WESTVIEW AT ELLISVILLE ASSISTED LIVING.

PRINTED: 06/10/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF OEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 ] (X4) ID : SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION i (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 j DEFICIENCY) ‘ WESTVIEW AT ELLISVILLE ASSISTED LIVING A2249. 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain ' Complete Fire Alarm Systems. (C) All facilities shall test and maintain the _ complete fire alarm system in accordance with : NFPA 72, 1999 edition. I/II * This regulation is not met as evidenced by: - Class Il Based on record review and interview on June 4, 2025, the facility failed to insure the complete fire alarm system was tested and maintained in _ accordance with NFPA 72, 1999 edition.. The ’ facility census was 67. This affected 67 out of 67 : residents. Record review at 11:30 A.M. showed no semi-annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1 and 7.3.2. Further review showed the last annual inspection was done on October 3, 2024. During an interview on June 4, 2025 at the time of discovery, the Maintenance Director stated he/she thought the inspection had been done, but couldn't find the paperwork. (X6) DATE DVYE#1 if continuation sheet 1 of 1 PRINTED: 06/10/2025 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 06/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on June 4, 2025, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition.. The facility census was 67. This affected 67 out of 67 residents. Record review at 11:30 A.M. showed no semi-annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1 and 7.3.2. Further review showed the last annual inspection was done on October 3, 2024. During an interview on June 4, 2025 at the time of discovery, the Maintenance Director stated he/she thought the inspection had been done, but couldn't find the paperwork. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 DVYE11 If continuation sheet 1 of 1 PLAN OF CORRECTION Provider/Supplier Name: Westview at Ellisville Assisted Living and Memory Care Street Address, a 27 Reinke Road, Ellisville MO 63021 City, Zip: Date of Survey: 06/04/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2044777 PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Immediate Action: e The facility tests and maintains the complete fire alarm system in accordance with NFPA72, 1999 edition. * All residents have the potential to be affected A2249 Fire e The semi-annual inspection has been completed on the fire alarm Alarm System- t 07/13/2025 Test/Maintain ayer e The Executive Director will review fire alarm inspections monthly during the safety meeting e = The Director of Maintenance and or designee will audit fire alarm inspections quarterly to ensure compliance with National Fire Protection Association 72, 1999 edition The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 6X4) 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) WESTVIEW AT ELLISVILLE ASSISTED LIVING A4506 19 CSR 30-86.045(3)(A)(6)(A) Individual : Evacuation Plan-Staff Requirements General Requirements. . (A) If the facility admits or retains any individual needing more than minimal assistance due to _ having a physical, cognitive or other impairment | that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include : the following components: _ A. The responsibilities of specific staff positions in _ an emergency specific to the individual; II | This regulation is not met as evidenced by: ' Based on interview and record review, the facility ' failed to provide the responsibilities of specific staff members in an emergency on the Individual Evacuation Pian (IEP), for three of five sampled | residents (Residents #5, #2 and #4). The census was 53. | 1. Review of Resident #5's medical record, showed the facility admitted the resident on 12/14/22, with diagnoses which included major | depressive disorder, high cholesterol, dementia and high blood pressure. Review of the resident's undated IEP, showed the following: i ~The resident was 24 feet (ft) away from the Area : of Refuge (AoR); ' -The resident was 24 ft away from the nearest exit; -The resident had dementia and short and long term memory loss; ; -Required a wheeled walker; -Required more than three verbal interventions; -Required verbal assistance and direction to the Missouri Department of Health and Senior Services LABORA ESENTATIVE'S SIGNATURE TITLE (X6) DATE WYGL11 if continuation sheet 1 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 1 -The IEP did not address the staff position responsible for the resident in the event of an evacuation. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 4/8/24, with diagnoses which included diabetes, major depressive disorder and glaucoma. Review of the resident's undated IEP, showed the following: -The resident was 35 ft away from the AoR; -The resident was 129 ft away from the nearest exit; -The resident had poor memory and recall; -Required transfer assistance into his/her wheelchair and an escort to the AoR or nearest exit; -The IEP did not address the staff position responsible for the resident in the event of an evacuation. 3. Review of Resident #4's medical record, showed the facility admitted the resident on 6/11/24, with a diagnosis that included diabetes. Review of the resident's undated IEP, showed the following: -The resident resided in the AoR; -The resident was 158 ft away from the nearest exit; -The resident was blind and used a walker; -The resident was to follow the sound of someone's voice in the event of an evacuation; -The IEP did not address the staff position responsible for the resident in the event of an evacuation. 4. During an interview on 2/6/25 at 1:52 P.M., the Administrator said she was not aware the specific Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 2 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 staff positions were required to be listed on the resident's IEP. 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) test was completed prior to hire for two of four sampled staff and failed to ensure the staff had an annual screening. The facility also failed to ensure all residents had a two-step TB test upon admission for three of five sampled residents (Residents #1, #2, and #4). The census was 53. General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents and staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 3 documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease; -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test; -All employees and volunteers are required to obtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the initial test is negative, the second test should be given as soon as possible within one to three weeks after employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial Zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record; -Individuals with a chest x-ray shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -Employees and volunteers with a documented history of a positive TB/PPD test shall not be required to be retested. In the absence of documentation, a repeat test shall be required. 1. Review of Employee D's personnel file, showed the following: -Hire date 4/16/21; Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 4 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 4 -A chest x-ray dated 6/23/21; -A chest x-ray dated 7/1/24; -No documented two-step TB/PPD test, chest x-ray or blood test prior to hire; -No documented annual TB/PPD screening for 2022 or 2023. 2. Review of Employee B's personnel file, showed the following: -Hire date 5/27/21; -A TB/PPD blood test dated 5/28/21; -No documented annual TB/PPD screening for 2022, 2023 or 2024. 3. Review of Resident #1's medical record, showed the following: -Admit date 10/5/24; -No documented two-step TB/PPD test upon admission. 4. Review of Resident #2's medical record, showed the following: -Admit date 4/8/24: -ATB/PPD screening dated 6/20/24; -No documented two-step TB/PPD test upon admission. 5. Review of Resident #4's medical record, showed the following: -Admit date 6/11/24; -ATB/PPD screening dated 6/20/24; -No documented two-step TB/PPD test upon admission. 6. During an interview on 2/6/25 at 12:30 P.M., the Business Office Manager said she did not have the TB/PPD screenings for the employees who had a chest x-ray and blood test and she did not know they needed a screening after a chest x-ray and/or blood test. Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 5 of 32 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 27 REINKE ROAD WESTVIEW AT ELLISVILLE ASSISTED LIVING ELLISVILLE, MO 63021 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 5 7. During an interview on 2/6/25 at 1:58 P.M., the Administrator was aware upon admission the residents are required to have a two-step TB/PPD test. She said upon hire all employees should have a two-step TB/PPD test or a blood test, or a chest x-ray after a positive skin test. She said she was aware the annual screening had to be done for people who had the chest x-ray or blood test. She said she was aware the annual screening had to be done for the residents. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II 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 fall history and fall interventions, for five of five sampled residents (Residents #3, #1, #2, #4 and #5). The census was 53. Review of the facility's "Care Plan" policy dated 2/1/23, showed the following: -Policy: Using the community's Electronic Health Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 6 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 Record (EHR), the Director of Nursing (DON) will develop an individualized, comprehensive care plan for each resident based on the physician's assessment/history and physical information, resident/resident representative interview and the assessment completed in the EHR. Care plan tasks will be mutually agreed upon by the Community and the resident or the resident representative and serves as a basis for the service delivery contract between the provider and the resident. The care plan is designed to be resident directed and meet the specific needs and preferences of the resident and serves as a communication tool for the team members that assists the providing quality, individualized care; -Expectation of care plans: The care plans are resident directed and describe the resident's preferences. Inspire the resident to meet their fullest potential. Includes flexibility that helps the resident function at the highest level possible. Emphasize the resident's own sources of self-esteem and pleasure. The care plans are signed by appropriate family members/personal representatives. The care plans contain all relevant documentation demonstrating the facility is fully engaged with their residents. The care plans consider cultural needs. The care plans use familiar language acceptable to the resident and family. The care plans ensure care is well-documented and the plans are used as communication tools. The care plans have been discussed and reviewed with all members of the care team. The care plan involve and support family and other loved ones. Lastly, the care plans are continuously updated to ensure the facility provides the care the resident required; -The care plan will address: the level of service the resident received. The team members responsible for the provision of the services needed. The resident preferences in how the task Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 is performed. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 10/5/25, with diagnoses of adverse effect of insulin and oral hypoglycemic medications. Observation on 2/6/25 at 7:45 A.M., showed the resident's forearms and legs covered with several bruises and scabs of various sizes and colors. On the resident's right shin, there was a small cut approximately 1/2 inch long. The cut looked dry and old. Review of the resident's progress notes dated 1/29/25 at 9:10 P.M., showed MA D found the resident on the floor during routine checks. There was a lump and bleeding coming from the back of the resident's head. MA D notified the resident's family member and he/she directed the resident be taken to the hospice for an evaluation. The resident left for the hospital at this minute. Review of the resident's ISP dated 12/19/24, showed the following: Need: Bathing: The resident would maintain and/or maximize his/her current level of functioning with bathing. The resident required a bench and hand held shower. The resident's level of assistance was independent. The resident did not require assistance with bathing; -Need: Grooming: The resident would maintain and/or maximize his/her current level of functioning with grooming/personal hygiene. The resident required glasses. The resident's level of assistance with grooming was independent. The resident did not require assistance with grooming/personal hygiene; -Need: Dressing: The resident would maintain and/or maximize his/her current level of Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 functioning with dressing. The resident's level of assistance with dressing was independent. The resident did not require assistance with dressing; -Need: Toileting: The resident would maintain and/or maximize his/her current level of functioning with toileting. The resident's level of assistance with toileting was independent. The resident did not require assistance with toileting; -Need: Coordination of Care: The resident would maintain and/or maximize his/her current level of functioning with coordination of care. The resident's level of assistance with coordination of care was independent. The resident did not require any additional nursing services or can manage services on his/her own; -Need: Fall prevention plan: The resident had a fall prevention plan. The staff were to check for appropriate lighting, clutter, and spills in the apartment. The staff were required to encourage proper footwear/nonskid footwear and educate the resident to push his/her pendant as needed for assistance with mobility. PERSONALIZE for resident specific prevention/interventions. During an interview on 2/6/25 at 7:55 A.M., Medication Aide (MA) B said the resident's skin has been bruised like that before and the resident's skin is very thin and he/she busied very easily because he/she had psoriasis (skin disease that causes a rash with itchy, scaly patches). MAB said the resident scratched at his/her scabs and cause them to re-open. MAB said he/she was not aware how the resident got the cut on his/her shin and had not noticed it until this morning. MA B said the resident would get a little frustrated at times and sometimes he/she did not want staff to touch him/her. MA B said the resident would soil him/herself and then refuse peri-care. The staff have to explain to him/her what they are doing but the resident would curse Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 9 at the staff during this time. During an interview on 2/6/25 at 11:10 A.M., Certified Nursing Assistant (CNA) E said the resident was on hospice and hospice gave the resident showers. He/she said the facility staff would also give the resident showers at times. He/she said the resident required total assistance with bathing, dressing and toileting. This meant hands on assistance, doing everything for the resident from rinsing, washing, wiping, dressing the resident and doing his/her hair. CNAE said the resident liked to help when he/she could, but usually did not help the staff perform these tasks. CNA E said it was important not to rush the resident and to "take it easy" with him/her. Review of the resident's ISP dated 12/19/24, showed the following: -The ISP did not address the resident's thin and easily bruised skin or the current bruises and cut the resident had; -The ISP did not address the resident being on hospice; -The ISP did not address hospice and facility staff were to shower the resident; -The ISP did not address the level of assistance the resident needed for dressing, bathing, grooming and toileting; -The ISP did not address the resident's refusal of peri-care at times; -The ISP did not address the resident's verbal aggression towards staff. -The ISP did not address the most recent fall the resident had or any new interventions for this fall; -The ISP did not address how the staff had to "take it easy” with the resident. 2. Review of Resident #3's medical record, showed the facility admitted the resident on Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 10 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 10 9/7/24, with diagnoses which included Alzheimer's disease and dementia. Review of the resident's progress notes, showed the following: -On 1/14/25 at 10:42 A.M., a Resident Aide (RA) checked on the resident and found him/her on the floor in front of his/her dresser. The RA and MAB got him/her off the floor. The resident said he/she did not have any pain and there were no signs of skin tears or bruises; -On 1/14/25 at 12:00 P.M., a RA helped the resident get out of his/her chair to go over to the dining room to eat lunch. The RA put the resident's walker in front of him/her to walk with and the resident lost his/her balance and fell down with his/her walker. There were no injuries; -On 1/14/25 at 12:05 P.M., the resident was combative when staff tried to assist the resident using his/her walker and not leaving it. The resident was very unsteady on his/her feet and would continue to keep falling resisting help that he/she needed. This was his/her second fall within an hour. Review of the resident's ISP dated 1/15/25, showed the following: -Need: Psychological: The resident did not have a current or history of disruptive, aggressive, verbal or socially inappropriate behavior; -Need: Bathing: The resident would maintain and/or maximize his/her current level of functioning with bathing. The resident required a hand held shower, the resident preferred a shower, the resident required a shower chair, the resident required enabling devices used for bathing. PERSONALIZE: Other bathing device. PERSONALIZE: Other bathing preference; -Need: Grooming/Personal Hygiene: The resident would maintain and/or maximize current level of Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 11 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 11 functioning with grooming/personal hygiene. The resident had glasses. The resident required physical assistance to complete the task; -Need: Toileting: The resident would maintain and/or maximize his/her current level of functioning with toileting. The resident required verbal reminders for toileting tasks. Other incontinence Products Provider. PERSONALIZE: Who provides incontinence products?; -Need: Fall prevention plan: the staff were required to check for appropriate lighting, clutter, and spills in apartment. The staff were required to encourage the resident to use proper footwear/nonskid footwear and educate the resident to push his/her pendant as needed for assistance with mobility. Review of the resident's progress notes, showed the following: -On 1/27/25 at 3:05 P.M., a MA found the resident in the shower, hanging onto the assistance pole located in the shower area. The MA checked the resident for any head injuries that would indicate a fall, and none were found. The MA also checked for any type of bruising, and none were found. The resident did not complain of pain; -On 1/31/25 at 10:28 A.M., the resident was combative with the staff when they tried to assist him/her with getting dressed. The resident refused his/her medication this morning; -On 2/6/25 at 9:22 A.M., the resident refused his/her medication. During an interview on 2/6/25 at 11:00 A.M., CNA E said it all depended on the resident's behavior for the day, as to how much assistance the resident required. CNAE said the resident was different with every staff member and got combative when there were two staff members in the room with him/her. He/she said sometimes Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 12 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 12 the resident would move his/her arms towards the staff members as if to hit them when they provided care. He/she said the resident would take his/her shoes off a lot and he/she heard from the night shift the resident had stripped his/her clothes frequently. CNA E said the resident did not like to be touched and it was best to slowly approach the resident with a smile. CNAE said when providing peri-care, it depended on how the resident's behavior was that day and how far he/she would let the staff member help him/her. CNAE said sometimes the staff would do everything for him/her, including wiping but other days he/she would do it him/herself. CNA E said the resident was on hospice and hospice would shower him/her. Sometimes the resident would get combative, and the hospice team would ask the facility staff for assistance. He/she said on good days, the resident would help dress him/herself with the top portion of his/her body, but on bad days, the resident required help with top and bottom but on good days he will help with the tops. CNAE said the resident had an extensive fall history. During an interview on 2/6/25 at 11:17 A.M., RAF said the staff were required to help the resident get up in the morning and help him/her dress. He/she said the resident required a lot of hands on care. RAF said the resident required total assistance with showering. RAF said the resident had a fall history. He/she said it would help him/her prevent falls if he/she knew more interventions to prevent the falls. Review of the resident's ISP dated 1/15/25, showed the following: -The ISP did not address the resident's combative behavior or refusal of medications; -The ISP did not address the resident's physical Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 13 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 aggression towards staff; -The ISP did not address the resident's dislike of others touching him/her; -The ISP did not address the resident's need of assistance bathing, dressing and toileting; -The ISP did not address the resident's need of hospice; -The ISP did not address the hospice team being responsible for bathing the resident; -The ISP did not address the resident's most recent falls and the new interventions for those falls. 3. Review of Resident #2's medical record, showed the facility admitted the resident on 4/8/24, with diagnoses which included diabetes, major depressive disorder and glaucoma. Review of the resident's ISP dated 12/10/24, showed the following: -Need: Neurocognitive: The resident had short term memory impairment. PERSONALIZE. The resident had a vision impairment. PERSONALIZE; -Need: Transferring: The resident would maintain and/or maximize current level of functioning with transferring. The resident was independent. The resident did not require assistance with transferring; -Need: Bathing: The resident would maintain and/or maximize current level of functioning with bathing. The resident required the use of a bench, hand held shower, and grab bar. The level of assistance was physical assist. The resident required physical assistance with participation by the resident to complete the shower; -Need: Toileting: The resident was independent. The resident did not require assistance with toileting. Other incontinence Products Provider PERSONALIZE - who provides incontinence Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 14 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 14 products?; -Coordination of Care Category: Health Area: Coordination of Care. The resident will maintain and/or maximize current level of functioning with coordination of care. The level of assistance - Coordination of Care: Independent. The resident did not require any additional nursing services or can manage services on his/her own; -Need: Fall prevention plan. The staff were required to check for appropriate lighting, clutter, and spills in the resident's apartment. The staff were required to encourage proper footwear/nonskid footwear and educate the resident to push his/her pendant as needed for assistance with mobility. Review of the resident's progress notes, showed the following: -On 1/8/25 at 3:01 P.M., a RA found the resident on the floor in his/her apartment and notified an MA. The resident said he/she did not remember what happened or how he/she fell; -On 1/28/25 at 8:47 P.M., MAD found the resident on the floor at 8:00 P.M. The resident had a lump on his/her head and was bleeding. MA D notified the resident's family member and hospice who made the decision to have the resident get checked out at the hospital. During an interview on 2/6/25 at 10:54 A.M., CNA E said the level of assistance the staff provides the resident depended on how the resident felt each day. CNAE said the resident required transferring assistance to get to and from the bathroom. On a good day, the resident would pull his/her brief and pants down him/herself, but if it's not a good day, the resident would either go really slow or ask for the staff to do it. CNAE said the resident required assistance with peri-care and could not do it him/herself. CNA E said the Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 15 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 15 resident had a fall history, so the staff try to assist him/her anyway, so he/she didn't fall. CNA E said when dressing the resident, the staff would only assist the resident with the bottom portion. CNAE said the resident's hospice team showered him/her. CNA E said the staff have to help the resident with everything in the shower. CNA E said the resident was capable in helping with the shower, but preferred full assistance. CNAE said the resident required therapy and the therapy team wanted the facility staff to use the resident's walker and gait belt when transferring him/her. CNA E said on the good days, the resident used his/her walker but on the bad days, the resident used his/her wheelchair. CNA E said all of this information should be addressed on the resident's ISP to help new staff. Review of the resident's ISP dated 12/10/24, showed the following: -The ISP did not explain kind of vision and short term memory impairment the resident had; -The ISP did not address the resident's preference with bathing; -The ISP did not where the resident's incontinence products came from; -The ISP did not address the level of assistance the resident required with toileting or transferring; -The ISP did not address the resident's need for hospice or therapy; -The ISP did not address the resident's most recent falls. 4. Review of Resident #4's medical record, showed the facility admitted the resident on 6/11/24, with a diagnosis of diabetes. Review of the resident's progress notes, showed the following: -On 12/19/24 at 10:02 P.M., the resident was Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 16 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 16 easily agitated that day. In the morning he/she was curing at staff regarding his/her suspenders and his/her lunch, as well as cursing in general. He/she refused to shower and was insistent that he/she had received a shower earlier in the day, which had not happened. Most of the evening he/she was pressing his/her pendant and screaming for help. Each time staff responded to his/her calls for help, he/she cursed at them and complained that he/she was cold, that he/she wanted to die, and that he/she was frustrated. The staff assisted with turning up the heat in his/her room and giving him/her more blankets; -On 12/20/24 at 4:51 A.M., the resident was angry and irritable. Kept pressing his/her pendant but wanted to be left alone and asked staff why they kept coming back to his/her room; -On 12/25/24 at 7:55 A.M., the resident was reported to have been screaming most of the morning. When he/she was checked by staff he/she was consistently cursing at them. -On 1/11/25 at 10:32 P.M., the resident was yelling in his/her apartment after he/she was laid down in bed. The Director of Resident Care (DRC) went and spoke with him/her and asked him/her why he/she was yelling. He/she said "there's nothing else to do." The DRC explained to the resident he/she should not yell if nothing was wrong and he/she could use his/her pendent if he/she needed something; -On 1/25/25 at 2:37 A.M., the resident was in bed yelling and cursing, pressing his/her pendant. Staff asked him/her if he/she was in any pain, he/she said no and he/she just wanted to tell them he/she loved them; -On 1/29/25 at 1:33 P.M., the resident was yelling and cursing through the morning and day. He/she yelled at staff but was mostly yelling when he/she was alone. The resident denied being in any pain. Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 17 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 17 Review of the resident's ISP dated 1/15/25, showed the need for psychological assistance. The resident will maintain and/or maximize current level of functioning with disruptive/social inappropriate behavior. The resident did not have a current or history of disruptive, aggressive, verbal or socially inappropriate behavior. During an interview on 2/6/25 at 11:00 A.M., CNA E said they know not to be rude to the resident. He/she will cuss them out if they don't do what he/she asks them to do. He/she said they have to tell him/her where things are, like his/her hearing aids, phone, etc. They need to tell him/her that his/her drink is next to his/her bedside because he/she will call and complain he/she's thirsty. He/she said it takes a long time to assist the resident to get dressed due to his/her behaviors. He/she said he/she thought it would be helpful to have more details in his/her ISP so that they all know how best to assist the resident. Review of the resident's ISP dated 12/9/24, showed the following: -The ISP did not address the resident's behavior; -The ISP did not address the resident's physical aggression towards staff. 5. Review of Resident #5's medical record, showed the facility admitted the resident on 12/14/22, with diagnoses which included major depressive disorder, high cholesterol, dementia, and high blood pressure. Review of the resident's progress notes dated 1/13/25 at 10:41 A.M., showed an MA walked in to provide the resident with medications and he/she was found laying on the floor with his/her bed pads on top of him/her. The MA requested Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 18 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 18 the assistance of an RA and picked the resident up off the floor and checked him/her for any bruising. None were found. Review of the resident's ISP dated 12/18/24, showed a need for fall preventions. The staff were required to check for appropriate lighting, clutter, and spills in apartment. The staff were required to encourage the resident to use proper footwear/nonskid footwear and monitor care plan to anticipate needs and prevent falls. The ISP did not address the resident's most recent fall or any new interventions to prevent falls. 6. During an interview on 2/6/25 at 1:40 P.M., the DON said she was responsible for creating and reviewing the resident's ISP's. She said she was in the process of updating each resident's ISP but had not finished the process. The DON said she knew the kind of assistance the resident required should be indicated on the resident's ISP. The DON said if a resident was in therapy or on hospice, it should say so on the resident's ISP and it should indicate which provider was responsible for certain needs of the resident. 7. During an interview on 2/6/25 at 1:50 P.M., the Administrator said the care team coordinates the resident's ISPs and she would expect the team to follow the policy and procedures for completing the ISPs. She said if it was part of the policies and procedures to update the ISPs with the resident's behaviors, needs and falls, then she would expect the staff to do this. 19 CSR 30-86.047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 19 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 19 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 for a resident who fell and was helped up by a Medication Aide (MA) before an evaluation from a facility licensed nurse was conducted, for four of five sampled residents (Residents #1, #3, #2 and #5). The census was 53. Review of the facility's "Fall - Lift Assist" policy dated 1/6/24, showed the following: Procedure: Whenever a resident has fallen (witnessed or un-witnessed), 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 The team member must provide lift assistance when deemed appropriate instead of relying on emergency medical responders; -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 the following below steps. If there is not a licensed nurse available, the team member will follow the below steps, notifying the Director of Nursing (DON) or designee as soon as possible; -If the resident is conscious and not in pain and confirms by vocalizing or demonstrating no injury or only minor injury (bruising or small cut) is Missouri Department of Health and Senior Services STATE FORM residents who have fallen or need help getting up. (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 20 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 20 present; keep the resident still. Get on the resident's level. Ask the resident if they are able to get up to a sitting position. If the resident says "yes" call for an additional team member as needed if unable to assist the resident to a standing position. If the resident is able to move to a sitting position, encourage the resident to remain sitting until he/she is able to stand. Physically perform the lift assistance using techniques provided in team member training (including the use of a gait belt, monitoring the resident during the assist for pain or other problems). Once the resident is standing, stay with the resident and assist to a comfortable place where the resident can rest. At any time during this process if the resident complains of any pain, encourage the resident to stay on the ground while 911 is called. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 10/5/25, with diagnoses of adverse effect of insulin and oral hypoglycemic medications. Observation on 2/6/25 at 7:45 A.M., showed Medication Aide (MA) B entered the resident's room to administer the resident's medication and found the resident on the floor in front of his/her couch, in a seated position with his/her back towards the apartment door. MAB told the resident he/she was behind him/her and asked if he/she was in pain. The resident said his/her bottom hurt. The resident was not able to say how he/she fell or how long he/she had been on the floor. MAB told the resident he/she would be right back and left the apartment to get help and a pair of gloves. Certified Nursing Assistant (CNA) E entered the resident's room with MA B. The two asked the resident if he/she was okay. The resident said yes. CNAE put a gait belt around Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 21 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 21 the resident and positioned the resident's wheelchair close to the resident who was still on the floor. The two staff positioned themselves on each side of the resident and used the gait belt to lift the resident off the floor and assisted the resident into the wheelchair. Neither of the staff members called the DON, who was in the building, for an assessment prior to lifting the resident off the floor. During an interview on 2/6/25 at 10:38 A.M., MA B said he/she assessed the resident in the room prior to lifting the resident off the floor. He/she said no one told him/her only a Nurse could assess a resident after a fall. He/she said the only time he/she would call the Nurse if a resident fell and there was no Nurse in the building, was if the resident hit his/her head. During an interview on 2/6/25 at 10:54 A.M., CNA E said he/she was not aware only a Nurse could assess a resident after a fall and only after the assessment could the resident be lifted off the floor. He/she said the staff should have had the DON, who was in the building, come into the apartment to see the resident prior to them getting the resident up. CNA E said he/she did not call the DON because he/she "kinda already knew" what was going on with the resident and how he/she had been weak lately because the resident had kidney disease and if the resident was weak, the resident was going to fall. During an interview on 2/6/25 at 10:00 A.M., the DON said she knew the resident fell but did not get a notification until after the incident. She did not know only a nurse could assess a resident after a fall and only after the assessment can a resident be lifted off the floor. Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 22 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 22 2. Review of Resident #3's medical record, showed the facility admitted the resident on 9/7/24, with diagnoses which included Alzheimer's disease and dementia. Review of the resident's progress notes, showed the following: -On 12/23/24 at 10:26 A.M., a Resident Aide (RA) went to put laundry up in the resident's apartment and found the resident on the floor. MA B entered the apartment and asked the resident what happened and he/she could not explain to MAB how he/she fell. MA B asked the resident was he/she in any pain and the resident said his/her neck, back and head hurt. As MAB tried to assist the resident with getting up, the resident yelled out that "it hurts." MA B called the resident's family member and explained to him/her the resident was complaining of neck and back pain and when he/she tried to help the resident up, the resident said, "it hurt." MA B asked the resident's family member if he/she wanted the resident to go to the hospital to get checked out and the family member said he/she would think about it and give MAB a call back and that he/she would talk to the resident through the camera; -On 1/11/25 at 1:08 P.M., MAB found the resident on the floor in his/her apartment with a pillow under his/her head. The resident's family member called the facility to notify the staff that the resident was on the floor. MAB found a slight skin tear on the resident's left knee; -On 1/14/25 at 10:42 A.M., a RA went to check on the resident and found him/her on the floor in front of his/her dresser. The RA and MAB got him/her off the floor. The resident said he/she did not have any pain and there were no signs of skin tears or bruises; -On 1/14/25 at 12:00 P.M., a RA helped the resident get out of his/her chair to go to the dining Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 23 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 23 room to eat lunch. The RA put the resident's walker in front of him/her to walk with and the resident lost his/her balance and fell down with his/her walker. There were no injuries; -On 1/27/25 at 3:05 P.M., a MA found the resident in the shower, hanging onto the assistance pole located in the shower area. The MA checked the resident for any head injuries that would indicate a fall, and none were found. The MA also checked for any type of bruising, and none were found. The resident did not complain of pain. During an interview on 2/6/25 at 10:38 A.M., MA B said the resident had been falling a lot. MAB said he/she assisted the resident with the most recent falls with another team member. MAB said he/she did not get a Nurse's assessment during these falls because he/she did not know only a Nurse could assess a resident after a fall and only after the assessment could the staff get the resident off the floor. MAB said he/she believed a Nurse was in the building with each fall, because of the time of day of the progress note, but could not remember for sure. MAB said the resident had been falling more than usual lately. He/she said there were no new interventions other than frequently checking on the resident to prevent future falls. MA B said the resident would try to walk but the staff suggested that he/she should not walk because he/she was very unbalanced. 3. Review of Resident #2's medical record, showed the facility admitted the resident on 4/8/24, with diagnoses which included diabetes, major depressive disorder and glaucoma. Review of the resident's progress notes dated 1/8/25 at 3:01 P.M., showed a RA found the resident on the floor in his/her apartment and Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 24 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 24 notified a MA. The resident said he/she did not remember what happened or how he/she fell. During an interview on 2/6/25 at 2:50 P.M., MAD said on 1/8/25, he/she found the resident on the floor in his/her apartment. MA D said he/she called for another team member to come, and the two lifted the resident off the floor. MA D did not remember who he/she called for help to lift the resident. MA D said he/she was not aware only a Nurse could assess a resident after a fall. MAD said he/she assessed the resident after the fall. MA D said he/she reported the observation to the Nurse after him/her and the other staff member lifted the resident off the floor. 4. Review of Resident #5's medical record, showed the facility admitted the resident on 12/14/22, with diagnoses which included major depressive disorder, high cholesterol, dementia, and high blood pressure. Review of the resident's progress notes dated 1/13/25 at 10:41 A.M., showed a MA walked in to provide the resident with medications and he/she was found laying on the floor with his/her bed pads on top of him/her. The MA requested the assistance of a RA and picked the resident up off the floor and checked him/her for any bruising. None were found. During an interview on 2/6/25 at 12:08 P.M., MA H said on 1/13/15, he/she found the resident on the floor in his/her room with a blanket, pillow, and laying on a bed pad. He/she said he/she put the medications down and asked the resident if he/she was in any pain. He/she did not see any bruising or skin tears and the resident could not recall how he/she got to the floor. MAH said he/she called another MA for assistance to help Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 25 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING a ELLISVILLE, MO 63021 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 25 get the resident off the floor. He/she said they placed a walker in front of him/her, the resident pushed off with his/her right hand, grabbed a hold of the walker and stood up. MAH said he/she had not been trained to get a nurse when a resident falls. He/she said they ask the resident questions about pain and if they do not see any injuries, they are supposed to get the resident up. 5. During an interview on 2/6/25 at 1:30 P.M., the DON said she was not aware only a Nurse could assess a resident after a fall and only after the assessment could the resident be lifted off the floor. 6. During an interview on 2/6/25 at 2:01 P.M., the Administrator said she was aware the DON should be notified for a resident's fall, but she would refer to the policy and procedure to see what to do in the event of a resident's fall. She was not aware a resident required a Nurse's assessment prior to lifting the resident off the floor. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean A7002 Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/III This regulation is not met as evidenced by: Class II* Based on observation and interview, the facility Missouri Department of Health and Senior Services STATE FORM 6899 (X2) MULTIPLE CONSTRUCTION A. BUILDING: WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 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 26 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 26 failed to ensure all staff washed their hands and/or wore gloves when plating and serving food in the kitchen, for one of one observed meal. The census was 53. Review of the facilities hand hygiene policy dated February 9, 2024, showed the following: -Policy: Hand hygiene is the single most important measure for preventing the spread of infection and disease All team members will be responsible for carrying out the hand hygiene guidelines in accordance with the Centers of Disease Control and Prevention. -Procedure: 1. Team members will perform hand hygiene: a. Before, during, and after preparing food; b. Before and after eating food; 2. If hands are visibly soiled wash hand with soap and water. If hands are not visibly soiled, alcohol-based hand sanitizer could be used. Observation on 2/6/25 between 7:40 A.M. and 8:12 A.M., of the breakfast plating and service, showed the following: -At 7:40 A.M., Cook A donned a pair of gloves and with his/her left hand, grabbed a spatula to move a slice of quiche from the pan to a plate and placed his/her right hand on top of the quiche. He/she repeated this process for seven plates. He/she then used his/her right hand to open the lid on the steam table and set the lid to the side. He/she used his/her right hand to grab slices of bacon out of the pan and place them onto the resident plates. He/she walked to warmer and with his/her right hand, opened the warmer door and took out plate covers. He/she walked back to the servery and with his/her left hand, used a spatula to move a slice of quiche while he/she placed his/her right hand on top of the quiche to move it to the plate. He/she Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 27 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 27 repeated this process for three plates. He/she walked to the servery and with his/her right hand, grabbed bacon from the steam table and placed it on the plates. He/she put his/her right hand into an oven mitt and opened stove door, removing additional pans of quiche from the oven. He/she removed the oven mitt from his/her right hand and placed it on top of the oven. He/she walked back to the servery and used his/her left hand with a spatula to move the quiche from the pan, placed his/her right hand on top of the quiche and moved it to the plate. He/she repeated this process for a second plate. He/she then walked to the servery and used his/her right hand to put bacon onto the plates. He/she placed plate covers over the plates, walked them to the upright warmer, removed his/her gloves, and washed his/her hands; -At 8:00 A.M., Cook A donned a new pair of gloves, and with his/her right hand picked up a bowl. With his/her left hand he/she scooped pancake batter onto the stove top. With his/her left hand he/she stirred oatmeal. He/she then walked to the servery and with his/her left hand used tongs to place bacon onto a plate, and with his/her right hand repositioned the bacon on the plate. With his/her right hand, he/she lifted the lid for the steam well and placed it back over the bacon. With his/her left hand, he/she flipped the pancakes using a spatula. With his/her right hand, he/she picked up the lid from the steam table and placed it to the side and with same hand removed two sausage patties and placed them on the plate. He/she then walked to the stove top and with his/her left hand, used a brush to spread butter onto the surface. With his/her right hand, he/she cracked two eggs onto the surface of the stovetop. With his/her left hand, he/she used a spatula to move the pancakes from the stove top to the plate while placing Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 28 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 28 his/her right hand on top of the pancakes. With his/her left hand, he/she used a spatula to flip the eggs. With his/her right hand, he/she placed biscuits onto a cookie sheet and placed them into the oven. He/she then cracked two more eggs onto the stove top and removed his/her gloves; -At 8:12 A.M., Cook A donned a new pair of gloves, and with his/her right hand, cracked two eggs onto the stove top. He/she put an oven mitt on his/her right hand and opened the oven door to check on the biscuits. With his/her left hand, he/she used a spatula to remove the eggs from the stove top and with his/her right hand, slid the eggs off the spatula onto the plate. He/she put the oven mitt back on his/her right hand and opened the oven. He/she then walked to the servery and with his/her right hand, removed the lid from the steam well. He/she used tongs in his/her left hand to remove bacon from the steam well and then with his/her right hand, took the bacon and placed it on the plates. He/she used his/her left hand to grab the spatula and remove the eggs from the stove top and place them on the plate. With both hands, he/she placed a plate cover onto the plate and removed his/her gloves. During an interview on 2/18/25 at 1:55 P.M., the Administrator said the cook should change his/her gloves when the gloves are visibly soiled and follow whatever the policy and procedure states. She said it would appear the gloves would be considered soiled if he/she's touching a non-food surface before touching the food. She said she would expect the cooks to follow the company's policies and procedures for hand washing. *The higher classification is merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 29 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the proper use of beard guards when two employees, with beards, did not wear a beard guard, cooked and served food, for two of two observed meal preparation and service. The census was 53. Review of the facilities hairnet policy dated January 2025, showed the following: -Policy- All Food Handlers are required to wear effective hair restraints that cover all exposed body hair. Examples include caps, hats, nets, scarves, beard restraints and other reasonable forms of hair containment. They must be designed and work effectively to keep hair from contacting and contaminating exposed food, clean equipment, utensils, unwrapped single service items and single use articles; -Procedure- Beards: Place the beard net over your facial hair, ensuring it covers your nose and chin, with the elastic band securely positioned behind your ears. 1. Observation on 2/6/25 at 8:03 A.M., showed Server G assisted in preparing the breakfast meal for the residents, without a beard guard. The Server's beard was approximately 1/4 inch long. 2. Observation on 2/6/25 at 11:43 A.M., showed Server G assisted to prepare the lunch meal for Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 30 of 32 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 WESTVIEW AT ELLISVILLE ASSISTED LIVING (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 30 the residents, without a beard guard. The Server's beard was approximately 1/4 inch long. 3. Observation on 2/6/25 at 11:46 A.M., showed a Server entered the kitchen, walked into the kitchen to the serving line to get the prepared lunch plates and carried them out to the dining room, without wearing a beard guard. The server's beard was approximately 1/4 inch long. 4. During an interview on 2/6/25 at 1:57 P.M., the Administrator said if the staff are doing food preparations she would expect them to wear a beard guard. She was not aware they were not wearing beard guards while preparing the meals. 19 CSR 30-88.010(36) Personal Clothing/Possessions Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. II/Ill This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to ensure personal inventory lists were completed, for five of five sampled residents (Residents #5 #2, #4, #3 and #1). The census Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 WYGL11 PRINTED: 02/21/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/06/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 31 of 32 PRINTED: 02/21/2025 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 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING Continued From page 31 was 53. 1. Review of Resident #5's medical record, showed the following: -Admit date 12/14/22; -No documented inventory sheet. 2. Review of Resident #2's medical record, showed the following: -Admit date 4/8/24- -No documented inventory sheet. 3. Review of Resident #4's medical record, showed the following: -Admit date 6/11/24; -No documented inventory sheet. 4. Review of Resident #3's medical record, showed the following: -Admit date 9/7/24: -No documented inventory sheet. 5. Review of Resident #1's medical record, showed the following: -Admit date 10/5/24; -No documented inventory sheet. 6. During an interview on 2/6/25 at 2:00 P.M., the Administrator said she was aware the residents are required to have an inventory sheet upon admission and updated periodically. She was not aware the inventory sheets were not being done. Missouri Department of Health and Senior Services STATE FORM 6899 WYGL11 If continuation sheet 32 of 32 PLAN OF CORRECTION Provider/Supplier Name: Westview at Ellisville Assisted Living Street Address, City, Zip: 27 Reinke Road, Ellisville MO 63021 02/06/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 26D2044777 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE e = - Resident #5 Individual Evacuation Plan has been updated to include the staff person responsible for the resident in the event of an evacuation. « ~—= Resident #2 Individual Evacuation Plan has been updated to include the staff person responsible for the resident in the event of an evacuation. A4506 e ~—s- Resident #4 Individual Evacuation Plan has been updated to include 03/22/2025 the staff person responsible for the resident in the event of an evacuation ¢ = Allresidents with an Individual Evacuation Plan have the potential to be affected All Individual Evacuation Plans will be reviewed by the DON and or designee upon admission and quarterly to cnsure the staff person responsible for the resident in the event of an evacuation is addressed The facility screens residents and staff for tuberculosis ¢ Employee D has been screened for Tuberculosis A4724 03/22/2025 Date of Survey: * Employee B has been screened for Tuberculosis Resident #1 has received a two-step TB/PPD Resident #2 has received a two-step TB/PPD Resident #4 has received a two-step TB/PPD All employees and residents have the potential to be affected Employee files will be reviewed by the Business Office Manager and or designee upon hire and quarterly to ensure there is documentation of annual TB screens The DON and or designee will audit residents charts upon admission and quarterly to ensure residents have received an annual TB/PPD screening e = The facility has Individualized Service Plans for each resident that outlines the 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. « ~All residents have the potential to be affected. e — All falls will be reviewed and documented on the resident’s Individual Service Plan with appropriate interventions. e Individualized Services Plans have been updated and personalized for Resident #1, #2, #4 and #5 e ~=- Resident #3 is discharged e = Individualized Service Plans will be created by Director of Nursing and or designee upon admission and updated with change of condition, readmission and quarterly ED will review new and updated ISP’s during monthly safety meetings The facility provides protective oversight twenty-four (24) hours a day. All residents have the potential to be affected « = Alicensed nurse will be contacted for direction and assessment of all resident's post fall e The Director of Nursing has provided education to all care staff to notify licensed nurse when a resident falls or has a change of condition ¢ All falls will be documented in the resident Individual Service Plan along with appropriate interventions The Director of Nursing and or designee will review fall interventions during monthly safety meetings A4776 e The employees of the facility will maintain hand hygiene e = All residents have the potential to be affected e = All food and beverage employees have been in-serviced on hand hygiene A7002 for the next 3 months and once a quarter for a year. The DFB, Sous Chef, Restaurant Supervisor or designee will monitor staff daily to ensure staff are washing their hands The facility employees maintain clean outer clothing and use hair restraints to prevent the contamination of food or food-contact surfaces All residents have the potential to be affected A7003 All food and beverage employees have been in-serviced on the proper use of hair restraints for the next 3 months and once a quarter for a year. The DFB, Sous Chef, Restaurant Supervisor or designee will monitor staff daily to ensure proper hair restraints are being used. e Residents are permitted to retain and use personal clothing and possessions as space permits in this facility * The facility maintains records of personal items brought with the resident upon admission A8037 e = All residents have the potential to be affected * Personal inventory fists were completed for Residents #1, #2, #4, and #5 e ~—- Resident #3 has been discharged Personal inventories will be completed upon admission and reviewed and/or updated annually by the resident and/or ED, DON, or designee e The Director of Food and Beverage will in-service staff once a month The Director of Food and Beverage will in-service staff once a month 03/22/2025 03/22/2025 03/22/2025 03/22/2025 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.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. PRINTED: 05/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 05/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 27 REINKE ROAD ELLISVILLE, MO 63021 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTVIEW AT ELLISVILLE ASSISTED LIVING 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on May 13, 2024, the facility failed to insure the complete fire alarm system was tested and maintained in accordance with NFPA 72, 1999 edition.. The facility census was 51. This affected 51 out of 51 residents. Record review at 11:30 A.M. showed no semi-annual inspection had been done on the fire alarm system as required by National Fire Protection Association (NFPA) 72, 1999 ed. Table 7-3.1 and 7.3.2. Further review showed the last semi-annual inspection was done 9/1/22. During an interview on May 13, 2024 at the time of discovery, the Maintenance Director stated he/she would schedule an inspection. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 X4JG11 If continuation sheet 1 of 1 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)