FRIENDSHIP VILLAGE ASSISTED LIVING & MEMORY CARE.

“Based on observation, interview and record review, the facility failed to ensure alf unusable medication was destroyed by two people which included one person being a Nurse or Pharmacist when a Medication Technician (MT) destroyed two medications by him/herself and failed to document the reason for destroying unusable medication during the observed medication pass. The census was 66. Review of the facility's "Medication Administration Missouri) Department of Health and Senior Services PEFO11 If continuation sheet 1 of 4 02715C B.WING 09/23/2025 18250 VILLAGE VIEW DRIVE CHESTERFIELD, MO 63017 FRIENDSHIP VILLAGE ASSISTED LIV & MEMORY CAI and Disposal" policy dated 4/2019, showed the all medications that are controlled (Control of medication -shail mean assuming responsibility by the facility for all facets of control of medication, but not limited to, acquisition, storage, security and administration) by the facility must be disposed of, either by destroying them, returning to the pharmacy, or sending with the resident upon discharge. Medications that are not in current use shall be disposed of in accordance with Assisted Living Facility license regulations. Medication destruction will always involve two (2) people, one (1) of whom must be a pharmacist, nurse or state inspector. 1. Observation on 9/23/25 at 9:02 A.M., showed Certified Medication Technician (CMT) A walked to the medication cart and opened the sharps container and dropped in one Labetalo} HCL (medication used to treat high blood pressure) 200 milligram (mg) pill and one Amlodipine Besylate (medication used to treat high biood pressure) 10 mg pill. During interview on 9/23/25 at 9:05 A.M. and at 2:09 P.M., CMT A said he/she put the medication in the first floor sharps container attached to the medication cart for disposal. To his/her knowledge, no one unlocked the sharps container to empty the medication out it was just turned over to the company for disposal along with the sharp ifems inside. CMT A said it would be too dangerous to open the container and retrieve the items and no one would do it. CMT A said that disposal practice was common in the facility. CMT A said he/she was not aware of the facility policy to dispose of non-controlled medication using the two-party system or that he/she needed to document destroyed non-controlled 02715C B.WING 09/23/2025 15250 VILLAGE VIEW DRIVE CHESTERFIELD, MO 63017 DEFICIENCY} FRIENDSHIP VILLAGE ASSISTED LIV & MEMORY CAI medications. Observation on 9/23/25 at 9:21 A.M., of the internal sharps container attached to the medication cart, on the first floor, showed the container was approximately was approximately 1/2 way full of various needles and other smaller items surrounding the items and covering the bottom of the container, were hundreds of pills of random shape and color. The entire bottom of the container, approximately 1 inch in thickness, was filled with pills stacked up tightly against one another. 2. Observation on 9/23/25 at 9:27 A.M., of the internal sharps container attached to the medication cart, on the second floor, showed the container was approximately 1/2 way full of various needles and other smaller items surrounding the items and covering the bottom of the container, were hundreds of pills of random shape and color. The entire bottom of the container, approximately 3 inches in thickness, was filled with pills stacked up tightly against one another. 3. Observation on 9/23/25 at 9:42 A.M., of the internal sharps container attached to the medication cart, on the third floor, showed the container was nearly full of various needles and other smaller items surrounding the items and covering the bottom half of the container, were hundreds of pills of random shape and color filling the bottom of the container, which was approximately 5 inches in thickness. The pills were stacked up tightly against one another. 4. During an interview on 9/23/25 at 2:25 P.M., the Assistant Director of Nursing (ADON) said she was unaware staff members were disposing 02715¢ B.WING 09/23/2025 15250 VILLAGE VIEW DRIVE CHESTERFIELD, MO 63017 FRIENDSHIP VILLAGE ASSISTED LIV & MEMORY CAI A4833 | Continued From page 3 of medication by using the sharps container. The facility had the appropriate chemical disposai equipment located in the medication room of each floor. The ADON said staff should be conducting a proper two-party disposal of any medication per the facility policy and the staff should have documented when they destroyed medications. The ADON said she had never heard of staff members doing this type of medication disposal before, but she was new to the facility. The ADON said this practice is not acceptable and not according to basic medication regulation standards. 5. During an interview on 9/23/25 at 2:38 P.M., the Administrator said she was not aware the staff were not disposing of medication properly. *The higher classification merited due to the extent of the violation. PLAN OF CORRECTION Provider/Supplier Name: Friendship Village Assisted Living & Memory Care ows 15250 Village View Drive, Chesterfield, MO 63017 City, Zip: Date of Survey: 09/23/2025 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 Sharps containers were replaced on the medication carts on 9/23/25. All residents have the potential to be affected by this deficient practice. CMTs and nurses educated on Medication: Administration, A4833 Distribution, Stock Supply, Review, Control and Destruction 10/16/2025 Policy by ADON. Sharps containers will be audited by the DON or designee once weekly for four weeks and once monthly for the following three months. Results will be presented during the first interdisciplinary team meeting of the month. 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.”

“Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident ' s departure, of the resident ' s estimated length of absence from the facility, and of the resident ' s whereabouts while on voluntary leave. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“There shall be written documentation maintained in the facility showing actual hours worked by each employee. III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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 locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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 is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident ' s departure, of the resident ' s estimated length of absence from the facility, and of the resident ' s whereabouts while on voluntary leave. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Only activities necessary to the administration of the facility shall be contained in any building used as a long-term care facility except as follows: (A) Related activities may be conducted in buildings subject to prior written approval of these activities by the Department of Health and Senior Services (hereinafter-the department). Examples of these activities are Home Health Agencies, physician ' s office, pharmacy, ambulance service, child day care and food service for the elderly in the community; II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“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: A. Within five (5) calendar days of admission; II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident ' s condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident ' s physician so authorizes. All individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level I medication aide. I/II”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.

“In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III”

This is the rule that was cited, not the inspector’s specific finding. The detailed Statement of Deficiencies is in the official report below.