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

PRINTED: 11/09/2023 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 10/23/2023 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 A4754| 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; Il This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop individualized . service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) which included resident needs, services to be provided by staff and goals expected by the resident or the resident's legal representative for four of nine sampled residents (Residents #1, #8, #2 and #9). The census was 86. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 12/20/21, with diagnoses which included high blood pressure, depression and gastro-esophageal reflux disease. Review of the resident's ISP dated 1/8/23, showed the following: -Need: Skin maintenance; -Goal: To prevent bruises, injuries, pressure Missouri Department of Health and Senior Services LABORATORY,DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE I- 74-23 If continuation sheet 1 of 31 HM2E11 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 sores and infections, which posed a health and safety issue; -Service to be provided: Newly identified skin concerns will be reported to the nurse or director when observed during care. Home health would see the resident for small open area to buttocks; -Need: Transferring; -Goal: The resident was independent with transfers and used a walker for ambulation; -Services to be provided: The resident was independent with transfers and did not require any assistance from care staff; -Need: Fall prevention plan; -Services to be provided: An assessment indicated that the resident is a potential fall risk. Staff will check for appropriate lighting, clutter, and spills in apartment encourage proper footwear/nonskid footwear, and educate the resident to push the call pendant as needed for assistance with mobility. The resident had no falls in the last six months; -Need: Mobility/Ambulation; -Services to be provided: The resident was independent with mobility/ambulation. If he/she needed assistance, the resident was encouraged to use his/her call pendant and wait for staff to assist him/her. The resident used a walker to ambulate throughout the facility. Review of the resident's progress notes, showed the following: -On 8/2/23 at 8:32 A.M., the resident said he/she slid from his her recliner to the floor. He/she said he/she was okay and nothing was hurt. Staff assisted the resident off the floor and placed him/her in the wheelchair so the resident could go to dinner; -On 10/17/23 at 8:29 A.M., the resident said he/she tried to get into his/her wheelchair from his/her recliner and fell. He/she said nothing hurt Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 31 PRINTED: 11/09/2023 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 10/23/2023 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 and refused to go to the emergency department. The resident said he/she hit his/her head on the dresser but it did not hurt. Review of the resident's physician's orders dated 10/2023, showed the following: -Oxycodone HCI Oral Tablet 5 milligram (mg) take one tablet by mouth every 8 hours as needed for severe pain (max daily amount: 15 mg); -Oxycodone-acetaminophen oral tablet 10-325 mg, take one tablet by mouth every 6 hours as needed for pain; -Hydroxyzine HCI Oral tablet 10 mg, take one tablet by mouth once daily as needed for anxiety disorder; -Trazadone HCl oral tablet 100 mg, take one tablet by mouth at bedtime for major depressive disorder. Review of a resident care survey (a form filled out by the facility during the facility's annual licensure) dated 10/19/23, showed the resident used a wheelchair, needed assistance with transfers, had a fall history, was recently hospitalized and needed an individualized evacuation plan. During an interview on 10/20/23 at 10:12 A.M., Medication Aide (MA) C said the resident bumps his/her legs on the wheelchair when trying to transfer. The resident "ripped" his/her leg on the wheelchair and he/she entered a note into the resident's medical record. The resident's skin is paper thin. During an interview on 10/20/23 at 4:35 P.M., the Director of Nursing (DON) said it is not often the resident drank alcohol but it happens occasionally. Staff were not told to watch the resident to see if she was drinking. An alert Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 3 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 3 resident should know when to stop drinking before coming drunk. The resident should not drink alcohol and take narcotics. MA J should have called the physician if the resident appeared to be intoxicated. The residents's skin issues on his/her legs happened when the resident tried to get out of his/her wheelchair by him/herself. He/she hit his/her legs. The resident could transfer by his/herself but sometimes he/she needed help with transfers in the morning. The resident slept in a recliner. The DON said she thought she could not perform wound care for resident. She said she should have investigated the wounds on the resident's legs and it should have been documented. Observation on 10/20/23 at 10:09 A.M., showed the resident seated in his/her recliner. A wheelchair sat in front of him/her. He/she had multiple bruises on both legs. A healing sore on the resident's right leg looked like a deep wound. All of the bruises were black and blue. The resident said he/she wanted to get it looked by a physician. He/she said his/her legs have been like that for a while, but did not know how long. The resident said he/she bumps his/her legs on the wheelchair and that caused the bruises and the wound. During an interview on 10/19/23 at 10:02 A.M., the resident said he/she did not get his/her medications one day because MA J said he/she had been drinking. The resident said he/she occasionally liked to drink alcohol but he/she was never drunk. Review of the resident's ISP dated 1/8/23, showed the following: -The ISP did not address the resident's skin issues and the preventions and services to be Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 4 of 31 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 4 provided for reoccurring bruising due to his/her legs hitting the wheelchair; -The ISP did not indicate the resident's need for transfer assistance; -The ISP did not address the resident's two falls and what preventions and services were to be provided for those falls; -The ISP did not indicate the need for a wheelchair; -The ISP did not address the resident drinking alcohol. 2. Review of the facility's Resident Care Events/Incident Reporting and Investigation policy dated 2/1/23, showed the following: -Updating the care plan: -After the incident investigation and short-term observation monitoring are finalized and the resident has either, returned to baseline or reached a new baseline; the DON shall update the resident's care plan with interventions identified during the investigation; -The DON shall identify at least one intervention that will reduce the chance of the incident reoccurring; -The intervention will be added to the existing care plan in the electronic health record (EHR); -If the resident requires permanent or long-term changes to the care plan because of the incident, a change of condition assessment will be completed by the DON and a care conference scheduled; -Any changes to the care plan will be communicated to the resident and/or resident representative at the time of change; -Document any communication with the resident and resident representative in the EHR. Review of Resident #8's medical record, showed the facility admitted the resident on 5/18/21, with Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 5 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 5 a diagnoses which included hyperlipidemia (too many lipids in the blood), osteoporosis (bone disease) and high blood pressure. Review of the resident's progress notes dated 6/13/23 at 7:03 A.M., showed MA G went into the resident's apartment and found the resident on the floor on the right side of the bed. The resident had blood around him/her and in his/her hair. MA G performed range of motion on the resident and took the resident's vitals. The resident denied any pain other than soreness. MA G assisted the resident off the floor and assisted the resident to the shower. After washing the resident's face and hair, it was determined his/her nose bled. The resident did not have any other cuts or lacerations. The resident's right side of his/her face was swollen and red. The resident's eyes were bruised. MA G gave the resident an as needed Tylenol and applied an ice pack to the right side of his/her face. MA G notified the DON and hospice. During an interview on 10/20/23 at 8:55 A.M., MA G said he/she did not write a statement about what happened on 6/13/23, and he/she was not asked to do so. MA G said he/she spoke with the hospice nurse and the hospice nurse was able to order the resident a hospital bed with an air mattress with siding so the resident does not roll out of bed, which has prevented the resident from falling out of bed. MA G said the last time the resident fell out of bed was in June of 2023. Review of the resident's progress notes, showed the following: -On 6/13/23 at 10:00 A.M., MAH assisted the resident with peri-care (cleaning the private areas of a person) and getting into bed. As the resident began to lie down, he/she said "ouch, no that's Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 6 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 6 not right." MA H asked the resident if he/she needed to reposition his/her body. The resident said, "No, my fever is just really bad." MAH asked the resident if his/her head hurt and the resident said yes. MAH asked the resident if he/she wanted to go to the hospital and the resident said yes. MA H notified the DON and hospice. The paramedics were called and arrived at the facility but the power of attorney decided to have a hospice nurse come to check on the resident instead. The hospice nurse was scheduled to arrive at the facility after 10:00 P.M. The resident was currently awake in his/her chair waiting on the nurse; -On 6/13/23 at 10:28 P.M., the hospice nurse called the facility and said he/she had spoken with the resident's family member. They confirmed the resident's case manager came earlier to check on the resident and said the resident was a Do Not Resituate. Any comfort for the resident will need to be in the facility. The hospice nurse received an order for Morphine. Staff will continue to monitor. Review of the resident's ISP dated 8/17/23, showed the resident had a need of a fall prevention plan. The fall prevention plan indicated the resident was a potential fall risk. The facility staff were to check for appropriate lighting, clutter, and spills in the apartment, encourage proper footwear/nonskid footwear, and educate the resident to push the call light as needed for assistance with mobility. The facility staff should not allow the resident to ambulate without assistance. The resident had a fall on 10/11/22 and 4/7/23. On 4/7/23, the resident fell from his/her bed. The facility staff were to check on the resident every two hours. The ISP did not address the resident's fall on 6/13/23 and did not specify new preventions such as the hospital bed Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 7 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 7 and the air mattress. 3. Review of Resident #2's medical record, showed the facility admitted the resident on 1/18/21, with diagnoses which included mixed hyperlipidemia (a congenital disorder in which a person has naturally higher levels of cholesterol and fat in their body), chronic atrial fibrillation (a longstanding chaotic and irregular atrial arrhythmia) and venous insufficiency (leg veins don't allow blood to flow back up to the heart). Review of the resident's ISP dated 3/29/23, showed the following: -Need: Mobility/ambulation; -Services to be provided: The resident is independent with mobility/ambulation. The ISP did not address the resident's need for a walker; -The ISP did not indicate the resident's need for hospice services. Review of the resident's progress notes, showed the following: -On 7/9/23 at 12:23 P.M., the resident was assessed by a nurse, bilateral upper extremities with gross edema noted with blistering around wrist. The resident had a rash to entire trunk. POA (Power of Attorney) notified and would come take the resident to urgent care, No signs or symptoms of any distress at that time; -On 7/21/23 at 4:21 P.M., the resident returned from the hospital with a diagnoses of heart failure; On 8/4/23 at 12:48 P.M., the resident was short of breath with minimal exertion accompanied with some shortness of breath with speech. He/she had 3+ edema (swelling) to his/her bilateral legs, but no weeping. The Administrator spoke with the resident's care giver who said he/she could not find a scale for that day. The caregiver provided a list of the resident's medication which did not Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 8 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 8 include his/her diuretics (medications used to increase the production of urine). The resident was also not wearing any type of compression stockings on his/her legs. The caregiver was educated on the disease process of congestive heart failure and symptoms of fluid overload as well as the need for compression on the resident's legs and the need for weights; -On 8/7/23 at 1:40 P.M., the resident was admitted to hospice at that time; -On 8/27/23 at 9:15 P.M., the resident's legs were swollen and weeping. He/she was instructed to elevate his/her legs while in bed; -On 10/17/23 at 8:39 A.M., the hospice aide came to give the resident a shower and he/she found the resident on the floor bleeding from his/her head, arm and hands. The resident said his/her head was hurting a little bit but other that that he/she was okay. The resident could not remember how he/she fell. The hospice aide called the hospice nurse on call. The resident was left on the floor until the nurse came. The nurse patched him/her up and and advised to give the resident Tylenol. During an interview on 10/20/23 at 10:15 A.M., Primary Hospice Nurse (PHN) | said the resident recently "dealt" with a bad case of edema. It was so bad that it affected his/her behavior. It was the worst he/she had ever seen. The resident has been on hospice since sometime in August. The resident fell and hit his/her head on the dresser and he/she thought it had something to do with the resident's edema. It could have possible affected his/her balance. Review of the facility's resident care survey dated 10/19/23, showed the resident was a fall potential risk, had Alzheimer's disease, used a walker and was on hospice. Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 9 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 9 Observation on 10/20/23 at 9:48 A.M., showed the resident seated at the table for breakfast. He/she had an approximate 3 inch purple bruise on the right side of his/her face. 4. Review of Resident #9's medical record, showed the facility admitted the resident on 6/19/22 with diagnoses which included chronic kidney disease, Parkinson's disease, high blood pressure and thrombotic (blood has an increased tendency to form clots). Review of the resident's progress notes, showed the following: -On 6/8/23 at 9:28 P.M., a prior shift medication aide left a note that said the resident fell twice today. Once at lunch time, attempting to sit in the chair, and the second time, staff found the resident on the floor at 12:30 P.M. At 4:00 P.M., staff asked the resident if he/she had any pain or injuries related to his/her fall, and the resident said no. The resident's family member was in the facility and it was reported to the family member at that time. Staff observed the resident having an unsteady gait, The resident was having a hard time lifting his/her foot and began to shuffle and drag the foot. Review of the resident's ISP dated 8/14/23, showed the following: -Need: Fall prevention plan; -Service to be provided: The resident was a potential fall risk. Staff would check for appropriate lighting, clutter and spills in the apartment, encourage proper footwear/nonskid footwear, and educate the resident to use emergency pull cord for assistance. Care staff would ensure the resident had his/her walker while up ambulating. On 7/27/22, the resident fell Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 10 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 10 walking down the hall. Care staff would walk with the resident to ensure his/her safety. On 8/10/22, the resident fell trying to sit in a recliner and missed the seat. The resident was encouraged to reach back for arm of chair to guide him/herself to his/her seat. On 12/4/23, the resident fell walking to the bathroom without use of a walker. Care staff would encouraged the resident to have his/her walker at all times. On 5/21/23, the resident tripped coming out of bathroom without his/her walker. Care staff encouraged the resident to have his/her walker at all times. On 6/1/23, staff found the resident in front of the recliner seated on the floor. Staff encouraged the resident to use call light pendant while in the apartment and wait for staff assistance. The ISP did not address what services to be provided to prevent future falls due to 6/8/23, 10/17/23 and 10/18/23 fall incidents. Review of the resident's progress notes, showed the following: -On 10/8/23 at 9:15 P.M., the resident was having a hard time walking that evening. Staff observed the resident shuffling both feet and was unable to lift them up to take a step. The resident was assisted by two staff to the bathroom and guided by another staff member; -On 10/17/23 at 8:36 A.M., the resident "had really been out of it" that day. The resident's bed light went off and when staff got up there, the resident was on the floor. He/she said he/she fell in the bathroom and crawled to his/her bedroom to pull the light. Staff assisted the resident back up to his/her bed. The resident said he/she was okay and was not hurt anywhere. Staff would continue to check on him/her; -On 10/18/23 at 8:32 A.M., the resident screamed "Help, help!’ When staff entered the resident's room, staff found the resident seated in front of Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 11 of 31 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 9916 REAVIS ROAD SOUTHVIEW ASSISTED LIVING AFFTON, MO 63123 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 11 the door. He/she said he/she missed a step and fell. 5. During an interview on 10/20/23 at 4:50 P.M., the DON said all needs, interventions and preventions should be listed on the resident's ISP. The DON said any falls a resident has should be listed on the ISP with new preventions for each fall. 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Class |I* Based on interview and record review, the facility failed to follow physician's orders when residents did not receive medications according to physician's orders, for two of four residents observed during the medication pass (Residents #12 and #10). The census was 86. 1. Review of Resident #12's medical record, showed the facility admitted the resident on 10/27/18, with diagnoses which included high blood pressure and chronic kidney disease. Review of the resident's physician's orders dated 3/1/23, showed the following: -Amlodipine besylate (used to treat high blood pressure), 5 milligrams (mg). Take one tablet by mouth once daily; Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 12 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 12 -Atrovastatin Calcium (used to lower cholesterol), 40 mg. Take one tablet by mouth at bedtime; -Eliquis (used to prevent blood clots), 5 mg. Take one tablet by mouth two times per day, every day at 8:00 A.M. and 9:00 P.M.; -Folic acid oral tablet (used to prevent low levels of vitamin B9), 1 mg. Take one tablet by mouth once daily; -Levothyroxine sodium (to treat hypothyroidism, a condition where the thyroid does not produce enough thyroid hormone), 88 micrograms (mcg). Take one tablet by mouth once daily; -Loratadine (used to treat allergies), 10 mg. Take one tablet by mouth once daily; -Metoprolol succinate extended release (used to treat high blood pressures), 25 mg. Take one tablet by mouth once daily; -Vitamin B-12 (used to treat a vitamin deficiency), 1000 mcg. Take one tablet by mouth once daily; -Vitamin D3 (used to treat a vitamin deficiency), 50 mcg. Take one tablet by mouth once daily. Review of the resident's medication administration record (MAR) dated 3/1/23, showed the following: -On 3/1/23, Eliquis was not administered to the resident for the morning dose, with no documentation for the reason why; -On 3/5/23, Eliquis was not administered to the resident for the evening dose, with "drug not available" documented for the reason why; -On 3/9/23, metoprolol was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/13/23, levothyroxine sodium was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/15/23, Eliquis was not administered to the resident for the morning dose, with "other" Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 13 of 31 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 13 documented for the reason why; -On 3/15/23, amlodipine besylate was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/15/23, folic acid was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/15/23, Loratadine was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/15/23, metoprolol was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/15/23, vitamin B12 was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/15/23, vitamin D3 was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 3/25/23, atorvastatin calcium was not administered to the resident for the evening dose, with "other" documented for the reason why; -On 3/25/23, Eliquis was not administered to the resident for the evening dose, with "other" documented for the reason why. Review of the resident's progress notes dated 3/10/23 at 2:08 P.M., showed the resident called his/her family member and said he/she did not receive his/her Eliquis on 3/5/23 and again on 3/6/23. The resident's family member reported this to the regional director. Review of the resident's MAR dated 4/1/23, showed on 4/13/23, levothyroxine was not administered to the resident for the morning dose, with "other" documented for the reason why. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 14 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 14 Review of the resident's MAR, showed the following: -On 7/7/23 and 7/8/23, levothyroxine sodium was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 7/17/23 and 7/30/23, levothyroxine sodium was not administered to the resident for the morning dose, with no documentation for the reason why. Review of the resident's physician's orders dated 8/1/23, showed sertraline, (used to treat depression), 25 mg. Take one tablet by mouth at bedtime. Review of the resident's MAR dated 8/1/23, showed the following: -On 8/18/23, sertraline was not administered to the resident for the evening dose, with "other" documented for the reason why; -On 8/19/23, sertraline was not administered to the resident for the evening dose, with no documented for the reason why; -On 8/20/23 and 8/27/23, sertraline was not administered to the resident for the evening dose, with "other" documented for the reason why; -On 8/31/23, amlodipine besylate was not administered to the resident for the morning dose, with "drug not available" documented for the reason why; -On 8/31/23, atorvastatin calcium was not administered to the resident for the evening dose, with "drug not available" documented for the reason why; -On 8/31/23, Eliquis was not administered to the resident for the evening dose, with "other" documented for the reason why; -On 8/31/23, folic acid was not administered to the resident for the morning dose, with "drug not Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 15 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 15 available" documented for the reason why; -On 8/31/23, Loratadine was not administered to the resident for the morning dose, with "drug not available" documented for the reason why; -On 8/31/23, sertraline was not administered to the resident for the evening dose, with "other" documented for the reason why; -On 8/31/23, vitamin D3 was not administered to the resident for the morning dose, with "drug not available" for the reason why. Review of the resident's progress notes dated 9/1/23 at 4:03 P.M., showed the resident told staff he/she did not get his/her medication on 8/31/23. The staff notified the resident's physician and left a message with the nurse. Review of the resident's physician's orders dated 9/1/23 and 10/1/23, showed the following: -Eliquis, 5 mg. Take one tablet by mouth two times per day. Administration time 8:00 A.M. and 9:00 P.M.; -Levothyroxine sodium, 88 mcg. Take one tablet by mouth once daily. Administration time, 6:00 A.M. Review of the resident's MAR dated 9/1/23, showed the following: -On 9/1/23, the documented charted administration time for Eliquis, for the morning medication was 9:16 A.M.; -On 9/1/23, levothyroxine was not administered to the resident for the morning dose, with "other" documented for the reason why; -On 9/5/23, the documented charted administration time for Eliquis, for the morning medication was 10:25 A.M.; -On 9/9/23, the documented charted administration time for Eliquis, for the morning medication was 10:34 A.M.; Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 16 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 16 -On 9/11/23, the documented charted administration time for Eliquis, for the morning medication was 9:26 A.M.; -On 9/12/23, the documented charted administration time for Eliquis, for the morning medication was 9:26 A.M.; -On 9/14/23, the documented charted administration time for Eliquis, for the morning medication was 9:32 A.M.; -On 9/16/23, the documented charted administration time for Eliquis, for the morning medication was 9:21 A.M.; -On 9/16/23 metoprolol was not administered to the resident for the morning dose, with no documentation for the reason why; -On 9/17/23, the documented charted administration time for Eliquis, for the morning medication was 9:34 A.M.; -On 9/18/23, the documented charted administration time for Eliquis, for the morning medication was 9:44 A.M.; -On 9/21/23, levothyroxine was not administered to the resident for the morning dose, with no documentation for the reason why; -On 9/25/23, the documented charted administration time for Eliquis, for the morning medication was 9:10 A.M.; -On 9/29/23, the documented charted administration time for Eliquis, for the morning medication was 10:12 A.M.; -On 9/30/23, the documented charted administration time for Eliquis, for the morning medication was 9:18 A.M.; -On 9/30/23, vitamin D3 was not administered to the resident for the morning dose, with "drug not available" documented for the reason why; -On 10/1/23, the documented charted administration time for Eliquis, for the morning medication was 9:11 A.M.; -On 10/3/23, the documented charted Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 17 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 17 administration time for Eliquis, for the morning medication was 9:11 A.M.; -On 10/6/23, the documented charted administration time for Eliquis, for the morning medication was 9:16 A.M.; -On 10/9/23, the documented charted administration time for Eliquis, for the morning medication was 10:18 A.M.; -On 10/10/23, the documented charted administration time for Eliquis, for the morning medication was 9:30 A.M.; -On 10/11/23, the documented charted administration time for Eliquis, for the morning medication was 9:45 A.M.; -On 10/14/23, the documented charted administration time for Eliquis, for the morning medication was 9:12 A.M.; -On 10/15/23, the documented charted administration time for Eliquis, for the morning medication was 2:01 P.M. During an interview on 10/19/23 at 9:20 A.M., the resident said on 10/15/23, he/she did not get his/her medications until 2:00 P.M. The resident said he/she heard no medication aide came into cover the morning shift. The resident said he/she had a stroke on 12/30/22 so it was "very important" to take his/her Eliquis on time each day. He/she knew Eliquis was a blood thinner and would help prevent another stroke. The resident said he/she was worried about taking his/her medication so late in the date on 10/15/23, but he/she took it anyway because he/she was more worried about having another stroke. 2. Review of Resident #10's medical record, showed the facility admitted the resident on 3/24/22 with diagnoses which included Parkinson's disease, coronary heart disease, history of skin cancer, abnormal heart rhythm and Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 18 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 18 vertigo. Review of the resident's physician's orders dated 9/24/23, showed the resident was scheduled to receive bupropion hci, carbidopa-levodopa, escitalopram oxalate, ezetimibide, finasteride, Gabapentin, tamsulosin, topiramate, and xarelto at 8:00 A.M. Observation on 10/20/23 at 10:47 A.M., of the medication pass for the resident, showed Medication Aide (MA) C reviewed the MAR for the resident and prepared the following medication: -Bupropion hci 150 mg (antidepressant used to treat depression); -Carbidopa-levodopa 25-100 mg (used to treat Parkinson's disease); -Escitalopram oxalate 10 mg (used to treat depression); -Ezetimibide (used to treat high cholesterol); -Finasteride (used to treat enlarged prostate); -Gabapentin (used to reduce the excitability of nerve cells in the brain); -Tamsulosin (used to help the passage of kidney stones); -Topiramate (used to treat seizures); -Xarelto (used to treat blood clots in the legs and help prevent strokes). During an interview on 10/20/23 at 11:05 A.M., MAC said the medication should have been given at 8:00 A.M. but he/she ran late because of an issue with another resident. MAC said he/she knew the residents had medication that needed to be given at a specific time but he/she did not call for assistance because he/she did not think any other staff would be available. During an interview on 10/20/23 at 4:30 P.M., the Director of Nursing (DON) said she was not Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 19 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 19 aware medications were given to the resident late. The DON said MAC should have notified her and another staff member could have been brought in to assist with the other resident so MA C could have continued the medication pass on time. The DON said if the medication was given late, the resident's physician should have been notified and given permission for the medication to be given. The DON said all residents should receive their medication within one hour of the time the physician prescribed the medication to be given. 3. During an interview on 10/19/23 at 1:20 P.M., the DON said all orders should be followed. The DON said she had trouble with the staff charting the medications. The DON said when she would document "other" in the resident's MAR it was because that day was left blank and she would put "other" to alert her to ask the medication aides why it was left blank. The DON said she did not know why some of the dates were left blank and there was no way to prove if the resident got his/her medication or not. The DON said she changed the resident's medication times to make it easier on the medication aides to adhere to the medication time since the medication aides had to pass so many medications in the morning. The DON said she changed one hall to 8:00 A.M., another to 9:00 A.M., and another to 10:00 A.M. The DON said Resident #12 was on the 8:00 A.M., medication pass time. The DON said she did not call each resident's physician to confirm she could change the medication administration time. The DON said she did not know she could not change a medication administration time without a physician's order to do so. The DON said on 10/15/23 the Medication Aide on the schedule could not make it in because he/she had car trouble. The DON said he/she lived an Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 20 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 20 hour away from the facility and arrived at the facility at or around 8:00 A.M. on 10/15/23. The DON said he/she started passing medications to the residents immediately and charted the administration times after he/she was finished passing the medication which was why the medication administration time for Resident #12 showed to 2:01 P.M. The DON said she expected the Medication Aides to chart the administration time as soon as the resident took the medications. The DON said she did not do this on 10/15/23 because she was in such a hurry that day. 4. During an interview on 10/19/23 at 1:30 P.M., the Administrator said she did not know Resident #12 was not getting his/her medication some days. The Administrator said the Medication Aides know when to order more medication so the residents should not run out of medication. The Administrator said she did not know the DON did not call the physician before changing the medication administration time for Resident #12. The Administrator said she was aware a physician's order could not be changed without physician permission. MO00217928 19 CSR 30-87.020(5) Toxic Material Storage Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 21 of 31 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 21 locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents when chemicals were found in unlocked areas accessible to residents, for two of two days of observation. This had the potential to affect all residents. The census was 86. 1. Observation on 10/19/23 between 6:28 A.M. and 1:30 P.M. and on 10/20/23 between 9:42 A.M. and 4:40 P.M., on the second floor, in the community room, showed the following: -Underneath the sink, a 3/4 full 32 ounce (oz) Ecolab bio enzyme odor eliminator. The precautionary statement read, "Causes serious eye irritation. Wash skin thoroughly after handling. Wear eye protection/face protection"; -In the back of the room, on the right side, in the top cabinet, showed: -Two full, 12 oz cans of Rust-o-leum spray paint. The precautionary statement read, "Vapor harmful. May affect brain or nervous system causing dizziness, headache, or nausea. Causes eye, skin, nose and throat irritation. Keep out of reach of children"; -Two 1/2 full, 12 oz cans of Rust-o-leum spray paint; -One 1/4 full, 20 oz can of Faultless Luxe finish. The precautionary statement read, "Warning: Contains gas under pressure; may explode if heated. Protect from sunlight. Store in a well-ventilated place. Avoid all unnecessary exposure. Do not breathe vapor, mist or spray. Keep out of reach of children."; -One 1/2 full, 11 0z can of Krylon spray paint. The Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 22 of 31 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 22 precautionary statement read, "Wear eye or face protection. Wear protective clothing. Keep away from heat, hot surfaces, sparks, open flames and other ignition sources. No smoking. Avoid contact with eyes and skin. Wear gloves or wash hands after using. Extremely flammable aerosol. Contains gas under pressure; may explode if heated. May be fatal if swallowed and enters airways. Causes skin irritation."; -On the counter, a full quart of Bulls Eye 1-2-3 primer for all surfaces. The precautionary statement read, "Keep away from heat, sparks and flame. No sparking tools should be used. Avoid contact with skin and eyes. Avoid the inhalation of dust, particulates, spray or mist arising from the application of this mixture. Avoid inhalation of dust from sanding. Use appropriate personal protective equipment. Keep out of eyes. Keep out of reach of children." Observation on 10/20/23 between 11:11 A.M. and 11:25 A.M., on the second floor, in the community room, showed four residents sat gathered ina circle, talking. No staff members were present. 2. Observation on 10/20/23 between 9:43 A.M. and 4:45 P.M., of the first floor laundry room, in the bottom left cabinet, showed a 1/4 full gallon of Ecolab Super Trump. The precautionary statement read, "Causes severe skin burns and eye damage. Wash skin thoroughly after handling. Wear protective gloves/protective clothing/eye protection/face protection. Keep out of reach of children.” 3. During an interview on 10/20/23 at 3:00 P.M., the Administrator said there was no chemical policy but the staff members knew to lock all chemicals away. The Administrator was not aware there were chemicals in the community Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 23 of 31 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 23 room and first floor laundry room. The Administrator said the chemicals should not be there, all chemicals should be locked up out of access of residents. 19 CSR 30-88.010(23) Develop/Implement A/N Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Class |I* Based on interview and record review, the facility failed to follow their Resident Care Events/Incident Reporting and Investigation policy when a resident (Resident #8) had an unwitnessed fall on 6/13/23, and resident (Resident #11) had an unwitnessed fall on 9/20/23, and no investigation was completed. The census was 86. Review of the facility's Resident Care Events/Incident Reporting and Investigation policy dated 2/1/23, showed the following: -The community will investigate any incidents involving residents or visitors to determine the cause of the incident. The incident report must be filled out with accurate information after an Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 24 of 31 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 24 incident has happened and immediately after the person involved in the incident is safe. The investigation and conclusions shall be completed within three days; -Incidents requiring an incident investigation are required but not limited to the following: -Abrasions, elopement, abuse or alleged abuse and falls; -The incident investigation will be completed within three days of the incident by the Director of Nursing (DON). The incident investigation summaries the investigational findings and prevention measures to assure the resident is cared for, the care plan is updated, and reduce the change of incident reoccurring; -The incident investigation will be completed by the DON in the electronic health record (EHR) after the incident report, short-term observation, and assessment is completed within three days of the incident; -Review the incident report, assessment, and short-term observations documentation to ensure that all documentation has been completed; -After completing all incident reports and investigations in the EHR, the DON will print and obtain required signatures; -The following documents, including all required signatures, must be scanned and sent via email to the appropriate parties: -Incident reporter, incident investigation, abuse investigation (if required) and state report (if required); -Maintain incident reports and incident investigations in a separate binder by month with most recent incident on top. 1. Review of Resident #8's medical record, showed the facility admitted the resident on 5/18/21, with a diagnoses which included hyperlipidemia (too many lipids in the blood), Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 25 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 25 osteoporosis (bone disease) and high blood pressure. Review of the resident's progress notes, showed the following: -On 6/13/23 at 7:03 A.M., Medication Aide (MA) G went into the resident's apartment and found the resident on the floor, on the right side of the bed. The resident had blood around him/her and in his/her hair. MA G performed range of motion on the resident and took the resident's vitals. The resident denied any pain other than soreness. MA G assisted the resident off the floor and in to the shower. After washing the resident's face and hair, it was determined his/her nose bled. The resident did not have any other cuts or lacerations. The resident's right side of his/her face was swollen and red. The resident's eyes were bruised. MA G gave the resident an as needed Tylenol and applied an ice pack to the right side of his/her face. MA G notified the DON and hospice; -On 6/13/23 at 10:00 A.M., MAH assisted the resident with peri-care (Cleaning the private areas of a person) and getting into bed. As the resident began to lie down, he/she said "ouch, no that's not right." MA H asked the resident if he/she needed to reposition his/her body. The resident said, "No, my fever is just really bad." MA H asked the resident if his/her head hurt and the resident said yes. MAH asked the resident if he/she wanted to go to the hospital and the resident said yes. MA H notified the DON and hospice. The paramedics were called and arrived at the facility but the power of attorney decided to have a hospice nurse come to check on the resident instead. The hospice nurse was scheduled to arrive at the facility after 10:00 P.M. The resident was currently awake in his/her chair waiting on the nurse; Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 26 of 31 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 26 -On 6/13/23 at 10:28 P.M., the hospice nurse called the facility and said he/she had spoken with the resident's family member. They confirmed the resident's case manager came earlier to check on the resident and said the resident was a Do Not Resituate. Any comfort for the resident will need to be in the facility. The hospice nurse received an order for Morphine (narcotic pain medication). Staff will continue to monitor. Review of the resident's hospice note dated 6/13/23 at 9:34 P.M., the staff called the hospice nurse about a reported fall where the resident had possibly hit his/her head. The facility staff gave the phone to the paramedics on site and the paramedics, family member and hospice staff talked about taking the resident to the hospital. The hospice staff asked the family member what he/she wanted to do and the family member hung up the phone because he/she wanted the hospice staff to decide for him/her. The hospice staff told the facility staff to have paramedics leave and the next on-call hospice nurse would visit the resident. The next on-call hospice nurse called the facility and said he/she would be out shortly to check on the resident. The hospice nurse arrived later that night. The hospice nurse assessed the resident and found the resident's pain was currently managed at a level acceptable to the resident. There were signs of infection or complications identified on the resident's left ankle and the hospice nurse notified the physician for appropriate intervention. The hospice nurse informed the resident and caregiver about the need to provide adequate nutrition/hydration, as tolerated, to promote wound healing. The resident tolerated wound care with minimal discomfort. The caregiver demonstrated proper wound care. The facility Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 27 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 27 staff were knowledgeable and involved in the hospice plan of care for the resident. The resident's continuity of care among both providers was achieved. During an interview on 10/20/23 at 4:44 P.M., the DON said on 6/13/23, Resident #8 rolled out of bed and fell on his/her face. The DON said there was no documented investigation for this fall. The DON said an investigation should have been completed to gather details of the falls for the resident, to determine the cause of the fall which would help learn/use other preventions. The DON said all incidents and falls should be investigated. The DON said she did not know why this fall was not investigated. 2. Review of Resident #11's medical record, showed the facility admitted the resident on 3/31/22, with a diagnoses of major depressive disorder, insomnia, sleep apnea, chronic pain syndrome, high blood pressure, lymphedema (the build-up of fluid in soft body tissues when the lymph system is damaged or blocked) and cellulitis of right lower limb. Review of the resident's hospital records dated 9/20/23, showed the resident was admitted after he/she was found on the ground covered in urine and feces and was unsure how long he/she was on the ground. The resident said he/she had fallen and started bleeding, but was unable to say where the bleeding occurred. The resident complained of back pain. Review of the resident's progress notes dated 9/21/23, showed staff found the resident on the floor. The Resident Assistant (RA) called the ambulance and the resident was sent to the hospital. Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 28 of 31 PRINTED: 11/09/2023 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 10/23/2023 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 28 During an interview on 10/20/23 at 2:57 P.M., Certified Medication Technician (CMT) | said the resident was found during the first round for the night shift on 9/20/23 or 9/21/23. CMT | said the resident always had dried blood because he/she picked at things. CMT | said he/she did not remember seeing feces and did not think the resident was on the ground long. CMT | said the resident was a fall risk and had falls on the assisted living side, but was new to the memory care unit. CMT | said the resident was very confused and could never tell staff what he/she did. No one from the facility asked CMT | what happened or to write a statement about the incident. During an interview on 10/20/23 at 4:44 P.M., the DON said there was no documented investigation for this fall. The DON said an investigation should have been completed to gather details of the falls for the resident, to determine the cause of the fall which would help learn/use other preventions. The DON said all incidents and falls should be investigated. The DON said she did not know why this fall was not investigated. 3. During an interview on 10/20/23 at 3:15 P.M., the Administrator said the only documentation the facility had regarding the fall Resident #8 had, was the hospice care note for 6/13/23. The Administrator said there was an incident report made but it was an internal document. The Administrator said there should have been an investigation for all unwitnessed falls for both Resident #8 and #11. M000224771 Missouri Department of Health and Senior Services STATE FORM 6899 HM2E11 If continuation sheet 29 of 31 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 29 19 CSR 30-88.010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III This regulation is not met as evidenced by: Class III Based on interview, the facility failed to ensure all staff treated each resident with respect and dignity, when a Medication Aide (MA) asked a resident if the resident wanted his/her "dope" when administering his/her medications, for one of nine sampled residents (Resident #1). The census was 86. Review of Resident #1's medical record, showed the facility admitted the resident on 12/20/21, with diagnoses which included high blood pressure, depression and gastro-esophageal reflux disease. Review of the resident's physician's orders dated 10/2023, showed the following: -Oxycodone HCI Oral Tablet 5 milligram (mg) take one tablet by mouth every 8 hours as needed for severe pain (max daily amount: 15 mg); -Oxycodone-acetaminophen oral tablet 10-325 mg, take one tablet by mouth every 6 hours as Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 30 of 31 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 30 needed for pain; -Hydroxyzine HCI Oral tablet 10 mg, take one tablet by mouth once daily as needed for anxiety disorder; -Trazodone HCI oral tablet 100 mg, take one tablet by mouth at bedtime for major depressive disorder. During an interview on 10/20/23 at 2:56 P.M., MA K said said she administers the resident's evening oxycontin medications and he/she does ask the resident if he/she wants his/her "dope", but MA K said he/she was just kidding. MAK said he/she did not realize how embarrassing that was to say to someone. During an interview on 10/20/23 at 4:21 P.M. the he Administrator said it was unacceptable for MA K to call the resident's narcotics "dope". *The higher the classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 HM2E11 PRINTED: 11/09/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 10/23/2023 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 31 of 31 RETIREMENT COMMUNITIES Ww SPECTRUM REASON FOR PLAN Annual Survey SURVEY [Wplype} Response [lypaype} DATE Due Date OPERATOR ENTITY Spectrum Retirement Communities COMMUNITY NAME Southview Assisted Living and Memory Care (eT O) YAy. es chon) RS) 0) COS Viissouri Department of Health and Senior Services DEFICIENCY ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS Responsible Person for Action Due Date(s) for Example: 19 CSR 30-86.047(28)(G) Individual Service Community Executive Director, Director of Nursing and Director of Resident Care |Debbie 11/30/23 Plan - Develop will update sampled residents #1, #8, #2 & #9 Care Plan/Individual Service Plan |Carron, DON to reflect fall interventions, clinical interventions, proper care needs & services to |& Kim Russo, The facility may admit or retain an individual for be provided by 11/30/23 DRC residency in an assisted living facility only if the Education to Director of Nursing & Director of Resident Care on service plan individual does not require hospitalization or interventions and services to be provided notated timely and properly on ISP by 11/30/23 one nursing ‘agai as aie Ra Education to all Care team members regarding incident reporting and rule, and only if the facility: (G) Develops an interventions on ISP by 11/30/23 individualized service plan (ISP), which means Those care team members who have not received the education by 11/30/23 will the planning document prepared by an assisted be educated prior to their first shift worked. living facility which outlines a resident ' s needs The Director of Nursing and/or Director of Resident Care is responsible for and preferences, services to be provided, and compliance. goals expected by the resident or the resident ' This will be covered with residents, POA’s & team members at residents move in, 30-day ISP meeting, routine (every 3 months for Memory Care, every 6 months for Assisted Living) ISP meeting & if any significant change ISP/Assessment. Random monthly audits to be completed by the Executive Director and/or designee to ensure elements in the training have been implemented & specific information is on all ISP’s Results of audit will be brought to the Director of Nursing & Director of Resident Care for review, identify any trends and the need for further auditing. s legal representative in partnership with the facility. This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop individualized service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the Page 1 of 6 POC Blank Template v2.0 / 10.2023 RETIREMENT COMMUNITIES Ww SPECTRUM REASON FOR PLAN Annual Survey SURVEY [Wplype} Response [lypaype} DATE Due Date OPERATOR ENTITY COMMUNITY NAME GOV. AGENCY ISSUING DEFICIENCY ALLEGED VIOLATION facility) which included resident needs, services to be provided by staff and goals expected by the resident or the resident's legal representative for four of nine sampled residents (Residents #1, #8, #2 and #9). The census was 86. 19 CSR 30-86.047(47)(A) Physicians Orders Followed Medication Orders. (A) No medication, treatment or diet shall be administered without an order from an individual lawfully authorized to prescribe such and the order shall be followed. II/III This regulation is not met as evidenced by: Class |I* Based on interview and record review, the facility failed to follow physician's orders when residents did not receive medications according to physician's orders, for two of four residents observed during the medication pass (Residents #12 and #10). The census was 86. Spectrum Retirement Communities Southview Assisted Living and Memory Care Missouri Department of Health and Senior Services Person for Action Responsible CORRECTIVE ACTION ITEMS/STEPS Community Executive Director, Director of Nursing and Director of Resident Care Debbie will contact physicians on pass times by 11/30/23 Carron, DON Education to Director of Nursing & Director of Resident Care on physician orders | & Kim Russo, and pass times and changes made to orders by 11/30/23 DRC Education to all MA’s on physician orders and pass times will be completed by 12/08/23 Resident #12 and #10 doctor will be called, as well as any other residents if/when a medication is missed or late. The Director of Nursing and/or Director of Resident Care is responsible for compliance. Any physician order changes will be covered with the resident and/or POA. Random monthly audits to be completed by the Executive Director and/or designee to ensure elements in the training have been implemented. Results of audit will be brought to the Director of Nursing & Director of Resident Care for review, identify any trends and the need for further training and/or auditing. Page 2 of 6 Due Date(s) for 11/30/23 POC Blank Template v2.0 / 10.2023 RETIREMENT COMMUNITIES Ww SPECTRUM REASON FOR PLAN Annual Survey 1092814 2h 10/20/23 Response [lypaype} DATE Due Date OPERATOR ENTITY Spectrum Retirement Communities COMMUNITY NAME Southview Assisted Living and Memory Care (eT O) YAy. es chon) RS) 0) COS Viissouri Department of Health and Senior Services DEFICIENCY ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS Responsible Person for Action Due Date(s) for 19 CSR 30-87.020(5) Toxic Material Storage Immediate correction prior to DHSS exit of the community on 10/19/23 Katrina 11/15/23 Poisonous or toxic materials consist of the Education to Entertainment & Programming Director, Maintenance Manager and_ | Waldorf, ED — following categories: insecticides and team regarding importance of keeping chemicals and paint locked up and stored | John Latham, rodenticides; disinfectants, sanitizer and related in a place not accessible to residents. oo MM cleaning or drying agents: and caustics, acids, Random weekly audits to be completed by Executive Director and/or designee to . - ensure elements in the training have been implemented and that toxic materials polishes and other chemicals. Each of these are locked up and stored in a place not accessible to residents. three (3) categories set forth shall be stored Results of the audit will be brought to the Entertainment & Programming Director and physically located separate from each and the Manager of Maintenance for review, identify any trends and the need for other. All poisonous or toxic materials shall be further auditing. stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents when chemicals were found in unlocked areas accessible to residents, for two of two days of observation. This had the potential to affect all residents. The census was 86. Page 3 of 6 POC Blank Template v2.0 / 10.2023 RETIREMENT COMMUNITIES Ww SPECTRUM REASON FOR PLAN Annual Survey SURVEY [Wplype} Response [lypaype} DATE Due Date OPERATOR ENTITY COMMUNITY NAME ALLEGED VIOLATION 19 CSR 30-88.010(23) Develop/Implement AIN Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Class |I* Based on interview and record review, the facility failed to follow their Resident Care Events/Incident Reporting and Investigation policy when a resident (Resident #8) had an unwitnessed fall on 6/13/23, and resident (Resident #11) had an unwitnessed fall on 9/20/23, and no investigation was completed. The census was 86. Spectrum Retirement Communities Southview Assisted Living and Memory Care (eT O) YAy. es chon) RS) 0) COS Viissouri Department of Health and Senior Services DEFICIENCY Person for Action Responsible CORRECTIVE ACTION ITEMS/STEPS Community Executive Director, Director of Nursing and Director of Resident Care Debbie will update sampled resident #8’s ISP with fall interventions by 11/15/23, resident | Carron, DON #11 expired. & Kim Russo, Education to Director of Nursing & Director of Resident Care on fall investigation DRC & service plan interventions on ISP by 11/15/23 Education to all Care team members regarding incident reporting and investigations by 11/15/23 Those care team members who have not received the education by 11/15/23 will be educated prior to their first shift worked. The Director of Nursing and/or Director of Resident Care is responsible for compliance. This will be covered with residents, POA’s & team members at the time of the incident and at residents move in, 30-day ISP meeting, routine (every 3 months for Memory Care, every 6 months for Assisted Living) ISP meeting & if any significant change ISP/Assessment. Random monthly audits to be completed by the Executive Director and/or designee to ensure elements in the training have been implemented. Results of audit will be brought to the Director of Nursing & Director of Resident Care for review, identify any trends and the need for further auditing. Page 4 of 6 Due Date(s) for 11/15/23 POC Blank Template v2.0 / 10.2023 RETIREMENT COMMUNITIES Ww SPECTRUM REASON FOR PLAN Annual Survey 1092814 2h 10/20/23 Response [lypaype} DATE Due Date OPERATOR ENTITY COMMUNITY NAME ALLEGED VIOLATION 19 CSR 30-88.010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III This regulation is not met as evidenced by: Class IIl Based on interview, the facility failed to ensure all staff treated each resident with respect and dignity, when a Medication Aide (MA) asked a resident if the resident wanted his/her "dope" when administering his/her medications, for one of nine sampled residents (Resident #1). The census was 86. Spectrum Retirement Communities Southview Assisted Living and Memory Care (eT O) YAy. es chon) RS) 0) COS Viissouri Department of Health and Senior Services DEFICIENCY Person for Action Responsible CORRECTIVE ACTION ITEMS/STEPS Director of Nursing and Director of Resident Care will assess resident #1 for Katrina dignity concerns and update ISP if necessary by 11/15/23 Waldorf, ED Education to all team members on Dignity/Privacy by 11/30/23 & Debbie Those team members who have not received the education by 11/30/23 will be Carron, DON educated prior to their first shift worked. The Executive Director & Director of Nursing is responsible for compliance. Random monthly audits to be completed by the Executive Director and/or designee to ensure elements in the training have been implemented & residents Results monthly of audit will be brought to the Management Team for review, identify any trends and the need for further training and auditing. Page 5 of 6 Due Date(s) for 11/30/23 POC Blank Template v2.0 / 10.2023 RETIREMENT COMMUNITIES Ww SPECTRUM REASON FOR PLAN Annual Survey 1092814 2h 10/20/23 Response [lypaype} DATE Due Date OPERATOR ENTITY Spectrum Retirement Communities COMMUNITY NAME Southview Assisted Living and Memory Care GOV. AGENCY ISSUING DEFICIENCY Missouri Department of Health and Senior Services Responsible Person for Action Due Date(s) for ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS 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 & Memory Care (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 the Missouri Department of Health and Senior Services following the survey that was completed on or about 10/20/2023. 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. Page 6 of 6 POC Blank Template v2.0 / 10.2023