilities) in accordance with state law
through established procedures. See also: Reporting Reasonable Suspicion of a Crime
Policy;
-The facility leadership will designate a staff member to oversee the abuse prohibition
policy (Facility Abuse Coordinator);
-All alleged violations concerning abuse, neglect, or misappropriation of property are to
be reported verbally immediately to the Facility Abuse Coordinator, the Administrator and
to other officials in accordance with state law including the State Survey and
Certification Agency;
-Complete the Investigation Summary Log, maintained by the administrator or his/her
designee;
-The facility maintains that all allegations of abuse, neglect, misappropriation of
property, etc. are thoroughly investigated and appropriate actions are taken.
2. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/21/18, showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Extensive assistance of one person required for bed mobility, transfers, dressing and
personal hygiene;
-Walking in room/corridor: Activity did not occur;
-Physical impairment of both lower extremities;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 – Some

(continued… from page 10)
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record showed the resident was admitted to a local
hospital on [DATE] and returned on 7/11/18.
Review of a Complaint/Grievance Report, dated 7/13/18 and completed by the Social Service
Director (SSD), showed the following:
-Communicated verbally by the resident;
-Communicated to the administrator or Director of Nurses (DON): Blank;
-Describe concerns in detail: Playstation 3 and 2 hand controllers and 1 game;
-Findings of investigation: None;
-Complaint/grievance solved? No. Items stolen while away in hospital;
-Is complainant satisfied? No;
-Complainant remarks: Wants to be compensated.
Review of a Complainant/Grievance Report, dated 8/9/17, and completed by the SSD, showed
the following:
-Communicated verbally by the resident;
-Concerned about: Playstation 3;
-Describe concern in detail: He/she had a total of 17 games and they took 11 of them and
left 6. They also took the other controller.
During an interview on 8/29/18 at 8:11 A.M., the resident said he/she was admitted to the
hospital last month for a few days. When he/she returned, he/she noticed someone had
stolen his/her Playstation 3 video game, three controllers and 11 games. He/she told the
staff about the stolen items, including the DON and administrator, the day he/she
returned.
During an interview on 8/29/18 at 8:21 A.M., Certified Nursing Assistant (CNA) I said
he/she had worked at the facility for several years. He/she had taken care of the resident
several times. He/she confirmed the resident had the Playstation 3, controllers and games
prior to going to the hospital. He/she was working when the resident returned from the
hospital. He/she was in the resident’s room when the resident told him/her the items had
been stolen.
During an interview on 8/29/18 at 8:25 A.M., CNA O said he/she had worked at the facility
about 5 years and is familiar with the resident. He/she knows the resident had the
Playstation 3, controllers and video games prior to going to the hospital. The resident
told him/her about those things being stolen when he/she returned from the hospital.
He/she told the charge nurse and the administrator.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she is the designated
Facility Abuse Coordinator. She is responsible to investigate allegations of theft. She
was aware the resident was missing a video game, but not all of the other things the
resident said was missing. Someone told her when the resident returned from the hospital
something was missing. She recalled asking some staff about it, but she did not document
her findings. She did not follow the policy and notify local law enforcement or the State
Survey Agency because she did not have a reason to believe a staff member stole the items.
She acknowledged she failed to follow the policy. She understood the problem and in the
future, will follow the policy.
During an interview on 8/30/18 at 9:24 A.M., the SSD said she had worked at the facility
since (MONTH) (YEAR). She had not been in-serviced or read the facility Abuse, Neglect,
Misappropriation policy or Reporting Reasonable Suspicion of a Crime policy. It is her
responsibility to complete the Complaint/Grievance form.
3. Review of Resident #43’s quarterly MDS, dated [DATE], showed the following:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 – Some

(continued… from page 11)
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-BIMs score of 15;
-Extensive assistance of two (+) persons required for bed mobility;
-Walking in room/corridor did not occur;
Extensive assistance of one person required for dressing and personal hygiene;
-[DIAGNOSES REDACTED].
Review of a Complaint/Grievance Report, dated 7/25/18 and completed by the SSD, showed the
following:
-Communicated by staff;
-Concerned about: Money stolen;
-Describe concern in detail: Resident had $155 in his/her night stand and noticed it was
gone Sunday morning. Resident put money in his/her drawer Saturday night;
-Reported incident to his/her CNA on Monday morning;
-Plan to resolve complaint/grievance: Will report to nursing supervisor.
During an interview on 8/29/18 at 9:08 A.M., the resident said he/she was missing money
last month. It was the middle of the month, but he/she could not recall the exact day.
He/she said the money, about $145 dollars, was in an envelope in his/her nightstand
drawer. He/she was going to buy some computer items. He/she told the SSD the day he/she
realized the money was missing. He/she did not see anyone take the money. The SSD said she
was going to a meeting and would inform the administrator. No one has told him/her the
outcome of the missing money.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she is the designated
Facility Abuse Coordinator. She spoke to the resident who told her he/she was missing $20.
The resident said he/she thought his/her roommate took the money although he/she did not
see the roommate take it. The resident asked her not to speak to the roommate about it so
she didn’t. She did not document the conversation with the resident, investigate the
missing money or contact the State Survey Agency.
3. Review of Resident #29’s admission MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Understood/understands;
-BIMs of 15;
-Expensive assistance of one person required for bed mobility, dressing and personal
hygiene;
-Extensive assistance of two (+) persons required for transfers;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
During an interview on 8/29/18 at 8:29 A.M.,, the resident said about a month ago, he/she
had about $15 or $17 dollars in the top drawer of his/her nightstand that went missing.
He/she told the SSD and several staff. He/she never heard anything else about it.
During an interview on 8/30/18 at 9:24 A.M., the SSD said the resident had told her about
the missing money. The resident told her on the day he/she was getting ready to leave for
a [MEDICAL TREATMENT] treatment. She thought she would complete the Complaint/Grievance
form when he/she returned, but she completely forgot.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she had not been
informed about the resident’s allegation of missing money so she did not report the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 – Some

(continued… from page 12)
allegation to the State Survey 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 interview and record review, the facility failed to follow their policy and
thoroughly investigate one residents stolen video game component, game controllers and
video games and failed to investigate two other resident’s complaints regarding stolen
money. (Resident’s #26, #43 and #29). The census was 60.
Review of the facility Abuse, Neglect, Exploitation, or Mistreatment policy, dated
9/13/17, showed the following:
-The facility’s leadership prohibits neglect, mental, physical and/or verbal abuse, use of
a physical and/or chemical restraint not required to treat a medical condition,
involuntary seclusion, corporal punishment and misappropriation of a patient’s/resident’s
property and/or funds and ensures that alleged violations involving abuse, neglect,
exploitation or mistreatment, including injuries of unknown source and misappropriation of
resident property, and are reported immediately;
-The facility shall report immediately, but not later than 2 hours after the allegation is
made, if the events that cause the allegation involve abuse or result in serious bodily
injury, or not later than 24 hours if the events that cause the allegation do not result
in serious bodily injury to the administrator of the facility and to other officials
(including to the State Survey Agency and adult protective services where state law
provides for jurisdiction in long-term care facilities) in accordance with state law
through established procedures. See also: Reporting Reasonable Suspicion of a Crime
Policy;
-The facility leadership will designate a staff member to oversee the abuse prohibition
policy (Facility Abuse Coordinator);
-All alleged violations concerning abuse, neglect, or misappropriation of property are to
be reported verbally immediately to the Facility Abuse Coordinator, the Administrator and
to other officials in accordance with state law including the State Survey and
Certification Agency;
-Complete the Investigation Summary Log, maintained by the administrator or his/her
designee;
-The facility maintains that all allegations of abuse, neglect, misappropriation of
property, etc. are thoroughly investigated and appropriate actions are taken.
1. Review of Resident #26’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 6/21/18, showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Extensive assistance of one person required for bed mobility, transfers, dressing and
personal hygiene;
-Walking in room/corridor: Activity did not occur;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 13)
-Physical impairment of both lower extremities;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated on 12/6/17, showed the following:
-At risk for suicide related to prior attempts of suicide;
-Resident will not harm self and his/her depression will be resolved;
-Encourage resident to become involved with activities;
-Encourage resident to verbalize feelings and fears;
-Provide realistic hope.
Review of the resident’s medical record, showed the resident was admitted to a local
hospital on [DATE] and returned on 7/11/18.
Review of a Complaint/Grievance Report, dated 7/13/18 and completed by the Social Service
Director (SSD), showed the following:
-Communicated verbally by the resident;
-Communicated to the administrator or Director of Nurses (DON): Blank;
-Describe concerns in detail: Playstation 3 and 2 hand controllers and 1 game;
-Findings of investigation: None;
-Complaint/grievance solved? No. Items stolen while away in hospital;
-Is complainant satisfied? No;
-Complainant remarks: Wants to be compensated.
Review of a Complainant/Grievance Report, dated 8/9/17, and completed by the SSD, showed
the following:
-Communicated verbally by the resident;
-Concerned about: Playstation 3;
-Describe concern in detail: He/she had a total of 17 games and they took 11 of them and
left 6. They also took the other controller.
Review of the resident’s social service progress notes, showed no documentation regarding
the stolen items or if it was having an impact the resident’s life.
During an interview on 8/29/18 at 8:11 A.M., the resident said he/she was admitted to the
hospital last month for a few days. When he/she returned, he/she noticed someone had
stolen his/her Playstation 3 video game, three controllers and 11 games. A family member
gave him/her the Playstation 3 and accessories about a year ago. He/she receives $30 a
month and cannot afford to replace those items. He/she told the staff about the stolen
items, including the DON and administrator, the day he/she returned. The DON told him/her
the facility was not responsible for stolen items because he/she had signed an admission
agreement. The staff on the night shift was nice enough to get him/her a used Playstation.
He/she had to spend about $12 of his/her own money to buy new cords for the Playstation.
Review of the facility Admission Agreement, signed by the resident on 1/6/17, showed the
following:
-Page 1, #2 Personal Property: It is understood that the facility is not responsible for
either damage to or theft/loss of valuables, monies or clothing belonging to the resident
unless they are held in trust by the facility for safekeeping and the damage, theft or
loss was caused by the neglect or willful conduct of facility personnel. Personal property
will not be considered to be held in trust unless the policies and procedures outlined in
the Admission Handbook, which is made a part of this agreement by reference herein, and
any future amendments thereto, have been followed. Facility reserves the right to prohibit
certain personal effects, funds, or other property of resident in accordance with state
and federal law. The facility is not liable for either damages to or theft/loss or any
personal belongings or personal care items, such as dentures, hearing aides and
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 14)
eyeglasses, except with respect to damage, theft or loss caused by negligent or willful
conduct of facility personnel.
Review of the resident’s Inventory of Personal Effects, dated 7/8/17, showed no
documentation of a Playstation 3, game controllers or video games.
During an interview on 8/29/18 at 8:21 A.M., Certified Nursing Assistant (CNA) I said
he/she had worked at the facility for several years. He/she had taken care of the resident
several times. He/she confirmed the resident had the Playstation 3, controllers and games
prior to going to the hospital. He/she was working when the resident returned from the
hospital. He/she was in the resident’s room when the resident told him/her the items had
been stolen.
During an interview on 8/29/18 at 8:25 A.M., CNA O said he/she had worked at the facility
about 5 years and is familiar with the resident. He/she knows the resident had the
Playstation 3, controllers and video games prior to going to the hospital. The resident
told him/her about those things being stolen when he/she returned from the hospital.
He/she told the charge nurse and the administrator.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she is the designated
Facility Abuse Coordinator. She is responsible to investigate allegations of theft. She
was aware the resident was missing a video game, but not all of the other things the
resident said was missing. Someone told her when the resident returned from the hospital
something was missing. She recalled asking staff about it, but she did not document her
findings. She did not investigate the resident’s stolen items because she did not have a
reason to believe a staff member stole the items. She acknowledged she failed to follow
the policy.
During an interview on 8/30/18 at 7:39 A.M., the resident said because of his/her physical
condition, he/she stays in bed most of the time. The Playstation 3 was his/her main source
of entertainment and he/she played the games nearly everyday. He/she was mad when he/she
returned and found the equipment gone. It was about a month before the night shift staff
were nice enough to bring in the other Playstation. Since reporting the theft, the
facility has not said anything else to him/her. He/she has never received compensation
from the facility for any of the stolen items.
During an interview on 8/30/18 at 9:24 A.M., the SSD said she had worked at the facility
since (MONTH) (YEAR). She had not been in-serviced or read the facility Abuse, Neglect,
Misappropriation policy or Reporting Reasonable Suspicion of a Crime policy. It is her
responsibility to complete the Complaint/Grievance form. A CNA or nursing staff member
told her about the resident’s stolen Playstation 3 and accessories. The nursing department
had already told the administrator. She spoke to the resident and completed the
Complaint/Grievance forms. The resident said he/she was upset about the items being
stolen. She assumed the administrator was investigating. The administrator did not ask her
anything else about the missing items after she completed the Complaint/Grievance form.
During an interview on 8/30/18 at 10: 20 A.M., the Activity Director said said the
resident use to get up more often than he/she does now. He/she does not want her to do one
on one activities, but she still takes him/her snacks. He/she likes to play video games
and she takes him movies to watch. He/she likes his/her video games. He/she did tell her
about the missing Playstation 3. He/she was upset it had been stolen.
2. Review of Resident #43’s quarterly MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 15)
-BIMs score of 15;
-Extensive assistance of two (+) persons required for bed mobility;
-Walking in room/corridor did not occur;
-Extensive assistance of one person required for dressing and personal hygiene;
-[DIAGNOSES REDACTED].
Review of a Complaint/Grievance Report, dated 7/25/18 and completed by the SSD, showed the
following:
-Communicated by staff;
-Concerned about: Money stolen;
-Describe concern in detail: Resident had $155 in his/her night stand and noticed it was
gone Sunday morning. Resident put money in his/her drawer Saturday night;
-Reported incident to his/her CNA on Monday morning;
-Plan to resolve complaint/grievance: Will report to nursing supervisor.
During an interview on 8/29/18 at 9:08 A.M., the resident said he/she was missing money
last month. It was the middle of the month, but he/she could not recall the exact day.
He/she said the money, about $145 dollars, was in an envelope in his/her nightstand
drawer. He/she was going to buy some computer items. He/she told the SSD the day he/she
realized the money was missing. He/she did not see anyone take the money. The SSD said she
was going to a meeting and would inform the administrator. No one has told him/her the
outcome of the missing money.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she is the designated
Facility Abuse Coordinator. She spoke to the resident who told her he/she was missing $20.
The resident said he/she thought his/her roommate took the money although he/she did not
see the roommate take it. The resident asked her not to speak to the roommate about it so
she didn’t. She did not document the conversation with the resident, investigate the
missing money or contact the State Survey Agency.
During an interview on 8/30/18 at 9:24 A.M., the SSD said she had heard the Medical
Records Clerk said the resident was missing some money. She completed a
Complaint/Grievance form. She was not assigned to complete any part of the investigation
other than the Complaint/Grievance form.
3. Review of Resident #29’s admission MDS, dated [DATE], showed the following:
-admission date of [DATE];
-Adequate hearing and vision;
-Understood/understands;
-BIMs of 15;
-Extensive assistance of one person required for bed mobility, dressing and personal
hygiene;
-Extensive assistance of two (+) persons required for transfers;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
During an interview on 8/29/18 at 8:29 A.M., the resident said about a month ago, he/she
had about $15 or $17 dollars in the top drawer of his/her nightstand that went missing.
He/she told the SSD and several staff. He/she never heard anything else about it.
During an interview on 8/30/18 at 9:24 A.M., the SSD said the resident had told her about
the missing money. The resident told her on the day he/she was getting ready to leave for
a [MEDICAL TREATMENT] treatment. She thought she would complete the Complaint/Grievance
form when he/she returned, but she completely forgot.
During an interview on 8/29/18 at 10:14 A.M., the administrator said she had not been
informed about the resident’s allegation of missing money so she did not investigate or
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 16)
report the allegation to the State Survey Agency.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to develop and
implement a comprehensive person-centered care plan for each resident for thee of 15
sampled residents (Resident #2, #25 and #38). The census was 60.
1. Review of Resident #2’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/12/18, showed no interview for
activities preference completed. Staff assessment for activities preference, showed
interests included participating in favorite activities, doing things with groups of
people, listening to music, staying up past 8:00 P.M. and snacks between meals. Review of
the care area assessment summary, showed activities triggered as a care area and the
facility indicated activities to be addressed in the care plan.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Brief interview of mental status (BIMS, a screen for cognitive impairment) score of 1 out
of a possible score of 15;
-A BIMS score of 0-7, showed the resident had severe cognitive impairment;
-Disorganized thinking: Behavior continuously present;
-Wandering: Behavior of this type occurred daily.
Review of the facilities (MONTH) fall summary for the resident, showed:
-Fall 6/25/18 on the 3:00 P.M. to 11:00 P.M. shift, resident got out of the wheelchair at
the nurses station and lost balance and fell to floor- no injuries;
-Fall 7/11/18 on the 7:00 A.M. to 3:00 P.M. shift, resident leaned forward to pick up
something from the floor and fell forward out of the wheelchair- no injuries.
Review of the resident’s transfer form, dated 7/11/18, showed reason for transfer,
[MEDICAL CONDITION] grand mal (a [MEDICAL CONDITION] characterized by severe shaking,
trembling and contracting of the muscles). The resident had been hospitalized recently two
times for [MEDICAL CONDITION] activity. Readmitted [DATE]. Had a fall this morning on the
7-3 shift. Resident had three [MEDICAL CONDITION], grand mal, and [MEDICATION NAME] 2-3
minutes each. Is now post [MEDICAL CONDITION] and not much response noted. The primary
care physician notified and wants the resident sent to the hospital. Next of kin notified
and wants the resident sent to the hospital.
Review of the resident’s physician order [REDACTED].
-[DIAGNOSES REDACTED].
-Activity and mobility: Up as desired in wheelchair;
-An order dated 8/7/18, for [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) 0.5
milligram (mg), three tabs three times a day. [DIAGNOSES REDACTED].>Review of the
resident’s nurse’s notes, showed:
-On 8/8/18 at 7:00 P.M., the resident continues to wander;
-On 8/8/18, next of kin called and aware the resident went outside of the building today;
-On 8/18/18 at 7:00 P.M., the resident in front of building. Returned to inside of
building. Wander guard remains on, elopement sheet started. On call nurse called, Director
of Nursing (DON) called, physician called;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
-On 8/20/18 at 2:00 P.M., resident noted to self-propel in the hallway. Gets confused
looking for room or bathroom. Needs redirection at times;
-On 8/22/18 on the 3-11 shift, elopement every 30 minute precautions complete times 72
hours. Will continue to monitor.
Review of the resident’s care plan, in use at the time of the survey, showed:
-Problem: Baseline care plan:
-Fall risk: Encourage use of call light, orient to room, safety device (type of safety
device not specified);
-Activity preferences: Attends activities of choice (no further documentation of activity
preferences);
-The fall on 6/25/18 and 7/11/18, not listed on the care plan with updated interventions;
-The resident’s wandering behavior not identified on the care plan;
-The resident’s history of [MEDICAL CONDITION] or approaches for staff if the resident had
a [MEDICAL CONDITION] not listed on the care plan;
-The resident’s need for redirection when unable to locate the room or bathroom not listed
on the care plan.
Observation on 8/27/18 at 2:05 P.M., showed the resident propelled him/herself in his/her
wheelchair around the nurse’s station. At 2:39 PM., the resident propelled him/herself
down the 400 hall. On 8/28/18 on 7:41 A.M., the resident sat in a wheelchair and propelled
him/herself around the main dining room as staff served breakfast. A staff person walked
up behind the resident and propelled the resident out of the main dining room and into the
assist dining room. On 8/29/18 at 8:25 A.M., the resident propelled him/herself down the
700 hall. On 8/29/18 at 9:00 A.M., the resident propelled back down the 700 hall.
Certified Medication Technician (CMT) P told the resident no, go the other way.
During an interview on 8/29/18 at 12:21 P.M., Certified Nursing Assistant (CNA) O said the
resident is resistant to care at times, especially in the evening. He/she can suddenly
become aggressive and punch at staff. The resident wanders. He/she gets confused about
where he/she is going and may go in rooms he/she should not be in. When this happens,
staff redirect the resident.
During an interview on 8/29/18 at 12:34 P.M., Registered Nurse (RN) L said the resident is
an elopement risk. He/she believed it was within the last 3 week that the resident eloped.
Staff do more frequently monitoring of the resident. After the elopement, the resident was
on 15 minute checks for a few days. Staff ensure care provided to the resident is
consistent with the care plan by looking at the care plan.
During an interview on 8/30/18 at 1:48 P.M., the administrator and Director of Nursing
(DON) said care plans should be complete and accurate, consistent with the resident’s care
needs. The resident eats in the assist dining room because that is just where he/she tends
to wander. The resident had a history of [REDACTED]. He/she had a wander guard on.
Wandering behaviors should be listed on the care plan. Interventions included staff
checking on the resident more often. The resident is free to roam. The DON said she was
not aware of any combative behaviors exhibited by the resident. The resident had a history
of [REDACTED]. When awake at night, the resident goes out to the nurse’s station because
he/she likes to be out there where he/he can see other people. He/she sleeps on the
couches throughout the facility at night as well. The facility does not necessarily put
activity preferences on the care plan. The administrator said she was not aware of the
resident’s elopement and would check to verify if the elopement occurred on (MONTH) 8th or
18th. At approximately 3:30 P.M., the administrator clarified that the elopement occurred
on the 18th. The resident got out the 100 hall door.
Further review of the resident’s care plan, showed:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
-Problem: Baseline care plan:
-Elopement risk: Wander guard on the left ankle;
-The resident’s preference to be at the nurse’s station at night when awake or sleeping on
couches throughout the facility at night not listed on the care plan;
-The resident’s elopement on the 18th not listed on the care plan with updated
interventions;
-The resident’s resistance to care and history of being combative with care not listed on
the care plan.
2. Review of Resident #25’s admission MDS, dated [DATE], showed:
-An admission date of [DATE];
-Came from the community;
-Severe cognitive impairment;
-Rejects care daily;
-Wanders daily;
-Supervison/set up assistance with bed mobility, walking, locomotion on and off unit and
eating;
-Limited assistance with transfers, dressing and toilteting;
-Extensive assistance with personal hygiene;
-Uses a cane/crutch;
-[DIAGNOSES REDACTED].
Review of the resident’s baseline care plan, dated 6/14/18, showed:
-Goal: get stronger, stay long term;
-Services and treatments: medical management;
-Fall risk: encourage use of call light, orient to room and bathroom. Safety device:
valker;
-Elopement risk: no;
-Skin intergrity: intact;
-Diet: regular;
-Teeth: dentures top and bottom;
-Bed mobility and eating: independent;
-Toileting, transfers and ambulation (walker) with assist of one.
Review of the resident’s activity evaluation completed on 6/16/18, showed he/she has
hearing aids, is Baptist, not interested in voting, unable to determine if he/she belongs
to any clubs/organizations, has children and likes: exercise family/friend visits, movies,
music, religious services/studies,TV, walking.
During an interview on 8/30/18 at 8:50 A.M., the activity director said they have tried to
offer 1:1 activities with the resident, but he/she will tell them to get out. He/she stays
to himself/herself and is still adjusting. They will keep trying the 1:1s and get him/her
to come to group activities, but for now he/she is not participating. She brought some
stuffed animals and the resident did not want them. He/she does like to sweep, so the
administrator bought him/her a broom. The resident just will not go to group things. They
can get him/her to come out and sit in the common area at times and he/she will talk to
some residents, but not really with staff. The resident is still adjusting.
Observations of the resident, showed:
-On 8/27/18 at 9:03 A.M., he/she walked into his/her room, wearing a wanderguard, sat on
the bed, removed his/her shoes and laid on the bed facing the TV, which was on;
-On 8/28/18 at 1:22 P.M., showed he/she sat in the assist dining room. He/she had a full
plate of food and drinks, but just sat and looked around;
-On 8/30/18 at 8:18 A.M., he/she lay in bed on his/her side facing the TV, which was on.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
Review of the resident’s care plan, in use at the time of the survey, showed:
-Activities of daily living self-care performance deficit related to (blank),
-Limited physical mobility related to (blank),
-Resistive to care (SPECIFY) related to (blank),
-Elopement risk/wanderer (SPECIFY) related to (blank),
-Impaired cognitive function/dementia or impaired thought processes related to (blank),
-Communication problem related to (blank),
-Has had an actual fall with (SPECITY: no injury, minor injury, serious injury),
-Nutritional problem or potential nutritional problem (SPECIFY) related to (blank),
-[MEDICAL CONDITION] related to (blank),
-Impaired visual function related to (blank).
-There was no specific/personalized information about the resident regarding the above
focus areas, goals or interventions.
During an interview on 8/28/18 at 10:25 A.M., the MDS coordinator said she just got a
basic care plan put into the system for the resident and would have to go back and
personalize it.
3. Review of Resident #38’s annual MDS, dated [DATE], showed:
-Brief interview of mental status (BIMS) score, 15
-Eating set up help only
-Bed mobility: Number of staff, two;
-Dressing, Number of staff, one
-Transfer: Number of staff, two;
-Impairment on one side
-Mobility: none
-Diagnoses: [REDACTED].
-Activities preferences, very important to the resident
-Care area triggered, the facility would care plan activities
Review of the resident’s care plan, (undated), used during the survey, showed:
-Diet: Regular
-Bed mobility: Number of staff, two;
-Bed mobility: utilize trapeze to maximize independence
-Transfer: Number of staff, two;
-Dressing, Number of staff, one
-The use of a Hoyer (mechanical lift), number of staff, two
-Diagnoses: [REDACTED].
-Activities preferences not care planned.
Review of the resident’s activity logs for the months of (MONTH) (YEAR) and (MONTH)
(YEAR), showed the resident participating in the following activities every day; movies
and tv as well as current events/ news every day in the month of (MONTH) ’18.
During observations and interviews on 8/28/18 at 7:15 A.M. and 8/30/18 at 10:46 A.M., the
resident said he/she does not participate in any activities. The resident said he/she
leaves the facility four days a week to go to [MEDICAL TREATMENT]. The resident said when
he/she is at the facility; the staff does not put him/her in his/her wheelchair to
participate in activities. The resident said he/she would like to participate in
activities, but there is not any offered to him/her. The resident said he/she would like
to participate in activities at least once a week. The resident said he/she is not sure of
what all the facility offer. The resident said he/she knows the facility has popcorn and
some events like movie nights in which he/she would like to participate.
During an interview on 08/29/18 at 8:35 A.M., Certified Nursing Assistant (CNA) I said the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 20)
resident is a total care, but he/she can assist as he/she could use one arm. CNA I said
the resident does not participate in any activities, as he/she does not want to sit up in
the chair. CNA I said the resident is sort of a loner.
During an interview on 8/30/18 at 8:30 A.M., the Activity Director (AD) said the resident
is offered activities but he/she refuses. The AD said the resident use his/her game
station and phone, as he/she does not want to do anything.
During an interview on 8/30/18 at 1:48 P.M., the administrator and Director of Nursing
(DON) said care plans should be complete and accurate, consistent with the resident’s care
needs. The administrator said the facility does not necessarily put activity preferences
on the care plan. The administrator said he/she does not want to talk about activity
preferences on the care plan since they are so intimately involved with residents.
4. During an interview on 8/28/18 at 10:01 A.M., the MDS coordinator said the facility
recently changed medical record companies and when they did, they lost the most up-to-date
care plans for the resident’s. She is working on getting them all updated.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure
resident’s received their medications consistently without interruption, failed to access
the facility emergency medication kit when medications were not available in the
resident’s stock and failed to notify the resident’s physicians when they were unable to
administer medications as ordered. (Residents #42, #109, #57, #15, and #7). The census was
60.
1. Review of Resident #42’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/18/18, showed the following:
-admitted on [DATE];
-Adequate hearing and vision;
-Clear speech – distinct intelligible words;
-Understood/understands;
-Brief Interview for Mental Status score of 15 (a score of 13 – 15 indicates cognitively
intact);
-Supervision/oversight required for transfer, dressing and eating;
-[DIAGNOSES REDACTED].
Review of the resident’s MAR, dated 8/1/18 through 8/31/18, showed an order [MEDICATION
NAME] (medication used to treat DM) 1000 mg. The following doses were circled by the
nurses (an indication the medication was not administered) and there was no documentation
as to why:
-6:00 A.M.: 26th;
-5:00 P.M.: 24th, 25th and 26th.
Review of the resident’s nurse’s progress notes, showed no physician notification
regarding the missed doses of [MEDICATION NAME].
During an interview on 8/28/18 at 7:38 P.M., the resident said he/she had missed a few
dose of [MEDICATION NAME] recently. He/she was told they were out of the medication.
Observation on 8/28/18 at 10:30 A.M., showed the facility emergency kit (where several of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
the most frequently administered medications in the event of a new order or when a
resident’s medication has run out) showed a stock of [MEDICATION NAME] 500 mg.
During an interview on 8/30/18 at 12:57 P.M., the DON said a circled initial means the
dose was not administered. The nurse should document on the back of the MAR indicated
[REDACTED]. If a resident misses more than three consecutive doses, the nurse should
notify the physician.
2. Record review of Resident #7’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with [DIAGNOSES REDACTED].>-Muscle spasms of back;
-Pain in lower back;
-Hand contractures
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-[MEDICATION NAME] (Muscle relaxer) HCL 4mg (milligrams) take ½ tablet by mouth (PO) at
bedtime (HS) for spasms. ½ tab = 2mg. Dated 5/7/18.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]
-[MEDICATION NAME] HCL 4mg take ½ tablet PO at HS for spasms. ½ tab = 2mg. Dated 5/7/18.
-The [MEDICATION NAME] HCL 4mg was circled as not give on 7/27/18, 7/29/18, and 7/31/18.
-The [MEDICATION NAME] HCL 4mg was left blank on 7/28/18 and 7/30/18.
-The reason noted on the back on 7/27/18 and 7/28/18 was the medication was not available.

-No reason was provided for the medication not being administered on 7/29/18 through
7/31/18
Record review of the resident’s (MONTH) (YEAR) POS, showed:
-[MEDICATION NAME] HCL 4mg take ½ tablet PO at HS for spasms. ½ tab = 2mg. Dated 5/7/18.
Record review of the resident’s (MONTH) (YEAR) MAR, showed:
-[MEDICATION NAME] HCL 4mg take ½ tablet PO at HS for spasms. ½ tab = 2mg. Dated 5/7/18.
-The [MEDICATION NAME] HCL 4mg was circled as not give on 8/1/18 through 8/6/18, left
blank on 8/7/18, and circled as not given on 8/8/18 through 8/15/18.
-The reason noted on the back on 8/2/18, 8/3/18 and 8/8/18 was the medication was not
available.
-No reason was provided for the medication not being administered on 8/1/18, 8/4/18
through 8/7/18, and 8/9/18 through 8/15/18.
During an interview on 8/27/18 at 9:07 A.M., the resident said:
-He/she found it unacceptable to go that long without an ordered medication;
-The physician would not have prescribed the medication if he/she did not feel the
resident needed it;
-He/she had been living with increased muscle spasms and pain related to the medication
not being available;
-The increased muscle spasms and pain has affected his/her daily activity and quality of
life;
-As far as he/she knew, the facility did not contact the physician to obtain a
new/replacement order until this medication was delivered by the pharmacy.
3. Record review of Resident #15’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (nerve pain);

-Pain.
Record review of the resident’s (MONTH) (YEAR) POS, showed:
-[MEDICATION NAME] (for nerve pain) 300mg PO four times daily.
-[MEDICATION NAME] (narcotic pain medication) 5/325mg one tablet every 6 hours for pain.
Record review of the resident’s (MONTH) (YEAR) Medication Administration Record [REDACTED]

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-[MEDICATION NAME] 300mg PO four times daily was circled as not given for one dose on
8/28, three doses on 8/29 and two doses on 8/30. The back of the MAR indicated [REDACTED]
-[MEDICATION NAME] 5/325 mg one tablet every 6 hours for pain was circled as not given for
four doses on 8/26, 8/27, 8/28, 8/29 and two doses on 8/30. The back of the MAR indicated
[REDACTED].
During an interview on 8/30/18 at 9:42 A.M., the resident said:
-He/she had not received his/her pain medications for a few days;
-He/she had increased pain as a result of not receiving his/her pain medications;
-The increased pain has affected his/her daily activity and quality of life;
-He/she was never offered a substitute and the staff did not say they would check the
emergency kit;
-The facility is out of his/her pain medications often and he/she has increase pain during
those periods.
4. Record review of Resident #57’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with [DIAGNOSES REDACTED].>-Biliary [MEDICAL CONDITION] (a
progressive disease of the liver);
-Pain.
Record review of the resident’s (MONTH) (YEAR) POS, showed:
-[MEDICATION NAME] 5mg PO every six hours for pain.
Record review of the resident’s (MONTH) (YEAR) MAR, showed:
-[MEDICATION NAME] 5mg was initialed as given for the 6:00 P.M. dose on 8/28 and left
blank for the 12:00 A.M. dose on 8/29. The back of the MAR indicated [REDACTED]
During an interview on 8/30/18 at 9:38 A.M., the resident said:
-He/she had not received his/her pain medications for a few days.
-He/she had increased pain as a result of not receiving his/her pain medications.
-The increased pain has affected his/her daily activity and quality of life.
-He/she was never offered a substitute and the staff did not say they would check the
emergency kit
-The facility is out of his/her pain medications often and he/she has increase pain during
those periods.
-The unavailability of medications has become worse since the facility changed pharmacies.

5. Record review of Resident #109’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with [DIAGNOSES REDACTED].>-Heart failure;
-[MEDICAL CONDITION];
-[MEDICAL CONDITION].
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] 4mg 1 PO every 6 hours PRN
Observation of medication administration on 8/29/18 at 5:13 PM showed CMT K:
-Was asked by the resident for a dose of PRN [MEDICATION NAME] due to nausea.
-Was unable to find the medication in the medication cart and notified the nurse.
-Told the resident that the medication was unavailable and they were trying to get an
order for [REDACTED].>-Said the nurse called the resident’s physician and got a
one-time order for [MEDICATION NAME].
-Looked in the medication cart and the medication room and the [MEDICATION NAME] was not
available.
-Notified the resident that the medication was unavailable and the resident said that
he/she was going to vomit if he/she did not get the medication soon.
-Notified the nurse that the [MEDICATION NAME] was unavailable and the nurse called the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
physician a second time and received a one-time order for [MEDICATION NAME] ([MEDICATION
NAME]) 180mg 2 tabs PO 1 time only.
-Provided the [MEDICATION NAME] at 5:50 PM.
During an interview with the resident on 8/29/18 at 6:03 P.M., the resident said:
-He/she had little relief from the [MEDICATION NAME].
-He/she had already vomited before the [MEDICATION NAME] was administered.
-He/she believed he/she would not have vomited if he/she would have had his/her
-This was not the first time the facility was unable to provide medications due to them
not having the medication in stock.
6. During an interview on 8/29/18 at 5:38 P.M. CMT K said:
-It is not uncommon for medications to be unavailable for more than a day or two.
-If medication is not available, she/he lets the nurse know.
-Staff orders meds and they never come in from the pharmacy, and this happens often.
7. During an interview on 8/29/18 at 7:25 A.M., the Administrator said:
-The facility started with a new pharmacy company on 8/1/18;
-If a med is not available, he/she expected the nurse to look in emergency supply kit, if
it is not in there, they should call the pharmacy;
-The pharmacy has a super stat delivery system that is supposed to get medications to the
facility in two hours;
-If a resident misses 3 doses of a medication, nursing must call the resident’s physician.

8. During an interview on 8/30/18 at 7:39 A.M., the resident’s physician said:
-Anything over 3 doses of a medication not being available and not administered is
excessive;
-He/she expects staff to notify him/her if a medication is not available;
-It is not always the facility’s fault, sometimes pharmacy doesn’t get the medications to
them;
-He/she expects staff to follow all orders as written.
9. Record review of the facility’s Medication Management Program Policy revised on 7/1/16,
showed:
-If the resident is unable to take the medication or refuses it, the authorized
licensed/certified staff member circles his/her initials on the MAR, and documents the
reason refused or not given on the designated area of the MAR. The Physician is notified
as necessary.
MO 080

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 accurately
identify the amount of staff required to transfer one resident at risk for falls and
failed to ensure staff used a gait belt during two observations of the resident being
transferred. In addition, staff failed to secure one can of ant and roach spray while
unattended and observed in one resident’s room for four consecutive days. (Residents #39
and #47). The census was 60.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 24)
1. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/14/18, showed the following:
-Usually understood;
-Understands;
-Extensive assistance of one person required for bed mobility;
-Extensive assistance of two (+) persons required for transfers;
-Moving from seated to standing position: Not steady only able to stabilize with human
assistance;
-Physical impairment of one upper and one lower extremity;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, showed a problem first identified on 1/30/14, last
revised on 2/18/18 and identified as ongoing for the following:
-Assistance with activities of daily living. The resident requires bed mobility and
transfer assistance of one to two staff.
Review of the resident’s Central Information Tool (a scaled down care plan kept in a
folder at the nurse’s station for staff reference when providing assistance to residents),
undated, showed the following:
-Fall risk;
-Total dependence of two (+) staff required for transfers.
Observation on 8/28/18 at 4:58 A.M., showed Certified Nursing Assistant (CNA) A assisted
the resident to a sitting position on the side of the bed. He/she placed one hand on each
side of the waist band of the resident’s pants and began to assist the resident to a
standing position. The resident was unable to fully stand and the CNA lowered the resident
back to a sitting position on the side of the bed. After a couple of minutes, the CNA
repeated the transfer. The resident was able to stand, pivot and sit in the wheelchair.
The resident was unsteady during the transfer and he/she landed roughly into the
wheelchair. The CNA failed to use a gait belt (applied around the waist of the resident to
provide stability during a transfer) during the transfer. During an interview, the CNA
said the facility policy is to use a gait belt to transfer a resident that requires
assistance to transfer. The resident usually stands and transfers better than that. He/she
should have used a gait belt to transfer the resident. His/her gait belt is in his/her
car.
Observation on 8/29/18 at 6:01 A.M., showed CNA B prepared to transfer the resident from
the bed to the wheelchair. As CNA B placed the resident’s jacket on, staff member C opened
the door, observed what CNA B was doing and said he/she would assist with the transfer.
CNA B stood on one side of the resident as staff member C stood on the other side. Both
staff members were facing the resident. Both staff members locked one of their arms
underneath the resident’s arm pit, and placed their other hand on the back of the
resident’s waist band. The staff members stood and pivoted the resident into the
wheelchair. Neither staff used a gait belt to transfer the resident. During an interview,
CNA B said the facility policy is for staff to use a gait belt when transferring
resident’s that require assistance. His/her gait belt is in his/her car.
During an interview on 8/30/18 at 12:57 P.M., the Director of Nurses said gait belts are
required to transfer any resident that requires assistance. She expects staff to follow
the facility policy.
Review of the facility Gait Belt policy, dated 7/1/2016, showed the following:
-The facility regulates through policy the distribution and use of gait belts to ensure
resident safety;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 25)
-Always use the gait belt when the resident requires hands on assistance to ambulate or
transfer;
-Always place the belt around the waist in soft tissue, with buckle in front, and never on
the ribs, hipbones, or breasts with buckle at front of resident;
-Always have belt applied snugly so there is no possibility of it sliding up over the ribs
– never loosely;
-Always place belt over clothing or some type of covering – never on bare skin;
-Grasp gait belt with both hands; one at each side of resident’s waist;
-Brace resident’s knees as necessary – brace feet at same time;
-Assist resident to standing position and have resident pivot or turn and assist resident
to a sitting position.
2. Review of Resident #47’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/28/18, showed the following:
-Usually understood;
-Understands;
-Extensive assistance of one person required for bed mobility;
-Extensive assistance of one person required for transfers;
-Moving from seated to standing position: Not steady only able to stabilize with human
assistance;
-Physical impairment of one upper and one lower extremity;
-Mobility device: Wheelchair;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, dated 7/23/18, and in use during the survey showed the
following:
-Fall risk;
-Regular CCHO diet
-[DIAGNOSES REDACTED].
Observations on 8/27/18 at 10:09 A.M., 8/28/18 at 6:59 A.M., 8/29/18 at 6:55 A.M., and
8/30/18 at 11:00A.M., showed Hot Shot ant and roach spray (labeled CAUTION. Avoid contact
with skin, eyes, or clothing. First Aid
If Swallowed: Immediately call a Poison Control Center or doctor) on the windowsill of the
resident’s room.
During an observation and interview on 08/30/18 at 10:24 A.M., the resident said he/she
used to have a bug problem in his/her room. He/she said the facility was informed and now
there are no bugs.
During an observation and interview on 08/30/18 at 10:26 A.M, the resident’s roommate said
the resident used the bug spray for bugs in the air.
During an interview on 8/30/18at 2:07 P.M., the administrator said he/she cannot catch
everything. He/she said staff members have been trained to remove chemical substances from
resident’s rooms if they see it. He/she said that sometimes the resident’s family bring
things in. He /she said he/she was not aware of chemical substances in the resident’s
room. If informed, he/she would have made a quick note to remove it from the room.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 26)
Based on observation, interview and record review, the facility failed to ensure [MEDICAL
TREATMENT] services were contracted for, services were ordered, and communication with the
[MEDICAL TREATMENT] clinic was obtained for one of three sampled [MEDICAL TREATMENT]
residents (Resident #3). The facility census was 60 residents.
Record review of Resident #3’s admission face sheet, showed the resident was admitted to
the facility on [DATE] with [DIAGNOSES REDACTED].>-End stage [MEDICAL CONDITION]
(Kidney failure);
-Diabetes Mellitus; and
-[MEDICAL CONDITION] (abnormal brain function or brain structure).
Review of the resident’s 8/23/18-8/31/18 POS showed:
-[MEDICATION NAME] (used to control phosphorus levels in people with [MEDICAL CONDITION]
who are on [MEDICAL TREATMENT]) 800 mg (milligram) 2 tablets by mouth (PO) three times
daily with meals (5:00 A.M., 2:00 P.M., and 10:00 P.M.);
-Nepro (specialized renal nutrition for people at different stages of kidney disease) one
can PO daily;
-[MEDICATION NAME] (a vitamin containing [MEDICATION NAME] acid, [MEDICATION NAME], folic
acid, [MEDICATION NAME] and [MEDICATION NAME] acid) one capsule PO daily at 5:00 A.M.;
-No [MEDICAL TREATMENT] (the clinical purification of blood by [MEDICAL TREATMENT], as a
substitute for the normal function of the kidney) orders indicating the resident is
receiving [MEDICAL TREATMENT] treatments, what company is providing the services and what
days the resident attends;
-No orders to check the [MEDICAL TREATMENT] catheter (a catheter used for exchanging blood
to and from a [MEDICAL TREATMENT] machine and a patient);
-No order to monitor the resident’s weight;
-No order to monitor the resident’s intake and output.
Record review of the resident’s medical record, showed no written communication from the
[MEDICAL TREATMENT] clinic.
Record review of the resident’s undated comprehensive care plan showed:
-The resident goes to [MEDICAL TREATMENT] 3 times a week on Tuesday, Thursday and
Saturday.
-Weigh the resident upon return from [MEDICAL TREATMENT].
-No blood pressure (BP) on the arm with the [MEDICAL TREATMENT] catheter.
-Monitor and report signs of localized/systemic infection (fever, lassitude or malaise,
localized swelling, redness, pain or tenderness at [MEDICAL TREATMENT] site, change in
mental status).
-One can of Nepro BID.
-The [MEDICAL TREATMENT] clinic the resident uses was not noted.
-Order to monitor the resident’s intake and output was not noted.
During an interview on 8/29/18 at 4:30 P.M., the resident said:
-Staff does not look at or monitor the [MEDICAL TREATMENT] catheter site.
-The staff does not weigh him/her when he/she gets back from [MEDICAL TREATMENT].
-Staff takes blood pressures on both arms.
-Staff does not monitor or document his/her output when he/she uses the bathroom.
-He/she does not bring paperwork back from [MEDICAL TREATMENT] visits.
Observation of Medication Administration Record [REDACTED].M., showed certified medication
technician (CMT) K:
-Attempted to take resident’s blood pressure (BP) with a wrist cuff on the resident’s
right wrist;
-Was unable to get a BP reading;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 27)
-Attempted to use the cuff on the resident’s left wrist with no results;
-Went to the cart and retrieved an electronic arm cuff and attempted to obtain a BP with
no results x2 (once on the right upper arm and once on the left upper arm);
-Returned to the resident’s room with the wrist cuff at 4:56 P.M. and was unable to obtain
a BP on the resident’s right wrist;
-Did not administer the resident’s medications and told the resident that he/she would
have the Nurse come and obtain the resident’s BP;
-As of 6:08 P.M., the resident still had not received his/her medications.
During an interview on 8/30/18 at 7:39 A.M. the resident’s physician said:
-He/she expected staff to use the arm that did not have the [MEDICAL TREATMENT]
shunt/catheter for blood pressures and venipunctures;
-It was unacceptable to obtain a blood pressure in the arm with the shunt/catheter;
-He/she does not approve of using a wrist cuff for blood pressures;
During an interview on 8/30/18 at 10:08 A.M. Nurse L said:
-There should have been an order to check [MEDICAL TREATMENT];
-There should have been an order in chart showing the name of the [MEDICAL TREATMENT]
clinic the resident was to receive services and the days and times the resident went to
the [MEDICAL TREATMENT] clinic;
-The [MEDICAL TREATMENT] clinic does not routinely send paperwork back with the resident;
-Nurse R usually calls once a week to get the resident’s weights;
-[MEDICATION NAME] should be given with meals;
-The [MEDICATION NAME] administration times should have been changed to meals times.
During an interview on 8/30/18 at 12:58 P.M., the Administrator and Director of Nursing
said:
-The facility does not get any type of communication from the [MEDICAL TREATMENT] clinic
unless there is an issue or they need something done like a lab or something;
-Staff does not perform weights when resident gets back from [MEDICAL TREATMENT];
-Staff does not monitor the resident’s input and output related to [MEDICAL TREATMENT];
-It is not acceptable for staff to take a BP in the arm with the [MEDICAL TREATMENT]
catheter;
-There is not an order in the resident’s chart for [MEDICAL TREATMENT] including the
clinic the resident goes to or the days and times he/she receives services;
-The facility does not have a [MEDICAL TREATMENT] contract with any of the [MEDICAL
TREATMENT] clinics their resident’s attend. The facility has never had a contract for
[MEDICAL TREATMENT] services.
Record review of the facility’s Care of [MEDICAL TREATMENT] Procedure dated revised on
7/1/13 showed:
-Review physician orders;
-Monitor for complications of [MEDICAL TREATMENT]:
-Monitor strict intake and output.
-Monitor blood pressure.
-Do not obtain blood pressures or vein puncture on the arm with vascular access.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
Based on interview and record review, the facility failed to ensure each nurse aide had no
less than 12 hours of in-service education per year based on their individual performance
review, calculated by their employment date rather than the calendar year. Of seven
certified nursing assistants (CNAs) employed at the facility for more than a year, five
were selected for sample. Issues were identified with all five. The census was 60.
Review of the CNA training record binder, showed:
-CNA F date of hire 2/24/12, six hours of training documented from (MONTH) (YEAR) through
(MONTH) (YEAR);
-CNA B date of hire 6/14/16, 11 hours and 5 minutes of training documented from (MONTH)
(YEAR) through (MONTH) (YEAR);
-CNA G date of hire 12/3/13, three hours and 50 minutes of training documented from
(MONTH) (YEAR) through (MONTH) (YEAR);
-CNA H date of hire 3/14/14, 10 hours of training documented from (MONTH) (YEAR) through
(MONTH) (YEAR);
-CNA I date of hire 3/1/02, 10 hours and 45 minutes of training documented from (MONTH)
(YEAR) through (MONTH) (YEAR);
-Several trainings with no length of time indicated;
-No method for tracking or tallying the number of hours completed per CNA based on
employment dated.
During an interview on 8/30/18 at 8:03 A.M., the Director of Nursing (DON) said she is the
person responsible for CNA training. It used to be the responsibility of the assistant
DON, but he/she left employment a few months ago. She tracks by hire date, but is not sure
how the assistant DON tracked hours. If there is no documentation indicating how long an
in-service lasted, she would not know. After the assistant DON left, she started to tally
staff dates starting with their most recent employment month date anniversary though
current. There is now a way to keep a running tally of the number of hours each CNA has
completed.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure a
medication error rate of less than 5%. Out of 28 opportunities, five errors occurred which
yields a medication error rate of 17.86%. The facility census was 60 residents.
1. Record review of Resident #15’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with diagnoses that included:
-[MEDICAL CONDITION] (nerve pain);
-Pain.
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
-[MEDICATION NAME] (for nerve pain) 300mg (milligrams) by mouth (PO) four times daily;
-Creon DR (delayed release-for pancreatic insufficiency) 12,000 units, two capsules four
times daily with meals and snacks;
-[MEDICATION NAME] (narcotic pain medication) 5/325 mg one tablet every 6 hours for pain.
Observation of medication pass on 8/29/18 at 5:32 P.M., showed certified medication
technician (CMT) K:
-Popped [MEDICATION NAME] into a medication cup;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
-Looked in the medication cart and was unable to find the resident’s [MEDICATION NAME]
300mg and [MEDICATION NAME] 5/325 mg;
-Administered [MEDICATION NAME] only;
-The resident’s [MEDICATION NAME] 300 mg and [MEDICATION NAME] 5/325 mg was not
administered due to the medications unavailability;
-CMT K said the resident did not get the medications because they were not available.
2. Record review of Resident #23’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with diagnoses that included [MEDICAL CONDITION].
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] (anticonvulsant) 25 mg PO two times daily. No [DIAGNOSES REDACTED].
Observation during a medication administration on 8/29/18 at 4:35 P.M. showed CMT K:
-Looked in the medication cart and was unable to find the resident’s [MEDICATION NAME] 25
mg. This medication was not administered due to unavailability.
-CMT K said the resident did not get the medications because they were not available.
3. Record review of Resident #32’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with diagnoses that included:
-Diabetes Mellitus (DM).
Record review of the resident’s (MONTH) (YEAR) POS showed:
-[MEDICATION NAME] HCL (for DM) 1000 mg every morning and evening with meals.
Observation of medication administration on 8/29/18 4:43 P.M. showed CMT K:
-Looked in the medication cart and was unable to find the resident’s [MEDICATION NAME] HCL
1000 mg. This medication was not administered due to unavailablity.
-CMT K said the resident did not get the medications because they were not available.
4. Record review of Resident #57’s admission face sheet, showed the resident was admitted
to the facility on [DATE] with diagnoses that included:
-Biliary [MEDICAL CONDITION] (a progressive disease of the liver);
-Pain.
Record review of the resident’s (MONTH) (YEAR) POS showed:
-Senna 8.6 mg, two times daily.
-[MEDICATION NAME] 500 mg, two times daily.
-[MEDICATION NAME] 5 mg every six hours for pain.
Observation during a medication administration on 8/29/18 at 4:38 P.M., showed CMT K:
-Popped Senna 8.6mg and [MEDICATION NAME] 500 mg into a medication cup.
-The resident refused the Senna 8.6mg and CMT threw into trash can on med cart.
-[MEDICATION NAME] HCL 5mg was not administered to the resident due to unavailability.
-CMT K said the resident did not get the medications because it was not available.
5. During an interview on 8/29/18 at 5:38 P.M. CMT K said:
-It is not uncommon for medications to be unavailable for more than a day or two;
-If medication is not available, she/he lets the nurse know;
-Staff orders medications and they never come in from the pharmacy, and this happens
often.
6. During an interview on 8/29/18 at 7:25 A.M., the administrator said:
-The facility started with a new pharmacy company on 8/1/18;
-If a medication is not available, he/she expects the nurse to look in the emergency
supply kit, and if it is not in there, they should call the pharmacy;
-The pharmacy has a super stat delivery system that is supposed to get medications to the
facility in two hours;
-If a resident misses 3 doses of a medication, nursing must call and notify the resident’s
physician.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
7. During an interview on 8/30/18 at 7:39 A.M., the resident’s physician said:
-Anything over 3 doses of a medication not being available and not administered is
excessive.
-He/she expects staff to notify him/her if a medication is not available.
-It is not always the facility’s fault, sometimes pharmacy doesn’t get the medications to
them.
-He/she expects staff to follow all orders as written.

F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to ensure medications, on two of
four medication carts, were appropriately labeled and dated after being opened. The census
was 60.
1. Observation of 8/29/18 at 8:01 A.M., of the 200/300 hall medication cart, showed:
-One bottle with approximately 100 capsules, with no label. There had been a label, but it
had been peeled off;
-One bottle of latanoprost 0.005% (eye drop used to treat [MEDICAL CONDITION]), with no
open date.
During an interview on 8/2/9/18 at 8:10 A.M., Certified Medication Technician Q said
he/she knows the medication in the bottle was [MEDICATION NAME] [MEDICATION]) and who it
belongs to. The resident doesn’t have an order for [REDACTED]. The latanoprost eye drop
bottle was good for 30 days after being opened. Whoever opened it didn’t put the date it
was opened.
2. Observation on 8/29/18 at 8:54 A.M., of the 100/700 medication cart, showed:
-One open bottle of [MEDICATION NAME] 0.5% (eye drop used to treat [MEDICAL CONDITION]),
with no open date;
-One bottle of olopatadine 0.2% (drop to treat allergy related itchy watery eyes), with an
open date of 7/23/18.
During an interview on 8/30/18 at 6:56 A.M., Registered Nurse L said staff should write
the date opened on a bottle of eye drops and then it was good for 28 to 30 days depending
upon the specific medication.
3. During an interview on 8/30/18 at 7:24 A.M., the administrator said the facility policy
doesn’t state the days to discard after opening an eye drop, but staff are taught to
discard after 28 days. Medications should be labeled with the residents name, the type of
medication and the order.
4. During an interview on 8/30/18 at 12:57 P.M., the Director of Nurses said medications
that were unlabeled and not in use should not be left on the medication cart.

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.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

Based on observation and interview, the facility failed to follow recipes for three of
four pureed meals observed for five residents on puree diets. The facility census was 60.
1. Observation on 8/28/18 at 11:00 A.M., showed the dietary manager (DM) prepared pureed
meatloaf. He/she used five cups meatloaf, removed from the meatloaf tray, five slices of
bread and four cups milk. He/she placed the meatloaf, bread slices, and cups of milk into
the blender and pureed the items for approximately one minute. The DM took the top off the
blender and tested the consistency with a spatula. The puree was thin and soup like. The
DM said the consistency was not where it should be so he/she needed to add more bread. The
DM added three additional slices of bread at this time and pureed the meatloaf for an
additional minute. The consistency remained thin. The DM said the pureed meatloaf would
thicken as it warmed in the oven.
Review of the pureed meatloaf recipe, showed the following for five servings:
-15 ounces of meat;
-1 1/4 cups of broth;
-2 1/2 slices of bread;
-Place in the food processor.
2. Observation on 8/29/18 at 7:16 A.M., showed the dietary manager (DM) prepared pureed
pancakes. He/she use ten pancakes, removed from the pancake tray and syrup from a metal
container. The DM placed the ten pancakes into the blender and poured an unmeasured amount
of syrup into the blender. The DM said the recipe called for milk but he/she would use the
syrup instead. The DM pureed the items for approximately one minute. The puree was thick
like in consistency.
Review of the pureed pancake recipe, showed the following for five servings:
-5 servings of pancakes;
-1 cup of milk;
-Place in the food processor.
3. Observation on 8/29/18 at 7:23 A.M. showed the dietary manager (DM) prepared pureed
breakfast sausage. He/she use five cups sausage, removed from the sausage tray, and broth
from a metal container. The DM placed the sausage into the blender and poured an
unmeasured amount of broth into the blender. The DM pureed the items for approximately one
minute. The DM took the lid off the top of the blender and used a spatula to stir the
mixture. The puree was thin and watery like in consistency. The DM said when the
consistency is not achieved, he/she will not use thickener; bread will be used instead.
The DM used five slices of bread in the mixture and pureed the items for approximately
another minute.
Review of the pureed breakfast sausage recipe, showed the following for five servings:
-10 ounces of sausage;
-6 2/3 cups of broth;
-Place in the food processor.
During interviews on 8/28/18 at 8:59 A.M., and 8/30/18 at 12:30 P.M., the dietary manager
(DM) said when preparing puree meals, he/she use a spread sheet which tells her what size
each puree get and a recipe book to tell her what each puree need. The DM said he/she
should be consistent with following the recipe book or spread sheet instead of switching
back and forth between the two. The DM said it is important to follow the recipes as
written when preparing the puree meals. He/she further said it is important to follow the
policy when preparing the meals.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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

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, interview, and record review, the facility failed to date all food
inside the walk in cooler, storage room, and freezer. These deficient practices had the
potential to affect all residents who ate at the facility. The facility census was 60.
Observations on 8/27/18 at 9:20 A.M., 8/28/18 at 8:59 A.M., 8/29/18 at 7:30 A.M. and
8/30/18 at 8:30 A.M., showed:
-Container of beef base in the storage room on the shelf dated 3/8/18;
-Opened jar jelly in the cooler, date not legible;
-Four bags of sandwich buns on bottom shelf in freezer without dates;
-Three bags of fries on shelf in freezer without dates;
-Open box in freezer containing 4 bags of frozen mixed vegetables, without dates;
-Brisket on bottom shelf in freezer without a date.
During an interview on 8/30/18 at 9:00 A.M., the dietary manager said his/her method for
using items on the shelves is using old items first then the newer items. The DM said
he/she rotates the old items out for the new items so that he/she can get rid of old items
and then discard all old items. The DM said the meat on the bottom shelf in the freezer
was a brisket. He/she said he/she had forgotten about it. He said all foods in the storage
areas, cooler and freezer should have a date.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed acceptable infection control standards during three of three observations of
staff providing incontinence care. In addition, the facility failed to ensure soiled
linens were not stored next to the clean linen. (Residents #39 and #43). The census was
60.
1. Review of Resident #39’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 7/14/18, showed the following:
-Usually understood;
-Understands;
-Extensive assistance of one person required for dressing, personal hygiene and bathing;
-[DIAGNOSES REDACTED].
Observation on 8/28/18 at 4:58 A.M., showed the resident lay in bed wearing a wet
incontinence brief. Certified Nursing Assistant (CNA) A donned a pair of gloves, removed
the resident’s incontinence brief and washed the resident’s genitalia then the resident’s
buttocks. Without removing his/her gloves, the CNA touched the following items wearing the
soiled gloves: Side rail, bed remote control, privacy curtain, entrance door door handle
and as he/she dressed the resident, both of the resident’s ankles, the new incontinence
brief, pants and shirt. The CNA did not removed his/her soiled gloves until he/she stepped
out into the hall to discard the soiled linens. During an interview, the CNA said he/she
should have removed his/her soiled gloves after washing the resident’s genitalia and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265586

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

NAME OF PROVIDER OF SUPPLIER

ST LOUIS PLACE HEALTH & REHABILITATION

STREET ADDRESS, CITY, STATE, ZIP

2600 REDMAN ROAD
SAINT LOUIS, MO 63136

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 – Some

(continued… from page 33)
buttocks and prior to touching anything clean to avoid spreading germs.
Observation on 8/29/18 at 6:01 A.M., showed the resident lay in bed wearing a wet
incontinence brief. CNA B donned a pair of gloves removed the incontinence brief and
washed the resident’s genitalia and buttocks. Without removing his/her soiled gloves, the
CNA touched a package of disposable wipes and the new incontinence brief before changing
gloves. During an interview at that time, the CNA said he/she should not have touched the
package of disposable wipes and new incontinence brief with the soiled gloves to avoid
spreading infection.
2. Review of Resident #43’s quarterly MDS, dated [DATE], showed the following:
Understood/understands;
-Extensive assistance of one person required for dressing, personal hygiene and bathing;
-[DIAGNOSES REDACTED].
Observation on 8/29/18 at 9:20 A.M., showed the resident lay in bed wearing a wet
incontinence brief.
CNA’s D and E provided incontinence care. CNA D washed the resident’s genitalia, then
assisted the resident to his/her side as CNA E washed the resident’s buttocks. CNA E
removed his/her gloves after washing the resident’s buttocks, donned a new pair of gloves
then washed the resident’s buttocks again. Without removing those gloves, CNA E touched
the new incontinence brief before removing his/her soiled gloves.
3. During an interview on 8/30/18 at 12:57 P.M., the Director of Nurses (DON) said she
expects staff to remove their soiled gloves prior to touching anything clean to limit
cross contamination. She expects staff to follow the facility policy.
4. Review of the facility Peri-Care Policy, dated 7/1/13 and revised on 10/27/16, showed
after cleansing the genitalia and buttocks, staff should discard their soiled gloves and
wash their hands.
5. Observation on 8/29/18 at 7:21 A.M., showed staff transported a three level clean linen
cart, stocked with clean linen, up the 400 hall, down the 700 hall and into the 700
central bath. Staff stored the linen cart in the central bath uncovered with a yellow
dirty linen bin within 4 inches of the clean linen cart.
Observation on 8/30/18 at 6:50 A.M., showed the central bath between the 200 and 300 hall
with a three level clean linen cart. Only the top self was covered. The bottom two
shelves, stocked with clean linen and uncovered. At 8:34 A.M., the clean linen cart
remained in the central bath. The cover over the top shelf draped to the side and all
three shelves of clean linen uncovered.
During an interview on 8/30/18 at 8:26 A.M., the maintenance supervisor said he is also
the supervisor over the laundry department. The yellow tubs are for dirty linen. The
laundry department takes the clean linen to the linen storage room. Nursing staff then
stock the small carts and store them in the central baths. They should be covered and
dirty linen should not be stored next to them.