Southview Assisted Living.

PRINTED: 07/31/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: me Renae COMPLETED B.WING 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9916 REAVIS ROAD AFFTON, MO 63123 {X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) SOUTHVIEW ASSISTED LIVING A9998) State Statute This regulation is not met as evidenced by: Class II 9998-State Statue Based on record review and interview on July 30, 2025, the facility failed to have a current boiler inspection certification under 11 CSR40-2.022. The facility census was 83. This deficiency affects 83 out of 83 residents. 11 CSR 40-2.022 Section (4) states: |" Frequency of inspection of heating boilers, | water heaters, pool heaters, and fired jacketed steam kettles. (A) Steam heating boilers shall be inspected every two (2) years. The certificate inspection shall be an internal inspection where construction permits; otherwise the inspection shall be as complete as possible while the boiler is in operation. (B) Hot water heating boilers and fired jacketed steam kettles shall be inspected every two (2) years. 1. Hot water heating and hot water supply boilers over thirty (30) years old shall be internally inspected every two (2) years where construction permits, otherwise the inspection shali be as complete as possible while the boiler is in operation. 2. Hot water heating and hot water supply boilers that are not over thirty (30) years old shail be externally inspected every two (2) years. The inspector may mandate an internal inspection if the inspector feels it is necessary. 3. Water heaters, pool heaters, and fired jacketed steam kettles shall be externally | inspected every two (2) years." | Record review at 14:10 A.M. showed that there was no documentation of a current inspection Missouri Department of Health and Senior Services 7 (X6) DATE (f continuation sheet 1 of 2 PRINTED: 07/31/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED BuWMING. zee es or 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 9916 REAVIS ROAD AFFTON, MO 63123 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION} CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) SOUTHVIEW ASSISTED LIVING Continued From page 1 certification for the boiler. Further review showed the State Certificate had expired 6/26/25. During an interview on July 30, 2025 at the time of discovery, the Maintenance Director stated he/she thought the inspection had been done in May or June. Missouri Department of Health and Senior Services STATE FORM ase cB2911 If continuation sheet 2 of 2 PLAN OF CORRECTION aan ia 5 sei Southview Assisted Living Name: Street Address, : i 9916 Reavis Road, Affton Mo. 63123 City, Zip: ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Failure to have Boiler inspection certificate. | called Travelers and the inspection was done 1/20/2025 and has sent me the certificate today 7/31/2025. | replied to with Travelers by 7/31/2025 email asking to have the report filed with the State and asked to make sure it gets reported here after they complete inspections. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/15/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9916 REAVIS ROAD AFFTON, MO 63123 SOUTHVIEW ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE DATE | | DEFICIENCY) | 19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents ' social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. I/II | Time Personnel Residents 7 a.m. to 3 p.m. | (Day)* 1 3-15 3 p.m. to 9 p.m. (Evening)* 1 3-20 9 p.m. to 7 a.m. (Night)* 1 3-25 “If the shift hours vary from those indicated, the | hours of the shifts shall show on the work | schedules of the facility and shall not be less than six (6) hours. Ill This regulation is not met as evidenced by: Class || | Based on interview and record review, the facility care staff failed to notify a nurse for an assessment after a resident fell. The staff lifted | the resident off the floor, without an assessment | by a qualified person, for one of one sampled resident (Resident #1). The census was 45. Missouri Department of Health and Senior Services LABORATORY OIRFCTOR'S OR (X6) DATE If Continuatién sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER SOUTHVIEW ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 Review of the facility's fall policy dated 6/29/23, showed the following: -Incident Report: any team member who observes or is first on the scene to a reportable incident, must report immediately to the Director of Nursing (DON) and Administrator; -The DON or Administrator must document what was observed and report on the Incident Report Form; -Evaluation: The DON or Wellness Nurse will evaluate the resident after the incident has occurred. If the incident resulted in multiple changes to the care plan or significant change of condition, the DON would complete a full reassessment; -The assessment will be completed by the DON or Wellness Nurse and documented in the resident's chart; -All incidents involved residents require an evaluation within three business dates of the incident. Review of Resident #1's medical record, showed the facility admitted the resident on 4/29/24, with diagnoses which included high blood pressure, acid reflux and chronic obstructive pulmonary disease (long term lung disease). Review of the resident's progress notes dated 12/17/24 at 11:42 P.M., showed Medication Technician (MT) A answered the resident's call light. When MT A entered the resident's room, the resident was observed lying in front of his/her bed saying he/she tried to go to bed and he/she fell. MT A assisted the resident from the floor to the resident's bed. The resident had vomited twice and complained of back pain. MT A gave the resident an as needed pain medication. MT A notified the DON and the resident's family member of the incident. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 2MZJ11 PRINTED: 01/28/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/15/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 9916 REAVIS ROAD AFFTON, MO 63123 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 4 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9916 REAVIS ROAD AFFTON, MO 63123 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) SOUTHVIEW ASSISTED LIVING Continued From page 2 Review of the facility's incident tracking report dated 12/17/24, showed the investigation included environmental factors reviewed, medical factors reviewed, and resident specific factors reviewed. The details showed the resident attempted to put self to bed. The intervention included the resident's care plan was updated with interventions and the resident was educated. During an interview on 1/15/25 at 1:52 P.M., MTA said he/she remembered the resident falling that night and said he/she called the DON after the resident fell. MT A kept going back and forth on whether or not he/she talked to the DON, so MTA checked his/her phone and said he/she had only texted the DON. MT A read the text he/she sent to the DON which read, the resident fell. He/she is okay. He/she did not hit his/her head. MT A said the DON texted back, "Okay." MT A said he/she could not remember if he/she sent the text to the DON after helping the resident off the floor or before. MT A said he/she was the one who got the resident off the floor with the help of another staff member but he/she did not remember who the staff member was. MT A said he/she was told only a Nurse could assess a resident after a fall, but said he/she had been trained on how to do an assessment and thought he/she could complete the assessment on the resident. During an interview on 1/15/25 at 1:15 P.M., the DON said MT A called her about the resident's fall and she had assessed the resident over the phone. During an interview on 1/15/25 at 2:40 P.M., the Administrator said the DON should have written a progress note or an incident report regarding the fall. She said MT A should have called the DON to Missouri Department of Health and Senior Services STATE FORM 6899 2MZJ11 If continuation sheet 3 of 4 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 9916 REAVIS ROAD AFFTON, MO 63123 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) SOUTHVIEW ASSISTED LIVING A4841 Continued From page 3 get an assessment completed on the resident prior to MT A lifting the resident off the floor. The DON responding okay was not an assessment. M000245323 Missouri Department of Health and Senior Services STATE FORM 6899 2MZJ11 If continuation sheet 4 of 4 RETIREMENT COMMUNITIES wt SPECTRUM REASON FOR PLAN OPERATOR ENTITY COMMUNITY NAME Complaint SURVEY (#¥Abyplyt) Response Psp) DATE Due Date Spectrum Retirement Communities Southview Assisted Living (eT O) Ay. Oa) RO) COS Vissouri Department of Health and Senior Services DEFICIENCY ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS Responsible Person for Action Due Date(s) for This Plan of Correction is being submitted by Spectrum Retirement Communities (the “Operator”), which is the licensed operator of the community known as Southview Assisted Living (the “Community”). This Corrective Action Plan has been prepared with the assistance of Operator’s management company (a subsidiary of Spectrum Retirement Communities, LLC, together with its subsidiaries and affiliates, collectively, “Spectrum”) to respond to the deficiencies alleged by Missouri Department of Health and Senior Services following the survey that was completed on or about 01/15/2025. This Corrective Action Plan has been prepared and is being submitted in order for the Community to satisfy and demonstrate its compliance with the requirements of state laws, rules, and regulations and to avoid an adversarial dispute process; however, the Community’s preparation and submission of this Corrective Action Plan is not, and shall in no way be deemed or construed to be, an admission or agreement that any of the findings or alleged deficiencies existed, were correctly cited, and/or are substantiated. This Corrective Action Plan may include actions to be taken by employees of Spectrum who do not work at the Community for the benefit of the Operator, and all such actions are, for all purposes, deemed to be actions taken by Operator. The Operator’s submission of the Corrective Action Plan and any acceptance of same is conditioned upon and subject to the foregoing terms and understandings and if this Corrective Action Plan is not accepted, then Operator reserves the right to dispute the alleged deficiencies. Tag Number and Title of Tag Immediate Action: Katrina 2/17/2025 19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents ' social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. I/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 13-15 3 p.m. to 9 p.m. (Evening)* 1 3-20 9 p.m. to 7 a.m. (Night)* 13-25 Education to Director of Nursing on fall investigations, assessments and follow up documentation per company policy and regulations. Completed on 1/29/25 Education all Medication Assistants regarding incident notification, evaluation & documentation. Will be completed by 2/14/25 Education from Legacy Therapy Department on active range of motion - evaluation by 2/14/25 Those team members who have not received the training/education by 2/14/25 will be educated prior to their first shift worked. The Director of Nursing is responsible for compliance. Audits will be conducted weekly by the Executive Director and/or designee to ensure elements in the training have been implemented and will document all actions taken as part of compliance with regulatory compliance. Results of the audit will be brought to the Director of Nursing for review, identify any trends and the need for further auditing. Page 1 of 2 Waldorf, Executive Director & Debbie Carron, Director of Nursing POC Blank Template v2.0 / 10.2023 df PECTRUM ee ESE ROM REASON FOR PLAN Complaint 1093814 20" 1/15/2025 Response PAR/PWs) DATE Due Date OPERATOR ENTITY Spectrum Retirement Communities Responsible COMMUNITY NAME Southview Assisted Living GOV. AGENCY ISSUING DEFICIENCY Missouri Department of Health and Senior Services Person for Action Due Date(s) for ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. Page 2 of 2 POC Blank Template v2.0 / 10.2023