LUTHERAN SENIOR SERVICES AT MERAMEC BLUFFS.

PRINTED: 12/30/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING; (X3) DATE SURVEY COMPLETED 23643N B. WING 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 50 MERAMEC TRAILS DRIVE BALLWIN, MO 63021 LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x4) 1D PREFIX TAG 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) test was completed prior to admission and annual screenings were completed for nine of nine sampled residents (Residents #4, #1, #5, #3, #2, #6, #8, #9 and #7). The facility also failed to ensure the results of the TB/PPD tests were documented for two of seven sampled staff. The census was 90. General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents and staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (x6) one / { 7/ Vir) STATE FORM 6299 L3XK14 Ifcontinuation sheet 1 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 23643N NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 50 MERAMEC TRAILS DRIVE BALLWIN, MO 63021 LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 (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 Continued From page 1 repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease; -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test; -All employees and volunteers are required to obtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the initial test is negative, the second test should be given as soon as possible within one to three weeks after employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial Zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record. 1. Review of Resident #4's medical record, showed the following: -Admit date 1/8/24: -No documented two-step TB/PPD test administered prior to admission. 2. Review of Resident #1's medical record, showed the following: -Admit date 9/25/24; -No documented two-step TB/PPD test administered prior to admission. 3. Review of Resident #5's medical record, showed the following: -Admit date 2/19/24; Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 DEFICIENCY) If continuation sheet 2 of 12 PRINTED: 12/30/2024 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 23643N — 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 50 MERAMEC TRAILS DRIVE BALLWIN, MO 63021 (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) LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF Continued From page 2 -No documented two-step TB/PPD test. 4. Review of Resident #3's medical record, showed the following: -Admit date 3/4/21; -No documented two-step TB/PPD test administered prior to admission; -No read result for first step TB/PPD dated 11/8/24; -No read result for second step TB/PPD dated 11/15/24. 5. Review of Resident #2's medical record, showed the following: -Admit date 9/8/23; -No read result for initial two step TB/PPD dated 9/18/23; -No read result for second step TB/PPD dated 9/25/23; -No documented annual screening for 9/2024. 6. Review of Resident #6's medical record, showed the following: -Admit date 4/3/24: -A first-step TB/PPD test administered on 4/4/24 and read on 4/6/24, with no result documented; -A second-step TB/PPD test administered on 4/11/24 and read on 4/13/24, with no result documented. 7. Review of Resident #8's medical record, showed the following: -Admit date 8/31/23; -A first-step TB/PPD test administered on 8/8/23 and read on 8/11/23, with no result documented; -A second-step TB/PPD test administered on 8/15/23 and read on 8/18/23, with no result documented. 8. Review of Resident #9's medical record, Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 If continuation sheet 3 of 12 PRINTED: 12/30/2024 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 23643N — 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 50 MERAMEC TRAILS DRIVE BALLWIN, MO 63021 (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) LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF Continued From page 3 showed the following: -Admit date 6/17/24: -A first-step TB/PPD test administered on 6/17/22 and read on 6/19/22, with a "negative" result. No documented reaction of induration in mm; -A second-step TB/PPD test administered on 6/24/22 and read on 6/26/22, with a "negative" result. No documented reaction of induration in mm. 9. Review of Resident #7's medical record, showed the following: -Admit date 12/12/23, -A first-step TB/PPD test administered on 3/29/24 and read on 3/31/24, with no result documented; -A second-step TB/PPD test administered on 4/5/24 and read on 4/7/24, with no result documented. 10. Review of Employee C's personnel file, showed the following: -Hire date 5/7/14: -No read result for annual TB/PPD test dated 9/24/24. 11. Review of Employee F's personnel file, showed the following: -Hire date 5/10/21; -A one step TB/PPD test administered on 10/9/24 and read on 10/11/24, with "negative" documented. No mm of induration of reaction documented. 12. During an interview on 12/16/24 at 3:59 P.M., the Administrator said nursing is responsible to ensure a two step PPD is administered at time of admission and the annual screenings are being completed. She did not know why they were not completed for some of the residents, and she did not know they had not been completed. Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 If continuation sheet 4 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23643N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 50 MERAMEC TRAILS DRIVE LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF BALLWIN, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually 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: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to complete a community based assessment (CBA), at least semiannually, for six of nine sampled residents (Residents #3, #2, #4, #5, #7 and #8). The census was 90. 1. Review of Resident #3's medical record, showed the facility admitted the resident on 3/4/21, with diagnoses which included congestive heart failure, diabetes, high cholesterol and major depressive disorder. Review of the resident's CBA dated 11/20/24, showed the following: -The health problems section was left blank; -The prescription medication section said "refer to myUnity for updated med list, treatment and diagnosis" with no attachment to the document; -The dosage section was left blank. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 9/8/23, with diagnoses which included Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23643N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 50 MERAMEC TRAILS DRIVE LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF BALLWIN, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 depression, high cholesterol, and congestive heart failure. Review of the resident's CBA dated 8/12/24, showed the following: -The health problems section was left blank; -The prescription medication section said "refer to myUnity for med list and dx" with no attachment to the document; -The dosage section was left blank. 3. Review of Resident #4's medical record, showed the facility admitted the resident on 1/8/24, with diagnoses which included dementia, anxiety, high blood pressure, and heart disease. Review of the resident's CBA dated 8/30/24, showed the following: -The health problems section was left blank; -The prescription medication section said "see attachment for med list and diagnosis" with no attachment to the document; -The dosage section was left blank. 4. Review of Resident #5's medical record, showed the facility admitted the resident on 3/16/24, with diagnoses which included dementia, chronic kidney disease and insomnia. Review of the resident's CBA dated 10/15/24, showed the following: -The health problems section was left blank; -The prescription medication section was left blank; -The dosage section was left blank; -The pharmacy section was left blank. 5. Review of Resident #7's medical record, showed the facility admitted the resident on 3/21/24, with diagnoses which included Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23643N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 50 MERAMEC TRAILS DRIVE LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF BALLWIN, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 Parkinson's disease, Alzheimer's disease, dementia and anxiety. Review of the resident's CBA dated 9/25/24, showed the following: -The health problems section was left blank; -The prescription medication section was left blank; -The dosage section was left blank; -The pharmacy section was left blank. 6. Review of Resident #8's medical record, showed the following: -Admit date 8/31/23; -Diagnoses included Alzheimer's disease, hearing loss and acid reflux; -The resident moved to the memory care unit on 7/24/24. Review of the resident's significant change CBA dated 7/29/24, showed the following: -The health problems section was left blank; -The prescription medication section was left blank; -The dosage section was left blank; -The pharmacy section was left blank. 7. During an interview on 12/16/24 at 4:05 P.M., the Administrator said she was aware the staff were referring to the electronic physician's orders sheet for the CBAs. She said she was not aware the physician's orders sheet had to be attached to the CBA to make it a complete document. 19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change The facility may admit or retain an individual for residency in an assisted living facility only if the Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23643N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 50 MERAMEC TRAILS DRIVE LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF BALLWIN, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: C. Whenever a significant change has occurred in the resident ' s condition, which may require a change in services. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to fully complete a community based assessment (CBA), for residents who had a significant change, for five of nine sampled residents (Residents #8, #7, #5, #6 and #9). The census was 90. 1. Review of Resident #8's medical record, showed the following: -Admit date 8/31/23; -Diagnoses included Alzheimer's disease, hearing loss and acid reflux; -The resident moved to the memory care unit on 7/24/24. Review of the resident's significant change CBA dated 7/29/24, showed the following: -The health problems section was left blank; -The prescription medication section was left blank; -The dosage section was left blank; -The pharmacy section was left blank. 2. Review of Resident #7's medical record, showed the following: -Admit date 12/12/23, Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23643N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 50 MERAMEC TRAILS DRIVE LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF BALLWIN, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 -Diagnoses included Parkinson's disease, Alzheimer's disease, dementia and anxiety; -The resident moved to the memory care unit on 3/21/24; -No documented significant change CBA dated for 3/2024. 3. Review of Resident #5's medical record, showed the following: -Admit date 2/19/24: -Diagnoses included dementia, chronic kidney disease and insomnia; -The resident moved to the memory care unit on 3/16/24; -No documented significant change CBA dated for 3/2024. 4. Review of Resident #6's medical record, showed the following: -Admit date 4/3/24: -Diagnoses included neurocognitive disorder with Lewy Bodies (a progressive form of dementia characterized by cognitive decline, movement problems, and hallucinations), vascular dementia with agitation, anxiety and diabetes; -The resident moved to the memory care unit on 71/24/24. Review of the resident's significant change CBA dated 7/25/24, showed the following: -The health problems section was left blank; -The prescription medication section was left blank; -The dosage section was left blank; -The pharmacy section was left blank. 5. Review of Resident #9's medical record, showed the following: -Admit date 6/17/24; -Diagnoses included Alzheimer's disease, anxiety Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 12 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 23643N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 50 MERAMEC TRAILS DRIVE LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF BALLWIN, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 and repeated falls; -The resident moved to the memory care unit on 7124/24. Review of the resident's significant change CBA dated 7/29/24, showed the following: -The health problems section was left blank; -The prescription medication section was left blank; -The dosage section was left blank; -The pharmacy section was left blank. 6. During an interview on 12/16/24 at 4:05 P.M., the Administrator said she was aware the staff were referring to the electronic physician's orders sheet for the CBAs. She said she was not aware the physician's orders sheet had to be attached to the CBA to make it a complete document. She was not aware some residents did not have a significant change CBA. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/III This regulation is not met as evidenced by: Class |I* Based on observation, interview and record review, the facility failed to ensure staff washed their hands and/or changed gloves between tasks while preparing and serving resident meals for Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 PRINTED: 12/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/16/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 12 PRINTED: 12/30/2024 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 23643N — 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 50 MERAMEC TRAILS DRIVE BALLWIN, MO 63021 (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) LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF Continued From page 10 one of one observed prepared and served meal. This had the potential to affect all residents. The census was 90. Observation on 12/16/24 between 7:28 A.M. and 7:52 A.M., showed the following: -At 7:31 A.M., Cook D donned a pair of gloves and placed bread in the toaster with his/her left hand. He/she walked to the servery and picked up an egg. He/she walked to the stove top and cracked the egg with his/her right hand onto the skillet surface. He/she picked up a whisk with his/her right hand and stirred the pancake batter. He/she picked up a scoop with his/her right hand and scooped batter onto the skillet surface. He/she picked up a spatula with his/her right hand and flipped the eggs over. He/she opened the warmer with his/her left hand and grabbed a plate with his/her right hand. With his/her right hand, he/she grabbed a spatula and flipped the pancakes over on the skillet surface and plated the eggs onto the plate. With his/her right hand he/she grabbed a set of tongs and put bacon onto the plate. He/she walked over to the toaster and with his/her right hand, grabbed the toast and placed it onto the plate. He/she walked back to the stove top and with his/her right hand, picked up a spatula and flipped the pancakes. With his/her right hand, he/she grabbed a whisk and stirred the pancake batter. He/she grabbed a scoop and scooped pancake batter onto the skillet top and removed his/her gloves; -At 7:46 A.M., Cook D donned a new pair of gloves. With his/her right hand, he/she picked up tongs and placed bacon onto a plate. He/she used his/her right hand and grabbed a scoop and scooped scrambled eggs onto the plate. He/she grabbed a spatula with his/her right hand and flipped over the pancakes on the skillet top. With his/her right hand he/she lifted the lid off the Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 If continuation sheet 11 of 12 PRINTED: 12/30/2024 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 23643N — 12/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 50 MERAMEC TRAILS DRIVE BALLWIN, MO 63021 (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) LUTHERAN SENIOR SERVICES AT MERAMEC BLUFF Continued From page 11 warmer and placed pancakes into the warmer. He/she walked over to the refrigerator and opened the door, with his/her right hand. He/she then walked over to the toaster and with his/her right gloved hand, took toast out of the toaster and placed it onto the plate. He/she then removed his/her gloves; -At 7:52 P.M., Cook D donned a new pair of gloves and with his/her right hand picked up a plate and put it on the servery surface. With his/her right hand he/she grabbed a scoop and scooped scrambled eggs onto the plate. He/she walked over to the toaster and with his/her right gloved hand, he/she took the toast out of the toaster and placed it onto the plate. He/she picked up a scoop with his/her right hand and scooped pancake batter onto the skillet top. He/she walked the bowl of batter to the counter top and covered it with plastic wrap. He/she then walked the bowl to the refrigerator and placed the bowl in the refrigerator. He/she then removed his/her gloves. During an interview on 12/16/24 at 3:59 P.M., the Administrator said the Director of Dining is responsible for oversight of the kitchen staff. She said she expected the cook to wash his/her hands between tasks when preparing food. She expected the cook to change his/her gloves after touching food and after touching other non-food surfaces. She said after cracking an egg he/she should have changed his/her gloves and washed his/her hands. She was unsure why he/she did not change his/her gloves and wash his/her hands between tasks. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 L3XK11 If continuation sheet 12 of 12 PLAN OF CORRECTION Provider/Supplier Meramec Bluffs Name: Street Address, | 54 Meramec Trail Dr. Ballwin, Mo 63021 City, Zip: Date of Survey: 12/16/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE 19 CSR 30- TB Screen Residents & Staff March 31st, 86.047(19) 2025 What corrective action will take place? Residents: Facility will readminister the TB test and document results in mm. Residents will receive a yearly TB Screen/symptom check. Resident #4 After further review of resident’s medical record. Facility located appropriate 2-step TB test from admission. (Attachment A-1). Resident #1 2- step TB test will be readministered for appropriate documentation. Test #1 on 1/1/2025/ & read on 1/3/2025 Test #2 on 1/8/2025 & will be read on 1/10/2025 (Attachment A-2) Resident #5 2-step TB test will be readministered for appropriate documentation. Test #1 on 1/1/2025/ & read on 1/3/2025 Test #2 on 1/8/2025 & will be read on 1/10/2025 (Attachment A-3) Resident #3 2-step TB test will be readministered for appropriate documentation. Test #1 on 1/1/2025/ & read on 1/3/2025 Test #2 on 1/8/2025 & read on 1/10/2025 (Attachment A-4) Resident #2 After further review of resident’s medical record. Facility located appropriate 2-step TB test from admission. (Attachment A-5). Resident #6 After further review of resident's medical record. Facility located appropriate 2-step TB test from admission. (Attachment A-6). 19 CSR 30- 86.047(28)(F) (1)(B) & 19 CSR 30- 86.047(28)(F) 1)(C Resident #8 After further review of resident’s medical record. Facility located appropriate 2-step TB test from admission. (Attachment A-7). Resident #9 After further review of resident’s medical record. Facility located appropriate 2-step TB test from admission. (Attachment A-8). Resident #7 After further review of resident’s medical record. Facility located appropriate 2-step TB test from admission. (Attachment A-9). Employees: Beginning 12/17/2024 any new employee will receive a 2- step TB test prior to New Employee Orientation. The Results will be documented in mm vs. negative/positive. All Employees will receive 1-step TB test annually. What measures will be put into place to assure this deficient practice does not reoccur? The DON/Designee will provide education to the clinical staff on documentation of the TB test results (Attachment B). Resident medical record will include a new order set to be put into place to indicate mm of induration. (Attachment A 2-4). Admission tool will now include the reading of mm for the TB test (Attachment C). Employees: The form used will be adjusted to indicate primary way to read the TB test site in mm. Disclosure added if greater than 10mm will be a follow up- using pre-hire process. (Attachment D- and D-2). How does the facility plan to monitor for compliance? The DON/Designee will conduct audits of current residents to ensure TB test results are documented correctly in mm. Every new employee orientation/annual event will receive a PPD test. All new admissions will require a 2-step PPD test. DON/Designee will monitor compliance with every new admission and New Employee Orientation. Monitoring will be documented on audit tool for compliance for the next 12 weeks. The audit tools will remain in place for 12 weeks and those findings will be submitted monthly to the QA committee. (Attachment E) Community Based Assessment- Semi-Annually & Significant Change 12/18/24 What corrective action will take place? Facility will complete Community Based Assessments by adding an attachment to the CBA of the resident diagnoses and active medications. Resident #3: CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-1)} Resident #2: CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-2) Resident #4: CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-3) Resident #5 CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-4) Resident #7 CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-5) Resident #8 CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-6) Resident #6 CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-7) Resident # 9 CBA was printed off resident EMR. Medications and resident diagnoses were attached to resident CBA. (Attachment F-8) How to identify others at risk? Any resident who resides within the community will be at risk of this deficient practice. What measures will be put into place to assure this deficient practice does not reoccur? The DON/designee completed an audit of every assisted living resident. (Attachment G). Every resident CBA was printed with attached diagnoses and medication list. Upon semi-annual review or with any significant change the documents will be uploaded into resident EMR. How does the facility plan to monitor for compliance? The DON/designee will audit all CBAs for completion with each new admission, every 6 months, and with any significant change in condition. (Attachment H) The DON/designee will determine if further interventions are needed to maintain compliance. All audits will be submitted monthly to the QA committee. 19 CSR 30- Wash Hands/Arms & Clean Fingernails March 13th, 87.030 (2 2025 What Corrective action will take place? Dining director/ designee will educate dining staff and include the following, Review state regulations regarding sanitation requirements. “Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employee shall keep their fingernails clean and trimmed” Proper handwashing techniques (Attachment I) In-service with demonstration and return demonstration and completion of a quiz (Attachment J) How to identify others at risk? Any resident or staff within the Community could be affected with this deficiency What measures will be put into place to assure this deficient practice does not reoccur? Dining Director/designee completed education to all current dining employees. (Attachment J-2) Dining Director/designee will discuss food safety, handwashing practices, during daily huddles and monthly meetings. How does the facility plan to monitor for compliance? Dining Director/designee will complete daily audits over all three meals x 14 days and weekly for 12 weeks. At the end of 12 weeks the Dining Director/designee will assess compliance for further educational needs. All audits will be submitted monthly to the QA committee. (Attachment K)