CREVE COEUR ASSISTED LIVING AND MEMORY CARE.

PRINTED: 11/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED BAVC 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF A2206 19 CSR 30-86.022(2)(H) Combustibles Not Stored Under Stairways General Requirements. (H) Facilities shall not use space under stairways to store combustible materials. I/II This regulation is not met as evidenced by: Class Il Based on observation and interview during the fire safety inspection process on November 24, 2025, the facility failed to ensure the space under the stairwell was not used to store combustible materials. The facility census was 74. This deficiency affects 74 out of 74 residents. Observation on November 24, 2025 at 12:33 PM, revealed the storage of combustible materials under the stairs within the West stairwell. During an interview on November 24, 2025 at 2:05 PM, maintenance advised he would pass the information on to management. 19 CSR 30-86.022(8)(A) Exit Sign Requirements A2236 Exit Signs. (A) Signs bearing the word EXIT in plain, legible letters shall be placed at each required exit, except at doors directly from rooms to exit passageways or corridors. Letters of all exit signs shall be at least six inches (6”) high and principle strokes three-fourths of an inch (3/4") wide, except that letters of internally illuminated exit signs shall not be less than four inches (4") high. I This regulation is not met as evidenced by: Class Il Missouri Department of Health a LABORATORY DIRECTOR'S ORP ea a fa REPRESENTATIVE’S SIGNATURE Wes l2/pos “TITLE (X6) DATE —— A) STATE FORM sas9 1G1G11 If continuation sheet 1 of 4 ai PRINTED: 11/25/2025 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 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF 19 CSR 30-86.022(2)(H) Combustibles Not Stored Under Stairways General Requirements. (H) Facilities shall not use space under stairways to store combustible materials. I/II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 24, 2025, the facility failed to ensure the space under the stairwell was not used to store combustible materials. The facility census was 74. This deficiency affects 74 out of 74 residents. Observation on November 24, 2025 at 12:33 PM, revealed the storage of combustible materials under the stairs within the West stairwell. During an interview on November 24, 2025 at 2:05 PM, maintenance advised he would pass the information on to management. 19 CSR 30-86.022(8)(A) Exit Sign Requirements Exit Signs. (A) Signs bearing the word EXIT in plain, legible letters shall be placed at each required exit, except at doors directly from rooms to exit passageways or corridors. Letters of all exit signs shall be at least six inches (6") high and principle strokes three-fourths of an inch (3/4") wide, except that letters of internally illuminated exit signs shall not be less than four inches (4") high. I This regulation is not met as evidenced by: Class II Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1G1G11 If continuation sheet 1 of 4 PRINTED: 11/25/2025 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 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 1 Based on observation and interview during the fire safety inspection process on November 24, 2025, the facility failed to clearly mark all exits. Exit Signs bearing the word EXIT in plain, legible letters shall be placed at each required exit, except at doors directly from rooms to exit passageways or corridors. Letters of all exit signs shall be at least six inches (6") high and principle strokes three-fourths of an inch (3/4") wide, except that letters of internally illuminated exit signs shall not be less than four inches (4") high. The facility census was 74. This deficiency affects 74 out of 74 residents. Observation on November 24, 2025 at 12:40 PM, revealed no exit sign on the ground floor exit of the East stairwell. During the exit interview on November 24, 2025 at 2:10 PM, maintenance stated he would place an exit sign at the exit. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview during the fire safety inspection process on November 24, 2025, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. The facility census was 74. This deficiency affects 74 out of 74 residents. Missouri Department of Health and Senior Services STATE FORM 6899 1G1G11 If continuation sheet 2 of 4 PRINTED: 11/25/2025 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 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 2 Observation on November 24, 2025 at 12:53 PM, revealed an unapproved metal and plastic wastebasket in use in the first floor laundry room. Observation on November 24, 2025 at 12:46 PM, revealed an unapproved metal and plastic wastebasket in use in the Bistro. Observation on on November 24, 2025 at 12:42 PM, revealed an unapproved plastic wastebasket in use in the hair salon. Observation on on November 24, 2025 at 12:15 PM, revealed an unapproved plastic wastebasket and a wicker wastebasket in use in room 230. Observation on November 24, 2025 at 12:56 PM, revealed an unapproved metal and plastic wastebasket in use in the maintenance office. During the exit interview on November 24, 2025 at 2:15 PM, maintenance believed metal wastebaskets with no bottom and/or plastic components were acceptable. He now understands which wastebaskets are approved and will remove all the unapproved waste baskets, as soon as he can obtain approved replacements. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected 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, Missouri Department of Health and Senior Services STATE FORM 6899 1G1G11 If continuation sheet 3 of 4 PRINTED: 11/25/2025 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 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 3 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 regulation is not met as evidenced by: Class Ill Based on observation and interview during the fire safety inspection process on November 24, 2025, the facility failed to ensure the facility's electric wiring was properly maintained. The facility census was 74. This deficiency affects 74 out of 74 residents. Record review on November 24, 2025 at 2:20 PM revealed the facility was unable to provide a electrical wiring certificate. During the exit interview on November 24, 2025 at 2:25 PM, maintenance stated he would have to look for the certificate and have a new electrical inspection if they could not find it. Missouri Department of Health and Senior Services STATE FORM 6899 1G1G11 If continuation sheet 4 of 4 RETIREMENT COMMUNITIES wt SPECTRUM CONFIDENTIAL — FOR INTERNAL USE ONLY REASON FOR PLAN Fire Marshal Inspection SURVEY }e@Z0.5 Response |px wi.) DATE Due Date COMMUNITY NAME Creve Coeur Assisted Living and Memory Care LOL ONAP UC) CO) BS) 00 FCO DHSS/STL County Fire Marshall DEFICIENCY ALLEGED VIOLATION | CORRECTIVE ACTION ITEMS/STEPS Responsible Person for Action Due Date(s) for Immediate Action: The Director of Maintenance immediately went into the stairwell and gathered the combustible A2206 —Combustibles Not Stored Under Starways|material as directed. This material was disposed of accordingly and removed from the building. All (19 CSR 30-86.022(2)(H) stairwells were also walked and there were no combustible materials found. ** Deficiency:** The facility had the storage of eet Quality Measure (to ensure no recurrence of citation/violation): combustible materials under the stairs within the West The facility has set up weekly walks to inspect all stairwells and common areas for any stairwell. further combustible items. e The Executive Director, Maintenance Manager, and/or designee will ensure walk is completed and any issues are brought up in the monthly safety meeting. Tag Number and Title of Tag - DA WZ ‘ Zz /f / /2 Ze Page 1of5 POC Blank Template v4.0F/10.2023 Tag Number and Title of Tag Immediate Action: e Maintenance purchased exit sign the same day. Exit lights were installed by 12/1/2025. A2236 — Exit Sign Requirements (19 CSR 30- 86.022(8)(A) Long-Term Quality Measure (to ensure no recurrence of citation/violation): **Deficiency:** The facility failed to clearly e ED/Maintenance and/or designee will ensure that weekly walks of the building include mark all exits. Exit Signs bearing the word EXIT in checking for all signage for exits to be visible and appropriate according to the mandated plain, legible letters shall be placed at each regulations. required exit, except at doors directly from rooms to exit passageways or corridors. Letters of all exit signs shall be at least six inches (6") high and principal strokes three-fourths of an inch (3/4") wide, except that letters of internally illuminated y SPECTRUM ey Rl “ap RETIREMENT COMMUNITIES CONFIDENTIAL — FOR INTERNAL USE ONLY REASON FOR PLAN Fire Marshal Inspection SURVEY [}kBZ3)) Response [PAS ies) DATE Due Date OPERATOR ENTITY COMMUNITY NAME Creve Coeur Assisted Living and Memory Care GOV. AGENCY ISSUING DEFICIENCY DHSS/STL County Fire Marshall Person for Action Due Date(s) for Responsible Actions ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS exit signs shall not be less than four inches (4") high. Tag Number and Title of Tag Immediate Action: 11/25/25 A2286 — 19 CSR 30-86.022(15)(A) Wastebaskets, e = 0n11.25.25 all trashcans that were non-compliant in the common areas were removed |Branch Metal/UL/FM-Requirements and replaced with URL compliant trashcans in the POC (1rst floor laundry, bistro, hair salon, Apt 230, maintenance). Housekeeping and Maintenance are currently walking Deficiency: the facility failed to ensure only metal through all occupied units and replacing trashcans that are non-compliant. All trashcans or UL- or FM-fire-resistant rated wastebaskets found non-compliant will be replaced by 12/16/25. were being used for trash. The facility census was 74, Long-Term Quality Measure (to ensure no recurrence of citation/violation): e Maintenance, Housekeeping, and/or designee will continue to monitor rooms for trash This deficiency affects 74 out of 74 residents. cans that may need replacement during routine weekly housekeeping services and 11.25.25 maintenance work orders. ED or designee will continue to ensure that URL trashcans are on all inventory sheets and move in supply lists for all new residents that move into the community. Page 2 of 5 POC Blank Template v4.0F/10.2023 CONFIDENTIAL — FOR INTERNAL USE ONLY REASON FOR PLAN Fire Marshal Inspection SURVEY }kBZ9)) Response [pAwiys) DATE Due Date OPERATOR ENTITY COMMUNITY NAME Creve Coeur Assisted Living and Memory Care DHSS/STL County Fire Marshall Responsible Person for Action Due Date(s) for Actions GOV. AGENCY ISSUING DEFICIENCY ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS Tag Number and Title of Tag Immediate Action: : 11.25.25 ¢ DOM has a vendor in place that is now approved to work in the community. Appointment A3214: 19 CSR 30-86.032(13) Electrical Wiring, being set as of 12/8/2025. Maintained, Inspected. Long-Term Quality Measure (to ensure no recurrence of citation/violation): Deficiency: the facility failed to ensure the e Facility DOM will ensure that all electrical needs and inspections are done as required by facility's electric wiring was properly maintained. regulation and on file for inspections. The two year wire inspection will be reviewed at the The facility census was 74. This deficiency affects next safety committee meeting and will be kept in the safety meeting binder. 74 out of 74 residents. Page 3 of 5 POC Blank Template v4.0F/10.2023 RETIREMENT COMMUNITIES 2” SPECTRUM 4p CONFIDENTIAL — FOR INTERNAL USE ONLY REASON FOR PLAN Fire Marshal Inspection SURVEY /#a@Zes) Response [|¥R:Wi0y2) DATE Due Date OPERATOR ENTITY COMMUNITY NAME Creve Coeur Assisted Living and Memory Care DHSS/STL County Fire Marshall Person for Action Due Date(s) for Responsible Actions GOV. AGENCY ISSUING DEFICIENCY ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS Note: When preparing/finalizing the response to be sent to the governmental agency that issued the citation, please include the following language (to be modified as applicable) above the first citation response: This rt e OF \ being submitted by [ rt name of 1 (the “Operator”), which is the licensed operator of the community known as [inse! nunit ame] (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 following the survey that was completed on or about . 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 Page 40f5 POC Blank Template v4.0F/10.2023 RETIREMENT COMMUNITIES -” SPECTRUM v CONFIDENTIAL — FOR INTERNAL USE ONLY REASON FOR PLAN Fire Marshal Inspection SURVEY /;em@Zs; Response }pAwiys> DATE Due Date OPERATOR ENTITY COMMUNITY NAME Creve Coeur Assisted Living and Memory Care GOV. AGENCY ISSUING DEFICIENCY DHSS/STL County Fire Marshall Responsible Person for Action Due Date(s) for ALLEGED VIOLATION CORRECTIVE ACTION ITEMS/STEPS 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, forall 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 5 of 5 POC Blank Template v4.0F/10.2023

Missouri Department of Health and Senior Servicas STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER CLIA 1A2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 693 DECKER LANE CREVE COEUR ASSISTED LIVING AND MEMORY CAF CREVE COEUR, MO 63147 PRINTED: 06/16/2025 FORM APPROVED {X3) DATE SURVEY COMPLETED 29440 | BING oe Cc 05/21/2025 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES r PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL OREFIK EACH COR TAG REGULATORY OR LSC IDENTIFYING INFORMATION, ROSS. A4754 19 CSR 30-86.047(28)(G) Individual Service Plan A4754 - 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 pia (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; UI This regulation is not met as evidenced by: Based on interview and record review. the facility failed to develop individualized service plans (ISP) which included resident needs and services to be provided by staff, for four of eight sampled residents (Residents #5, #1, #3 and 8). The census was 80. 4. Review of Resident #5's medical record, showed the facility admitted ihe resident on 10/9/25, with diagnoses which included dementia. high cholesterol, diabetes, and high blood pressure, Review of the resident's progress notes, showed the following: -On 5/2/25 at 11:00 A.M., the Director of Nursing (DON), completed the resident assessment at the hospital because the resident was going to be discharged on Monday so home heaith can evaluate and start treatment to the resident's toe. The resident's family was called and updated on the information by the DON; -On 5/8/25 at 3:55 P.M., the DON noted the resident returned from the hospital, family was Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROYIDER/SUPPLi EPRESENJATIVE'S SIGNA | Lit TTL VeKR1t STATE FORM TIVE ACTICN SHOULD BE COMPLETE -RENCED TO THE APPROPRIATE DATE DEFICIENCY} ii 22S Hf continuation sheet 1 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 1 made aware, and home health was set up for wound care to the toe amputation dressing; -On 5/10/25 at 4:08 P.M., Medication Aide (MA) D noted the resident threw his/her dinner plate at the MA on duty and called him/her a "bitch" and told him/her to "kiss my ass." Review of the resident's ISP dated 5/12/25, showed the following: -Need: Wound monitoring- to avoid infection, accelerate healing, and minimize scarring. PERSONALIZE with community monitoring schedule and home health treatment plan; -Need: No behavior issues- The resident does not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior. During an interview on 5/20/25 at 12:04 P.M., MA E said the resident can sometimes be combative with care. He/she preferred to do things on his/her own and if they attempt to use hands on assistance he/she would become combative. He/she had treatment for his/her toe prior to going out to the hospital but the resident often refused treatment. The family was notified by the DON and also attempted to assist with encouraging the resident for treatment but he/she would become combative. MAE said it would be helpful to have additional direction on how to assist the resident with his/her care. During an interview on 5/21/25 at 10:46 A.M., the Administrator said the information for the resident's wound, care and behavior should have been included in the ISP for the resident's care. Review of the resident's ISP dated 5/12/25, showed the ISP did not address the resident behaviors or how to assist the resident if he/she had a behavioral episode. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 2 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 2 2. Review of Resident #1's medical record, showed the facility admitted the resident on 7/12/24, with diagnoses which included stress incontinence and mixed hyperlipidemia (too many lipids in the blood). Review of the resident's ISP dated 2/12/25, showed the following: -Need: Medication: The resident required daily assistance or cueing and must be reminded to take medication and treatments; -Need: Bathing: The resident required physical assistance with his/her shower in the early morning to be given by the night shift preferably 5:30 A.M. During an interview on 5/20/25 at 2:25 P.M., the resident said he/she required physical assistance in the shower, but it was only to help him/her get into and out of the shower. He/she said sometimes he/she needed physical assistance for the hard to reach areas because his/her right knee "liked to give out." The resident said he/she self-administered his/her own medication and had alarms on his/her phone for when to take the medication. The resident said the staff do not assist him/her with taking medication. Review of the resident's ISP dated 2/12/25, showed the following: -The ISP did not address what kind of assistance the resident required with bathing; -The ISP did not address the resident self-administered his/her own medication; -The ISP did not address the resident's right knee that "gave out." 3. Review of Resident #3's medical record, showed the facility admitted the resident on Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 3 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 3 6/14/24, with diagnoses which included depression, high blood pressure, dementia, diabetes and Parkinson's disease. Review of the resident's ISP dated 5/16/25, showed the resident required stand by and/or physical assistance with parts of toileting tasks. During an interview on 5/20/25 at 2:00 P.M., the resident said he/she needed physical assistance in the bathroom. He/she said the staff usually help him/her in and out of the bathroom as well as clean up. Review of the resident's ISP dated 5/16/25, showed the ISP did not address what kind of physical assistance the resident needed with toileting. 4. Review of Resident #8's medical record, showed the facility admitted the resident on 1/30/25, with diagnoses which included dementia, age related osteoporosis, mild cognitive impairment and Vitamin D deficiency. Review of the resident's ISP dated 5/1/25, showed the following: -Need: Bathing: Physical assist, resident required physical assist with participation by the resident to complete task. The ISP did not address the assistance with bathing; -Need: Morning and night care: Resident requires physical assist with waking and getting out of bed. "ADD WAKE AND BED TIME." The ISP failed to add the time the resident preferred to wake and go to bed. 5. During an interview on 5/21/25 at 10:45 A.M., the Administrator said she expected the ISPs to contain all relevant information to help staff care Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 4 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 4 for the resident. This information should include all specific tasks and responsibilities of the staff, as well as the preferences of the resident. 19 CSR 30-86.047(58)(A) Resident Record Admission Info The facility shall maintain a record in the facility for each resident, which shall include the following: (A) Admission information including the resident ' s name; admission date; confidentiality number; previous address; birth date; sex; marital status; Social Security number; Medicare and Medicaid numbers (if applicable); name, address and telephone number of the resident's physician and alternate; diagnosis, name, address and telephone number of the resident ' s legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to maintain a record for each resident which included contact information of the resident's preferred pharmacy, funeral director and dentist, for seven of eight sampled residents (Residents #6, #3, #1, #5, #2, #7 and #8). The census was 80. 1. Review of Resident #6's medical record, showed the following: -Admit date 2/2/24: -Diagnoses included dementia, insomnia, and osteoarthritis; -No documented preferred dentist; -No documented preferred funeral home. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 5 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 5 2. Review of Resident #3's medical record, showed the following: -Admit date 6/14/24; -Diagnoses included depression, high blood pressure, dementia, Parkinson's disease and diabetes; -No documented preferred dentist; -No documented preferred funeral home. 3. Review of Resident #1's medical record, showed the following: -Admit date 7/12/24; -Diagnoses included stress incontinence and mixed hyperlipidemia (too many lipids in the blood); -No documented preferred pharmacy; -No documented preferred funeral home. 4. Review of Resident #5's medical record, showed the following: -Admit date 10/9/24; -Diagnoses included dementia, high cholesterol, diabetes, chronic kidney disease and high blood pressure; -No documented preferred dentist; -No documented preferred funeral home. 5. Review of Resident #2's medical record, showed the following: -Admit date 5/7/25; -Diagnoses included cognitive communication deficit, history of falls, muscle weakness, stress incontinence, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system (brain and spinal cord); -No documented preferred dentist; -No documented preferred funeral home. 6. Review of Resident #7's medical record, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 6 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 6 -Admit date 10/25/24; -Diagnoses included bradycardia (a condition where the heart rate is too slow); -No documented preferred dentist. 7. Review of Resident #8's medical record, showed the following: -Admit date 11/12/24: -Diagnoses included Parkinson's disease; -No documented preferred funeral home. 8. During an interview on 5/21/25 at 10:45 A.M., the Administrator said she was aware the resident's dentist, funeral home and pharmacy were required to be a part of the record. The facility only recently became aware the information was not listed for all of the residents after conducting an internal audit. The facility has not yet had the time to correct the problem and add the information for all residents. 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 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 Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 7 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 7 to residents. This had the potential to affect all residents. The census was 80. 1. Observation on 5/20/25 between 8:22 A.M. and 2:25 P.M., of resident room 212 B, showed a full bottle of Woolite Carpet & Upholstery cleaner on the bathroom counter which the resident had unimpeded access to. The precautionary statement read, "In case of eye contact, flush thoroughly with water for 15 minutes. If irritation persists, consult physician. Use in well-ventilated area. Intentional misuse by deliberately concentrating and inhaling contents can be harmful or fatal. Keep out of the reach of children”. During an interview on 5/20/25 at 3:30 P.M., the Administrator said she was not aware the resident had the chemical in his/her room. The Administrator said residents should not have access to chemicals and all chemicals should be locked up when not in use. 2. Observation on 5/20/25 between 7:45 A.M. and 9:06 A.M., on the first floor in the unlocked soiled laundry room, inside an unlocked cleaning cart, showed the following: -A full 32 ounce (0z) spray bottle of Clorox clean up disinfectant Clorox pro. The precautionary statement read, "Avoid contact with eyes and skin. Avoid breathing spray mist. Provide adequate ventilation. Wear appropriate personal protective equipment. Wash thoroughly after handling. Use good industrial hygiene practices in handling this material. When using do not eat or drink. KEEP OUT OF REACH OF CHILDREN AND PETS. Store this product in a cool [dry] area, [away from direct sunlight and heat] to avoid deterioration."; -A 1/2 full 19 oz spray can of Lysol. The Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 8 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 8 precautionary statement read, Hazardous to humans and domestic animals. Causes mild eye irritation. Do not spray in eyes, on skin, or on clothing. Wash hands thoroughly after use and before eating. Keep out of reach of children."; -Two 32 oz spray bottles of Clorox Fusion. One full and the other 1/2 full. The precautionary statement read, "The product causes burns of eyes, skin and mucous membranes. Thermal decomposition can lead to release of irritating gases and vapors. Inhalation: May cause irritation of respiratory tract. May cause pulmonary edema. Eye contact: Corrosive to the eyes and may cause severe damage including blindness. Causes serious eye damage. Skin contact: Avoid contact with skin. Corrosive. Causes burns. Ingestion: Ingestion causes burns of the upper digestive and respiratory tracts. Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea. Do not breathe dust/fume/gas/mist/vapors/spray. Wash face, hands and any exposed skin thoroughly after handling. Wear protective gloves/protective clothing/eye protection/face protection. Keep away from children."; -A 1/2 full 32 oz spray bottle of Ecolab 73 disinfecting acid bathroom cleaner. The precautionary statement read, "IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Immediately call a POISON CENTER/ doctor. Absorb spillage to prevent material damage. Do not mix with bleach or other chlorinated products - will cause chlorine gas."; -A 1/4 full 14 oz container of Comet with bleach. The precautionary statement read, The precautionary statement read, "CAUTION: May cause eye irritation. In case of contact with eyes, flush thoroughly with water. If irritation persists, see a physician. If swallowed, drink a glassful of Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 9 of 10 PRINTED: 06/16/2025 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 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 9 water. May be irritating to skin. For sensitive skin or prolonged use, wear gloves.; -Multiple residents walked past the unlocked closet with no staff present. During an interview on 5/21/25 at 11:30 A.M., the Administrator said she was not aware the soiled laundry closet was unlocked. 3. Observation on 5/20/25 between 2:23 P.M. and 2:39 P.M., on the third floor, in front of resident room 307, showed an unlocked cleaning cart. One resident wheeled past the unlocked cleaning cart in his/her wheelchair. The cleaning cart had a full 32 oz spray bottle of Clorox clean up disinfectant Clorox pro, a 1/2 full 19 oz spray can of Lysol, two 32 oz spray bottles of Clorox Fusion, a 1/2 full 32 oz spray bottle of Ecolab 73 disinfecting acid bathroom cleaner. and a 1/4 full 14 oz container of Comet with bleach. No staff were present. 4. During an interview on 5/20/25 at 2:45 P.M., the Administrator said all chemicals should be locked up. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR11 If continuation sheet 10 of 10 — Name: Provider/Supplier | Street Address, City, Zip: f t 693 Decker Lane Creve PLAN OF CORRECTION Creve Coeur Assisted Living and Memory Care Coeur MO 63679 | observed H i a Date of Survey: 6/21/2025 | PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 7 | ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION. (EACH CORRECTIVE ACTION | COMPLETION | SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) / DATE Tag Immediate Action: - DON and ED conducted an | : Number | audit of the ISPs for all current residents to identify | and Title | and address missing or incomplete specific details of | of Tag i the ISPs. « Revised ISPs will be completed for A4754-19 | Residents #5, #1, #3. and #8 to include detailed | | CSR 30- | instructions of assistance with ADLs such as bathing | 86.047 | and transiers, resident preferences to include care | (28)(G) times, behavioral interventions, instructions for Individual } medication self-administration and mobility | Service | limitations by July 16, 2025. Long-Term Quality Plan | Measure (to ensure no recurrence of Developm | citation/violation}: - AIL ISPs will be reviewed jent: The | within 72 hours of admission and during quarterly facility | service plan updates to ensure complianee. « Care | 716.0095 | failed to staff will receive quarterly training on individualized | develop care planning and appropriate documentation for the | individuali | residents. Who is Responsible for Long-Term | zed service | Quality Measure Outcomes: > DON, ED. or plans that | designee. State of Review in QAPI Monihly addressed ! Meeting: - Each move in will be reviewed within 72 residents’ | hours of move in and discussed each month at | specific QAP needs and | | staff | responsibil | ities. This | | | in 4 of 8 sampled i residents. ISPs lacked behavioral interventio | ns, bathing ' assistance i details, self- ion | guidance, and mobility medication | administrat | | A4836- | L9CSR | (58) (A) ; Resident | Record: Admission | Informatio in: The facility failed to maintain | complete admission records for several of either | sampled residents. Specificall y, | resident’s | record _ | Immediate Action: - DON and ED will review all | _ resident records to verify and collect missing ; preferred provider information (dentist, pharmacy and funeral home) by July 16th. 2025. Residents or : Power of Attorneys will be contacted to obtain | preferred providers where documentation is incomplete. Records for Residents #6, #3, #1, #5, #287, and #8 will be updated by 7/16/2025 Long- | Perm Quality Measure (10 ensure no recurrence of | citation/violation): - Each resident file will be audited within 72 hours of move in to ensure the appropriaic information is captured. Who is ; Responsible for Long-Term Quality Measure Outcomes: - DON. DRC. ED. or designee State of Review in QAP! Monthly Meeting: - All new i residents will be reviewed each month to ensure accuracy of admission records. 7.416.2025 lacked documenta tion of preferred pharmacy, dentist and funeral] home as | required. A6005-19 CSR 30- 87.020 (5) i ~ Toxic Material Storage The facility failed to ensure toxic materials {cleaning agents, disinfectan ts, etc.) were secured and inaccessibl e to residents. Observatio ns revealed unlocked carts and closets containing hazardous products on multiple Immediate Action: - All unsecured toxic materials have been removed and secured into locked storage. Staff have been re-educated on the requirement to keep all toxic or hazardous materials locked when ‘not actively in use, - Soiled laundry rooms have been inspected to ensure no chemicals are unsecured. Staff has been educated that the laundry door is to remain closed and locked at all times. - A full community sweep of the residents apartments and community spaces will be conducted by July 16th to ensure there are no hazardous chemicals in the residents’ apartments. Long-Term Quality Measure (to ensure n re oO i recurrence of citattion/violation): - Housekeeping, Maintenance "and care teams will inspect the residents’ apartments when they are completing a work order a weekly housekeeping service to ensure there are not chemicals in the residents” apartments or ave in any community spaces. - All housekeeping carts will be locked when the cart is unattended. - Quarterly in-services will be provided to all staff on , chemical safety and safe storage protocols. Who is i : ayy . Responsible for Long-Term Quality Measure ulable Outcomes: - Maintenance Manager, Housekeeping Supervisor, ED, or designee State of Review in QAPI Monthly Meeting: - Chemical safety will be reviewed during monthly safety meetings. 7/16/2025 floors and | ! | _ in resident- | ; accessible | | | areas, — _ ee _ | aan Ja =a = ann Wide _ EE a mm To ee a ee i poets i oe ma —-— - a 4 —-—t worse eee 7 so 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. 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 CREVE COEUR ASSISTED LIVING AND MEMORY CAF SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4)ID PREFIX : TAG {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 i provided, and goals expected by the resident or the resident’ s legal representative in partnership with the facility; II This regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 5/21/25. | Based on interview and record review, the facility : failed to develop individualized service plans ; {ISP} and to follow their policy when ISPs were i not updated to include falls and new interventions i to prevent future falls. The facility also failed to : include other specific information on residents , ISPs such as skin conditions and healing : processes of skin conditions, behaviors and . detailed instruction on de-escalation techniques, certain triggers for residents, wandering issues, - exit seeking and behaviors of refusing care which included instruction on what to do when a resident refused, as well as what kind of assistance the residents may need while maintaining the resident's dignity and independence. The facility also failed to personalize certain needs and sections of the ISPs which prevented it from being individualized, for nine of nine sampled residents (Residents #5, #10, #6, #9, #12, #13, #20, #3, and #8). The Missouri Department of Health and SetfopServices (\. DIRECTOR'S OR Np be R REPRESENTATIVE'S SIGNATURE CA —— (jo (X2) MULTIPLE CONSTRUCTION A, BUILDING: B. WING {A4754} 6899 he V8KR12 PRINTED: 09/23/2025 FORM APPROVED (x3) DATE SURVEY COMPLETED R-C 09/03/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) TITLE Gert. $e (X6) DATE Jo (3/2025, lf continuation sheet 41 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 1 {A4754} census was 82. Review of the facility's "Fall Management Plan" policy dated 3/25/25, showed the following: -The community must have a Fall Management Plan (FMP) including fall prevention training for staff, education and materials for residents and family members, and individualized resident care plans addressing fall risk and coordination of care with the resident's primary care provider to address fall risk; -Communities would provide resident activities to improve strength and balance. Communities would also routinely inspect the property and maintain a safe exterior and interior environment; -Procedure: -Resident is identified at risk for falling on assessment - each resident's care plan would address the fall risk related to deficits in strength, balance, and eyesight, or effects of medication; -In the resident's Electronic Health Record (EHR) access Care Plan, open Potential Fall Risk action; -Basic interventions are included in the description in the EHR -Notify the resident's primary care provider; -The resident's care plan must be updated to include interventions implemented and/or orders received; -lf there is a change of condition: -Complete a change of condition assessment, update care plan as necessary, and review with appropriate parties and obtain signatures. 1. Review of Resident #5's medical record, showed the facility admitted the resident on 10/9/24, with diagnoses which included dementia, high cholesterol, diabetes, and high blood pressure. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 2 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 2 {A4754} Review of the resident's progress notes, showed the following: -On 5/2/25 at 11:00 A.M., the Director of Nursing (DON), completed the resident assessment at the hospital because the resident was going to be discharged on Monday so home health could evaluate and start treatment to the resident's toe. The DON called the resident's family to update them on the information; -On 5/8/25 at 3:55 P.M., the DON noted the resident returned from the hospital, family was made aware, and home health was set up for wound care to the toe amputation dressing; -On 5/10/25 at 4:08 P.M., Medication Aide (MA) D noted the resident threw his/her dinner plate at the MA on duty and called him/her a "bitch" and told him/her to "kiss my ass." Review of the resident's ISP, last modified 8/15/25, showed the following: -Need: Wound monitoring- to avoid infection, accelerate healing, and minimize scarring. PERSONALIZE with community monitoring schedule and home health treatment plan; -Need: Neurocognitive: Long Term Memory: Impairment PERSONALIZE; -Need: Neurocognitive: Short Term Memory: Impairment PERSONALIZE; -Need: Psychosocial: No behavior issues. Resident does not have current or history of disruptive, aggressive verbal or socially inappropriate behavior; -Need: Disruptive Behaviors: Resident would be redirected, and care staff would utilize de-escalation techniques as needed to ensure resident safety and wellbeing; -The ISP did not address the resident's amputated toe; -The ISP did not address what de-escalating techniques the staff should use when the resident Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 3 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 3 {A4754} became verbally aggressive; -The ISP did not address which de-escalation techniques to use for the resident and whether or not there were specific ways to redirect/care for the resident when they became agitated; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 2. Review of Resident #10's medical record, showed the facility admitted the resident on 11/18/24 with a diagnosis of dementia. Review of the resident's ISP, last modified 8/15/25, showed the following: -Need: Diagnoses: PERSONALIZE - if resident has any specific needs directly related to active diagnoses; -Need: Psychosocial: No behavior issues. Resident did not have current or history of disruptive, aggressive, verbal or socially inappropriate behavior; -Need: Psychosocial: Chronic mood and depression issues. Resident had current or history of chronic depression or mood disorder; -Need: Toileting: Level of assistance: The resident required total physical assistance with all tasks related to toileting., The resident may require assistance with closed drainage system/catheter; -Need: Toileting: Other incontinence products provider. PERSONALIZE - who provides incontinence products?; -Need: Meal consumption: hydration stations. Resident had been informed of hydration station locations. PERSONALIZE; -Need: Meal consumption: Level of assistance: Resident did not require assistance with meal consumption; -Need: Emergency response: Emergency Pull Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 4 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 4 {A4754} Cord: PERSONALIZE; -Need: Evacuation: Resident required some physical assistance to evacuate residence or to request emergency assistance. During an interview on 8/27/25 at 10:30 A.M., Resident Aide (RA) H said the resident hated to have a shower, but the staff still tried to shower the resident. RA H said the resident had a Private Aide (PA) who came in every day and knew the resident's routine. RA H said the resident would "eat and eat and eat" until his/her stomach hurt and he/she threw up. RA H said he/she saw this him/herself and the PA told him/her about this behavior as well. RAH said the resident would defecate a lot when he/she eats a lot. RAH said the resident knew how to get out of bed on his/her own, would get his/her snacks and go back to bed. There would be crumbs all over his/her room when the resident had this behavior. RA H said he/she thought management already knew this behavior. During an interview on 8/27/25 at 10:54 A.M., MA J said he/she heard from staff the resident would eat so much, he/she would have an upset stomach and then throw up. Review of the resident's ISP, last modified 8/15/25, showed the following: -The ISP did not personalize the resident's needs specific to his/her diagnoses; -The ISP had no direction for staff on how to care for the resident's chronic mood and depression issues; -The ISP did not address whether or not the resident had a catheter and did not direct staff on how to care for the catheter if applicable; -The ISP did not address who provided incontinence products and prompted the writer to Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 5 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 5 {A4754} add this information; -The ISP did not address the resident's behavior of eating so much until he/she got sick and did not address staff interventions for this behavior; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 3. Review of Resident #6's medical record, showed the facility admitted the resident on 2/2/24, with diagnoses which included dementia and insomnia. Review of the resident's ISP, last modified 8/25/25, showed the following: -Need: Diagnoses: PERSONALIZE - if resident has any specific needs directly related to active diagnoses; -Need: Neurocognitive: Communication: Mild impairment. Resident had current or history of occasionally difficult communicating and receiving information; may have occasional difficulty following instructions with using the telephone and other communication devices; -Long Term Memory: Impairment. PERSONALIZE; -Short Term Memory: Impairment. PERSONALIZE; -Need: Psychosocial: Frequent behavior issues. Resident had current or history of frequent disruptive, aggressive, or socially inappropriate behavior, either verbally or physically improper; -Extensive wandering issues. Resident wandered outside and leaves immediate area. Had a history of leaving immediate area, getting lost, or being combative about returning. Consider if resident had to eliminate, and cue or offer to help resident to the bathroom, consider if resident was hungry or thirsty. Encourage rest. Offer toileting. Redirect resident with activities, Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 6 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 6 {A4754} music and socialization experiences. Keep nightlight on at night. Keep calm and do not raise your voice; -Need: Wandering: Resident did not have history of wandering behaviors; -Need: Mobility: Resident would receive "hands on" assistance during ambulation; -Need: Transfers/mobility: Resident would receive "hands on" assistance during transfers; -Need: Morning and night care: Level of assistance: Physical assist. Resident required x1 moderate physical assistance with walking and getting out of bed; -Need: Bathing: Resident would receive shower/bath 2 times per week - 1 person assist; -Need: Dressing: Resident would receive "hands on" assistance with dressing; -Need: Toileting frequency: Resident would toilet 4-6 times per day - 1 person; -Need: Coordination of Care: Outside services: PERSONALIZE; -Need: Emergency response: Level of assistance: Moderate. Resident required frequent reminding with how to use the emergency response system; -Need: Pendent: Resident did not require reminders to use pendant alarm appropriately; -Need: Evacuation: Level of assistance: Physical assist. Resident required some physical assistance to evacuate residence or to request emergency assistance; -Need: Temporary monitoring need: PERSONALIZE for resident specific. 9/29/24, resident fought staff, staff are to make sure resident was safe and leave him/her, attempting care later. 10/13/24 incident where resident hit and bit staff, staff are to make sure resident is safe and leave him/her, attempting care at a later time. During an interview on 8/27/25 at 10:30 A.M., RA Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 7 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 7 {A4754} H said the resident resisted showers frequently and bit, kicked, scratched, and punched the staff when they would try to assist him/her in the shower. RA H said he/she had not been told to try a bed bath instead. RA H said the resident had his/her good days and bad days, but the bad days were "really bad." RA H said it was not recommended to assist the resident without a second person present, if not only to be a witness of the care provided because of how "combative" the resident could be. RAH said when assisting the resident, he/she would yell, "Stop", "Fuck you, get out of here", and also call the aide a "bitch." RA H said it was always best to "quickly get it done" besides to come back to him/her at a later time. RA H said the resident could not walk and had to use a wheelchair and the resident could not stand up on his/her own. RAH said he/she did not use the ISPs. RA H thought management already knew about the resident and his/her needs. During an interview on 8/27/25 at 10:45 A.M., RA | said while in the shower, the resident could not physically wash his/her bottom and did not participate with his/her top half either even though he/she "probably could." RA | said it was best to care for the resident with two people present. RA | said the resident used a shower bench and grab bar while in the shower. RA | said the resident would curse, spit at and kick the aides when they would try and provide care. RAI said he/she could not see resident ISPs and thought it would be best if he/she was able to. During an interview on 8/27/25 at 10:54 A.M., MA J said the resident would bite staff and call them names and he/she sometimes required staff to leave and come back, but at times, the resident was "just too wet" (wet with urine) to leave Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 8 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 8 {A4754} him/her. Review of the resident's ISP, last modified 8/25/25, showed the following: -The ISP did not personalize the resident's needs specific to his/her diagnoses; -The ISP was contradicting with whether or not the resident had wandered; -The ISP did not address which de-escalation techniques to use for the resident and whether or not there were specific ways to redirect/care for the resident when they became agitated; -The ISP did not give new or additional ways to intervene and redirect the resident when he/she had aggressive behaviors towards staff. The behavior was not temporary; -The ISP did not address what kind of assistance (partial/total) the resident required; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information; 4. Review of Resident #9's medical record, showed the facility admitted the resident on 7/24/25, with a diagnosis of dementia. Review of the resident's ISP, last modified 8/11/25, showed the following: -Need: Bathing frequency: Reminders only. Resident would receive shower/bath 2 times per week; -Need; Care coordination: Resident would receive assistance with care coordination [PERSONALIZE] at least once monthly; Need: Disruptive behaviors: Resident would be redirected, and care staff would utilize de-escalation techniques as needed to ensure resident safety and well-being; -Need: Meals: Resident did not require assistance with eating; Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 9 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 9 {A4754} -Need: Mobility Escorts: Resident would be provided with verbal reminders on how to reach their next activity/meal; -Need: Orientation: Resident would receive prompting and redirection as needed; -Need: Transfers-mobility: Resident did not require assistance with transferring; -Need: Wandering: Resident would be provided with redirection as needed to ensure resident's safety. During an interview on 8/27/25 at 10:30 A.M., RA H said the resident had been at the facility for about a month now. RA H said the resident stood around the elevator a lot and when the resident's family member would come and visit, the resident would be very "triggered" afterwards when the family member would leave. The resident would get angry at the staff sometimes, when they tried to redirect him/her away from the elevator. During an interview on 8/27/25 at 11:45 A.M., MA K said the resident continued to stand at the elevator and usually did this behavior more after a family member would visit the resident. Review of the resident's ISP, last modified 8/11/25, showed the following: -The ISP did not address the resident's behavior of standing around the elevator and ways for staff to redirect him/her; -The ISP did not address how the resident's family member triggered the resident and ways for the staff to calm the resident down after the family member had left; -The ISP did not address what kind of assistance (partial/total) the resident required; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information; Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 10 of 33 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 (X2) MULTIPLE CONSTRUCTION A. BUILDING: 693 DECKER LANE CREVE COEUR, MO 63141 CREVE COEUR ASSISTED LIVING AND MEMORY CAF (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) {A4754}| Continued From page 10 5. Review of Resident #12's medical record, showed the facility admitted the resident on 12/30/21, with diagnoses which included arthritis, dementia and high blood pressure. Review of the resident's progress notes, showed the following: -On 5/1/25 at 8:51 P.M., hospice came to evaluate the resident. The facility received verification the resident qualified for the hospice program. The hospice team would follow up with the resident's physician and family regarding the next steps of participation in the program; -On 5/5/25 at 8:23 P.M., a staff member called the (previous) Administrator regarding the resident being found on the floor in his/her apartment. The staff helped the resident to the bathroom without difficulty and 15 minutes after completing the task, the resident pushed his/her pendant, and the staff answered to find the resident on the floor. The staff contacted the nurse and left a message with the resident's family member. The resident initially wanted to go to the hospital and staff called 911 but once the paramedics came, the resident changed his/her mind, and the Paramedics supported this decision. A head to toe assessment was completed and showed no bruising, abrasions and was within normal limits of the resident. The staff and paramedics indicated the resident's wheelchair appeared to not be intact. The staff notified the after hours hospice line of the incident and issues concerning safety with the resident's wheelchair. The hospice nurse would be out tomorrow for a follow-up assessment new low profile wheelchair would be delivered before noon tomorrow. A transport chair from the office was used temporarily; -On 5/21/25 at 8:38 A.M., a staff member called Missouri Department of Health and Senior Services STATE FORM {A4754} 6899 V8KR12 PRINTED: 09/23/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED R-C 09/03/2025 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 11 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 11 {A4754} the DON and said staff found the resident on the floor, under the couch. The resident had a raised area and discoloration above his/her left eye and abrasion on the bridge of his/her nose. The resident was alert and speaking. The resident complained of head and neck pain. The staff called 911; -On 5/28/25 at 12:29 P.M., the DON completed and updated the resident's ISP due to the resident falls and increased assistance with care. The DON left a message with the resident's family member. Review of the resident's ISP, last modified 8/15/25, showed the following: -Neurocognitive: Long Term Memory: Impairment PERSONALIZE; -Need: Mobility/Ambulation: Level of assistance: Physical assistance. The resident required physical assistance by staff members; -Need: Escorts: Level of assistance: Physical assistance. The resident required physical assistance and had an assistive device for mobility/ambulation; -Need: Transferring: Level of assistance: One person. The resident required occasional physical assistance with transfers and/or changes in position; -Need: Morning and night care: Level of assistance: Physical assistance: The resident required physical assistance with waking and getting out of bed - ADD WAKE AND BED TIME; -Outside services: Other. PERSONALIZE: provider, frequency, etc.; -Need: Emergency response: Pendant: PERSONALIZE; -Need: Fall prevention plan: assessment indicated a potential fall risk. The facility staff would check for appropriate lighting, clutter, and spills in apartment, 4/5/23, fell in apartment. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 12 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 12 {A4754} Resident reminded to put shoes on when getting up to walk. 9/11/24 - Fall in resident's apartment, found on floor near wheelchair in kitchen area. Staff stated resident tried to clean his/her wall. The resident was encouraged to ask for help especially when needing assistance with something that causes him/her to lean forward in his/her wheelchair. The resident was educated on the importance of clutter free pathways in his/her apartment and a referral was sent to homecare therapy. 10/17/24, the resident was found sitting beside his/her bed and stated he/she slipped out of bed and thought it was because of the foam mattress topper. The staff notified the resident's family member and foam mattress topper was removed the same day to avoid further issues; -The ISP did not address the resident's need of hospice and what the hospice team was responsible for, along with what the facility staff were responsible for; -The ISP did not address the resident's most recent falls; -The ISP did not address what kind of assistance (partial/total) the resident required; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 6. Review of Resident #13's medical record, showed the facility admitted the resident on 10/19/22, with a diagnosis of high blood pressure. Review of the resident's ISP, last modified 8/15/25, showed the following: -Need: Morning and night care: The resident required physical assistance with waking and getting out of bed - ADD WAKE AND BED TIME; -Need: Fall prevention plan: assessment indicated a potential fall risk. The facility staff were required to check for appropriate lighting, Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 13 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 13 {A4754} clutter, and spills in apartment, encourage proper footwear/nonskid footwear, and educate the resident to push pendant as needed for assistance with mobility, PERSONALIZE for resident specific prevention/interventions. Review of the resident's progress notes dated 8/20/25 at 5:11 P.M., showed the resident had a fall while he/she walked inside the building. The resident said he/she fell on his/her elbow. Review of the resident's ISP, last modified 8/15/25, showed the following: -The ISP did not address the resident's most recent falls and specific prevention/interventions for the fall; -The ISP did not address what kind of assistance (partial/total) the resident required; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 7. Review of Resident #20's medical record, showed the facility admitted the resident on 10/22/24, with a diagnosis of anxiety. Observation on 8/27/25 at 2:00 P.M., of the resident's room, showed the following: -A PA sat in a chair in the corner of the living room, while the resident lay in his/her bed in the bedroom, watching television; -A bedside commode filled with brown liquid, with the lid closed. When the lid was opened, a strong urine odor permeated the resident's bedroom. Review of the resident's ISP, last modified 8/15/25, showed the following: -Need: Diagnoses: PERSONALIZE - if resident has any specific needs directly related to active diagnoses; Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 14 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 14 {A4754} -Need: Psychosocial: Chronic anxiety issues. The resident had current or history of chronic anxiety; -Need: Psychosocial: Chronic mood and depression issues. The resident had current or history of chronic depression or mood disorder; -Need: Mobility: The resident would receive "hands on" assistance during ambulation; -Need: Mobility-Escorts: The resident would receive "hands on" assistance on the way to and from meals/activities; -Need: Transfers-Mobility: the resident would receive "hands on" assistance during transfers; -Need: Morning and night care: Level of assistance: Physical assistance. The resident required physical assistance with waking and getting out of bed - ADD WAKE AND BED TIME; -Need: Bathing frequency: The resident would receive a shower/bath 2 times per week with one person assist; -Need: Dressing: The resident would receive "hands on" assistance with dressing; -Need: Toileting frequency: One person: Resident would be toileted 1-3 times per day with one person assist. During an interview on 8/27/25 at 1:45 P.M., the resident's PA said the resident required a commode next to the resident's bed and the PA had to empty the commode several times a day. The PA said if he/she missed a day, the commode was usually filled when he/she arrived at the facility again. The PA said the resident required a bed bath because he/she was too weak to stand in the shower and he/she gave the resident a bed bath when the resident needed one. The PA said he/she came a couple times a week. During an interview on 8/27/25 at 2:05 P.M., the resident said he/she had the commode for a Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 15 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 15 {A4754} while and the staff were supposed to be emptying it several times a day. The resident said sometimes the facility staff do not empty the commode for three to four days, even a week has gone by without it being emptied. The resident said he/she preferred to have bed baths rather than showers. Review of the resident's ISP, last modified 8/15/25, showed the following: -The ISP did not address the resident's need for a commode by his/her bedside and how often the staff were to check/empty the commode to prevent feces and urine odor permeating the room; -The ISP did not address the resident's need for a PA and what the PA was responsible for and what the facility staff were responsible for when the PA was not at the facility; -The ISP did not address what kind of assistance (partial/total) the resident required; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 8. Review of Resident #3's medical record, showed the facility admitted the resident on 6/14/24, with diagnoses which included depression, high blood pressure, dementia, diabetes and Parkinson's disease. Review of the resident's ISP, last modified 8/21/25, showed the following: -Need: Diagnoses: PERSONALIZE - if resident has any specific needs directly related to active diagnoses; -Need: Mobility: Resident required "hands-on" assistance during ambulation; -Need: Mobility and Escorts: Resident required "hands-on" assistance on the way to and from Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 16 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 16 {A4754} meals; -Need: Transfers-Mobility: Resident required "hands-on" assistance during transfers; -Need: Morning and Night Care: Resident required a verbal reminder for waking and getting out of bed, but is able to get out of bed independently - ADD WAKE AND BED TIMES; -Need: Bathing Frequency: Resident required shower/bath two times per week with one person assist; -Need: Toileting-Frequency: Resident required to toilet 4-6 times per day with one person assist; -Need: Emergency response: Pendant: PERSONALIZE; -Need: Evacuation: Level of assistance - evacuation: physical assistance. Resident required some physical assistance to evacuate residence or to request emergency assistance; -Need: Fall prevention plan: Assessment indicates a potential fall risk. Community team would check for appropriate lighting, clutter, and spills in apartment, encourage proper footwear/nonskid footwear, and educate resident to push pendant as need for assistance with mobility. PERSONALIZE for resident specific prevention/interventions; -The ISP did not personalize the resident's needs specific to his/her diagnoses; -The ISP did not explain what "hands-on assistance meant (partial/total) for mobility, transfers and toileting/frequency; -The ISP did not address the resident's preferred wake and bed time; -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 9. Review of Resident #8's medical record, showed the facility admitted the resident on 1/30/25, with diagnoses which included dementia, Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 17 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 17 {A4754} age related osteoporosis, mild cognitive impairment and vitamin D deficiency. Review of the resident's ISP, last modified 8/15/25, showed the following: -Need: Diagnoses: PERSONALIZE - if resident has any specific needs directly related to active diagnoses; -Need: Neurocognitive: Short Term Memory: Impairment PERSONALIZE; -Need: Escorts: Level of assistance-escorts: Physical assist: Resident required physical assistance and had an assistive device for mobility/ambulation; -Need: Transferring: Grab bar. Level of assistance: One person resident required occasional x1 moderate physical assistance with transfers to all surfaces and/or changes in position; -Need: morning and Night care: Level of assistance: Physical assist. Resident required x1 moderate physical assistance with waking and getting out of bed in the AM and PM; -Need: Grooming/Personal Hygiene: Level of assistance: Physical assist. Resident performed grooming/personal hygiene but required physical assistance to complete task; -Need: Meal consumption: Resident had been informed of hydration station locations. PERSONALIZE; -Need: Emergency response: Emergency pull cord. Pendant. PERSONALIZE: -Need: Evacuation: Level of assistance: Physical assist. Resident required some physical assistance to evacuate residence or to request emergency assistance; -The ISP did not personalize the resident's needs specific to his/her diagnoses; -The ISP did not address what kind of assistance (partial/total) the resident required; Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 18 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 18 {A4754} -The ISP was not personalized in some areas, leaving the word "PERSONALIZE" which prompted the writer to add more information. 10. During an interview on 8/27/25 at 10:54 A.M., MA J said he/she thought the RAs should be able to see the ISPs, but did not have access to them and the ones that were printed off in the book weren't updated. MA J thought the RAs could provide better care if they had access to the residents ISPs. During an interview on 9/2/25 at 10:39 A.M., the DON said moderate physical assist meant the staff were not having to transfer the resident in the shower, but still helping them in the shower, washing their hair and "things like that." The DON said the assistance needed to be more detailed to maintain the resident's level of independence. He said all of these situations (behaviors, falls, whether or not the resident was on hospice and what hospice was responsible for, needed a catheter, a private aide and what that private aide was responsible for) should be detailed on the ISPs. He was not told Resident #9's family member triggered him/her, but it should be on the ISP and ways to calm the resident down when the family member leaves should be detailed on the ISP. He said if a resident has excessive wandering and exit seeking, it should be detailed on the ISP so the staff would know what to do and how to redirect the resident. The DON said if a resident resisted care, the staff should notify the manager, and the manager can step in and help the resident or document it and then the ISP should be updated. During an interview on 9/2/25 at 11:12 A.M., the Administrator said the ISPs should have detail on the resident's personal care and help direct staff Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 19 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A4754}| Continued From page 19 {A4754} to care for the resident in the resident's preferred ways. If someone is resisting care, the staff should go get a second person and if the two cannot do the care, then try again at a later time, then after coming back at a later time, if the resident still resisted care, the staff were to report this to management. The staff should have reported all the information they knew on how best to care for the resident to the DON so he could update the ISPs. She said all of the care needs regarding hospice and their responsibilities, behaviors and interventions/preventions of behaviors, catheters and how to care for them, private aides and their responsibilities, falls and new interventions/preventions for each fall, all of that should be detailed on the ISP so the staff can best care for the resident. She was not aware some staff did not have access to the ISPs. 19 CSR 30-86.047(35) Protective Oversight 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 regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to provide protective oversight when staff did not follow their "Fall Recovery - Lift Assist" policy when a Level One Medication Aide (LIMA) failed to report a fall to a nurse and receive a Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 20 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 20 nurse's assessment prior to lifting a resident off the floor, after a fall resulting in a broken hip, for one of nine sampled residents (Resident #16). The census was 82. Review of the facility's "Fall Recovery - Lift Assist" policy dated 1/6/25, showed the following: -Policy: -All team members will take appropriate action whenever a resident has fallen based on the specific procedures described below. Emergency personnel will be notified when appropriate; -Definitions: -Fall - Asudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object: -Unwitnessed fall - occurs when a resident is observed on the floor and neither the resident nor anyone else knows how he/she got there; -Procedure: -Whenever a resident has fallen (witnessed or unwitnessed), team members will determine if there is a need to call 911, using the questions below or if team members can assist the resident. Team members are to assist residents who have fallen or need help getting up. Team member must provide lift assistance when deemed appropriate instead of relying on emergency medical responders; -1. Call 911 immediately if: -The resident is unconscious or unresponsive; -The resident says he/she is in pain; -The resident has mental status change from his/her baseline; -The resident has an obvious head injury; -Hematoma, laceration, swelling of the head including face; Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 21 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 21 -It is apparent that a limb is obviously rotated beyond a normal point or appears displaced; -If one leg appears shorter than the other; -lf the resident requests the call; -If the resident is on anticoagulation and hit their head or had an unwitnessed fall; -2. If any of the above apply, do not move the resident; -3. The team member will initially evaluate the situation with the on-call nurse; -Contact a community licensed nurse to assess the resident. The nurse will direct the care required by following the below steps: -Keep the resident still; -Get on the resident's level; -Ask the resident if they are able to get up to a sitting position. Review of Resident #16's medical record, showed the facility admitted the resident on 12/16/24, with a diagnosis of diabetes. Review of the resident's incident form dated 4/28/25 at 12:00 P.M., showed the resident pushed his/her button for assistance. The staff member came to answer the call and the resident said he/she was in pain from his/her fall last night and someone assisted him/her with getting back in bed. The resident had to go the bathroom when he/she walked in. The staff member asked the resident if he/she was in any kind of pain and the resident pointed to his/her left hip. The staff asked if anything else was bothering the resident or hurting him/her when the resident took a few steps in between to get to the restroom. The staff member had to take his/her time with the resident to get him/her at a balanced pace. The resident said it hurt when he/she walked or even moved his/her left side. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 22 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 22 Review of the resident's progress notes, showed the following: -On 4/29/25 at 11:27 A.M., the Resident Aide (RA) reported to the Medication Aide (MA) the resident said he/she fell last night and the staff came and picked him/her off the floor and put him/her to bed. The MA asked the resident if he/she wanted to go to the hospital and he/she said no and wanted to wait to see if the pain would pass. The MA asked if he/she had pain, and the resident said yes, left hip pain. The resident could barely stand up and was vomiting. The MA notified the resident's family member and the family member wanted the MA to give the resident an as needed pain medication. The family member said he/she would be back in town to take the resident for an x-ray. The MA notified the nursing leadership; -On 4/29/25 at 12:23 P.M., the Director of Nursing (DON) documented the resident said he/she had a fall and was assisted up by the staff. He/she fell on his/her bottom. After assessing the resident, the pain appeared to be towards the sciatic nerve. There was no discoloration of skin. The resident was having muscle spasms in his/her left leg and toes causing the great toe to point upwards. The DON called the resident's Physician to get orders for x-ray and an as needed muscle relaxer to help spasms; -On 4/29/25 at 1:06 P.M., staff informed the resident's family member about the x-ray order and new medication; -On 4/29/25 at 3:58 P.M., the DON obtained orders for x-ray to the resident's left hip and an order for the muscle relaxer; -On 4/29/25 at 4:37 P.M., update: x-ray was ordered, the x-ray was completed and showed a broken left hip. The resident was sent to the hospital. The resident's family member and Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 23 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 23 nursing leadership were notified; -On 4/30/25 8:20 A.M., the DON documented when assessing the resident at 11:45 A.M., the RA reported to him, the resident had a fall and complained of hip pain. The DON asked the resident what happened, and the resident said he/she fell on his/her bottom and got up and had pain in his/her right hip; -On 4/30/25 at 9:01 A.M., the DON documented the resident was sent out to the hospital due to the x-ray showing a fracture to the right hip area. The resident's family member was contacted and agreed to send the resident out to the hospital. The DON updated the resident's Physician about the correction from left to right hip; -On 5/8/25 at 11:38 A.M., the (previous) Administrator documented clarification of report of call notes. Notes from 4/29 to 4/30 are due to one incident with multiple follow up after the resident reported to staff. An x-ray was obtained and subsequent 911 post results received for evaluation and treatment; -On 5/9/25 at 10:42 A.M., the (previous) Administrator documented the resident's family member was present at the facility and shared the resident's prognosis was poor as he/she did not tolerate the surgery well and the family opted for him/her to return to his/her home in order for all of his/her children to be with him/her. Hospice will provide support. During an interview on 8/28/25 at 1:01 P.M., LIMA M said it was him/her and another staff member who answered the resident's pendant during the evening on 4/27/25. When the two staff members came into the room, the resident was on the floor near his/her doorway. The resident's bottom was on the floor and his/her feet were facing the kitchen area. The two staff members did vitals on the resident, and everything was within normal Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 24 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 24 limits. The resident told them he/she tried to get something to eat and dropped his/her plate of food. LIMA M said the refrigerator door was open and the food was on the floor, but asked the resident how he/she ended up closer to the bedroom than the kitchen. The resident said he/she did not remember. LIMA M said he/she and the other staff member assessed the resident and looked at the resident's legs, but did not see any bruising or marks. LIMA M said the two staff members cuffed the resident's arms with their arms, lifted the resident off the floor and placed him/her in a wheelchair. The two staff members toileted the resident and then put him/her in the bed. LIMA M said the two staff members were trying to be as gentle as possible with the resident because he/she was "in a lot of pain." LIMA M said he/she did not report the fall because the other staff member was supposed to report the fall. LIMA M said he/she came back to work the next day and went to the resident to toilet him/her and the resident could not stand on two legs, he/she only stood on one leg because his/her other leg hurt so bad. LIMA M said on that night, 4/27/25, he/she went to another LIMA to have them report the pain to the DON, but LIMAM didn't see the other LIMA ever call the DON. LIMA M said the resident was not sent out to the hospital until two days later on 4/29/25, when a staff member finally reported it to the DON. LIMA M said he/she never had "proper orientation or education" about falls. He/she did not know it was the facility's policy to call a nurse prior to lifting a resident off the floor. During an interview on 8/28/25 at 5:30 P.M., LIMA L said he/she took care of the resident on 4/28/25, the night after the fall. LIMA L said the resident told him/her and another staff member about the fall. LIMA L said the resident told Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 25 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 25 him/her the staff picked the resident off the floor and put him/her back in bed. LIMA L said he/she charted on the incident based on what the resident said. On 4/29/25, LIMA L worked the day shift and said the resident was non-weight bearing. He/she said the staff got the resident out of bed and the resident could barely stand and was in a lot of pain. LIMA L said he/she and another staff member put the resident back in bed and he/she started taking the resident's vitals, charting and reaching out to the management team. LIMA L said when he/she touched the resident's hip, the resident said "Ouch" and when LIMA L looked at the resident's legs, one leg was higher than the other one. LIMA L said he/she thought it was the right hip that was broken. LIMA L said no one in management told him/her only a nurse could assess a resident after a fall, but he/she told the nurse only a nurse could assess a resident after a fall, and the nurse told him/her that was incorrect. During an interview on 9/2/25 at 11:18 A.M., the DON said the staff should have reported the fall to him on 4/27/25, prior to lifting the resident off the floor. He said the staff did not report the resident's pain until a couple days later. He said he got an order for the x-rays and once the x-rays came through, he called the family members and told them the facility needed to send the resident out for a broken hip. The DON said since the resident complained about his/her hip, the staff should have called 911. He said the resident should have gotten a nurse's assessment prior to being lifted, per facility policy. During an interview on 9/2/25 at 11:22 A.M., the Administrator said if a resident fell and complained of extreme pain, the staff should have called the nurse and had the nurse assess Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 26 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 26 the resident over the phone and then decide if they need to call 911 from there, but this should have happened prior to the staff getting the resident off the floor. M000254887 {A6005}, 19 CSR 30-87.020(5) Toxic Material Storage {A6005} 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 regulation is not met as evidenced by: This deficiency is uncorrected. For previous examples, please refer to the Statement of Deficiencies dated 5/21/25. 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. This had the potential to affect all residents. The census was 82. Review of the facility's undated "Common Area Cleaning Procedures" policy, showed all chemicals must be locked securely in housekeeping carts or closets anytime they are not actively in hand with the housekeep staff. 1. Observation on 8/27/25 between 9:54 A.M. and Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 27 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A6005}| Continued From page 27 {A6005} 10:14 A.M., on the fourth floor, near resident room 404, showed the following: -Between 9:54 A.M. and 9:56 A.M., the cleaning cart's roll top hood was opened with chemicals visible and the resident's apartment door was closed; -At 9:56 A.M., Housekeeper F exited the resident's room, approached the cleaning cart, shut the roll top and went back into the resident's room. Although shut, the roll top remained unlocked. The resident's apartment door was shut; -At 10:01 A.M., an unknown resident rolled by the unlocked cart. There were no staff present; -At 10:03 A.M., Housekeeper F got a mop off the cleaning cart and went back into the resident's room, the cart remained unlocked; -At 10:11 A.M., Housekeeper G approached the cleaning cart and at the same moment, Housekeeper F came out of the resident's room. The two Housekeepers whispered with each other and then Housekeeper G left the area. Housekeeper F returned to the resident's apartment, but propped the door open and moved the cart in front of the resident's apartment; -At 10:14 A.M., the cleaning cart remained unlocked, and Housekeeper F was inside the resident's bathroom with his/her back towards the resident's apartment door. The surveyor was able to lift the roll top and look at the chemicals inside without Housekeeper F hearing; -Inside the compartment, showed the following chemicals: -A full 32 ounce (0z) spray bottle of Clorox clean up disinfectant Clorox pro. The precautionary statement read, "Avoid contact with eyes and skin. Avoid breathing spray mist. Provide adequate ventilation. Wear appropriate personal protective equipment. Wash thoroughly after handling. Use good industrial hygiene Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 28 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A6005}| Continued From page 28 {A6005} practices in handling this material. When using do not eat or drink. KEEP OUT OF REACH OF CHILDREN AND PETS. Store this product in a cool [dry] area, [away from direct sunlight and heat] to avoid deterioration."; -One 1/2 full 32 oz spray bottle of Clorox Fusion. The precautionary statement read, "The product causes burns of eyes, skin and mucous membranes. Thermal decomposition can lead to release of irritating gases and vapors. Inhalation: May cause irritation of respiratory tract. May cause pulmonary edema. Eye contact: Corrosive to the eyes and may cause severe damage including blindness. Causes serious eye damage. Skin contact: Avoid contact with skin. Corrosive. Causes burns. Ingestion: Ingestion causes burns of the upper digestive and respiratory tracts. Ingestion may cause gastrointestinal irritation, nausea, vomiting and diarrhea. Do not breathe dust/fume/gas/mist/vapors/spray. Wash face, hands and any exposed skin thoroughly after handling. Wear protective gloves/protective clothing/eye protection/face protection. Keep away from children."; -A 3/4 full 32 oz spray bottle of Ecolab 73 disinfecting acid bathroom cleaner. The precautionary statement read, "IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to do. Continue rinsing. Immediately call a POISON CENTER/ doctor. Absorb spillage to prevent material damage. Do not mix with bleach or other chlorinated products - will cause chlorine gas."; -A 1/2 full 14 oz container of Comet with bleach. The precautionary statement read, "CAUTION: May cause eye irritation. In case of contact with eyes, flush thoroughly with water. If irritation persists, see a physician. If swallowed, drink a glassful of water. May be irritating to skin. For sensitive skin or prolonged use, wear gloves. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 29 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A6005}| Continued From page 29 {A6005} 2. Observation on 8/27/25 between 10:00 A.M. and 3:15 P.M., inside resident room 430, on the kitchen counter, showed the following: -A full 12 oz spray can of Lysol. The precautionary statement read, "Hazardous to humans and domestic animals. Causes mild eye irritation. Do not spray in eyes, on skin, or on clothing. Wash hands thoroughly after use and before eating. Keep out of reach of children"; -A full 70 count container of Lysol wipes. The precautionary statement read, "Hazards to humans and domestic animals. Caution: may cause eye irritation. Avoid contact with eyes or clothing. Keep out of reach of children”. 3. Observation on 8/27/25 between 10:00 A.M. and 3:03 P.M., showed a 1/2 full bottle of Clorox Fuzion cleaner disinfectant bleach, on the table, just inside the first floor, unlocked laundry room door. There were no staff present. 4. Observation on 8/27/25 between 9:46 A.M. and 2:58 P.M., in the activity room, across from the first floor beauty shop, showed the following; -Inside the unlocked cabinet under the sink, on the right side, 32 oz 1/2 full Pro Un-believable spray cleaner. The precautionary statement read, "Causes mild skin irritation. Causes eye irritation. Avoid breathing dust/fume/gas/mist/vapors/spray. Do not get in the eyes, on skin, or on clothing. Do not eat, drink or smoke when using this product. Avoid release to the environment. Use personal protective equipment as required. Dispose of material in accordance with all State and Federal guidelines and regulations. Keep out of reach of children."; -In the unlocked cabinet next to the sink, a full 11 oz spray can of Mod Podge. The precautionary statement read, "Use in a well-ventilated area to Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 30 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF {A6005}| Continued From page 30 {A6005} avoid inhaling fumes or vapors which can irritate the respiratory tract. Wear protective gloves, clothing and eye protection to prevent skin and eye irritation. Wash your hands thoroughly with soap and water after handling. Do not eat, drink or smoke while using the product, as these actions can lead to accidental ingestion. Keep containers tightly closed when not in use and store in a cool, dry place. Extremely flammable. Keep away from heat, sparks and open flames. Do not smoke while using or spray on ignition sources. Keep out of reach of children."; -At 2:58 P.M., eight unknown residents were in the activity room waiting for an activity to start. No staff were present. During an interview on 9/2/25 at 11:16 A.M., the Administrator said all chemicals should be locked up in the appropriate areas like the laundry room. She said the carts should be locked. She said the chemicals can be stored in a locked cabinet on the cleaning cart or in the locked roll top compartment. She said when a Housekeeper goes into a resident's room, the Housekeeper should lock the cart. The Administrator said the Housekeepers should not be parking the carts to the side of the resident apartment's door, it should be visible to them, especially when it's not locked. 19 CSR 30-87.020(11) No Deodorizers/Sprays to Eliminate Odors Deodorizers or sprays shall not be used to cover up odors. Odors shall be eliminated to the source by prompt cleaning of bedpans and commodes, floors, furniture and equipment and by proper ventilation. II/III Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 31 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 31 This regulation is not met as evidenced by: Class |I* Based on observation and interview, the facility failed to eliminate odors from the source when dried feces was observed throughout a resident's shower and a strong odor of urine and feces permeated the resident's apartment. The smell was so strong the odor from the apartment spread into the hallway of the second floor. The census was 82. 1. Observations on 8/27/25 between 9:20 A.M. and 3:11 P.M., of the second floor, showed a strong odor of urine was noticeable once the elevator doors and secured door opened towards the memory care unit. Observations on 8/27/25 between 9:30 A.M. and 3:15 P.M., of resident room 220B, showed the following: -An extremely strong odor of urine and feces permeated the resident's apartment which lead out into the hallway; -Inside the resident's bathroom, showed dried feces on the shower bench and shower floor. Both areas were approximately 9 inches in circumference; -A small area of dried feces on the toilet seat. During an interview on 9/2/25 at 11:14 A.M., the Administrator said the residents should get a once a week cleaning service and then as needed service if they are needing additional cleaning. The Administrator said the aides should be doing their room rounds and then letting housekeeping know when to clean the bathrooms and rooms. She was not aware the room was in the condition it was in. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 32 of 33 PRINTED: 09/23/2025 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 R-C 09/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 693 DECKER LANE CREVE COEUR, MO 63141 (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) CREVE COEUR ASSISTED LIVING AND MEMORY CAF Continued From page 32 *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 V8KR12 If continuation sheet 33 of 33 City, Zip: remem | ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE es Immediate Action: -An audit of housekeeping supplies was performed on (10/2/2025) and all deodorizing sprays were removed from resident care and commons areas. Staff was 10/6/2025 instructed to discontinue the use of any odor-masking products. - Housekeeping and Care staff will be reeducated on proper odor elimination practices by (10/6/2025). A6011 Deodorizers/ | Long-Term Quality Measure (to ensure no recurrence of Sprays to citation/violation): - Eliminate The Executive Director, Housekeeping Supervisor or designee Odor will perform daily environmental rounds for the next 3 weeks and then weekly thereafter to confirm compliance. 10/24/2025 Responsible for Long-Term Quality Measure Outcomes: Executive Director, Housekeeping Supervisor, or designee. State of Review in QAPI Monthly Meeting: Findings will be documented in the monthly safety meeting. Immediate Action: ¢ All chemicals and toxic cleaning supplies were removed from any unsecured locations and placed in a lock housekeeping closet. Housekeeping staff were directed to ensure all materials 9/8/2025 remain locked when not in direct use. Housekeeping carts have been repaired to ensure that locks are properly installed. A6005 Toxic * All housekeeping and activity staff received in-service training Chemicals on 10/6/2025 regarding proper toxic material storage and regulatory requirements training records will be stored in Safety 10/6/2025 Binder Long-Term Quality Measure (to ensure no recurrence of citation/violation): * The Housekeeping supervisor, Executive Director or designee will conduct daily spot checks of proper chemical storage for the A4754 Individual Service Plan Development A4776 Protective Oversight next 2 weeks, and then conducted weekly thereafter to ensure compliance. Who is Responsible for Long-Term Quality Measure Outcomes: - Housekeeping supervisor, Executive Director or designee State of Review in QAPI Monthly Meeting: * Monitoring results will be reviewed monthly during the Safety meeting. Immediate Action: The Director of Nursing has reviewed charts documented during the recent revisit and updated the ISP with individual information that will formulate the best care of the residents. A 9/26/2025 full review is currently being conducted of all charts to ensure individual information is added to each care plan. Long-Term Quality Measure (to ensure no recurrence of citation/violation): ¢ Director of Nursing, ED, or designee will randomly audit 10% 10/24/25 of the resident population every week for the next 2 months and monthly thereafter. ¢ Residents will have quarterly care plan review to ensure proper ISP language that is person centered to the resident Who is Responsible for Long-Term Quality Measure Outcomes: - Director of Nursing, ED, or designee State of Review in QAPI Monthly Meeting: - Quarterly, care plans will be reviewed to ensure compliance. Immediate Action: ¢ All care staff has been in-serviced and reeducated 09/25/2025 on the fall/lift policy. Long-Term Quality Measure (to ensure no recurrence of citation/violation): Transfer and fall recovery training with the Director of nursing and OT from Legacy Healthcare Services is scheduled on 10/15/2025 for all care staff. Quarterly training will be provided thereafter for regular team member training/retraining. 10/15/2025 Who is Responsible for Long-Term Quality Measure Outcomes: - Director of Nursing, ED, or designee State of Review in QAPI Monthly Meeting. ‘Documentation of team members participating in the Transfer Fall training will be kept in QAPI binder and reviewed monthly to ensure all team members are aware of the fall policy. a a 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.

FEB/21/2024/WED 31:14 PM FAX No, P, 002 PRINTED: 02/06/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFIGIENCIES 041) PROVIDER/SUPPLIER/CLIA ANO PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED SS CG 01/29/2024 B. WING . <_<. NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 893 DECKER LANE CREVE COEUR, MO 63141 CREVE COEUR ASSISTED LIVING AND MEMORY CAF (Xa) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x3) PREFIX (EACH DEFIGIENGY MUST BE PRECEDED AY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE ‘ GOMPLETE TAS i REGULATORY OR LSC IDENTIFYING INFORMATION) ! TAG : CROSS-REFERENCED TO THE APPROPRIATE ; DATE | ; ; DEFICIENCY) { AS211; 19 CSR 30-86.032(10) Heaters-Approved Label, «| Ag2t1 Venting, No Portable system is installed in an existing licensed facility, | the heating of the building shall be restricted to steam, hot water, permanently installed electric heating devices or a warm air system employing central heating plants with installation such as to safeguard the inherent fire hazard, or approved installation of outsice wall heaters which bear the approved label of the American Gas Association or National Board of Fire Underwriters. The foragoing requirements are applicable to : residential care facilities. In assisted living facilities, the heating of the building shall be | restricted to steam, hot water, permanently | installed electric heating devices or a warm alt | system employing central heating ptants with installation such as to safeguard the inherant fire | : hazard, or approved installation of outside wall heaters which bear the approved label of the | : American Gas Association or National Board of : Fire Undenwriters. For ail facilities, oil or gas ; i heating appliances shall be properly vented to the : outside and the use of portable heaters of any ' kind is prohibited, lf approved wall heaters are used, adequate quards shall be pravided to safeguard residents. I/t | In newly licensed facilities or if a new heating | i ‘ This regulation is not mat as evidenced by: Clase II | Based on observation and interview, the facility failed to ensure portable space heaters were not i : used in the facility at all times, for one of one day ; of observation, The census was 57, 1. Observation on 1/26/24 at 8:09 A.M., of room | 301, showed a space heater, on the floor below | the living room window. The space heater was Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PR ER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE R (X86) DATE Lt nT, Cree wee Alzi/ 24 STATE FORM 6a99 WEOM"1 lfcontinualion sheet 1 of 2 State of Missouri 3143403414 02/21/2024 01:15PM Pg 02/03 7EB/21/2024/WED 1:15 PM Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIOER OR SUPPLIER CREVE COEUR ASSISTED LIVING AND MEMORY CAF (x4) ID: SUMMARY STATEMENT OF DEFICIENCIES PREFIX / (EACH DEFICIENCY MUST BE PRECEDED BY FULL yA REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 ! plugged inte the wall but not turned on. ' During an interview on 1/26/24 at 8:10 A.M. a . resident's family member said the cold was getting bad in tha room & couple of weeks ago sa | the facility staff brought in a heater to keep the ? place warm. The family member said the heater | Was used for a faw days but not needed after that. ! 2. Observation on 1/26/24 at 8:15 A.M., of roam 416, showed a space heater, on the flaor below : the thermostat, in the room. The space haater , was not plugged into the wall. | 3. During an interview on 1/26/24 at 1:35 P.M., . the Administrator said there was a problem with : the heat in a few of the rooms several weeks ago. ! The adminisirator said a faw of the residents and : famities complained about the temperature. The : prablem was identified but the facility wanted ta do something te help the residents while the ! issue was being fixed. The Administrator said she ' thought space heaters were not allowed but had : been told by the corporate office that certain : space heaters were acceptable. The | Administrator said she thought she should have | called the Department of Haalth and Senior | Services and confirm but did not. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING; B. WING FAX No, P, 003 PRINTED: 02/06/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/29/2024 STREET ADORESS, CITY, STATE, ZIP CODE 693 DECKER LANE GREVE COEUR, MO 63141 PROVIDER'S PLAN OF GORRECTION (x5) (EAGH CORRECTIVE ACTION SHQULD BE | COMPLETE CROSS-REFERENCED TO THE APPROPRIATE : DATE DEFIGIENCY) : The unplugged space heaters found in apartments 301 and 416 were immediately remaved from the apartments and community. Executive Director conducted a full sweep of the community to ensure there were no additional spaces heaters found in the community. Care staff and team have been in serviced; no space heaters are allowed in the community. Going forward the Executive Director, or designee during routine weekly community walk through inspections will ensure there are no space heaters in the community. Results of weekly waik through will be reviewed during monthly OAPI meetings WEOM11 IF continuation sheet 2 af 2 State of Missouri 3143403414 02/21/2024 01:15PM Pg 03/03