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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 – Few

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to verify code status (FULL CODE
– if the heart stops beating or breathing ceases, all life saving methods are performed;
or NO CODE – do not resuscitate, no life prolonging methods are performed) by having
conflicting information in the medical record for one resident (Resident #75) and not
obtaining a signed code sheet for one resident (Resident #34). The sample size was 19. The
census was 73.
1. Review of Resident #75’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated [DATE], showed the following:
-No cognitive impairment;
-Extensive assistance required for mobility and personal care;
-[DIAGNOSES REDACTED].
Review of the medical record, showed an 8 inch by 11 inch green sheet of paper in the
front of the chart with black block letters that read FULL CODE. There was no facility
code status form in the chart.
Review of the physician’s orders [REDACTED].
Review of the care plan, dated [DATE], showed the following:
-Problem: Resident has chosen to be a do not resuscitate;
-Goal: Resident’s wishes will be followed;
-Approaches: DO NOT initiate CPR (cardio-pulmonary resuscitation) if found without a
heart beat or
respirations, notify family of death, notify funeral home and provide post mortem care.
2. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADLs);
-Upper extremity impairment on one side and lower extremity impairment on both sides;
-At risk for pressure ulcers;
-Gastrostomy ([DEVICE], a tube surgically inserted into the stomach to provide hydration,
nutrition and medications) tube;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Tracheotomy (Tube surgically inserted into the trachea for the purpose of breathing);
-[MEDICAL CONDITION] (A surgical procedure that brings one end of the large intestine out
through the abdominal wall);
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed an 8 inch by 11 inch sheet of green paper
with FULL CODE in the front of the record. There was no signed outside the hospital Do Not
Resuscitate (OHDNR) form found in the medical record. As late as 2:00 P.M. on [DATE], the
facility did not provide the resident’s OHDNR form.
Review of the resident’s care plan, updated [DATE], showed the following:
-Problem, code status is full code;
-Goal, resident’s wishes will be carried out;
-Approach, in the event of a respiratory or [MEDICAL CONDITION], initiate CPR;
-Notify physician/family of resident status.
Review of the resident’s POS, dated [DATE] through [DATE], showed the resident’s status as
full code.
3. During an interview on [DATE] at 9:00 A.M., the Director of Nursing said code status is

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 – Few

(continued… from page 1)
listed in the chart on a sheet of paper directly in the front of the chart. The form is
green in color. It is also written on the POS and on an OHDNR. If someone chooses to be a
full code, they sign the revocation on the OHDNR form. He said the OHDNR form is always
purple in color but they started making it white because it caused too much confusion. He
said in an emergent situation, he expected staff would look in the front of the chart and
ideally also the POS. He said the facility does not have a facility code status form; they
use the OHDNR form. He said it is important for all three places to match.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to issue a Skilled Nursing
Facility Advanced Beneficiary Notice (SNF ABN), a Centers for Medicare and Medicaid
Services (CMS) Form (a required notice to beneficiaries of covered skilled services
ending) when benefits were not exhausted and the resident remained in the facility, for
two of three sampled residents (Resident #30 and #61), who remained in the facility upon
discharge from Medicare Part A services. The facility’s census was 73.
1. Review of Resident #61’s medical record, showed:
– The resident’s Medicare Part A skilled services, start date of 12/29/18 and end date of
2/14/19;
– The facility initiated a discharge on 2/12/19 from Medicare Part A Services when benefit
days were not exhausted;
– No SNF ABN Form issued.
2. Review of Resident #61’s medical record, showed:
– The resident’s Medicare Part A skilled services, start date of 11/26/18 and end date of
12/20/18;
– The facility initiated a discharge on 12/18/18 from Medicare Part A Services when
benefit days were not exhausted;
– No SNF ABN Form issued.
3. During an interview on 4/2/19 at 10:45 A.M., the social worker said, at times, she
supplies the SNF ABN Form . She called the responsible party for Resident #30 and spoke to
Resident #61 in person. She did not issue the forms. She knows she should have provided
the ABN SNF Form and had access to them.
4. During an interview on 4/3/19 at 9:00 A.M., the administrator said she would expect the
SNF ABN Form to be provided when appropriate.

F 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to establish a grievance policy

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0585

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
that included the name of the Grievance Official and failed to notify residents
individually, or post the name of the official, including contact information. The census
was 73.
1. Review of the facility’s Social Services Policies and Procedures for
complaints/Grievances Process, revised 5/1/18, showed the following:
-Procedure, the facility will identify a Grievance Official who is responsible for
overseeing the grievance process, receiving and tracking grievances through their
conclusion and leading the investigation, maintaining the confidentiality of all
information associated with the grievance;
-Post the contact information of the Grievance Official with whom a grievance can be
filed, that is, his or her name, business address (mailing and email) and business phone
number;
-Grievances/complaints are accepted by the following, but not limited to:
-Administrator;
-Department manager or his/her designee;
-Supervisor;
-Unit manager.
2. During a meeting and interview with the resident council on 3/29/19 at 9:30 A.M., and
attended by the resident council president and five other residents, all six residents
agreed they did not know who the facility’s Grievance Official was or how to file a
grievance. A couple of years ago, the social worker said to come to him/her to file a
grievance, and it would be followed up on. Since then, the facility had many changes in
staff. Some took their concerns to the Director of Nursing and others mentioned they spoke
with the social worker.
3. During an interview on 4/3/19 at 9:00 A.M., the administrator said the social worker
was the facility’s Grievance Official. They just started a guardian angel program where
department heads were assigned residents and met with them weekly to find out any concerns
they may have. Any concerns were given to the social worker to follow up. The residents
were notified which staff was their guardian angel. This may have caused come confusion
with them not knowing who the Grievance Official was. The Grievance Official should be
named in the facility’s policy.

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow appropriate discharge
procedures and complete discharge and/or transfer documentation. This affected two of four
reviewed closed records (Residents #178 and #77). The census was 73.
1. Review of Resident #178’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/19/18, showed the following:
-admission date of [DATE];
-Cognitively intact;
-No behaviors;
-Required extensive assistance from staff for toileting, hygiene, dressing and transfers;

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
-[DIAGNOSES REDACTED].
Review of the resident’s closed medical record, showed the following:
-A face sheet with an admission date of [DATE] and a discharge date of [DATE];
-An admission evaluation, dated 9/11/18, showed the following:
-Discharge potential: Guarded;
-Discharge anticipated within 90 days of admission? No, due to dependent on others for
all activities of daily living, condition expected to deteriorate, mental health status;
-Discharge plan of care, dated 9/20/18, Goal: will strengthen body; or accept assistance
with help at home;
-Discharge plan review, dated 12/20/18, resident wants to be independent and reports
wanting to return home. However, appears to not be realistic about needing a mechanical
lift or accepting assistance such as psychiatrist, or what he/she can do for self. Next
review date: (MONTH) 2019.
Review of the social service notes, showed the following:
-A social service care plan note, dated 12/20/19, showed neither the resident nor a
representative attended. The social worker from the resident’s [MEDICAL TREATMENT] center
(process for removal of waste and excess water from the blood due to kidney failure)
called to ask about the resident’s diet and discharge plans. The social service designee
(SSD) explained the resident’s goal was to return home, but it would be difficult since
the resident was dependent on others for care and the resident’s son was unable to assist
due to his own health concerns. The [MEDICAL TREATMENT] center social worker was in
agreement. The SSD tried to talk to the resident’s durable power of attorney (DPOA) and
appeared to be more helpful than going to the resident. The DPOA could get more
accomplished. The resident was alert and oriented to person, place and time. The resident
had a [DIAGNOSES REDACTED]. The resident refused seeing a psychiatrist;
-A social service note, dated 3/13/19, showed the SSD prepared discharge paperwork. The
unit manager, Nurse B, discussed the discharge instructions with the resident. The SSD
spoke with the resident’s DPOA on 2/26/19, about the resident being happier somewhere
else. The SSD would send referrals and give the resident options about moving. The DPOA
understood the resident’s concerns and understood the resident was accepted at another
facility. The SSD spoke with the DPOA every step of the way due to the resident talking to
third parties about what needed to happen with his/her care, instead staff. The SSD
explained the resident could get what he/she wanted sooner by coming to a facility staff
member rather than a third party. The resident did not understand why he/she was being
transferred. The resident reported he/she didn’t want to be at the facility and wanted a
different facility. The DPOA and resident were agreeable to transfer;
-The staff did not document what resources were provided to the resident regarding the
selection of another nursing home.
Review of the nurses’ notes, showed the following:
-A note, dated 3/13/19 at 11:45 A.M., showed the resident returned from [MEDICAL
TREATMENT] and made aware the facility he/she chose would be there to transfer him/her
between 1:00 P.M. and 2:00 P.M.;
-A note, dated 3/13/19 at 2:05 P.M., showed the other nursing home there to transport the
resident. The DPOA was present at the bedside. Both the resident and the DPOA received
discharge instructions about medications and follow-up appointments. They refused to sign
the discharge paperwork. Two nurses signed that verbal consent was given and instructions
were provided;
-A note, dated 3/13/19 at 5:00 P.M., showed, clarification: Resident does not want to be
at the nursing home, as also stated to others, signed by the Director of Nursing (DON);
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-Staff did not document any conversations with the resident regarding his/her voiced
concerns or the resident’s desire to leave.
Review of the (MONTH) 2019 physician order [REDACTED]. The order did not say why the
resident needed to be discharged or if it was at the resident’s request.
Review of the resident’s discharge paperwork, dated 3/13/19, showed the following:
-Discharge to: long term care facility;
-Reason for discharge: left blank;
-Physical and mental function status: Has increased anxiety and tendency to self-isolate;
-Mental and psychosocial status: Alert and oriented;
-Activities potential: Enjoys watching television, visiting with son and friends;
-Social service discharge summary: Has supportive son and friends. Goes to [MEDICAL
TREATMENT] three times a week. Has a tendency to tell third party companies he/she does
not want to be at facility. When facility staff try to discuss, resident is not honest.
Encourage psychiatrist to meet with resident and possibly psychologist;
-Nursing: Course of treatment while in facility, including complications:
-[MEDICAL TREATMENT] three times a week;
-Incontinent;
-Reposition;
-Total/dependent on care;
-Light on side of table. Reports to be legally blind;
-Summary of length of stay:
-discharge date /time: 3/13/19, no time documented;
-Reason for discharge: Staff checked Resident and/or family request transfer to another
long term care facility for personal reasons;
-I (resident) have received and understand the above information and instructions: left
blank;
-The resident did not sign the document.
Review of the resident’s Discharge Instructions for Care, dated 3/13/19, and included in
the closed record, showed the following:
-You are being discharged to: Staff wrote current nursing home name and address;
-Resources/services: State Ombudsman contact information provided, home healthcare: not
applicable, other: Staff wrote nursing home resident transferring to;
-The Discharge Instructions for Care have been reviewed with me in a language I
understand, and my questions have been answered to my satisfaction. I have received the
medications or prescriptions listed above. Signature of Person Receiving Instructions:
Staff wrote Refused to sign. Gave verbal instructions;
-The resident did not sign the document.
During an interview on 3/14/19 at approximately 11:00 A.M., the resident said he/she just
admitted to the new facility on 3/13/19, but did not want to be discharged . Nurse B just
came in to the resident’s room and said You’re being transferred and gave no notice or
choice in the matter. The resident was told it was because he/she complained about
everything and did not seem happy there. The resident was angry about the discharge and
was tearful during the interview. The resident’s only family member was his/her son, and
he cannot drive to visit him/her. He/she received [MEDICAL TREATMENT] three times a week
and liked the center by the other nursing home. The resident was afraid he/she would have
to transfer to a new [MEDICAL TREATMENT] center.
During an interview on 4/2/19 at 10:45 A.M. the SSD said the resident’s discharge was an
odd case. The resident wouldn’t say if he/she wanted to move to another facility, but
asked for a list of phone numbers to check on other homes. The SSD went through the DPOA
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
to figure out how to make the resident more comfortable, but the resident’s behaviors
escalated as evidenced by claiming he/she did not feel comfortable at the nursing home. It
was common behavior for the resident to say he/she did not want to be there, but would
also say he/she didn’t want to leave. The SSD said he/she should have documented more of
these conversations and what she did to try to assist the resident. The resident was
provided with a booklet which contained a list of nursing homes in the area. The SSD
believed this was the resident’s way of saying he/she wanted to move. The SSD included the
DPOA in the process and thought he/she would be more instrumental. She assumed the DPOA
was also talking to the resident about moving. The resident did not want to discharge to a
different facility and did not sign the discharge paperwork. The SSD assumed the resident
wanted to leave because he/she asked for phone numbers of other nursing homes.
On 4/2/19 at 2:19 P.M. the SSD provided additional documentation regarding the resident.
This documentation was in her office and not in the closed record provided to the state
surveyor. Review of the documentation, showed the following:
-A social service note, dated 3/7/19, showed the SSD spoke with the DPOA regarding options
for other nursing homes. The SSD complied with sending referrals to the nursing homes the
DPOA approved of. The resident was given a booklet of area nursing home and the SSD
observed the resident to be bewildered. They talked about the resident not being happy at
the nursing home and how a different environment could be better for the resident;
-A social service note, dated 3/8/19, showed the SSD followed up with the resident. The
resident said he/she did not have a preference in nursing home choices. The resident
enjoyed seeing his/her son. However, the DPOA reported he/she could not always transport
the son to the nursing home. The resident and the DPOA were notified referrals would be
sent and the resident could choose from facilities;
-A social service note, dated 3/11/19, showed a representative from another nursing home
came to assess the resident and accepted the resident. The resident became tearful and
bewildered. The resident reported he/she did not want to go to that nursing home.
During an interview on 4/2/19 at 1:30 P.M., the administrator said she was under the
impression the discharge was the resident’s desire and the SSD had documentation to back
this up. She was aware of the resident’s discharge, but the SSD was handling it. They have
worked on improving their discharge process.
2. Review of Resident #77’s care plan, revised 11/30/18, showed no assessment for
discharge planning.
Review of the resident’s admission MDS dated [DATE], showed the following:
-admission date of [DATE];
-Severe cognitive impairment;
-Extensive staff assistance needed with toileting, hygiene, transfers and mobility;
-Used a tube feeding (hollow tube surgically inserted into the stomach to provide liquid
nutrition) for nutrition;
-[DIAGNOSES REDACTED].
-Expected to remain at the facility;
-No discharge planning.
Review of the medical record, showed the following:
-A nurse communication form, dated 2/4/19, stated the resident had a change in condition
and the resident’s feeding tube had become dislodged. The nurse notified the resident’s
physician and received a new order noted to send the resident to the emergency room for
evaluation and treatment;
-The social service progress notes showed no follow-up discharge documentation.
During an interview on 4/2/19 at 11:17 A.M., the social worker said the resident left 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
facility to the hospital on [DATE]. She called the hospital and was told by the hospital
case manager the resident would not be readmitted into the facility. She did not write a
discharge summary in the resident’s medical record. She forgot to write the discharge
summary.
During an interview on 3/29/19 at 11:46 A.M., the administrator said there should have
been a nurse and social worker discharge progress note, which should include where the
resident discharged to and what the facility did to help with the discharge.

F 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

PASARR screening for Mental disorders or Intellectual Disabilities

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure residents with a
mental disorder and individuals with intellectual disability had a DA-124 level I screen
(used to evaluate for the presence of psychiatric conditions to determine if a
preadmission screening/resident review (PASARR) level II screen is required) as required
for four of 19 sampled residents (Residents #44, #33, #28 and #21). The census was 73.
1. Review of Resident #44’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-Independent with most ADLs;
-Continent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-No DA-124 level I screen found;
-No PASARR level II screen found.
2. Review of Resident #33’s quarterly MDS, dated [DATE], showed the following:
-admitted to the facility on [DATE];
-No cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-No DA-124 level I screen found;
-No PASARR level II screen found.
3. Review of Resident#28’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Verbal behaviors occurred between one to three days of seven days observed;
-Required extensive assistance from staff for bed mobility, transfers, dressing and
toileting;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed no DA-124 level I screen found.
4. Review of Resident #21’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Behaviors occurred on 4-6 days of seven days observed;
-Required extensive assistance from staff for most activities of daily living;
-[DIAGNOSES REDACTED].
Review of the resident’s medical records showed the following:
-No DA-124 Level I screening;
-No PASARR Level II screening.

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0645

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
5. During an interview on 4/3/19 at 9:00 A.M., the administrator said the hospital social
worker initiated Level 1, and PASARR level II screenings, if needed, prior to a resident
being admitted . The facility social worker was responsible for initiating and maintaining
them for the remainder. There should be a system in place for auditing screenings and
making them part of the residents’ medical records.

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 change an
ordered peripherally inserted central catheter (PICC, used for extended intravenous (IV)
therapy) dressing (Resident #75), failed to ensure diagnoses had been provided for ordered
antibiotic use and antibiotics were administered as ordered (Residents #75, #3 and #63),
failed to ensure the discontinuation of ordered compression stockings (TED hose, aide in
blood circulation in the legs) (Resident #44), failed to ensure oxygen orders were entered
onto the physician order [REDACTED].#33 and #17), and failed to document the placement of
an electronic monitoring device (Resident #36). This affected eight out of 19 sampled
residents. The census was 73.
1. Review of Resident #75’s admission Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 3/21/19, showed the following:
-No cognitive impairment;
-Extensive assistance required for mobility and personal care;
-Received IV medications;
-Received antibiotics seven of seven days;
-Diagnoses included heart failure, diabetes, [MEDICAL CONDITION] and right above the knee
amputation.
Review of the physician’s orders [REDACTED].
-Diagnoses included osteo[DIAGNOSES REDACTED] (bone infection) of the vertebrae, sacral
(bony structure at the base of the vertebrae) and sacrococcygeal (tailbone) region;
-An order, dated 3/7/19, to administer [MEDICATION NAME] (antibiotic) 2 grams (gm) IV in
50 milliliters (ml) of saline every twelve hours. Staff had not documented a [DIAGNOSES
REDACTED].
-An order, dated 3/7/19, to flush the PICC line with 10 cubic centimeters (cc)s of normal
saline (NS) every 12 hours before and after the IV antibiotic;
-An order, dated 3/7/19, to change the PICC line dressing every three days and as needed
(PRN).
Observations on 4/1/19 at 2:00 P.M., 4/2/19 at 10:00 A.M. and 4/3/19 at 7:34 A.M., showed
the resident lay in bed and the PICC line dressing showed a date of 3/29/19.
During an interview on 4/3/19 at 9:00 A.M., the Director of Nursing (DON) said the PICC
line dressing should be changed as ordered, and if the date showed 3/29/19, then that
showed staff had not changed the dressing as ordered.
2. Review of Resident #3’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Diagnoses included heart failure, dementia, stroke and urinary tract infection [MEDICAL

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 8)
CONDITION].
Review of the POS [REDACTED]. Staff had not listed a [DIAGNOSES REDACTED].
Review of the Medication Administration Record [REDACTED]
-No diagnosis listed for administration of [MEDICATION NAME];
-The first dose of [MEDICATION NAME] not administered until 8:00 P.M. on 2/26/19;
-A total of 11 doses of [MEDICATION NAME] administered instead of the ordered 14 doses.
Further Review of the POS [REDACTED]. Staff had not listed a [DIAGNOSES REDACTED].
Review of the MAR, dated 3/16 through 3/25/19, showed [MEDICATION NAME] listed and
administered. Staff had not listed a [DIAGNOSES REDACTED].
During an interview on 4/3/19 at 9:00 A.M., the DON said all medications that are
administered should have a supporting diagnosis, including antibiotics. Staff should know
why the medication is given.
3. Review of Resident #63’s admission MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Required extensive assistance from staff for most activities of daily living;
-Always incontinent of bowel and bladder;
-Diagnoses included high blood pressure, end stage [MEDICAL CONDITION], diabetes and
[MEDICAL CONDITION].
Review of the resident’s (MONTH) 2019 POS, showed the following:
-An order, dated 2/26/19, for [MEDICATION NAME] (antibiotic) 250 mg tablet to be given
four times a day for 30 days immediately (STAT);
-Staff did not include a [DIAGNOSES REDACTED].
-An order, dated 2/27/19, for [MEDICATION NAME] 250 mg/10 ml, to be given four times a
day;
-Staff did not include a [DIAGNOSES REDACTED].
4. Review of Resident #44’s quarterly MDS, dated [DATE], showed the following:
-Independent with most activities of daily living (ADLs);
-Continent of bowel and bladder;
-Diagnoses included: heart failure, [MEDICAL CONDITION] ([MEDICAL CONDITION], poor
circulation), diabetes, high cholesterol, [MEDICAL CONDITION] ([MEDICAL CONDITION]
infection causing liver inflammation), [MEDICAL CONDITION] disorder (mood swings) and
[MEDICAL CONDITION] (breakdown in relation between thought, emotion and behavior leading
to faulty perception, inappropriate actions and feelings).
Review of the resident’s care plan, updated on 2/15/19, showed the following:
-Problem: at risk for pressure ulcers/skin breakdown;
-Goal: skin will remain intact;
-Approach: provide treatments as ordered, see treatment administration record (TAR).
Review of the resident’s POS, dated (MONTH) 2019, showed the following:
-An order, dated 5/30/16 for [MEDICATION NAME] (a type of compression stocking) to
bilateral (both sides) lower extremities at all times, as resident allows, remove for
bathing;
-An order, dated (MONTH) (YEAR), for elastic support stockings, on in the morning and off
in the evening.
Review of the resident’s TAR for (MONTH) and (MONTH) 2019, showed the following:
-[MEDICATION NAME] to bilateral lower extremities at all times, initialed as done each day
in (MONTH) and on (MONTH) 1, 2019;
-Elastic tubular stockings, initialed as done each day in (MONTH) 2019 and on (MONTH) 1,
2019.
Observation of the resident 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 9)
-On 3/28/18 at 10:45 A.M., the resident sat in a wheelchair in his/her room and wore
[MEDICATION NAME] on both legs underneath white tube socks;
-On 3/29/19 at 7:24 A.M., the resident lay in bed on top of the covers and wore
[MEDICATION NAME] on both legs underneath white tube socks;
-On 4/1/19 at 5:10 P.M., the resident propelled him/herself down the hall in a wheelchair
and wore [MEDICATION NAME] on both legs underneath white tube socks. At 7:10 P.M., the
resident sat in a wheelchair in his/her room and wore [MEDICATION NAME] on both legs
underneath white tube socks.
During observation and interview with the resident at approximately 8:28 A.M. on 4/2/19,
he/she lay in bed with bare feet and said he/she wore ‘leggings’ under his/her socks.
He/she took them off last night. The resident found the socks and ‘leggings’ and held them
up. The ‘leggings’ the resident referred to were [MEDICATION NAME]. He/she did not wear
elastic support stockings.
During an interview on 4/2/19 at approximately 1:50 P.M., Nurse B said at one time, the
resident did have an order for [REDACTED].
During an interview on 4/2/19 at approximately 8:25 A.M., the DON said it did not make
sense for the resident to have orders for both [MEDICATION NAME] and elastic support
stockings to be applied each day. He would not expect staff document on the TAR that they
applied both daily.
5. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Extensive assistance of staff required for most ADL’s;
-Lower extremity impairment on both sides;
-Incontinent of bowel and bladder;
-Diagnoses included heart failure, [MEDICAL CONDITION], high blood pressure, [MEDICAL
CONDITION], stroke and [MEDICAL CONDITION] (difficulty speaking).
Review of the resident’s care plan, updated 3/20/19, showed the following:
-Problem: medical [DIAGNOSES REDACTED].
-Goal: will not have an exacerbation of [MEDICAL CONDITION] signs/symptoms, or infection
over the next 90 days;
-Approach: apply oxygen (O2) as ordered by physician, monitor O2 saturations and document
in the clinical record;
-Problem: history of [MEDICAL CONDITION] and is at risk for shortness of breath, [MEDICAL
CONDITION] (chest pain), increased [MEDICAL CONDITION] (swelling) and elevated blood
pressure;
-Goal: no complaints of shortness of breath, [MEDICAL CONDITION], increased [MEDICAL
CONDITION] or elevated blood pressure over the next 90 days;
-Approach: apply O2 for complaints of chest pain and notify physician.
Review of the resident’s (MONTH) 2019 POS, showed an order, handwritten and dated 3/9/19,
for O2 at 2 liters (L) per nasal cannula (NC, device used to deliver oxygen with two small
tubes that fit into the nostrils) PRN.
Review of the resident’s (MONTH) 2019 POS showed no order for O2 PRN.
Observation of the resident showed:
-On 3/28/19 at approximately 11:00 A.M., the resident lay in bed with eyes closed, the
head of the bed up slightly, and no oxygen concentrator in the room;
-On 3/29/19 at 9:00 A.M., the resident lay in bed with eyes closed, the head of the bed up
slightly, and no oxygen concentrator in the room;
-On 4/1/19 at 5:11 P.M., the resident lay in bed, the head of the bed up slightly and no
oxygen concentrator in the room;
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 10)
-On 4/3/19 at 8:23 A.M., the resident sat in a wheelchair in his/room and shook his/her
head yes, he/she used oxygen when needed. There was no oxygen concentrator in the room.
During an interview on 4/3/19 at 8:51 A.M., LPN F said he/she thought the resident
returned from the hospital recently with an order for [REDACTED].>During an interview
on 4/3/19 at 9:00 A.M., the DON said if the resident needed PRN O2, an order should be on
the POS that included the flow rate, and there should be a concentrator in the room.
6. Review of Resident #33’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Unable to ambulate;
-Required limited to extensive assistance with bed mobility and personal care;
-Diagnoses included stroke with paralysis to the left side of the body, heart failure,
anxiety and depression.
Review of the current POS, showed the following:
-An order, dated 10/27/18, to administer [MEDICATION NAME] (relieves heartburn by reducing
stomach acid) 20 mg once a day;
-An order, dated 1/17/19, to increase [MEDICATION NAME] to 20 mg twice a day for eight
weeks then decrease back to once a day.
Review of the MARs, dated 1/17 through 2/28/19, showed [MEDICATION NAME] 20 mg
administered once a day at 10:00 A.M.
Further Review of the POS [REDACTED].M. The order did not clarify if the medication
changed back to once a day administration or only to change the time of the morning
administration.
Further review of the MAR, dated 2/1 through 2/28/19, showed a line drawn through 10:00
A.M. and 6:00 A.M. written. Staff did not provide date to show when the time change
occurred.
Review of the care plan, last updated on 2/5/19, and in use during the survey, showed no
information regarding his/her complaints of stomach discomfort.
Further Review of the POS [REDACTED]
-Discontinue [MEDICATION NAME] and administer [MEDICATION NAME] (relieves heartburn by
reducing stomach acid) 20 mg every morning;
-Obtain a GI ([MEDICATION NAME], treats diseases of the gastrointestinal tract) consult.
Review of the nurses’ notes showed no documentation from 3/13/19 forward.
During an interview on 3/29/19 at 8:57 A.M., the resident said he/she experienced stomach
upset and was under the impression that he/she was supposed to have tests done to
determine the cause but had heard nothing further.
During an interview on 4/3/19 at 9:00 A.M., the DON said it was the nurses’ responsibility
to follow orders as they were written. He added that when staff receive a consult order,
they should document the information regarding the date and time of the consult on the POS
and in the nurses’ notes. If no information was in the chart, then there was no evidence
that the consult was completed.
7. Review of Resident #17’s quarterly MDS, dated [DATE], showed the following:-No
cognitive impairment;
-Required limited assistance with care;
-Diagnoses included high blood pressure, poor circulation, [MEDICAL CONDITION] and
diabetes.
Review of the nurses’ notes showed the following:
-On 1/29/19 at 12:20 P.M., the nurse received an order from the physician to obtain a
consult with a cardiologist;
-On 1/29/19 at 12:50 P.M., the nurse scheduled an appointment with a cardiologist for
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 11)
2/15/19 at 1:15 P.M.
Review of the POS [REDACTED].
Further review of the medical record, showed:
-No nurses’ notes showed documentation on 2/15/19 that the resident left the building for
a cardiology consult;
-No documentation in the medical record regarding a cardiology visit or referral.
Further Review of the POS [REDACTED]. Staff did not list a diagnosis listed for the
administration of the medication.
Review of the MAR, dated 2/1 through 2/28/19, showed the medication administered with no
diagnosis listed for the administration of the medication.
During an interview on 4/1/19 at 6:14 P.M., the resident said that other than an outside
appointment with a pain specialist, he/she had not left the facility for any other doctor
appointments.
During an interview on 4/3/19 at 9:00 A.M., the DON said staff should place any
information regarding consults under the consult tab in the chart. (A request was made for
any further information about the consult, and by 4/3/19 at 2:15 P.M., no further
information had been provided).
8. Review of Resident #36’s annual MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Behaviors included delusions and wandering;
-Required limited assistance from staff for transfers, walking, dressing, toileting and
personal hygiene;
-Used a wheelchair for mobility;
-Diagnoses included [MEDICAL CONDITION], dementia and anxiety;
-Daily use of wander/elopement alarm.
Review of the resident’s (MONTH) and (MONTH) 2019 POS, showed an order, dated 4/6/18, for
placement of a wanderguard (worn device used to alert staff if resident is at an exit) to
the resident’s ankle.
Observations of the resident on 3/28/19 at 3:00 P.M., 3/29/19 at 9:00 A.M., 4/1/19 at 1:50
P.M., 4/2/19 at 2:15 P.M., and 4/3/19 at 8:00 A.M., showed a wanderguard placed on the
back of the resident’s wheel chair.
Further observations of the resident on 4/2/19 at 8:00 A.M. and 1:30 P.M. and on 4/3/19 at
9:14 A.M., showed the resident in bed with his/her eyes closed and without a wanderguard
on his/her ankle.
Review of the resident’s (MONTH) and (MONTH) 2019 TAR showed staff documented the
placement of the wanderguard on the resident’s ankle.
During an interview on 4/3/19 at 10:00 A.M., the DON said staff do not need to obtain an
order to change the placement of a wander guard. The DON agreed the resident was not
always in his/her wheelchair.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure one resident received
treatment and care in accordance with professional standards of practice by delaying

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
treatment of [REDACTED]. It helps regulate fluid balance, muscle contractions and nerve
signals) level and not following up on the eventual treatment provided. This failed
practice affected one of 19 sampled residents (Resident #17). The census was 73.
Review of Resident #17’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 1/7/19, showed the following:
-No cognitive impairment;
-Required limited assistance with care;
-[DIAGNOSES REDACTED].
Review of the medical record, showed a laboratory report, dated 1/18/19, of a basic
metabolic panel (BMP, a blood test that gives doctors information about the body’s fluid
balance, levels of electrolytes, and how well the kidneys are working). The result showed
a K+ level of 5.5. The normal range is 3.5-5.3.
Review of the nurse’s notes, dated 1/19/19, showed the following:
-At 8:40 A.M., blood test results faxed to the attending physician;
-At 12:20 P.M., spoke with the covering physician and obtained orders for breathing
treatments and cough medicine. The nurse did not document notifying the physician of the
high K+ level.
Review of the laboratory report, showed a memo written by the nurse that he/she refaxed
the report to the attending physician on 1/25/19; no time noted.
Review of the nurse’s note, dated 1/25/19, showed no information regarding staff faxing
the blood work to the physician.
Further review of the nurse’s notes on 1/29/19, showed the following:
-At 10:00 A.M., the attending physician sent the facility a fax with a new order for
[MEDICATION NAME] (a liquid medication used to remove some of the excess K+ in the blood);
-At 12:20 P.M., the physician called the facility and the nurse informed him/her the
resident complained of shortness of breath with exertion and had swelling in both legs.
Review of the POS [REDACTED].
During an interview on 4/3/19 at 11:00 A.M., a representative from the facility’s
participating laboratory said that a K+ level of 5.5 is considered a panic level and is
called to the facility.
Review of the facility’s Physician Communication Grid Policy, dated 7/1/16, showed the
following:
-Three levels of communication with the physician depending on the severity of the issue;
-Treatment required within one hour, treatment required within four hours and routine
physician notification;
-Treatment required within one hour included a K+ level of over 5.5.
During an interview on 4/3/19 at 9:00 A.M. and 12:30 P.M., the Director of Nursing (DON)
said the nurse should have been more expedient with getting the information to the
physician. He/she should have faxed the information again later that same day or at the
very least the next morning. If a resident had a critical lab value, the DON should have
been informed and if the nurse was unable to reach the attending physician, then the
facility’s medical director should have been informed. He said that a follow up lab should
have been drawn to determine the effectiveness of the treatment, and if the physician did
not order lab work, the nurse should have pursued an order. The DON said he would expect
the nurse to have called the physician instead of sending a passive fax. He said the
facility policy, shows to call the physician for a K+ level of over 5.5, but he would
expect the nurse to call for a level of 5.5. He added that the nurse should have persisted
until he/she spoke with the 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

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

Based on observation, interview and record review, the facility failed to follow physician
orders [REDACTED]. This affected three of 19 sampled residents (Resident #21, #30 and
#26). The census was 73.
1. Review of Resident #21’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/15/19, showed the following:
-Severe cognitive impairment;
-Rejected care between 4-6 days observed;
-Required extensive assistance from staff for bed mobility, transfers, dressing, personal
hygiene and toilet use;
-Impaired range of motion on both sides, upper and lower extremities;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, last revised on 1/19/19 and in use during the survey,
showed the following:
-Problem: Resident is at risk for pain related to contractures with limited mobility and
due to impaired ability to make needs known;
-Goal: Resident will verbalize relief of pain;
-Approaches included the use of non-medicated pain relief measurers such as physical
therapy, stretching and strengthening exercises.
Review of the resident’s medical record, showed the following:
-An (MONTH) 2019 physician order [REDACTED].
-No documentation to show the resident was evaluated by OT or PT or received treatment.
During an interview on 4/2/19 at approximately 11:30 A.M., the regional therapy manager
said they did not receive the order to evaluate and treat the resident. When a physician
gives the order, the nursing department will contact the therapy department to make them
aware. They did not evaluate or treat the resident.
During an interview on 4/03/19 at 9:53 A.M., the Director of Nursing (DON) said therapy is
made aware of orders at morning clinical meeting. This was discussed and therapy declined
to evaluate the resident because he/she had recently been screened. This should have been
documented by therapy and nursing should have discontinued the order.
2. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Mild cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADLs);
-Lower extremity (LE) impairment on both sides;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Review of a certificate of medical necessity, dated 8/9/18, showed the following:
-Prognosis: excellent;
-Function level: ambulatory with assistive device;
-Justification: to improve gait and continue ambulation for normal activity;
-Ankle-foot orthosis (AFO), single upright, articula (To help support the repair &
regeneration of articulations & joints);
-Additional notes, date of service 8/9/18, signed by the physician on 9/9/18: Patient

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
suffers from right lower extremity (RLE) foot drop, has difficulty ambulating due to RLE
weakness, prefabricated AFO not appropriate due to varus (inward angulation) deformity of
ankle and hypertonic (increased tension) lower extremity;
-physician’s orders [REDACTED].
Review of the resident’s PT evaluation and plan of treatment, dated 10/5/18, showed the
following:
-Patient requires skilled PT services to improve tone in LE, improve dynamic balance,
increase functional activity tolerance, increase independence with gait and promote safety
awareness in order to enhance patient’s quality of life by improving ability to decrease
level of assistance from caregivers and return to prior level of functional abilities;
-Splint/orthotics recommendations: It is recommended the patient wear other AFO for right
lower extremity
RLE for during daily tasks in order to improve active range of motion (AROM) for adequate
hygiene, increase ability to perform self care tasks and manage tone;
-Risk factors: due to the documented physical impairments and associated functional
deficits, without skilled therapeutic intervention, the patient is at risk for decreased
skin integrity and further decline in function.
Review of a therapy and nursing communication form, dated 10/29/18, showed the following:
-Resident discharged from physical therapy on 10/29/18;
-Recommendations: do not don right AFO until patient receives diabetic shoes.
Review of the PT discharge summary, dated 10/29/18, showed the patient does not have
appropriate shoe to support AFO. Shoe is too narrow and leaves a red mark. Social worker
has started paperwork and states not sure how long the shoe will take to arrive. The
resident will remain discharged from PT until appropriate shoe arrives for further
training.
During observation and interview on 4/3/19 at 8:22 A.M., the resident sat in his/her room
in a wheelchair and wore tennis shoes, no right AFO and shook his/her head ‘no’ when asked
if he/she ever wore anything on his/her right foot.
During an interview on 4/3/19 at 8:45 A.M., Licensed Practical Nurse (LPN) F said the
resident did have an AFO at one time but it was making his/her heel red so it was taken
away. The therapy department would know more about it.
During an interview on 4/3/19 at 8:57 A.M., Physical Therapist Assistant (PTA) G said the
resident was assessed for and received diabetic shoes, but the AFO was not taken into
account when measurements were done. The resident has not received the correct shoes yet.
During an interview on 4/3/19 at 9:00 A.M., the DON said the resident had to be remeasured
for diabetic shoes to accommodate the AFO. He thought it would take two to three months to
receive the shoes.
During an interview on 4/4/19 at 2:24 P.M., the administrator said the social worker had
additional information regarding the resident’s diabetic shoes, provided information that
the shoes were received on 2/11/19 and the shoe company was notified between the middle to
end of (MONTH) that the shoe needed to fit the AFO.
During an interview on 4/5/19 at 3:05 P.M., the social worker said a text was sent to the
shoe representative on 4/3/19, and the second pair of shoes should be received by 4/12/19.

3. Review of Resident #26’s quarterly MDS dated [DATE], showed:
-Severe cognitive impairment;
-Extensive staff assistance needed for toileting, mobility, transfers and hygiene;
-[DIAGNOSES REDACTED].
-Received no physical or restorative therapy (RT).

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0688

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
Review of the care plan, updated on 1/21/19, showed no evaluation of paralysis or therapy
needs.
Review of the POS [REDACTED].
Review of the RT service book, showed the resident did not have an RT order in the service
book or a nursing rehab/restorative plan of care sheet completed.
During an interview on 4/1/19 at 4:15 P.M., the administrator said the facility had not
had a restorative nurse aide available to perform RT services for the residents for the
last two months. She hired a new RT aide and that staff member was starting in the next
week. If a resident had been ordered RT services, there was a good chance that they had
not been receiving them.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed provide immediate
safety interventions to a voiced suicidal resident (Resident #36) during the crisis and
after readmission from the hospital, failed to obtain a self administration order for
medications and left medications at the bedside unattended (Resident #61) and failed to
clarify transfer orders and techniques before a fall that resulted in an arm fracture
(Resident #26). This affected three of 19 sampled residents. The census was 73.
1. Review of Resident #36’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/6/19, showed the following:
-Moderate cognitive impairment;
-Behaviors included delusions and wandering;
-Required limited assistance from staff for transfers, walking, dressing, toileting and
personal hygiene;
-Used a wheelchair for mobility;
-[DIAGNOSES REDACTED].
-Daily use of wander/elopement alarm.
Review of the resident’s medical record, showed the following:
-A physician’s orders [REDACTED].
-A nurse’s note, dated 11/11/18 at 6:00 P.M., showed the nurse observed the resident to be
agitated and remembered the resident wandered the previous night without sleeping. When
the nurse returned, the resident continued to have lack of sleep. Around 6:00 P.M., the
resident propelled angrily down the hall. When asked what was wrong, the resident said
he/she was really mad because his/her spouse was fooling around with his/her best friend.
The resident became more agitated and requested to go to the hospital before he/she jumped
out of the window. The nurse documented he/she was doing a task and told the resident an
ambulance would be called. The resident said he/she wanted to go to the hospital now and
became loud and more agitated. The resident went to his/her room and tried to throw
himself/herself out of the window. Two certified nurse aides (CNAs) stopped the resident
and the nurse called 911. Staff were able to distract the resident until first responders
arrived;
-On 11/11/18 at 6:10 P.M., the police arrived, and the resident calmed down but still
wanted to be seen at the hospital. The resident stated he/she would throw him/herself out

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
of the window. The nurse explained the resident had not slept in two days and the resident
become more agitated. The resident was taken to the hospital;
-On 11/11/18 at 9:00 P.M. the nurse called the hospital and spoke to the social worker who
said the resident was calm and therefore there was no reason for a hospital admission;
-On 11/12/18 at 12:30 A.M., the resident arrived back at the facility and was calm;
-On 11/12/18 at 4:30 A.M., staff documented leaving a message with the resident’s
responsible party regarding the incident;
-On 11/12/18 at 6:00 A.M., staff documented the resident remained calm and safe;
-On 11/12/18, no time noted, staff documented the resident’s primary physician was
notified and gave no new orders. The primary physician wanted to wait to see what the
resident’s psychiatrist wanted to do. The psychiatrist said to watch the resident and call
back with any changes. In the future, the psychiatrist wanted to be notified when a
resident was being sent out. Staff will continue to monitor the resident;
-Staff failed to document how frequently they checked on the resident to ensure his/her
safety;
-Staff failed to document any interventions put into place to ensure the safety of the
resident.
Further review of the resident’s medical record, showed the following:
-A social services care plan note, dated 11/16/18, showed neither the resident nor a
representative attended the meeting. Staff discussed the resident’s wanderguard. Resident
has history of threatening to get out of window, and was sent to the hospital on [DATE] at
6:10 P.M. per nursing and returned on 11/12/18 at 12:30 A.M. The resident reported wanting
to move to Florida where he/she used to work;
-A social services note, dated 11/26/18, showed staff informed the resident he/she would
be receiving a new roommate. The resident was agreeable. (The resident remained in the
same room, in the same bed, next to the window he/she attempted to jump out of);
-A social service care plan note, dated 2/14/19, showed neither the resident and/or
representative attended the meeting. The resident had been evaluated by a psychiatrist.
The resident continued to report he/she wanted to go home, however there is no home. The
resident was confused and reported he/she was married, but was actually divorced. Long
term care was the goal. Staff will discuss the resident seeing a psychologist with the
resident’s representative.
Review of the resident’s Risk of Elopement/Wandering Review, dated 1/23/19, showed the
resident at risk for wandering. The resident had a [DIAGNOSES REDACTED].
Review of the resident’s care plan, last updated on 2/7/19 and in use during the survey,
showed the following:
-Problem: Resident has history of [MEDICAL CONDITION] with no plan to execute;
-Goal: Resident will reduce the number of times he/she exhibits [MEDICAL CONDITION] and
stating to staff he/she is going home;
-Approach: Staff to monitor, redirect and educate as needed; 15-minute checks as needed;
-Problem: Resident requires the use of a wanderguard and is at risk for injury from
wandering in an unsafe environment;
-Goal: Dignity will be maintained and resident will be able to wander in a safe
environment without occurrence of injury;
-Approaches included: Assess quarterly for continued necessity of wanderguard, document
any attempts to leave the facility, encourage activities throughout the day to decrease
wandering, monitor resident’s whereabouts in facility.
During an interview on 4/02/19 at 2:29 P.M., the resident said he/she was asked if he/she
would find it helpful to have someone at the facility to talk to and offer support. 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
resident was born with club feet and it is something that has bothered him/her for his/her
entire life. Sometimes he/she gets stuck on things in his/her stupid head. He/she talked
to professionals before and thinks it would be nice to have someone here to talk to and
check in on him/her. He/she doesn’t feel anxious often. He/she would like to leave, but
hasn’t tried recently. He/she was retired, so he/she would like to go play golf.
Observation of the resident’s room, on all days of the survey from 3/28/19, 3/29/19 and
4/1/19 through 4/3/19, showed the resident’s bed next to a large horizontal sliding
window. The window opened approximately two feet and had a screen in place. The room
number matched the room number documented in the previous nurse’s notes. Throughout the
survey, the resident was observed either in bed or propelling him/herself up and down the
hall.
During an interview on 4/2/19 at 10:45 A.M., the facility social service designee (SSD)
said she was aware of something to the effect of the resident’s attempt to jump out of a
window. She did not follow up with the resident regarding the incident. If she had, there
would be a note stating she met with him/her. The resident is alert and oriented with
confusion and has dementia. The SSD is part of the clinical team responsible for
addressing residents in crisis to ensure their safety and well-being. If a resident has
increased anxiety or increased suicidal thoughts, the care plan should be updated, but she
isn’t responsible for updating care plans. She did not recall if the resident had been
moved or if any changes were made to his/her window to ensure safety.
During an interview on 4/03/19 at 9:48 A.M., the administrator said she reviewed the
nurse’s note and knew the nurse who wrote the note tended to embellish. The nurse
constantly sent residents out rather than dealing with the issue. If a resident had
[MEDICAL CONDITION] or an attempt at elopement, the care plan should be updated and staff
should institute interventions which should be documented. When the resident returned from
the hospital, he/she should have been placed on frequent checks to ensure safety.
2. Review of Resident #61’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Required extensive assistance with personal hygiene and limited assistance from staff for
bed mobility and transfers
-[DIAGNOSES REDACTED].
Review of the resident’s (MONTH) and (MONTH) 2019 physician order [REDACTED].
-An order dated, 11/26/18, for Atrovent HFA aerosol inhaler (medication which opens up the
medium and large airways in the lungs) 17 micrograms (mcg)/actuation, two puffs for
[MEDICAL CONDITION] every six hours;
-An order, dated 11/26/18, for [MEDICATION NAME] HFA aerosol inhaler (medication used to
treat asthma and/or [MEDICAL CONDITION]), 160-4.5 mcg/actuation, two puffs for asthma to
be given twice a day;
-An order, dated 11/26/18, for [MEDICATION NAME] allergy relief spray (medication used to
treat non-allergy nasal symptoms), suspension 50 mcg/actuation two sprays in each nostril
every day;
-No orders for any medications to be left at bedside.
Observation and interview on 3/28/19 at 12:21 P.M., showed the resident in bed with an
over the bed table in place. On the table sat the Atrovent, [MEDICATION NAME] and
[MEDICATION NAME]. The resident said staff dropped off the medications this morning after
breakfast and haven’t picked them up yet. The staff who know the resident will leave the
medications. New staff will take the medications back until they get to know him/her
better.
During an interview on 4/03/19 at 9:52 A.M. the DON said medications should not be left at
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
the resident’s bedside unless there is a physician’s orders [REDACTED].>3. Review of
Resident #26’s current care plan, showed the following fall histories:
-Falls: The resident fell [DATE] in the shower, bruising to his/her forehead. Sent to the
emergency room with no new orders. No updated interventions noted to the care plan.
-Fall: On 11/3/17, the resident lowered to the floor during a transfer related to lost
balance. No injuries noted. No updated interventions noted to the care plan;
-Approach: Assure the floor is free of glare, liquids and foreign objects, keep personal
items in reach, orient to changes in the environment, provide an environment free of
clutter, provide proper well fitting footwear and teach safety measures, dated 4/19/16;
-Transfer the resident with assist of two staff, dated 1/19/17.
Review of the resident’s (MONTH) (YEAR) POS, dated 12/1/18 through 12/31/18, showed an
order, dated 2/1/16, for Hoyer transfer (mechanical lift used for transfers when a person
requires 90-100% assistance to get into and out of bed), 2-person as tolerated.
Review of the nurse notes dated 12/8/18, showed:
-At 10:45 A.M., the nurse called into the resident’s room and found the resident in a
seated position on the floor. A staff member at the side of the resident said he/she and
the resident fell together during the transfer. The resident landed on his/her left side
and complained of pain to his/her left arm. Assessment completed and range of motion
intact except to the left arm. Three staff assisted the resident into bed with a gait
belt. Upon further assessment, the resident’s left hand and left middle finger were
swollen and discolored, his/her upper left arm and shoulder were swollen and discolored
and painful to the touch;
-At 11:00 A.M., staff placed a call to the resident’s physician and received a new order
to send the resident to the emergency room for evaluation and treatment. The resident’s
son was aware and would meet the resident at the hospital;
-At 4:10 P.M., The resident returned to the facility. New orders were received for pain
medication, no weight bearing to the the left arm and continue to wear sling and wrist
splint until the resident was seen by the orthopedic physician;
-At 4:20 P.M., the results of the x-ray from the hospital, showed a left arm and wrist
fracture.
Further review of the care plan, showed:
-Falls: On 12/8/18, the resident was lowered to the floor during a transfer with two CNAs
present. The resident sustained [REDACTED]. He/she was transferred to the emergency room
and received treatment;
-Approach: Nursing staff to receive education on how to transfer the resident
successfully, dated 12/8/18.
-No interventions noted regarding care or comfort regarding the left sided fractures;
-Gait belt for all transfers, dated 1/18/18.
Review of the resident’s fall risk evaluations, showed on 12/8/18, a score of 16 (score of
10 or higher is at risk for falls) with interventions added of PT/OT evaluation and treat.
Review of the resident’s rehabilitation service screening request, dated 12/12/18, showed
the resident was assessed related to a fall. The left wrist and left arm were fractured
from a fall on 12/8/18, and two CNAs improperly transferred the resident. Nursing to
educate staff. No need for skilled therapy warranted at the time of evaluation.
Review of the resident’s fall risk evaluation on 1/14/19, showed a score of 16.
Review of the resident’s quarterly MDS, dated [DATE], showed the following:
-admitted [DATE];
-Severe cognitive impairment;
-Extensive staff assistance needed for toileting, hygiene, transfers and mobility;
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-[DIAGNOSES REDACTED].
-One fall with a major injury.
Review of the resident’s POS dated, 1/1/19 through 1/31/19, 2/1/19 through 2/28/19, 3/1/19
through 3/31/19 and 4/1/19 through 4/30/19, showed an order dated 2/1/16 for Hoyer
transfer (2-person, as tolerated).
During an interview on 4/2/19 at 10:17 A.M., Licensed Practical Nurse (LPN) F said the
resident transfers with a gait belt and two staff members. If a resident appeared weaker
before the transfer, he/she expected the CNAs to notify the charge nurse and the nurse
would determine if a Hoyer lift needed to be used. The resident did not like to be lifted
with a Hoyer and as a result the staff used a gait belt to transfer him/her.
During an interview on 4/02/19 at 10:19 A.M., CNA E said the resident transferred with two
staff and a gait belt. The resident did not stand well on his/her left side and was
paralyzed on the left side. He/she would use his/her right leg to bear his/her weight and
help to stand. Sometimes the resident was weak when standing during a transfer. If the
resident became weak during a transfer, staff should move the resident back to bed or into
the chair and get the nurse. The charge nurse would decide if a Hoyer lift needed to be
used for a transfer. CNA E used a Hoyer lift on the resident after he/she fell in (MONTH)
and received the left arm fracture. The resident did not like to use the Hoyer lift.
He/she did not know why the Hoyer lift transfers had stopped.
During an interview on 4/2/19 at 10:49 A.M., the facility physical therapy assistant (PTA)
said the therapy department had worked with the resident a few times. Normally after a
resident experienced a fall, the therapy department was notified and given a fall
notification packet. Therapy would perform an assessment and decide if a therapy
evaluation would be appropriate. If a therapy evaluation was deemed appropriate, the
therapy department would request a physician order [REDACTED]. The evaluation would
include transfer and mobility assessments. The therapy department would notify the nursing
department of the evaluation findings.
Review of the facility’s fall management policy, revised (YEAR), showed:
-Policy: The facility will identify each patient/resident at risk for falls and plan care
and implement interventions to manage falls. Staff will complete the fall risk evaluation
and determine if the resident is a fall risk. A fall risk management program will be
implemented to educates staff in creative functional strategies while recognizing rights
and the need to maintain the highest practical level of function;
-Procedures:
-Qualified staff evaluate all residents for fall risk at minimum upon admission,
quarterly, with a significant change and post fall;
-The fall risk evaluation assists in identifying the appropriate preventative
interventions that will be recorded on the resident’s care plan;
-Facility may implement visual identifiers for those at risk;
-If a fall occurs, staff evaluate the resident for injury from the fall and determine
what may have caused or contributed to the fall, including what the resident was trying to
do, address the risk factors for the fall such as the resident’s medical condition,
facility environment issues, staffing issues and determine appropriate interventions to
prevent future falls and complete the fall investigation worksheet;
-The physician and family are promptly notified and an incident report is completed.
During an interview on 4/2/19 at 1:35 P.M., the Director of Nursing said the current order
of the Hoyer transfer was unclear. It would be difficult for an aide to make the
determination if the resident needed to be a Hoyer transfer. Usually after a fall, the
resident was referred to therapy for an evaluation. It looked like therapy did not
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
complete the evaluation for his/her transfer status after the fall from 12/8/18. The
resident would remain in bed for now, until therapy completed a transfer evaluation. The
resident had a history of [REDACTED]. The care plan should include the transfer status as
well as resident refusals to use recommended transfer status. The charge nurses should
document if a resident refused to be transferred in the recommended manner.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
used proper urinary drainage bags and privacy bags for residents in bed, obtain
physician’s orders [REDACTED].#45, #75 and #34). The sample size was 19. The census was
73.
1. Review of Resident #45’s admission Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/18/19, showed the following:
-No cognitive impairment;
-Required limited assistance with all care;
-Suprapubic catheter (SP, a small rubber tube inserted through the abdomen in to the
bladder to drain urine);
-Special procedures included [MEDICAL TREATMENT] (a procedure that filters the blood to
rid the body of harmful waste);
-[DIAGNOSES REDACTED].
Review of the care plan, dated 2/19/19, showed the following:
-Problem: Required a SP catheter related to [MEDICAL CONDITION];
-Goal: SP catheter care will be managed appropriately as evidenced by not exhibiting signs
of obstruction, signs of infection, dislodgment of catheter, bowel perforation or trauma;
-Approaches: Assess drainage every shift and observe for signs/symptoms of infection,
avoid obstruction in the drainage, keep the system a closed system as much as possible,
position the bag below the level of the bladder.
Review of the physician’s orders [REDACTED]. The orders showed a check mark next to
catheter care.
During an observation and interview on 3/28/19 at 11:33 A.M., the resident lay flat in bed
with a urinary drainage bag strapped around his/her calf. He/she said he/she received
[MEDICAL TREATMENT] three times a week and had very little urine output.
Observation on 3/29/19 at 1:39 P.M., showed he/she lay flat in bed with no visible urinary
drainage bag.
During an observation and interview on 4/1/19 at 12:09 P.M., the resident said the
catheter was inserted three months ago and had never been changed. He/she emptied the bag
every day but there was usually only a few drops of urine in the bag. He/she added that
staff had not put a dressing on the insertion site.
Observations on 4/1/19 at 4:16 P.M. and 4/2/19 at 7:22 A.M. and 10:11 A.M., showed he/she
lay flat in bed with no visible urinary drainage bag.
2. Review of Resident #75’s admission MDS, dated [DATE], showed the following:
-No cognitive impairment;

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
-Extensive assistance required for mobility and personal care;
-Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle.
Slough or dead tissue may be present on some of the wound bed. Often includes undermining
(pockets beneath the wound) or tunneling);
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED]
-An order, dated 3/7/19 for indwelling urinary catheter (small rubber tube inserted
through the urinary meatus (opening) in to the bladder to drain urine), 24 French (size of
the catheter);
-No order for the size of the balloon;
-No order for when to change the catheter.
Observations on 3/28/19 at 9:13 A.M., 3/29/19 at 6:58 A.M. and 1:32 P.M., and 4/1/19 at
12:13 P.M. and 2:23 P.M., showed he/she lay in bed. The catheter drainage bag contained
yellow urine which hung on the bed frame at the foot of the bed, visible from the hallway,
and the urinary drainage privacy bag hung on the bed frame at the head of the bed.
Observation on 4/1/19 at 3:00 P.M. and 4:09 P.M., showed he/she remained in bed and the
urinary drainage bag or tubing could not be seen on either side of the bed.
During an interview on 4/1/19 at 5:00 P.M., Certified Nurse Aide (CNA) D said he/she had
just repositioned the resident and found the urinary drainage bag under the resident’s
legs, under the covers. He/she did not notice earlier that it was not visible. The
drainage bag should always be below the level of the bladder just so it doesn’t touch the
floor.
Observations, showed the following:
-On 4/1/19 at 5:48 P.M., CNA D exited the resident’s room. The urinary drainage bag hung
from the side of the bed and the bottom of the bag rested on the floor. The privacy bag
remained on the bed frame at the head of the bed;
-On 4/2/19 at 7:22 A.M., the resident lay in bed on his/her back. The urinary drainage bag
hung on the bed frame at the foot of the bed, visible from the hallway, and the privacy
bag hung on the bed frame at the head of the bed.
3. Review of Resident #34’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADL’s);
-Upper extremity impairment on one side;
-Lower extremity impairment on both sides;
-Indwelling catheter;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 3/18/19, showed the following:
-Problem: Indwelling urinary catheter related to [MEDICAL CONDITION] bladder;
-Goal: Will have catheter care managed appropriately as evidenced by not exhibiting signs
of urinary tract infection or urethral trauma;
-Approach: Change catheter per physician’s orders [REDACTED].
Review of the resident’s POS, dated 3/17/19 through 3/31/19, showed the following:
-A handwritten order, dated 3/17/19, for an indwelling catheter, 16 French with a 10 cubic
centimeter (cc) balloon;
-A handwritten order, dated 3/17/19, to change catheter every month on the 10th day of the
month and as needed;
-A handwritten order, dated 3/17/19, for catheter care every shift and as needed, record
output every shift.
Review of the resident’s POS, dated 4/1/19 through 4/30/19, 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-An order, dated 3/30/19, for catheter care every shift;
-No order for the use of [REDACTED]
-No order for the changing of the indwelling catheter.
Observations of the resident on 3/29/19 at 7:24 A.M. and at 11:59 A.M., 4/1/19 at 6:36
P.M. and 4/2/19 at 8:28 A.M., showed the resident lay in bed with the head of the bed up
slightly and a catheter collection bag on the side of the bed, and tubing draining yellow
urine.
4. Review of the facility’s Nursing Policies and Procedures, Use of Catheter/Urinary
Catheter, revised 7/1/16, showed the following:
-No guidance regarding the placement/positron of the urinary catheter drainage bag;
-No guidance for the use of a privacy bag;
-No guidance for the necessity of physician’s orders [REDACTED].>Review of the
facility’s Nursing Policies and Procedures, Changing of Suprapubic Catheter, revised
7/1/16, showed changing of a suprapubic catheter will be done by the appropriate licensed
nurse when there is a specific physician’s orders [REDACTED].>5. During an interview on
4/3/19 at 9:00 A.M., the Director of Nursing said when a resident had a catheter,
regardless if it is a SP or indwelling, the POS should have orders for the catheter, the
size of the catheter and the balloon, catheter care instructions and the frequency of
changing the catheter. The drainage bag should always be below the bladder to avoid the
risk of urine flowing back into the bladder. The urinary drainage bag should be in a
privacy bag and even if a resident wears a leg drainage bag through the day, the catheter
should be connected to a gravity drainage bag when in bed.

F 0698

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Past noncompliance – remedy proposed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a
contract with the [MEDICAL TREATMENT] company and orders for and pertaining to [MEDICAL
TREATMENT] (the clinical purification of blood to rid the body of harmful waste as a
substitute for the normal function of the kidney). In addition, the facility failed to
perform thorough assessments, monitoring and ongoing communication with the [MEDICAL
TREATMENT] center for one of one resident who received [MEDICAL TREATMENT] (Resident #45).
The sample size was 19. The census was 73.
Review of Resident #45’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 2/18/19, showed the following:
-No cognitive impairment;
-Required limited assistance with all care;
-Special procedures included [MEDICAL TREATMENT];
-[DIAGNOSES REDACTED].
Review of the care plan, dated 2/19/19, showed the following:
-Problem: Requires [MEDICAL TREATMENT];
-Goal: Resident will not exhibit signs of fluid volume excess;
-Approaches: Assess for fluid excess (weight gain, [MEDICAL CONDITION] (swelling),
increased urinary output, shortness of breath, increased blood pressure and/or bounding
pulse and notify the physician. Monitor lab work and administer medications as prescribed.
Review of the resident’s physician order [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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 23)
-No order for the resident to receive [MEDICAL TREATMENT], where or how often;
-No order for staff to assess and/or monitor the fistula (connection or passageway between
an artery and a vein, surgically created for [MEDICAL TREATMENT] treatments);
-No order for staff to assess the fistula for bruit and thrill (the thrill is the
vibration you feel as blood flows through the fistula. The bruit is the sound heard with a
stethoscope);
-No order for staff to assess the resident for signs and symptoms of infection;
-No order for staff to not check the blood pressure (BP) on the arm with the fistula.
Further review of the medical record, showed no [MEDICAL TREATMENT] communication form to
show communication with the [MEDICAL TREATMENT] facility.
Observation and interview on 3/29/19 at 1:35 P.M., showed the resident sat at the side of
the bed after return from [MEDICAL TREATMENT]. He/she lifted his/her left arm sleeve and
showed a dressing around the site of the [MEDICAL TREATMENT] fistula. He/she said the
nurse did not look at the [MEDICAL TREATMENT] site upon his/her return to the facility.
Review of the facility’s [MEDICAL TREATMENT] Policy and Procedure, revised on 7/1/16,
showed the following:
-Subject: [MEDICAL TREATMENT];
-Policy:
-The [MEDICAL TREATMENT] procedure will be under the direct responsibility and
supervision of an offsite contracted [MEDICAL TREATMENT] agency through an order by the
attending physician;
-The facility staff will participate in ongoing communication with the [MEDICAL
TREATMENT] center by using the [MEDICAL TREATMENT] communication form which is filed in
the resident’s medical record;
-The facility must inform each resident before or at the time of admission and
periodically during the resident’s stay of [MEDICAL TREATMENT] services. If this service
is not offered, the facility must help with relocation of a facility that does offer
transportation services;
-The facility must inform the [MEDICAL TREATMENT] facility if the resident is transferred
to an acute care setting.
During an interview on 4/2/19 at 1:14 P.M., the administrator said they do not have a
contract with the [MEDICAL TREATMENT] company. She said one had been created, but it is
not available because it has to go through the legal chain to get it approved.
During an interview on 4/3/19 at 9:00 A.M., the Director of Nursing said the POS should
have orders for [MEDICAL TREATMENT], the days of the week he/she received [MEDICAL
TREATMENT], not to check the BP on the arm where the [MEDICAL TREATMENT] access is located
and check for bruit and thrill every day.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

Based on interview and record review, the facility failed to establish a system of records
of receipt and disposition of all controlled drugs in sufficient detail to enable an
accurate reconciliation. The facility failed to properly document narcotic counts for the
controlled substances on two of the four facility medication carts. The facility census

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
was 73.
1. Review of the narcotic count sheet, dated 3/1 through 3/31/19, for the front hall of
the Fountain unit, showed the following:
-No signature by the evening shift nurse on 3/2 at 11:00 P.M.;
-No signature by the night shift nurse on 3/3 at 11:00 P.M.;
-No signature by the night shift nurse on 3/4 at 7:00 A.M. or 11:00 P.M.;
-No signature by the night shift nurse on 3/5 at 7:00 A.M.;
-No number of controlled substance cards or signature by the day or night shift nurse on
7/7 at 7:00 A.M.;
-No signature by the day shift nurse on 3/7 at 3:00 P.M.;
-No signature by the night shift nurse on 3/7 at 11:00 P.M.;
-No signature by the night shift nurse on 3/8 at 7:00 A.M. or 11:00 P.M.;
-No signature by the night shift nurse on 3/9 at 7:00 A.M.;
-No number of controlled substance cards on 3/9 at 11:00 P.M.;
-No signature by the day and evening shift nurse on 3/11 at 3:00 P.M.;
-No number of controlled substance cards or signature by the evening or night nurse on
3/11 at 11:00 P.M.;
-No signature by the night shift nurse on 3/12 at 7:00 A.M. or at 11:00 P.M.;
-No signature by the night shift nurse on 3/13 at 7:00 A.M.;
-No number of controlled substance cards and no signature by the night shift nurse on 3/14
at 7:00 A.M.;
-No number of controlled substance cards and no signature by the evening shift nurse on
3/14 at 3:00 P.M.;
-No signature by the night shift nurse on 3/14 at 11:00 P.M.;
-No signature by the day shift nurse on 3/15 at 7:00 A.M. or 3:00 P.M.;
-No signature by the day shift nurse on 3/16 at 3:00 P.M.;
-No signature by the day shift nurse on 3/17 at 7:00 A.M.;
-No controlled substance card count and no signature by the day shift or evening shift
nurse on 3/17 at 3:00 P.M.;
-No signature by the evening shift nurse on 3/17 at 11:00 P.M.;
-No signature by the night nurse on 3/19 at 11:00 P.M.;
-No signature by the night nurse on 3/20 at 7:00 A.M.;
-No signature by the day shift nurse on 3/21 at 7:00 A.M.;
-No controlled substance card count and no signature by the day, evening and night nurses
on 3/21 at 3:00 P.M. and 11:00 P.M. or on 3/22 at 7:00 A.M., 3:00 P.M. or 11:00 P.M.;
-No signature by the day nurse on 3/24 at 7:00 A.M.;
-No controlled substance card count and no signatures by the evening or night nurse on
3/24 at 3:00 P.M.;
-No signature by the night shift nurse on 3/24 at 11:00 P.M.;
-No signature by the evening nurse on 3/25 at 3:00 P.M. or 11:00 P.M.;
-No controlled substance card count and no signature by the evening shift nurse on 3/26 at
3:00 P.M.;
-No controlled substance card count and no signatures by the evening or night nurse on
3/26 at 11:00 P.M.;
-No signature by the day nurse on 3/27 at 7:00 A.M.;
-No signature by the evening shift nurse on 3/27 at 3:00 P.M. or 11:00 P.M.;
-No controlled substance card count on 3/28 at 7:00 A.M. and 3:00 P.M.;
-No signature by the evening shift nurse on 3/28 at 3:00 P.M. or 11:00 P.M.
2. Review of the narcotic count sheet, dated 3/1 through 3/31/19, on the back hall of 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 25)
Fountain unit, showed the following:
-No signature by the night shift nurse on 3/2/19 at 11:00 P.M.;
-No signature by the night shift nurse on 3/3/19 at 7:00 A.M.;
-No controlled substance card count and no signature by the evening shift nurse on 3/3 at
3:00 P.M.;
-No controlled substance card count and no signature by the evening or night shift nurse
on 3/3 at 11:00 P.M.;
-No signature by the night shift nurse on 3/4 at 7:00 A.M.;
-No signature by the evening shift nurse on 3/4 at 3:00 P.M. or 11:00 P.M.;
-No controlled substance card count or signature by the day shift nurse or the night shift
nurse on 3/7 at 7:00 A.M.;
-No signature by the day shift nurse on 3/7 at 3:00 P.M.;
-No signature by the night shift nurse on 3/7 at 11:00 P.M.;
-No signature by the night shift nurse on 3/8 at 7:00 A.M. or 11:00 P.M.;
-No signature by the night shift nurse on 3/9 at 7:00 A.M.;
-No controlled substance card count or signature by the night nurse on 3/9/19;
-No signature by the night nurse on 3/10 at 7:00 A.M.;
-No controlled substance card count on 3/10 at 11:00 P.M.;
-No signature by the night nurse on 3/11 at 11:00 P.M.;
-No signature by the night nurse on 3/12 at 7:00 A.M. or 11:00 P.M.;
-No signature by the night nurse on 3/13 at 7:00 A.M.;
-No signature by the night nurse on 3/14 at 7:00 A.M.;
-No signature by the evening nurse on 3/14 at 3:00 P.M. or 11:00 P.M.;
-No signature by the night nurse on 3/15 at 11:00 P.M.;
-No signature by the night nurse on 3/16 at 7:00 A.M.;
-No signature by the evening nurse on 3/16 at 3:00 P.M.;
-No controlled substance card count and no evening nurse signature on 3/17 at 3:00 P.M.;
-No evening nurse signature on 3/17 at 11:00 P.M.;
-No night nurse signature on 3/19 at 11:00 P.M.;
-No night nurse signature on 3/20 at 7:00 A.M.;
-No controlled substance card count and no signature by the evening or night nurse on 3/21
at 3:00 P.M.;
-No signature by the evening shift nurse on 3/21 at 11:00 P.M.;
-No signature by the day shift nurse on 3/22 at 7:00 A.M.;
-No controlled substance card count and no signature by the evening or night nurse on 3/22
at 3:00 P.M.;
-No signature by the evening shift nurse on 3/22 at 11:00 P.M.;
-No controlled substance card count and no signature by the evening and night shift nurse
on 3/24 at 3:00 P.M.;
-No signature by the evening shift nurse on 3/24 at 11:00 P.M.;
-No signature by the evening shift nurse on 3/25 at 3:00 P.M. or 11:00 P.M.;
-No controlled substance card count on 3/26 at 3:00 P.M.;
-No signature by the evening shift nurse on 3/27 at 3:00 P.M. or 11:00 P.M.;
-No controlled substance card count on 3/28 at 7:00 A.M. or 3:00 P.M.;
-No signature by the evening nurse on 3/28 at 3:00 P.M. 11:00 P.M.;
-No signature by the night shift nurse on 3/31 at 11:00 A.M
3. Review of the facility’s Policy and Procedure for Narcotic Count, revised on 7/1/16,
showed the following:
-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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 26)
-Schedule II drugs will be counted every eight or twelve hours (depending on the shift
hours) by a licensed nurse reporting on duty with the licensed nurse reporting off duty;
-The inventory of the Schedule II drugs will be recorded on the narcotic records and
signed for correctness of count;
-The controlled drug checklist will be signed by both the nurses coming on duty and going
off duty to verify the count of all schedule II drugs is correct;
-The staff will follow the method of operation for the administration and control of
Schedule II drugs, which will meet the requirements of state and federal narcotic
agencies;
-Procedures:
-At the end of every shift the authorized staff member reporting on duty and the
authorized staff member reporting off duty meet at the designated medication cart or
storage area to count Schedule II drugs;
-The off-going staff member reads down the Schedule II inventory sheet one drug at a
time;
-The on coming authorized staff member counts the number of remaining Schedule II drugs
and announces that number out loud;
-The off-going authorized staff member checks this number against the inventory sheet.
The remaining number is carried over to the Schedule II inventory sheet for the next
shift;
-In counting Schedule II drugs, the authorized staff member is alert for any evidence of
a substitution. Inspect tablets and solutions carefully. Note any defects in drug
container. Immediately report any suspicion of tampering with controlled drugs to the
Director of Nursing;
-If a discrepancy is found, check the resident’s order sheet and chart to see if a
narcotic has been administered and not recorded. Check previous recordings on the Schedule
II inventory sheets for mistakes in arithmetic or error in transferring numbers from one
sheet to the next;
-If the cause of the discrepancy can not be located and/or the count does not balance,
report the matter to the Director of Nursing/designee then contact the pharmacy and
police;
-Upon being relieved from duty, the off-going authorized staff member transfers the
controlled substance key to the authorized staff member taking his/her place.
4. During an interview on 4/3/19 at 9:00 A.M., the Director of Nursing said controlled
substances are counted only by licensed nurses and a count should take place at the end of
every shift by the on coming nurse and the off-going nurse. He said there are always at
least two nurses in the building and the count must be completed. It is not permissible
for one nurse to count, for the count to not be completed and/or for the number of
controlled substance cards to not be recorded. The nurses should notify him or the nurse
manager in charge of any discrepancies. If the count is not completed, it is too easy for
someone to divert the medication. He added that when the count is performed, each nurse
should write their initials in the box provided and also document the number of controlled
substance cards.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 27)
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure as needed (PRN) orders
for [MEDICAL CONDITION] drugs were limited to 14 days unless the attending physician or
prescribing practitioner believed that it was appropriate for the PRN order to be extended
beyond 14 days, document their rationale in the resident’s medical record and indicate the
duration for the PRN order, for two residents (Resident #54 and Resident #28). The
facility failed to ensure orders regarding PRN medications were clear. Furthermore, the
facility failed to ensure residents who use [MEDICAL CONDITION] drugs received gradual
dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue
these drugs by failing to ensure a resident’s monthly pharmacy drug regimen recommendation
was reviewed and acted upon by the physician for one sampled resident (Resident #28). This
resulted in a delay of four months to complete a GDR on a resident as recommended by the
pharmacist. The facility also failed to ensure all antipsychotic PRN medications had
appropriate diagnoses to show the necessity for the medication for one resident (Resident
#74). The sample size was 19 and the census was 73.
1. Review of Resident #54’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/23/19, showed the following:
-No cognitive impairment;
-Extensive assistance required for all care;
-Diagnoses included [MEDICAL CONDITION] (partial or total loss of movement to all four
limbs and torso), depression, anxiety and [MEDICAL CONDITIONS];
-Received antianxiety medication seven out of seven days.
Review of the physician’s orders [REDACTED].
Review of the Medication Administration Record [REDACTED].
Review of the MAR, dated 2/1 through 2/28/19, showed [MEDICATION NAME] 0.5 mg administered
26 times.
Further Review of the POS [REDACTED]. Start [MEDICATION NAME] after the supply of
[MEDICATION NAME] runs out.
Review of the MAR, dated 3/1 through 3/31/19, showed the following:
-[MEDICATION NAME] 0.5 mg administered 15 times;
-[MEDICATION NAME] 1 mg. administered 5 times;
-Both [MEDICATION NAME] and [MEDICATION NAME] administered on 3/30/19.
Review of the care plan, dated 2/25/19, showed the following:
-Problem: Receives antianxiety medication related to anxiety;
-Goal: Will not exhibit drowsiness, over sedation, delayed reactions or other adverse side
effects;
-Approaches: Assess behavior and mood, attempt non-pharmacological interventions, monitor
for the medication’s effectiveness and document the resident’s behaviors and moods.
During an interview on 4/3/19 at 9:00 A.M., the administrator said all psychoactive
medications have to be renewed every 14 days, and the Director of Nursing (DON) said the
medications should be reviewed monthly by the participating pharmacy. The DON said he
would have expected the pharmacy to pick up on the fact that the PRN medication had gone
beyond the 14 days. He added that the order for [MEDICATION NAME] should have never been
written the way it was. The [MEDICATION NAME] should have just been discontinued and then
start the [MEDICATION NAME]. He said the nurse should have obtained clarification of the
order, and actually the medication should be changed to routine since the resident used it

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 28)
so often.
2. Review of Resident #28’s quarterly MDS, dated [DATE], showed the following:
-Severe cognitive impairment;
-A score of 5 on the Patient Health Questionnaire (PHQ-9, tool to assess mood and
depression) indicating the resident felt down/depressed/hopeless, trouble falling asleep,
speaking slowly or being restless;
-Verbal behaviors observed one to three days;
-Required extensive assistance from staff for bed mobility, transfers, dressing and toilet
use;
-Diagnoses included [MEDICAL CONDITION], heart failure, high blood pressure, diabetes,
stroke, dementia, anxiety and depression;
-Use of antipsychotic medications for seven of seven days observed;
-Use of antianxiety medications for seven of seven days observed;
-Use of antidepressant medications for seven of seven days observed.
Review of the resident’s care plan, dated 1/22/19 and in use during the survey, showed the
following:
-Problem: Resident is at risk for adverse consequences related to the use of antipsychotic
medication for treatment of [REDACTED].
-Goal: The resident will not exhibit signs of drug related side effects or adverse drug
reaction;
-Approaches included pharmacy consultant review, review for continued need at least
quarterly.
Review of the resident’s medical record, showed the following:
-A pharmacy recommendation, dated 1/30/19, showed the following:
-Repeated recommendation from 11/12/18: Please respond promptly to assure facility
compliance with federal regulations. The resident has received [MEDICATION NAME] (sedative
and antidepressant) 100 mg at night for [MEDICAL CONDITION] since (MONTH) (YEAR);
-Recommendation: For the initial attempt at GDR in the facility, please consider
decreasing [MEDICATION NAME] to 75 mg, while concurrently monitoring for reemergence of
target and/or withdrawal symptoms. Non pharmacological interventions should be ongoing;
-Physician signature to accept the recommendation to please implement as written.
Decrease [MEDICATION NAME] 75mg every night, dated 2/18/19;
-Review of the (MONTH) 2019 POS and MAR, showed staff did not document a GDR for
[MEDICATION NAME];
-Review of the (MONTH) 2019 POS and MAR, showed the order for [MEDICATION NAME] 100 mg to
be given at night for [MEDICAL CONDITION] crossed off and a hand written order below,
showed [MEDICATION NAME] 75 mg at night for [MEDICAL CONDITION] with no order date.
Further review of the resident’s (MONTH) 2019 POS, showed the following:
-An order, dated 10/17/18, for [MEDICATION NAME] (antianxiety medication) 0.5 mg, give
half a tablet for anxiety, to be given up to four times a day PRN;
-Staff failed to ensure a [MEDICAL CONDITION] medication given PRN for more than 14 days
had documentation to show the rationale.
During an interview on 4/3/19 at 10:00 A.M., the DON said he would expect staff to follow
up and document the physician’s decision to a pharmacy recommendation within 48-72 hours.
Staff should document if the physician refused to address the recommendation. If a new
order was given, it should be implemented immediately. Staff should have acted on the
recommendation in (MONTH) sooner.
3. Review of Resident #74’s admission MDS, dated [DATE], showed the following:
-admitted [DATE];
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 29)
-Mild cognitive impairment;
-Diagnoses: [REDACTED].
-Received antipsychotic, antianxiety and antidepressant medications daily.
Review of the pharmacy review, dated 3/20/19, showed no recommendations.
Review of the resident’s care plan, revised on 3/22/19, showed the following:
-Problem: [DIAGNOSES REDACTED].
-Goal: The resident’s anxiety reduced over the next 90 days;
-Approach: Administer medications as ordered, document signs/symptoms, notify the
physician of any anxiety not reduced by interventions, remove the resident form the
situation;
-Problem: Receives antidepressant related to depression;
-Goal: The resident will not exhibit signs of drug related sedation;
-Approach: Staff to assess/record effectiveness of treatment, monitor and report signs of
sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms (side effects which can
include dry mouth and related dental problems, blurred vision, tendency toward overheating
(hyperpyrexia), and in some cases, dementia-like symptoms), monitor mood and response to
medication, pharmacy consultant review;
-Problem: The resident receives antianxiety medication;
-Goal: The resident will not exhibit drowsiness, slowed reaction, slurred speech or drug
dependence;
-Approach: The staff assess the resident’s mood and behavior, attempt non-medication
approaches before giving PRN (offer toileting, snack, time to talk, assist with group
activities), monitor mood and response to medication and document behaviors;
-Problem: The resident receives antipsychotic medication related to a [MEDICAL CONDITION]
-Goal: The resident will be given the lowest effective dose;
-Approach: Staff to obtain abnormal involuntary movement scale assessment (AIMS, used to
assess potential side effects of antipsychotic drug use) every quarter, assess behavior
and monitor, pharmacy consult review, document behavior and review need for medication
quarterly.
Review of the admission hand written MAR, dated 3/13/19 through 3/31/19, showed orders
dated 3/13/19 for the following:
-[MEDICATION NAME] (antipsychotic), take 5 mg at bedtime at 8:00 P.M., with no [DIAGNOSES
REDACTED].>-[MEDICATION NAME] (used to treat anxiety) take 10 mg daily, with no
[DIAGNOSES REDACTED].>-[MEDICATION NAME] 0.25 mg every 8 hrs PRN. Staff hand wrote a
[DIAGNOSES REDACTED].
4. During an interview on 4/3/19 at 10:00 A.M., the DON said [MEDICAL CONDITION]
medications ordered as a PRN should be only ordered for 14 days and reviewed by the
physician. The monthly pharmacy review should catch something like this as well.

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 store, prepare,
distribute and serve food in accordance with professional standards for food service

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 30)
safety. The facility failed to store dishware and bulk food items in a manner to protect
from cross contamination and maintain equipment free of food particles, debris, dust and
grease. These deficient practices had the potential to affect all residents who ate at the
facility. The census was 73.
1. Observations of the kitchen on 3/28/19 at 11:08 A.M., 3/29/19 at 6:55 A.M., 4/1/19 at
5:40 P.M., 4/2/19 at 2:46 P.M. and 4/3/19 at 8:00 A.M., showed the following:
-An accumulation of crumbs under the toaster;
-A layer of dust and food particles on the top of the convection oven. Dried brown drip
marks and a build up of grease on the doors and legs of the convection oven. Grease
splatter and dried bits of fried food particles on the side of the convection oven next to
the deep fat fryer;
-Dried bits of fried food particles on the deep fat fryer baskets. Fried food particles
floating on top of the grease in the deep fat fryer. Visible build up of grease and crumbs
under the deep fat fryer;
-A heavy build up of carbon on the side of the griddle next to the deep fat fryer. Food
crumbs and grime on the exterior of the oven doors;
-A yellowish build up of grime and food crumbs on the one inch tile ledge under the steam
table extending from one end of the table to the other;
-A heavy build up of crumbs and debris between the steam table and the work table;
-Dried spills and food particles on the bottom shelf of the steam table;
-A fan, positioned to blow on clean dishware, with small fragments of dark grayish dust on
the vents. The fan ran at all times.
During an interview on 4/3/19 at 8:00 A.M., the dietary manager said the kitchen should be
deep cleaned twice a week. There are daily cleaning tasks assigned to staff, but she did
not know if the tasks were posted. The deep fat fryer should be cleaned based on the
amount of use, but agreed it needed to be changed. The dietary manager is responsible for
ensuring the kitchen is cleaned. The fan should not have dust on it to prevent it from
blowing onto the cleaned dishes.
2. Observations of the kitchen on 3/28/19 at 11:08 A.M., 3/29/19 at 6:55 A.M., 4/1/19 at
5:40 P.M., 4/2/19 at 2:46 P.M. and 4/3/19 at 8:00 A.M., showed the following:
-A plate warmer with three stacks of plates positioned right side up. Noticeable dust and
food particles on the top of the warmer;
-A wired rack with stacks of bowls, saucers and plates, positioned right side up on the
top shelf in a walk way;
-A cart with stacks of plate lids positioned upside down by the dish machine;
-A bulk bin contained sugar, a black plastic mug and the lid to the bin;
-A bulk bin contained a bag of thickener and a black plastic mug.
During an interview on 4/3/19 at 7:58 A.M., the dietary manager said the dishware should
be stored upside down and the plate lids should be stored right side down to protect the
surfaces from cross contamination. There should not be any cups or lids in the bulk bins
to ensure the contents are protected from cross contamination.

F 0842

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

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

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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 31)
Based on interview and record review, the facility failed to maintain complete and
accurate records by not documenting wound treatments and the status of an application for
dental insurance for two of 19 sampled residents (Residents #34 and #61). The census was
73.
1. Review of Resident #34’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 2/6/19, showed the following:
-Severe cognitive impairment;
-Extensive assistance of staff required for most activities of daily living (ADLs);
-Upper extremity impairment on one side and lower extremity impairment on both sides;
-At risk for pressure ulcers;
-Gastrostomy ([DEVICE], a tube surgically inserted into the stomach to provide hydration,
nutrition and medications) tube;
-Indwelling catheter (a sterile tube inserted into the bladder to drain urine);
-Tracheotomy (Tube surgically inserted into the trachea for the purpose of breathing);
-[MEDICAL CONDITION] (A surgical procedure that brings one end of the large intestine out
through the abdominal wall);
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 3/25/19, showed the following:
-Problem: scrotum (a sac of skin that hangs from the body at the front of the pelvis,
between the legs) abscess, at risk for additional skin breakdown related to history of
breakdown to right buttocks and coccyx, limited mobility, poor nutrition, catheter,
[DEVICE], [MEDICAL CONDITION] and [MEDICAL CONDITION];
-Goal: scrotal wound will show signs of healing, there will be no pressure ulcer
development and comfort will be maintained;
-Approach: treatments as ordered, see treatment administration record (TAR).
Review of the resident’s physician’s orders [REDACTED].
-An order, dated 3/17/19, scrotal abscess, cleanse with normal saline, pack with dry
[MEDICATION NAME] (gauze strip used for sterile drainage of open and/or infected wounds)
strip, leave a wick and cover with 2 by 2 gauze and tape, daily and as needed;
-An order, dated 3/26/19, for Wound Care Plus (wound treatment provider) to evaluate and
treat;
-An order, dated 3/27/19, scrotal abscess, cleanse with normal saline, pack with dry
[MEDICATION NAME] strip, leave a wick and cover with 2 by 2 gauze and tape, daily and as
needed.
Review of the resident’s TAR dated 3/17/19 through 3/31/19, showed the following:
-Scrotal abscess: cleanse with normal saline, pack with dry [MEDICATION NAME] strip, leave
a wick and cover with 2 by 2 gauze and tape, daily and as needed; 3/17/19 through 3/23/19,
blank with no documentation on the back of the TAR, and initialed as completed 3/24/19
through 3/26/19 and marked 3/27/19 order changed;
-Scrotal abscess: cleanse with normal saline, pack with dry [MEDICATION NAME] strip, leave
a wick and cover with 2 by 2 gauze and tape, daily and as needed; initialed as done
3/27/19 through 3/30/19. The entry on 3/31/19 was blank with no documentation on the back
of the TAR.
Review of the resident’s medical record, found no documentation of an evaluation by Wound
Care Plus.
During an interview on 4/2/19 at 2:30 P.M., Nurse B said the resident came back from the
hospital with a surgical wound from a scrotal abscess lanced while in the hospital. Wound
Care Plus saw him last Wednesday and will be in again tomorrow. He/she had to print out
their notes and then put them in the medical record under ‘consults’. He/she may not have
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 32)
placed them in the medical record yet.
During interviews on 4/2/19 at approximately 3:00 P.M. and on 4/3/19 at 9:00 A.M., the
Director of Nursing (DON) looked at the (MONTH) TAR and said the nurse responsible for the
treatments on 3/17/19 through 3/23/19 did not document the treatments had been done. If
the TAR was blank with no documentation, the treatment had not been done. Consults should
be included in the medical record, and he had them on his desk.
2. Review of Resident #61’s quarterly MDS, dated [DATE], showed the following:
-admitted : 11/26/18;
-Moderate cognitive impairment;
-Weight loss, on physician prescribed weight loss regimen;
-Therapeutic diet;
-Oral/Dental status: blank;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed the following:
-Review of a Social Service Progress review, dated 11/27/18, showed the following:
-Does the resident have hearing or vision limitations that are affecting the resident’s
ability to function? (Down arrow) dentures-need to be realigned;
-Physical/functional status: dentures, referral in;
-Review of a Social Service Progress review, dated 3/5/19, listed dental care, referral,
in the physical/functional status section;
-On the (MONTH) 2019 and (MONTH) 2019 POS, a standing order, dated 11/26/18, Consults:
podiatry, ophthalmology, dental as needed;
-No further social service notes regarding the resident’s dentures being realigned or a
referral for the resident to be seen;
-No nurse’s notes or dietary notes regarding the resident’s use of dentures;
-No documentation on the resident’s care plan regarding the use of dentures.
During an interview on 3/28/19 at 12:05 P.M., the resident said he/she has dentures, but
they slide out. They need to be realigned. He/she is able to eat food ok. The facility
social worker told the resident his/her check hasn’t arrived yet. He/she cannot see the
dentist until the check arrives. The resident was not sure when or if he/she will be seen
by a dentist or when his/her dentures will be realigned. The resident has been in the
facility since (MONTH) (YEAR).
During an interview on 4/2/19 at 10:45 A.M., the social worker said the Social Security
interview had just been completed for the facility to become the resident’s representative
payee. The social worker has discussed this with the resident, but did not document it.
She agreed if it is not documented then it is hard to show the conversations happened. She
would look to see if she had any documentation.
During an interview on 4/3/19 at 11:00 A.M., the social worker was again asked to provide
any documentation to show the status of the resident’s dentures. The social worker said
she did not know if the resident had been seen previously or not. The dentist was coming
on 4/12/19 and if the resident had not been seen, he/she would be seen on that date. She
did not know if the resident had previously been fitted for dentures.
During an interview on 4/3/19 at 11:15 A.M., the social worker provided a copy of an
Application for Limited Benefit In-Facility Dental Policy, showed the following:
-A handwritten note which showed Faxed 1/4/19;
-Medicare: Yes;
-Medicaid: Yes;
-Premium selected: $85.00/month;
-Authorization: Resident understands the coverage will not be effective until this
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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 33)
application and applicable payment has been received and accepted by the company. This
application is also a request and authorization for necessary diagnostic and preventative
treatment as well as any necessary repair or adjustment of prosthodontics;
-Signed by the resident on 1/3/19.
During further interview, the social worker said the form was in the resident’s file in
her office. She did not know the status of the application and had not followed up on it.
The application should be part of the resident’s medical record.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow the
infection control policy and procedure to prevent potential spread of confirmed [MEDICAL
CONDITION] ([MEDICAL CONDITION], a bacteria that causes diarrhea and colon inflammation)
infection for one resident with [MEDICAL CONDITION] infection (Resident #63). This
practice placed current facility residents at risk for infection. The sample size was 19.
The census was 73.
Review of the facility’s Infection Prevention and Control policy and procedure for
[MEDICAL CONDITION] showed the following:
-Policy: The facility qualified staff will deliver care to the resident with [MEDICAL
CONDITION];
-General Information: [MEDICAL CONDITION] is a gram positive rod, spore forming organism
which produces toxin that damages the intestinal cells which may cause diarrhea and
[MEDICAL CONDITION];
-Transmission occurs when the organism or its spores get into a person’s mouth by direct
contact. It may transferred to residents if good hand hygiene/handwashing and appropriate
use of gloves are not practiced. The [MEDICAL CONDITION] spores can survive in the
environment for long periods of time;
-Precautions: Contact precautions will be implemented with known or suspected [MEDICAL
CONDITION]
*Full barrier precautions
-Gowns and gloves worn when staff are in contact with patients with [MEDICAL CONDITION]
infection and for contact with body fluids and environment;
-Gloves should be changed if visibly soiled and after touching or handling surfaces or
materials contaminated with feces;
-Gowns and gloves should be removed before exiting room.
Review of Resident #63’s medical record, showed the following:
-An order, dated 2/19/19, to obtain a [MEDICAL CONDITION] test sample;
-On 2/25/19, a positive [MEDICAL CONDITION] test;
-An order, dated 2/26/19, to begin [MEDICATION NAME] (antibiotic) 250 milligrams (mg) tab
four times a day for 30 days immediately.
During an observation and interview on 3/29/19 at 9:25 A.M., Certified Medication
Technician (CMT) H entered the resident’s room and did not wash his/her hands, gown, glove
or apply a mask. The resident’s door showed a red isolation precautions sign and
instructed staff must apply gloves, gown, mask and wash hands. CMT H placed the bottle 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:

265331

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

NAME OF PROVIDER OF SUPPLIER

SUNSET HILLS HEALTH AND REHABILITATION CENTER

STREET ADDRESS, CITY, STATE, ZIP

10954 KENNERLY ROAD
SAINT LOUIS, MO 63128

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 34)
the resident’s [MEDICATION NAME] (nasal allergy spray) medication on top of the resident’s
over the bed table. The CMT did not place a barrier under the medication bottle. CMT H
administered all of the resident’s medication to him/her via ungloved hands. CMT H removed
the [MEDICATION NAME] medication bottle, exited the resident’s room and placed the
[MEDICATION NAME] bottle on top of the facility medication cart in the hallway. CMT H
sanitized his/her hands at the medication cart, unlocked the medication cart and placed
the [MEDICATION NAME] bottle into the top drawer of the medication cart. CMT H said he/she
thought the resident was on contact isolation precautions for [MEDICAL CONDITION]
infection, he/she forgot to apply protective equipment before entering the room. He/she
touched the residents over bed table and repositioned the table for the resident and used
ungloved hands to move the table and give the resident his/her medication. Hand sanitizer
will not kill the [MEDICAL CONDITION] virus.
During an interview on 4/3/19 at 9:00 A.M., the Director of Nursing said if a resident had
an active contagious infection, he expected staff to apply a gown, gloves and a mask if
needed before entering the resident’s room. Staff should not touch or handle bedroom
furniture or supplies in a room that is currently used for contact isolation. Medication
containers should not be placed onto furniture in a room with contact isolation
precautions. If staff do not follow the infection control precautions, it could spread the
infection elsewhere in the facility.