FIELDS OF FLORISSANT.

PRINTED: 07/07/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED Cc B. WING 06/23/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) FIELDS OF FLORISSANT The operator shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. II This regulation is not met as evidenced by: Based on interview and record review, the operator failed to ensure a licensed Administrator was employed at all times. The census was 60. Review of an email dated 6/20/25 at 9:48 A.M., from the Board of Nursing Home Administrators , showed the following: -The board could not issue a temporary emergency license (TEL) to anyone because it has been more than ten days since the last licensed Administrator vacated the position on 6/1/25; -The first TEL was for Employee A for 6/1/25 - 6/17/25. The Board never received an application for licensure, payment and required documents for the TEL; 18 CSR 30-86.047(5) Administrator - Licensed -The second TEL was for Employee B for 6/17/25. The Board never received an application for licensure, payment and required documents for the TEL. During an interview on 6/23/25 at 2:31 P.M., the Executive Director said he was acting as the Administrator since the last licensed Administrator resigned the first week of June, 2025. He said he is not licensed in the state of Missouri and is aware there must be a licensed Administrator at all times. Missouri Department of Health and Senior Services (X8) DATE 2025 If continuation sheet 1 of 1 STATE FORM * Provider/Supplier Senne: Fields of Florissant Street Address, City, Zip: 1101 Garden Plaza Drive, Florissant, MO 63033 6/23/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER _ ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIEN DATE PLAN OF CORRECTION | I | { r i t ' 19 CSR 30-86.047 (5) Administrator - Licensed i t The operator shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. I The Vice President of Operations Willow Ridge - Fields of Florissant has hired an Administrator that started on 7/1/2025. That administrator will remain in place until the current Executive Director has obtained his licensure. The new Administrator will monitor and ensure compliance moving forward. 7/1/2025 F , : Ongoin The Vice President of Operations will ensure that the current Executive Director goes through the proper procedures to obtain his licensure for the state of Missouri. The Vice President of Operations will ensure that if the licensed administrator position is vacated again that it Ongoing immediately alerts the Board and completes the proper channels for a TEL within the 10 day requirements. 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: 03/13/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X3} DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 02/24/2025 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (X4}ID | SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION | {X5) PREFIX ' (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL i PREFIX (EACH CORRECTIVE ACTION SHOULD BE : GOMPLETE TAG; REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE DATE ! DEFICIENCY) i GARDEN PLAZA OF FLORISSANT A4724, 19 CSR 30-86.047(19) TB Screen Residents & A4724 : Staff | The facility shall screen residents and staff for ; tuberculosis as required for long-term care | facilities by 19 CSR 20-20.100. It { : This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required twa step tuberculosis | (TB) test was completed prior to hire and a one ' step completed annually for three of five sampled staff. The facility also failed to ensure the required two step TB test was completed prior to admission five of seven sampled residents (Residents #4, #2, #7, #6 and #3). The facility also failed to do the annual screening for three of : seven sampled residents (Residents #4, #2, and #7) The census was 59, 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 i i results are completed, and that documentation is | maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -If the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; | -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; | -All positive findings shall require a chest X-ray to Missouri Department of Health and Senior Services {X6} DATE COYB11 If continuation sheet 1 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 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. 1. Review of Employee A's personnel file, showed the following: -Hire date 2/23/20; -No documented two-step TB/PPD test upon hire; -No documented annual test for 2023 and 2024. 2. Review of Employee B's personnel file, showed the following: -Hire date 4/25/23; -A one-step TB/PPD test administered on 11/28/24 and read on 12/2/24 with 0 mm of induration documented. The test was not read within 72 hours; Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 2 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 2 -No documented two-step TB/PPD test upon hire. 3. Review of Employee C's personnel file, showed the following: -Hire date 1/31/24: -A one-step TB/PPD test administered on 12/2/24 and read on 12/4/24 with 0 mm of induration documented; -No documented two-step TB/PPD test upon hire. 4. Review of Resident #4's medical record, showed the following: -Admit date 9/9/13; -Documented annual screening dated 2/27/22: -No documented annual screening 2023 and 2024. 5. Review of Resident #2's medical record, showed the following: -Admit date 11/28/18; -No documented two-step TB/PPD test; -No documented annual screenings. 6. Review of Resident #7's medical record, showed the following: -Admit date 6/30/23; -No documented two-step TB/PPD test; -No documented annual screenings. 7. Review of Resident #6's medical record, showed the following: -Admit date 6/20/24; -No documented two-step TB/PPD test. 8. Review of Resident #3's medical record, showed the following: -Admit date 7/19/24; -No documented two-step TB/PPD test. 9. During an interview on 2/25/25 at 11:13 A.M., Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 3 of 30 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE GARDEN PLAZA OF FLORISSANT FLORISSANT, MO 63033 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 3 the Administrator said the Director of Nursing is responsible for completing the TB/PPD tests for both staff and residents. She said the residents and staff require a two-step TB/PPD test upon admission and hire. She was not aware the staff and residents did not have these TB/PPD tests, and she wasn't aware the annual screenings were not being 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 a resident's fall history and new interventions for each fall for six of seven residents (Residents #3, #2, #4, #5, #7 and #6). The census was 59. 1. Review of Resident #3's medical record, showed the facility admitted the resident on 7/19/24, with diagnoses which included chronic obstructive pulmonary disease (group of lung diseases that cause ongoing inflammation and damage to the airways and lungs, leading to Missouri Department of Health and Senior Services STATE FORM oeee COYB11 DEFICIENCY) If continuation sheet 4 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 4 breathing difficulties), asthma, high blood pressure and arthritis. Review of the resident's ISP dated 10/25/24, showed the resident had a need of Incidents: the resident has had no falls/incident within the last three months. Services: The resident has had no falls since admission. The staff were required to report all falls to the Director. Review of the resident's progress notes dated 11/22/24 at 3:51 P.M., showed the resident experienced increased anxiety and panic. The staff contacted the resident's physician's office, and the office requested the resident go to the emergency room. The resident declined wanting to go to the emergency room twice. The Nurse further explained to the resident the need for him/her to go to the emergency room. The resident agreed to go at 2:50 P.M., and left the facility at 3:41 P.M. Review of the resident's fall investigation summary dated 1/3/25, showed the following: -Overnight shift reported the resident was laying with a pillow underneath his/her head on the ground during rounds. The resident did not have any injury or distress noted at this time. The day shift reported the resident had a scratchy throat and what they described as possible indigestion or swallowing a pill wrong. The resident told the day shift he/she fell. The resident's family member said the resident was going to the commode from the bed and fell. Due to the discomfort, the resident was sent out for an evaluation to the hospital; -Conclusion: The resident was sent to the hospital for an evaluation where it was determined that he/she had fractured ribs. The resident was able to say he/she fell going from Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 5 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 5 the bed to the commode. Review of the resident's progress notes dated 1/9/25 at 1:10 A.M., (late entry) showed the resident said he/she fell and was able to say what happened to him/her. During an interview on 2/20/25 at 3:53 P.M., the resident remembered the fall and said he/she was putting on his/her undergarments and then woke up on the floor. He/she said the tables and chairs were in disarray when he/she woke up. The resident said he/she did not hit his/her head. The resident was not able to say how he/she fell but said he/she could not get off the floor so he/she laid on the floor until he/she fell asleep. The resident said around 3:00 A.M., a staff member helped him/her up by putting his/her arms underneath the resident's armpits and lifted the resident off the floor. The resident said after going back to bed at 3:00 A.M., he/she was woken up by a Medication Technician (MT) at 9:00 A.M., who gave him/her medication. The resident said he/she was in pain, so the MT sent him/her to the hospital where it was discovered the resident had fractured most of his/her ribs. The resident said the facility staff have helped him/her deal with the pain. The resident said he/she is pretty independent with dressing and going to the bathroom by his/her self but needed assistance with showering and transferring in and out of bed. The resident said he/she even had a sign above his/her bed that said the staff needed to help him/her. The resident said he/she struggled with anxiety a lot but was not able to describe what the staff could do to help him/her with his/her anxiety. Observation on 2/20/25 at 3:57 P.M., showed a sign on notebook paper, above the resident's bed Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 6 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 6 that read, "Please help the resident with getting in to and out of bed while his/her ribs heal. Thank you, therapy.” During an interview on 2/20/25 at 4:15 P.M., the Administrator said the resident had fuzzy socks on and was found between his/her bed and commode saying he/she was hurt. The resident told the MT he/she fell. The resident went out that day and the resident's family member was notified. The Administrator did not know which date the resident fell. During an interview on 2/20/25 at 4:30 P.M., MT E said the resident was unable to tell him/her how he/she fell and said he/she was not in any pain. MT E lifted the resident off the floor and helped him/her get into bed. MT E said the next day, the resident was in the hospital. MT E said the resident fell sometime early January. Review of the resident's ISP dated 10/25/24, showed no documentation of the resident's fall, no new interventions to prevent future falls, and no service identified to assist the resident in and out of bed while his/her ribs healed. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 11/28/18, with diagnoses which included diabetes, major depressive disorder, high blood pressure and anxiety. Review of the resident's progress notes dated 10/17/24 at 10:06 P.M., showed the staff notified the Nurse the resident had fallen out of bed. The resident landed face down on the floor. The staff sent the resident to the hospital via ambulance. Labs and x-ray test was done, and the resident had a closed fracture to his/her nose. He/she did Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 7 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 not have new orders and received a tetanus shot while at the hospital. The resident was to take his/her current order for Tylenol for discomfort. The resident denied any pain/discomfort. The resident's family member was made aware of the fracture. Review of the resident's ISP dated 12/12/24, showed no documentation of the resident's fall or new intervention for the fall. 3. Review of Resident #4's medical record, showed the facility admitted the resident on 9/9/13, with a diagnoses that included dysphagia (difficulty swallowing), hypothyroidism, and depressive episodes. Review of the resident's ISP dated 12/12/24, showed the following: -Resident had a chronic healthcare issues managed by a physician and followed by the Director of Nursing (DON). No documentation giving direction to the care partners on what signs and symptoms to look for and report; -The resident had depression. No documentation giving direction to the care partners on what signs and symptoms to look for and report; -The resident utilized in house therapy services. No documentation of what services were utilized. 4. Review of Resident #5's medical record, showed the facility admitted the resident on 7/16/24, with a diagnoses that included high blood pressure, history of stroke, and gout. Review of the resident's ISP dated 11/8/24, showed the following: -Resident occasionally required assistance with escort and mobility. No documentation of direction for care staff to assist with mobility; Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 8 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 -Resident had a chronic illness of high blood pressure. No documentation of signs or symptoms for care staff to report if needed. 5. Review of Resident #7's medical record, showed the facility admitted the resident on 6/30/23, with diagnoses which included malnutrition, high blood pressure, and heart attack. During an interview on 2/20/25 at 1:28 P.M., the resident said he/she needs some help with the shower because he/she has difficulty getting to the shampoo and soap. Staff will remind him/her to use the shampoo, but he/she found it difficult to locate where the shampoo was in the shower. The resident also said it is sometimes difficult to hold on to the soap and keep hold of it while washing. Review of the resident's ISP dated 10/12/24, showed the following: -Resident required some assistance with coordination of shower. The ISP did not address the resident required staff to identify where inside the shower the shampoo was located and it did not mention the resident could have difficulty handling the soap while in the shower; -Resident was mostly cooperative and pleasant. Resident could occasionally become irritable and required gentle approaches. The ISP did not explain what staff were to do to redirect the resident when he/she became irritable; -Resident wandered and could require redirection. The ISP did not explain what staff could do to redirect the resident. 6. Review of Resident #6's medical record, showed the facility admitted the resident on 6/20/24, with diagnoses which included dementia, Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 9 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 mood disturbance, anxiety, high blood pressure, and diabetes. Review of the resident's ISP dated 8/23/24, showed the following: -Resident required prompting related to where he/she is located or occasionally money was stolen from him/her. The ISP did not instruct staff on what prompting to use if the resident believed money had been stolen; -Resident was occasionally agitated but not frequently. Staff would use calm and gentle approach. The ISP did not explain what approaches would calm the resident; 5. During an interview on 2/25/25 at 11:20 A.M., the Administrator said the DON is responsible for completing the resident's ISPs and she gets help from the staff. The Administrator said there are "encircle meetings" with family and the residents to get to know the residents better and create the ISPs. The Administrator said the staff should report any sexual behavior, verbal and/or physical aggression to the DON. She said the kind of assistance should be outlined in the ISP. She said the new interventions after a resident falls are discussed every day with the staff and even therapy at times, but it should be documented in the ISP. She said new staff would get the information from side by side training. 19 CSR 30-86.047(41) Medication Storage/Accessibility All medication shall be safely stored at proper temperature and shall be kept in a secured location behind at least one (1) locked door or cabinet. Medication shall be accessible only to persons authorized to administer medications. Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 10 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 I/II This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to properly store resident's medications in a secure locked location when medications were kept in an unlocked medication cart and in an unlocked medication room, for one of one day of observation. The census was 59. Review of the facility's "Medication Administration and Disposal” policy dated 2/25/22, showed the medication carts were to be locked at all times, and keys are in the possession of the person in charge of the medication cart 1. Observation on 2/20/25 between 7:20 A.M. and 7:31 A.M., of the first floor medication room, showed the door propped open with a security container shred bin. Medication Technician (MT) B exited the medication room and left the door propped open. MT B went down the hallway. There were no staff around the medication room. An unknown staff member walked by the medication room, saw the door was open, shook his/her head and closed the door. Observation on 2/20/25 at 7:25 A.M., inside the medication room in the unlocked refrigerator, on the left hand side, showed six boxes of Insulin. Three of the six boxes were open. 2. Observation on 2/20/25 between 7:52 A.M. and 8:20 A.M., of the first floor medication pass, showed the following: -From 7:52 A.M. until 7:54 A.M., MT B parked the medication cart in front of room 105 and went Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 30 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 11 inside the resident's room and left the medication cart unlocked. The resident's door was closed, and the medication cart was out of the line of vision for MT B; -From 8:00 A.M. until 8:02 A.M., showed MT B walked back into room 105 and left the medication cart unlocked. The resident's door was closed, and the medication cart was out of line of vision for MT B; -From 8:12 A.M. and 8:20 A.M., the medication cart was locked but left unattended near resident room 105 and the following medications were on top of the medication cart: -Atorvastatin (used to lower cholesterol), 10 milligrams (mg). The blister pack was partially full; -Buspirone (used to treat anxiety), 5 mg. The blister pack was partially full; -Vitamin D3 (used to treat vitamin deficiency). The blister pack was partially full; -Diltiazem (used to treat high blood pressure), 180 mg. The blister pack was partially full; -Glipizide (used to treat high blood sugar), 10 mg. The blister pack was partially full; -Januvia (used to treat diabetes), 100 mg. The blister pack was partially full; -Lisinopril (used to treat high blood pressure), 40 mg. The blister pack was partially full; -Multivitamin (used to treat vitamin deficiency). The blister pack was partially full; -Vitamin B-complex (used to treat vitamin deficiency). The blister pack was partially full; -Amlodipine (used to treat high blood pressure), 10 mg. The blister pack was partially full; -Atenolol (used to treat high blood pressure), 50 mg. The blister pack was partially full. 3. During an interview on 2/25/25 at 1:24 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 DEFICIENCY) If continuation sheet 12 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 the Director of Nursing said the staff should be locking the medication cart at all times and it was never okay to leave the cart unlocked. 4. During an interview on 2/25/25 at 11:09 A.M., the Administrator said the staff should lock the medication room when leaving the room and it was never okay to leave the medication cart unlocked. The Administrator said the staff should have at least shut the door which locked automatically, if the refrigerator was not locked. She said all medications should be behind at least one lock. *The higher classification merited due to the extent of the violation. 19 CSR 30-86.047(47)(B) Physicians Orders Requirements Medication Orders. (B) Physician 's written and signed orders shall include: name of medication, dosage, frequency and route of administration and the orders shall be renewed at least every three (3) months. Computer generated signatures may be used if safeguards are in place to prevent their misuse. Computer identification codes shall be accessible to and used by only the individuals whose signatures they represent. Orders that include optional doses or include pro re nata (PRN) administration frequencies shall specify a maximum frequency and the reason for administration. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, facility Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 13 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 13 failed to ensure physician's orders were signed by a physician every three months for six of seven sampled residents (Residents #4, #2, #5, #7, #6 and #3). The census was 59. 1. Review of Resident #4's medical record, showed the facility admitted the resident on 9/9/13, with diagnoses which included dysphasia (difficulty swallowing), depressive episodes, and hypothyroidism. Review of the resident's physician's orders dated 11/2024, 12/2024 and 1/2025, showed no physician signature. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 11/28/18, with diagnoses which included high blood pressure, diabetes, acute kidney failure, major depressive disorder and anxiety. Review of the resident's physician's orders dated 11/2024, 12/2024 and 1/2025, showed no physician signature. 3. Review of Resident #5's medical record, showed the facility admitted the resident on 7/16/21, with diagnoses which included high blood pressure, history of stroke, and chronic gout. Review of the resident's physician's orders dated 11/2024, 12/2024 and 1/2025, showed no physician signature. 4. Review of Resident #7's medical record, showed the facility admitted the resident on 6/30/23, with diagnoses which included malnutrition, high blood pressure, and heart attack. Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 14 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 14 Review of the resident's physician's orders dated 11/2024, 12/2024 and 1/2025, showed no physician signature. 5. Review of Resident #6's medical record, showed the facility admitted the resident on 6/20/24, with diagnoses which included dementia, mood disturbance, anxiety, high blood pressure, and diabetes. Review of the resident's physician's orders dated 11/2024, 12/2024 and 1/2025, showed no physician signature. 6. Review of Resident #3's medical record, showed the facility admitted the resident on 7/19/24, with diagnoses which included chronic obstructive pulmonary disease (group of lung diseases that cause ongoing inflammation and damage to the airways and lungs, leading to breathing difficulties), asthma, high blood pressure and arthritis. Review of the resident's physician's orders dated 11/2024, 12/2024 and 1/2025, showed no physician signature. 7. During an interview on 2/25/25 at 11:12 A.M., the Administrator said the physician orders sheet should be signed quarterly and she was not aware this wasn't completed. *The higher the classification merited due to the extent of the violation. 19 CSR 30-86.047(56)(E)(1 - 2) Medications-Return to RX / Destroy, Records Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 15 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 Medications that are not in current use shall be disposed of as follows: (E) Medications may be returned to the pharmacy that dispensed the medications pursuant to 20 CSR 2220-3.040 or returned pursuant to the Prescription Drug Repository Program, 19 CSR 20-50.020. All other medications, including all controlled substances and all expired or otherwise unusable medications, shall be destroyed within thirty (30) days as follows: 1. Medications shall be destroyed within the facility by a pharmacist and a licensed nurse or by two (2) licensed nurses or when two (2) licensed nurses are not available on staff by two (2) individuals who have authority to administer medications, one (1) of whom shall be a licensed nurse or a pharmacist; and 2. Arecord of medication destroyed shall be maintained and shall include the resident 's name, date, medication name and strength, quantity, prescription number, and signatures of the individuals destroying the medications; II/III This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to ensure all unusable medication was destroyed by two people which included one person being a Nurse or Pharmacist when a Medication Technician (MT) destroyed two medications by him/herself and failed to document the reason for destroying unusable medication, during one of one observed medication pass. The census was 59. Review of the facility's "Medication Administration and Disposal" policy dated 2/25/22, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 16 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 16 -Medications will be destroyed if they are expired, discontinued, or if the resident no longer resides in the community due to death or discharge; -Medications identified for destruction will be returned to the medication room, in a locked area, until they are destroyed by the Executive Director and Director of Nursing (DON); -The Executive Director and DON will destroy any discontinued medications and medications for discharged residents at the end of each month after consultation with the treating physician or pharmacist as needed. Medication will be properly disposed of. The Medication Destruction form will be completed monthly by the Executive Director and DON; -All destruction of medications will be performed per applicable state rules; -All medications will be disposed of per applicable state rules; -The policy did not address who would destroy medications if the Executive Director was not a Nurse or a person with authority to administer medications. 1. Observation on 2/20/25 at 8:04 A.M., showed MT B popped two pills of Glimepiride (used to treat high blood pressure), 1 milligram (mg) into a medication cup. MT B only needed one pill and took the extra pill out of the medication cup and put it in the Sharp's container on the side of the medication cart. 2. Observation on 2/20/25 at 8:28 A.M., showed a resident dropped one pill of Buspirone (used to treat depression and anxiety) 5 mg. MT B picked the pill off the floor and put it in the Sharp's container on the side of the medication cart. 3. During an interview on 2/20/25 at 1:50 P.M., MT B said he/she put the medication in the Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 17 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 Sharp's container out of impulse. MT B said he/she only put medication in the Sharp's container if it is only one or two pills. MT B said the medication should have been destroyed using the chemical the facility has in the medication room. He/she said no one told him/her two people were required to destroy medication. 4. During an interview on 2/20/25 at 1:25 P.M., the DON said the facility has a drug buster chemical they use to destroy medication. She was not aware there needed to be two people present, one being a Nurse or a Pharmacist, when destroying medication. She said it was never okay to put medication in the Sharp's container and she was not aware MTs were putting medication in the Sharp's container. 5. During an interview on 2/20/25 at 11:11 A.M., the Administrator said the staff typically bring the medications to the Nurse and the Nurse destroys the medication per policy. She said usually it is two Nurses destroying medication. She said she would not advise the staff to put medication in the Sharp's container. *The higher classification merited due to the extent of the violation. 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 Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 18 of 30 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 1101 GARDEN PLAZA DRIVE GARDEN PLAZA OF FLORISSANT FLORISSANT, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 18 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 that included contact information of the resident's preferred dentist, pharmacist and funeral director for six of seven sampled residents (Residents #6, #2, #3, #4, #5 and #7). The census was 59. 1. Review of Resident #6's medical record, showed the following: -Admit date 6/20/24; -No documented preferred dentist. 2. Review of Resident #2's medical record, showed the following: -Admit date 11/28/18; -No documented preferred dentist; -No documented preferred funeral home. 3. Review of Resident #3's medical record, showed the following: -Admit date 7/19/24; -No documented preferred dentist; -No documented preferred funeral home; -No documented preferred pharmacist. 4. Review of Resident #4's medical record, showed the following: -Admit date 9/9/13; -No documented preferred dentist. 5. Review of Resident #5's medical record, Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 (X2) MULTIPLE CONSTRUCTION PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 19 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 19 showed the following: -Admit date 7/16/21; -No documented preferred dentist. 6. Review of Resident #7's medical record, showed the following: -Admit date 6/30/23; -No documented preferred dentist. 7. During an interview on 2/25/25 at 11:17 A.M., the Administrator said she was aware this information was required to be documented in their medical record. She said when the staff do the admission, the information is documented in the admission packet. She was not aware the information was not located in the admission packet. She said she would have liked this information to be in the electronic chart for each resident. 19 CSR 30-86.047(58)(B) Resident Condition/Medication Review The facility shall maintain a record in the facility for each resident, which shall include the following: (B) A review monthly or more frequently, if indicated, of the resident 's general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 20 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure a monthly summary which included the general condition and needs of each resident was completed for six of seven sampled residents (Residents #3, #4, #2, #5, #7 and #6). The facility also failed to document an incident in the resident's medical record when the resident fell on 1/3/25, for one of seven sampled residents (Resident #3). The census was 59. 1. Review of Resident #3's medical record, showed the following: -Admit date 7/19/24; -Diagnoses included chronic obstructive pulmonary disease (group of lung diseases that cause ongoing inflammation and damage to the airways and lungs, leading to breathing difficulties), asthma, high blood pressure and arthritis; -No documented monthly summaries. Review of the resident's progress notes dated 1/9/25 at 1:10 A.M., showed the resident said he/she fell and was "able to say what happened to him/her." Review of the resident's medical record, showed no detailed documentation on how the resident fell, where he/she fell or if the resident had any injuries from the fall. 2. Review of Resident #4's medical record, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 21 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 21 -Admit date 9/9/13; -Diagnoses included dysphasia (difficulty swallowing), depressive episodes, and hypothyroidism; -No documented monthly summaries. 3. Review of Resident #2'’s medical record, showed the following: -Admit date 11/28/18; -Diagnoses included high blood pressure, acute kidney failure, diabetes, major depressive disorder and anxiety; -No documented monthly summaries. 4. Review of Resident #5's medical record, showed the following: -Admit date 7/16/21; -Diagnoses included high blood pressure, history of stroke, and chronic gout; -No documented monthly summaries. 5. Review of Resident #7's medical record, showed the following: -Admit date 6/30/23; -Diagnoses included malnutrition, high blood pressure, and heart attack; -No documented monthly summaries. 6. Review of Resident #6's medical record, showed the following: -Admit date 6/20/24; -Diagnoses included dementia, mood disturbance, anxiety, high blood pressure, and diabetes; -No documented monthly summaries. 7. During an interview on 2/25/25 at 11:19 A.M., the Administrator said she was aware this was a requirement and was aware the residents didn't have the summaries, but it was brought to the Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 22 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 22 Nurse's attention recently and the facility was still working on them. 19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents ' social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. I/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3-15 3 p.m. to 9 p.m. (Evening)* 1 3-20 9 p.m. to 7 a.m. (Night)* 1 3-25 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. Ill This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to develop a system to ensure staff trained Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 23 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 23 in cardiopulmonary resuscitation (CPR) were available on each shift, to meet the needs of full code residents, for 37 of 59 residents who resided in the facility. The census was 59. The facility did not have a policy regarding staffing CPR trained staff. Review of the facility's list of residents' code status, showed 37 residents with a full code status, resided in the facility. Review of the facility's schedule for January 2025, showed the following: -On 1/1/25, no CPR trained person on any shift; -On 1/2/25, no CPR trained person on any shift; -On 1/3/25, no CPR trained person on any shift; -On 1/4/25, no CPR trained person on any shift; -On 1/5/25, no CPR trained person on any shift; -On 1/6/25, no CPR trained person on any shift; -On 1/7/25, no CPR trained person on any shift; -On 1/8/25, no CPR trained person on any shift; -On 1/9/25, no CPR trained person on any shift; -On 1/10/25, from 12:00 A.M. to 11:00 A.M. and from 2:00 P.M. to 12:00 A.M., no CPR trained person on shift; -On 1/11/25, no CPR trained person on any shift; -On 1/12/25, no CPR trained person on any shift; -On 1/13/25, from 12:00 A.M. to 12:50 P.M., and from 3:00 P.M. to 12:00 A.M., no CPR trained person on shift; -On 1/14/25, from 12:00 A.M. to 7:00 P.M., and from 8:00 P.M. to 12:00 A.M., no CPR trained person on shift; -On 1/15/25, from 12:00 A.M. to 12:30 P.M., and from 4:30 P.M. to 12:00 A.M., no CPR trained person on shift; -On 1/16/25, no CPR trained person on any shift; -On 1/17/25, from 12:00 A.M. to 11:50 A.M., and from 6:00 P.M. to 12:00 A.M., no CPR trained Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 24 of 30 PRINTED: 03/13/2025 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 02/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 (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) GARDEN PLAZA OF FLORISSANT Continued From page 24 person on shift; -On 1/18/25, from 12:00 A.M. to 7:00 P.M., no CPR trained staff on shift; -On 1/19/25, from 7:00 A.M. to 7:00 P.M., no CPR trained staff on shift; -On 1/20/25, from 1:00 A.M. to 1:30 P.M., no CPR trained staff on shift; -On 1/21/25, from 7:00 A.M. to 11:50 A.M., and from 6:00 P.M. to 12:00 A.M., no CPR trained person on shift; -On 1/22/25, from 12:00 A.M. to 12:15 P.M., and from 6:00 P.M. to 7:00 P.M., no CPR trained on shift; -On 1/23/25, from 7:00 A.M., to 11:40 A.M., no CPR trained staff on shift; -On 1/24/25, from 7:30 A.M., to 12:00 A.M., no CPR trained staff on shift; -On 1/25/25, no CPR trained staff on any shift; -On 1/26/25, no CPR trained staff on any shift; -On 1/27/25, from 12:00 A.M. to 7:00 P.M., no CPR trained staff on shift; -On 1/28/25, from 7:00 A.M. to 10:00 A.M., and from 4:00 P.M. and 12:00 A.M., no CPR trained staff on shift; -On 1/29/25, from 12:00 A.M. to 7:00 P.M., no CPR trained staff on shift; -On 1/30/25, from 7:00 A.M. to 12:00 A.M., no CPR trained staff on shift; -On 1/31/25, from 12:00 A.M. to 7:00 P.M., no CPR trained staff on shift. During an interview on 2/25/25 at 3:07 P.M., the Administrator said she is aware there is supposed to be 24 hours a day coverage. The Director of Nursing (DON) is responsible and maintains the schedule for the staffing. She said she was aware the DON, one part time nurse, and one overnight staff person were the only trained staff that were on the schedule during the month of January. She said they had classes scheduled to get Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 If continuation sheet 25 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 25 additional staff trained but those classes had not been held yet. 19 CSR 30-87.020(12) Floor Surfaces All floors in the facility shall be clean and shall be maintained in good repair. Floors and floor coverings of all food-preparation, food-storage and utensil-washing areas, and the floors of all walk-in refrigerating units, dressing rooms, locker rooms, toilet rooms and vestibules shall be constructed of smooth durable material such as sealed concrete, terrazzo, ceramic tile, durable grades of linoleum or plastic, or tight wood impregnated with plastic. Nothing in this section shall prohibit the use of antislip floor covering in areas where necessary for safety reasons. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the floors throughout the facility were kept clean. The census was 59. 1. Observation on 2/20/25 between 7:30 A.M. and 11:38 A.M., of the kitchen, showed the entire floor covered in a sticky substance to include the main kitchen, walk in refrigerator and walk in freezer. Food debris was scattered on the floor in the walk in refrigerator and freezer under the shelving. 2. Observation on 2/20/25 between 8:30 A.M. and 2:00 P.M., of the first floor bathroom closest to the elevator, showed the entire floor covered with a clear sticky substance. The floor was so sticky, the Inspector's shoes slipped off her heels when walking on the floor. 3. During an interview on 2/25/25 at 3:07 P.M., the Administrator said the cooks are responsible Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 26 for cleaning the kitchen but sometimes the servers help clean the kitchen. There is a formal schedule for cleaning. She said she is aware there's work to do in the kitchen and getting everything to where it should be for the sanitation of the facility. 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure all non-food contact surfaces were clean. The census was 59. Observation on 2/20/25 between 7:30 A.M. and 11:38 A.M. of the kitchen, showed the following: -The freestanding stainless steel fryer covered with built up grease and food debris on the interior shelf under the fry baskets, on the side panels of the interior of the fryer, and going down the outside of the fryer walls; -The cooking range covered with built up black grease going half way up the back splash behind the right rear burner. During an interview on 2/25/25 at 3:07 P.M., the Administrator said she was aware there was a build up of grease on the surfaces of those pieces of equipment and they were trying to get them cleaned. She said she was aware they needed to be cleaned. Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 27 of 30 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 1101 GARDEN PLAZA DRIVE GARDEN PLAZA OF FLORISSANT FLORISSANT, MO 63033 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 27 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to review resident rights with residents or their representative, annually, for five of seven sampled residents. (Residents #4, #6, #3, #2 and #5). The census was 59. 1. Review of Resident #4's medical record, showed the following: -Admit date 9/9/13; -No documented review of resident rights. 2. Review of Resident #6's medical record, showed the following: -Admit date 6/20/24; -No documented review of the resident's rights. 3. Review of Resident #3's medical record, showed the following: -Admit date 7/19/24; -No documented review of the resident's rights. 4. Review of Resident #2's medical record, showed the following: -Admit date 11/28/18; -An annual resident rights review dated 12/4/21; Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 (X2) MULTIPLE CONSTRUCTION PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 28 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 28 -No documented annual review for 12/2023 or 12/2024. 5. Review of Resident #5's medical record, showed the following: -Admit date 7/16/21; -An annual resident rights review dated 2/27/22; -No documented annual review for 2/2023 or 2/2024. 6. During an interview on 2/25/25 at 11:18 A.M., the Administrator said the resident rights should be reviewed annually but she wasn't aware this wasn't completed. *The higher the classification merited due to the extent of the violation. 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/III This regulation is not met as evidenced by: Class Ill Based on interview and record review, the facility failed to ensure personal inventory lists were Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 29 of 30 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 completed, for five of seven sampled residents (Residents #4 #5, #7, #6 and #3). The census was 59. 1. Review of Resident #4's medical record, showed the following: -Admit date 9/9/13; -No documented inventory sheet. 2. Review of Resident #5's medical record, showed the following: -Admit date 7/16/21; -No documented inventory sheet. 3. Review of Resident #7's medical record, showed the following: -Admit date 6/30/23; -No documented inventory sheet. 4. Review of Resident #6's medical record, showed the following: -Admit date 6/20/24; -No documented inventory sheet. 5. Review of Resident #3's medical record, showed the following: -Admit date 7/19/24; -No documented inventory sheet. 6. During an interview on 2/25/25 at 11:15 A.M., the Administrator said the initial inventory should be completed by sales and marketing. After the resident has moved in, if anything that is brought in with significant value, one of the staff, depends on who the resident or resident family member brings it to, should update the resident's inventory sheet. She said she was not aware the residents did not have the inventory sheets. Missouri Department of Health and Senior Services STATE FORM 6899 COYB11 PRINTED: 03/13/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 02/24/2025 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 30 of 30 Did not receive a plan of correction for State tag A4833- Medications-Return to RX/ Destroy, Records PLAN OF CORRECTION Provider/Supplier Name: Garden Plaza of Florissant Street Address, City, Zip: 1101 Garden Plaza Drive Date of Survey: 2/24/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan is prepared and executed because it is required by the provisions of State and Federal regulations and not because Garden Plaza of Florissant agrees with the allegations and citations listed on the statement of deficiencies. Garden Plaza of Florissant maintains that the alleged deficiencies do not individually and/or collectively jeopardize the health and safety of the residents nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Garden Plaza of Florissant's written credible evidence of compliance. By submitting this plan of correction, Garden Plaza of Florissant does not admit to the accuracy of the deficiencies. This plan of correction is 1D PREFIX TAG not meant to establish any standard of care, contract, obligation or position and Garden Plaza of Florissant reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action of proceeding. A two-step PPD will be administered to three staff members who did not receive a PPD prior fo hiring. Ali employees will be reviewed for completion of an initial two-step and annual TB testing/screening. Residents #2, #3, #4, #6, and #7 will be administered with a two-step PPD. Additionally, annual TB screenings will be completed for Residents #2, #4, and #7. A TB clinic will be scheduled for current residents and staff to complete any required testing. A4724 y require 9 4/30/2025 Director of Nursing or designee will conduct an audit of all active residents and staff to ensure TB screenings are current and compliant with regulatory requirements. Any identified staff or residents who are not in compliance will receive the required TB skin test. Annual one-step PPD skin tests will be scheduled each April for all active staff and residents ongoing. Initial two-step PPD skin test is initiated at the time of admission for residents and staff upon hire ongoing. The Director of Nursing, Clinical Care Coordinator, and Sales/Marketing team were in-serviced on this process on March 24, 2025 (Exhibit A). Individualized Service Plans (ISPs) are currently being updated for Residents #2, #3, #4, #5, #6, and #7. Audit to be completed by the Director of Nursing or designee to ensure that ISPs for all active residents are current and complete. Concerns that are identified during the audit will be addressed by the Director of Nursing or designee as needed. On March 24, 20285, the Director of Nursing received education on how 4/30/2025 A4754 to utilize the evaluation section within the system to enter notes (Exhibit B). The Community electronic medical record (EMR) system that automatically schedules semi-annual evaluations for all active residents. ISPs are also reviewed and updated whenever a significant change in a resident's condition occurs. A4782 Staff member MT B was in-serviced on February 25, 2025, regarding proper procedures for medication destruction and the importance of securing the medication room by locking/closing the door (Exhibit C). A comprehensive in-service will be provided to all staff on the requirements for securing medication rooms, locking medication carts, 4/30/2025 and proper medication destruction procedures (Exhibit D). Weekly door checks will be conducted for four weeks by the Memory Care Coordinator or designee. Random checks will be performed throughout each shift to ensure ongoing compliance. Residents #4, #2, #5, #7, #6 and #3’s orders will be signed. All resident records will be audited for physician signatures, all needed A4799 signatures will be obtained. 4/30/2025 The DON or designee will ensure that all orders are signed during admission and every 3 months on-going. All Facesheets will be reviewed and updated to include pharmacy, dentist and funeral home. Sales/Marketing and DON were in-serviced on this requirement on A4836 3/24/25 (Exhibit E.) 4/30/2025 Residents #6, #2, #3, #4, #5 and #7 Facesheet information will be updated. All new admissions will be screened and checked for information to ensure compliance by the DON or designee. 4/30/2025 Monthly summaries will be completed on residents #3, #4, #2, #5, #7 and #6. A4837 An audit will be conducted to check for monthly summaries. Any resident needing a monthly summary will be completed by 5/30/25 and each month gaing forward. The DON or designee will review monthly summary completion each month monthiy ongoing. Five additional staff members completed CPR training and are current as of March 24, 2025 (Exhibit F). Next CPR training session is scheduled for April 9, 2025. 4/30/2025 The Director of Nursing and Clinical Care Coordinator will ensure that each shift is staffed with CPR-certified personnel when developing the monthly schedule. The kitchen and bathroom floors are scheduled for deep cleaning on March 26, 2025. The Executive Chef will receive in-service training from the Executive Director by March 31, 2025, regarding proper procedures for cleaning A6012 kitchen floors. The Maintenance Director will also be in-serviced on 4/30/2025 appropriate cleaning of bathroom floors (Exhibit G). The Dining Director and Maintenance Director will conduct weekly audits of the kitchen and bathroom floors for a period of 30 days and then monthly to ensure ongoing cleanliness and compliance. The freestanding stainless steel fryer and cooking range will be deep cleaned by 4/30/25. The Executive Chef will be in-serviced by the ED by 3/31/2025 on 4/30/2025 cleaning the fryer and range. (Exhibit G). Monthly audits of the fryer and range will be completed monthly for 3 months. A7067 Resident Rights will be reviewed and signed for residents #4, #6, #3, #2 and #5. A8004 4/30/2025 ED, DON or designee will review Resident Rights are signed during the admission process for all new residents and will be reviewed annually each April. Inventory sheets will be obtained for resident #4 #5, #7, #6, #3. A8037 All inventory sheets will be audited and updated by 4/30/2025. Inventory sheets will be updated as items are brought into the Community. 4/30/2025 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.

PRINTED: 01/10/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERI/CLIA AND PLAN OF CORRECTION (IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION A. BUILDING: B, WING 27826 01/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (<4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG! REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2249| 19 CSR 30-86.022(9}(C) Fire Alarm System-Test/Maintain See atiached plan a poviectian), Complete Fire Alarm Systems. i (C) All facilities shall test and maintain the compiete fire alarm system in accordance with | NFPA 72, 1999 edition. {/tl ; This regulation is not met as evidenced by: Class II ' Based on record review and interview on January 08, 2025, the facility failed to ensure the complete | fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition. The facility | ' census on January 08, 2025 was 78. This j . deficiency potentially affects 78 of 78 residents. Record review on January 08, 2025, at 1:05 P.M. showed no semi-annual fire alarm system i inspection had been completed of the fire alarm system as required by (NFPA) 72, 1999 edition. Table 7-3.1, Documentation shows the most recent annual fire alarm system inspection was | completed on March 20, 2024. | During an interview on January 08, 2025, at 2:35 P.M. the facility Administrator said he/she couldn't find a record of the semi-annual fire alarm system ' inspection being completed. He/She said they would contact their fire alarm company and scheduled a semi-annual inspection. Missouri Department of Health and Senior Services LABORATORY DIR&CTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6} DATE If continuation sheet 1 of 1 STATE FORM $699 8M7Q11 PLAN OF CORRECTION Provider/Supplier Name: Garden Plaza of Florissant Street Address, 4491 Garden Plaza Dr. Florissant Mo. 63033 City, Zip: Date of Survey: 1/8/25 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: | HoUUn ee cree Roe SRRECTION: (EACH CORRECTIVE ACTION CORRECTIVE ACTION ___ SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE | HoUUn ee cree Roe SRRECTION: (EACH CORRECTIVE ACTION DATE This plan is prepared and executed because it is required by the provisions of State and Federal regulations and not because Garden Plaza of Florissant agrees with the allegations and citations listed on the statement of deficiencies. Garden Plaza of Florissant maintains that the alleged deficiencies do not individually and/or collectively jeopardize the health and safety of the residents nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Garden Plaza of Florissant’s written credible evidence of compliance. By submitting this plan of correction, Garden Piaza of Florissant does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation or position and Garden Plaza of Florissant reserves all rights to raise all possible contentions and defenses proceeding. in any civil or criminal claim, action of A2249 2/10/25 How will you identify other areas that have the potential to be affected by the deficient practice? All areas are potentially at risk of being affected by the deficient practice; however, no areas, residents or staff, were negatively affected by the practice or incident. What corrective action(s) will be accomplished for those areas who were found to have been affected by the deficient practice? A semi-annual inspection will be scheduled to be completed by 2/10/25. What measures will be put into place or what systemic changes will you make to ensure the deficient practice will not happen again? The Maintenance Director and Assistant will be provided with training regarding the requirement for semi-annual fire alarm testing. How will the corrective action be monitored to ensure that the alleged deficient practice will not recur? The Maintenance Director and/or Administrator will schedule semi-annual inspections. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 01/02/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: 42/26/2023 B. WING 27826 STREET ADDRESS, CITY, STATE, ZIP CODE 4101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 NAME OF PROVIDER OR SUPPLIER GARDEN PLAZA OF FLORISSANT (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} A2249, 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. {C) All facilities shail test and maintain the complete fire alarm system in accordance with NEPA 72, 1999 edition. Ill | This regulation is not met as evidenced by: Ciass |! Based on record review and interview on December 26, 2023, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition. The facitity census on December 26, 2023 was 71. This deficiency potentially affects 71 of 71 residents. Record review on December 26, 2023, at 2:05 P.M. showed no semi-annual fire alarm system inspection had been completed of the fire alarm system as required by (NFPA) 72, 41999 edition. Table 7-3.1. Documentation shows the most recent annual fire alarm system inspection was completed on February 02, 2023. During an interview on December 26, 2023, at 2:35 P.M. the facility Director of Maintenance said there was no record of the semi-annual fire alarm | system inspection being completed. He/She said they would contact their fire alarm company and scheduled a semi-annual inspection. 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 shail be installed and maintained in accordance with 4X6) DATE STATE FORM - IC2641 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 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 01/02/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 12/26/2023 STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 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 December 26, 2023, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition. The facility census on December 26, 2023 was 71. This deficiency potentially affects 71 of 71 residents. Record review on December 26, 2023, at 2:05 P.M. showed no semi-annual fire alarm system inspection had been completed of the fire alarm system as required by (NFPA) 72, 1999 edition. Table 7-3.1. Documentation shows the most recent annual fire alarm system inspection was completed on February 02, 2023. During an interview on December 26, 2023, at 2:35 P.M. the facility Director of Maintenance said there was no record of the semi-annual fire alarm system inspection being completed. He/She said they would contact their fire alarm company and scheduled a semi-annual inspection. 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 Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1C2611 If continuation sheet 1 of 3 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: 1101 GARDEN PLAZA DRIVE FLORISSANT, MO 63033 GARDEN PLAZA OF FLORISSANT (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on record review and interview on December 26, 2023, the facility failed to have the electrical wiring inspected every two (2) years by a qualified electrician. Electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition. The census on December 26, 2023 was 71. This deficiency potentially affects 71 of 71 residents. Record review on December 26, 2023, at 2:05 P.M. showed the last bi-annual electrical wiring certification was completed on October 28, 2021. During an interview on December 26, 2023, at 2:35 P.M. the facility Director of Maintenance said there was no record of the bi-annual electrical Missouri Department of Health and Senior Services STATE FORM 6899 1C2611 PRINTED: 01/02/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/26/2023 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 2 of 3 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1101 GARDEN PLAZA DRIVE GARDEN PLAZA OF FLORISSANT FLORISSANT, MO 63033 PRINTED: 01/02/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/26/2023 (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 A3214 | Continued From page 2 wiring inspection being completed. He/She said they would contact their electrical contractor and scheduled an inspection. Missouri Department of Health and Senior Services STATE FORM 6899 IC2611 DEFICIENCY) If continuation sheet 3 of 3 PLAN OF CORRECTION Provider/Supplier Garden Plaza of Florissant Name: Street Address, . . 4101 Garden Plaza Drive, Florissant, MO 63033 City, Zip: Date of Survey: 27826 COMPLETION DATE PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} ID PREFIX TAG This Plan of Correction is being submitted in accordance with State and Federal Regulations. The submission of this plan of correction does not constitute an admission by the provider of the alleged violations contained within the statement of deficiency. The submission of this plan of correction does not constitute admission by the provider that the alleged findings constitute a deficiency, or that the class determinations are correct, This plan of correction is intended to constitute the providers credible letter alleging compliance. 19 CSR 30-86.022(9)(C) Fire Alarm System -Test/Maintain 1. Allcurrent residents at Garden Plaza have the potential to be affected by this deficient practice. 2. The maintenance director was not the director during the last survey; however, he has been educated on the requirement of testing and maintaining the complete fire alarm system at least semi-annually and timely. 3. The second fire alarm system test has been scheduled A2249 for the last week in January by a contracted third party. VWati23 4. The semi-annual fire testing inspection task has been entered on our annual maintenance log sheets for the required semi-annual electrical inspections. 5. The Maintenance Director or Designee and Executive Director will monitor and follow the maintenance tasks systems to ensure timely compliance with this vendor for the upcoming year to test/maintain the fire alarm system semi-annually. The Administrator signing and dating the first page of the CMS-2567/State Form is in the plan of correction being submitted on this form. dicating their approval of PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 19 CSR 30 inspected iD PREFIX TAG -86.032(13) Electrical Wiring, Maintained, 1. All current residents at Garden Plaza have the potential to be affected by this deficient practice. 2. The maintenance manager has been educated on the requirements for the electrical wiring inspection that is required every two (2) years by a qualified electrician. A3214 3. An electrical wiring inspection was completed on 1/8/23 by a qualified electrical electrician. 4. The bi-annual wiring inspection task has been entered on our annual maintenance log sheet for the required bi- annual electrical inspection. The maintenance Director will monitor to ensure compliance as required and to ensure that it is completed in a timely manner. The Administrator signing and dating the first page of the CMS-2567/State Form is the plan of correction being submitted on this form. COMPLETION DATE 41/8/24 indicating their approval of