WESTBROOK TERRACE MEMORY CARE II.

PRINTED: 11/03/2025 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 20440D ol 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 (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) WESTBROOK TERRACE MEMORY CARE II A4773_ 19 CSR 30-86.047(34)(A) Disease/Infection Control, Report Category | The facility shall follow appropriate infection control procedures. The administrator or his or her designee shall make a report to the local health authority or the department of the presence or suspected presence of any diseases or findings listed in 19 CSR 20-20.020, sections (1)-(3) according to the specified time frames as follows: (A) Category | diseases or findings shall be reported to the local health authority or to the department within twenty-four (24) hours of first knowledge or suspicion by telephone, facsimile, or other rapid communication; I/II This regulation is not met as evidenced by: Class II Based on observation, interview and record review, facility staff failed to implement appropriate infection control procedures when the staff failed to perform hand hygiene as often as necessary to prevent cross-contamination during medication administration for three residents (Residents #1, #5 and #6) out of five residents observed and during meal service. The facility census was 21. 1. Review of the facility's policy titled “Handwashing Policy and Procedure" dated 03/23/23, showed the purpose of the policy is to prevent cross-contamination and the spread of infectious organisms and to define the guidelines for effective hand hygiene. Review showed the policy directed staff to perform hand hygiene: -Before each patient encounter; -Before touching a patient, even if gloves will be Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6 G0CQ11 If continuation sheet 1 of 19 J em ye regoy” alltel PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 1 worn; -After contact with the patient's intact skin; -When soiled; -After contact with bodily fluids, dressings, mucous membrane, et cetera, and hands are not visibly soiled; -After contact with medical equipment/supplies in patient areas; -After removing gloves; -Before exiting the patient's area after touching the patient or the patient's immediate environment. 2. Review of the facility's policy titled "Medication Administration-Sanitary Technique" dated 06/10/19, showed: -The policy directed staff who administer medications to clean their hands with soap and water and/or hand sanitizer for the standard length of time, -If the staff member is handing the medication cup to the resident to take the medications and not assisting or "laying hands on", hand sanitizer gel can be used between residents or wash with soap and water; -If staff administer any medications that require gloves to be worn, including eye drops, injectables, blood glucose monitoring, ear drops and nasal sprays, hand washing is to be completed before and after gloving. Observations on 10/20/25 from 10:40 A.M. to 11:05 A.M., showed the Certified Medication Aide (CMA) administered medications to Resident #5 in his/her room. Observation showed the CMA handed the medication cup with the medications inside to the resident and the resident placed the medication cup against his/her lips to ingest the Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 2 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 2 medications. Observation showed the CMA took the medication cup from the resident with his/her bare hands, disposed of it in the trash can and left the room. Observation showed the CMA entered the medication preparation room and, without performing hand hygiene, prepared medications in a medication cup for Resident #6. Observation showed the CMA then entered Resident #6's room and, without performing hand hygiene, handed the medication cup with the medications inside to the resident and the resident placed the medication cup against his/her lips to ingest the medications. Observation showed the CMA took the medication cup from the resident with his/her bare hands, disposed of it in the trash can and left the room. Observation showed the CMA returned to the medication preparation room and, without performing hand hygiene, prepared medications in a medication cup for Resident #1. Observation showed the CMA then entered Resident #1's room and, without performing hand hygiene, handed the medication cup with the medications inside to the resident and the resident placed the medication cup against his/her lips to ingest the medications. Observation showed the CMA took the medication cup from the resident, disposed of it in the trash can, and then administered a nasal spray to the resident. Observation showed the CMA then applied a pair of gloves, held the resident's right eye open with his/her gloved hand and administered eye drops. Observation showed the CMA removed his/her gloves and, without performing hand hygiene, gathered the bottles of nasal spray and eye drops and left the room. During an interview on 10/20/25 at 3:00 P.M., the Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 3 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 3 CMA said when staff prepare and administer medications, staff should perform hand hygiene after contact with every three residents. The CMA said it would make sense to perform hand hygiene after he/she touches a resident or something that would contain their bodily secretions, like saliva, and he/she did not know why he/she thought hand hygiene only needed to be performed after contact with three residents. During an interview on 10/21/25 at 12:10 P.M., the administrator said staff should perform hand hygiene before and after glove use, between providing care to residents, after they touch anything soiled or if they encounter bodily secretions. The administrator said staff who administer medications could use hand sanitizer between residents to perform hand hygiene, unless their hands got visibly soiled, and then they would need to wash their hands with soap and water after they have used hand sanitizer three times. The administrator said all staff are trained on infection control procedures, which includes when and how to perform proper hand hygiene, upon hire and as needed and he/she had never instructed staff to only perform hand hygiene after contact with three residents during a medication pass. 3. Review of the facility's policy titled "Kitchen Services" dated 05/07, showed "Proper hand washing technique will be maintained when entering the kitchen, during work as often as needed to keep clean, before and after food handling, before and after breaks, eating or smoking, after contact with soiled dishes, using restroom and garbage." Observation on 10/20/25 from 12:10 P.M. to Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 4 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 4 12:20 P.M., showed the cook applied a facial hair restraint with his/her gloved hands and then, without removing his/her gloves and performing hand hygiene, delivered eating utensils and a drink to a resident in the dining room. Observation showed, while wearing the same gloves, the cook returned to the kitchen, transferred prepared tuna casserole from one pan to another, wrapped a block of butter with plastic cling film and placed it in the refrigerator, turned the faucet of the sink on and filled a plastic container with soap and water from the faucet, and left the kitchen to return a case of prepackaged sherbet cups to the refrigerator in the dry goods pantry. Observation on 10/20/25 at 12:20 P.M., showed the administrator removed the cover to the trash can in the dining room with his/her gloved hands and scraped leftover food from the residents’ lunch plates. Observation showed the administrator removed one of his/her soiled gloves and, without performing hand hygiene, entered the kitchen to obtain a drink and delivered the drink to a resident in the dining room. During an interview on 10/20/25 at 12:25 P.M., the cook said he/she had been trained on hand hygiene during his/her employment and staff should change gloves and perform hand hygiene between dirty and clean tasks. The cook said he/she should have changed his/her gloves and performed hand hygiene after he/she put on the facial hair restraint and when he/she returned to the kitchen, but he/she was busy and did not think about it. During an interview on 10/21/25 at 12:10 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 5 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 5 the administrator said staff should perform hand hygiene before and after glove use, after they touch anything soiled, after they touch any part of their body, and before food preparation and service. The administrator said staff should also change their gloves between tasks and when soiled. The administrator said all staff are trained on infection control procedures, which includes when and how to perform proper hand hygiene, upon hire and as needed. The administrator said he/she should have performed hand hygiene after he/she removed his/her glove to give the resident the drink, but he/she just did not think about it at that time. 19 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures that all residents ' medications are administered by personnel at least eighteen (18) years of age, in accordance with physicians ' instructions using acceptable nursing techniques. The facility shall employ a licensed nurse eight (8) hours per week for every thirty (30) residents to monitor each resident's condition and medication. Administration of medication shall mean delivering to a resident his or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual dose from the pharmacy container and placing it in a small cup container or liquid medium for the resident to remove from the container and self-administer. External prescription medication may be applied by facility personnel if the resident is unable to do so and the resident's physician so authorizes. All Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 6 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 6 individuals who administer medication shall be trained in medication administration and, if not a physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Wl This regulation is not met as evidenced by: Class II Based on observation, interview and record review, facility staff failed to implement a safe and effective medication system when staff failed to administer eye drops in accordance with acceptable nursing techniques to two residents (Residents #1 and #2) out of two residents observed. The facility census was 21. 1. Review of the policies provided by the facility showed the records did not contain a policy related to the administration of ophthalmic (related to the eye) medications. Review of the Certified Medication Aide's (CMA) personnel records showed the CMA with a current Level 1 Medication Aide (LIMA) certification issued on 08/21/24. Review of the Level 1 Medication Aide (LIMA) Manual, revised November 1993, Unit 4, Lesson 12-Prepare and Administer Medications showed the steps to prepare, administer, report and record ophthalmic mediations included: -Position resident (sitting or lying) with head tilted backward; -Observe the affected eye(s) for unusual conditions that may need to be reported; -Cleanse the eye with a cotton ball, wiping from the inner corner outward; Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 7 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 7 -Ask the resident to look upward; -Hold lower eyelid away from the eye to forma pouch; -Instill drops onto the pouch, never directly onto the center of the eyeball; -Apply pressure to the inside corner of the eye with middle finger for about one minute; -Close the eye gently and instruct the resident to keep eyes closed for a few minutes and to not squeeze their eyes together. 2. Review of Resident #1's Community Based Assessment dated 05/06/25, showed staff assessed the resident as dependent on staff for his/her medication administration. Review of the resident's Physician Order Sheets (POS), dated October 2025, showed the resident's physician directed staff to provide the resident with one drop of 0.1 percent fluorometholone ophthalmic suspension (medicated eye drops used to treat inflammation and irritation in the eye) in his/her right eye every morning. Observation on 10/20/25 at at 10:50 A.M., showed the CMA ? entered the resident's room, applied a pair of gloves, tilted the resident's head back, held the resident's eye open with his/her gloved hand and used his/her other hand to place one drop of 0.1 percent fluorometholone ophthalmic suspension in the center of the resident's eye. Observation showed the resident closed his/her eyes, the CMA dabbed a tissue under the resident's right eye and then the resident opened his/her eyes. Observation showed the CMA did not cleanse the resident's eye with a cotton ball and ask the resident to look upward prior to administration of the eye drop, Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 8 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 8 The CMA also did not hold the resident's lower eyelid away from the eye to form a pouch, instill the eye drop into the pouch of the lower eyelid, apply pressure to the inside corner of the resident's eye with his/her middle finger for about one minute, and instruct the resident to keep his/her eyes closed for a few minutes and to not squeeze their eyes together after he/she administered the eye drop. 3. Review of Resident #2's Community Based Assessment dated 07/15/25, showed staff assessed the resident as needing staff assistance for taking his/her medications. Review of the resident's POS, dated October 2025, showed the resident's physician directed staff to provide the resident with one drop of dorzolamide hydrochloride ophthalmic solution (a medicated eye drop used to treat high pressure inside the eye) in each eye twice a day for glaucoma. Observation on 10/20/25 at 11:15 A.M., showed the CMA? entered Resident #2's room, applied a pair of gloves, tilted the resident's head back, held the resident's right eye open with his/her gloved hand and used his/her other hand to place one drop of dorzolamide hydrochloride ophthalmic solution in the center of the resident's eye. Observation showed the resident closed his/her eyes, the CMA dabbed a tissue under the resident's right eye and then the resident opened his/her eyes. Observation showed the CMA repeated the eye drop administration process for the resident's left eye. Observation showed the CMA did not cleanse the resident's eyes with cotton balls and ask the resident to look upward prior to administration of the eye drops, the CMA Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 9 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 9 also did not hold the resident's lower eyelids away from the eyes to form a pouch, instill the eye drops into the pouch of the lower eyelids, apply pressure to the inside corner of the resident's eyes with his/her middle finger for about one minute, and instruct the resident to keep his/her eyes closed for a few minutes and to not squeeze their eyes together after he/she administered the eye drops. 4. During an interview on 10/20/25 at 3:00 P.M., the CMA said when he/she became a certified LIMA in August 2024, used the current LIMA manual for training, and he/she is expected to administer medications in accordance with the manual. The CMA said he/she did not recall being instructed to cleanse the resident's eye with cotton balls and ask the resident to look upward prior to administration of eye drops. The CMA said he/she also did not recall being instructed to hold the resident's lower eyelid away from the eye to form a pouch, instill eye drops into the pouch of the lower eyelid, apply pressure to the inside corner of the resident's eye with his/her finger for about one minute, and instruct the resident to keep his/her eye closed for a few minutes and to not squeeze their eyes together after he/she administered eye drops. The CMA said he/she did not know that he/she needed to conduct those steps to properly administer eye drops. During an interview on 10/21/25 at 12:10 P.M., the administrator said staff who administer medications would be expected to administer medications in accordance with their training, which would include certification specific training. The administrator said the CMA is a certified LIMA and he/she is expected to administer Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 10 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 10 medications in accordance with LIMA procedures outlined in the LIMA manual unless otherwise directed. The administrator said when staff administer eye drops, they should tilt the resident's head back, look for anything unusual, cleanse the eye, hold the resident's lower eyelid away from the eye to form a pouch, instruct the resident to look up and instill the drops into the pouch, not onto the center of the eye. The administrator said after the staff administer eye drops, they should apply pressure to the inside corner of the eye for a few seconds, instruct the resident to close their eyes and blot away any excess moisture from around the eye. The administrator said he/she did not know the CMA did not know all the steps to properly administer eye drops. 19 CSR 30-87.020(5) Toxic Material Storage Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. II This regulation is not met as evidenced by: Class II Based on observation, interview and record review, facility staff failed to store toxic chemicals in a manner not accessible to residents. The facility census was 21. Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 11 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 11 1. Review of the facility's policy titled "Chemical Usage and Storage", dated 12/01/19, showed all chemicals should be stored in a secure location when not in direct use, and should never be left out in open where others may accidentally come into contact with it. Observation on 10/20/25 at 8:45 A.M., showed a 19 ounce (0z.) aerosol can of a quaternary ammonium based disinfectant spray on the counter of the activity kitchenette. Observation of the disinfectant spray's label showed hazard warnings that the product is hazardous to humans and could cause eye irritation. Observation showed residents sat in the adjacent common area and the area is unattended by staff. Observation on 10/20/25 at 9:55 A.M., showed the door to the front common toilet room unlocked and the room unattended by staff. Observation showed a 19 oz. aerosol can of a quaternary ammonium based disinfectant spray and a 32 oz. bottle of hydrochloric acid based toilet bowel cleaner stored unsecured in the room. Observation of the disinfectant spray's label showed hazard warnings that the product is hazardous to humans and could cause eye irritation. Observation of the toilet bowl cleaner's label showed a hazard warning that the product could cause irreversible eye damage. Observation showed residents sat in the adjacent dining room. Observation on 10/20/25 10:05 A.M., showed the door to the front shower room, located in the unlocked and unattended toilet room, unlocked and the room unattended by staff. Observation Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 12 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 12 showed a 32 oz. spray bottle of a quaternary ammonium based disinfectant stored unsecured in the room. Observation of the disinfectant's label showed hazard warnings that the product is hazardous to humans and could cause moderate eye irritation. During an interview on 10/20/25 at 10:30 A.M., the administrator said the chemicals belonged to the facility and the chemicals should be locked up and not accessible to the residents. The administrator said the doors to the toilet and shower rooms should be locked. The administrator said he/she had not designated anyone to conduct routine monitoring for the storage of chemicals, but all staff are trained to secure chemicals that are not in use Observation on 10/21/25 at 8:00 A.M., showed the door to the front toilet room unlocked and the room unattended by staff. Observation showed the door to the front shower room, located in the unlocked and unattended toilet room, unlocked and the room unattended by staff. Observation showed the 32 oz. spray bottle of a quaternary ammonium based disinfectant with the hazard warnings that the product is hazardous to humans and could cause moderate eye irritation, remained unsecured in the room. 19 CSR 30-87.020(32) Outside Dumpsters Cleanable/Covered Waste containers stored outside the establishment and dumpsters, compactors and compactor systems shall be easily cleanable, shall be provided with tight-fitting lids, doors or covers and shall be kept covered when not in actual use. In containers designed with drains, Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 13 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 13 drain plugs shall be in place at all times, except during cleaning. Ill This regulation is not met as evidenced by: Class Ill Based on observation, interview and record review, facility staff failed to ensure the outside dumpster remained closed when not in actual use. The facility census was 21. 1. Review of the facility's policy titled "Pest Control Policy and Procedure", undated, showed dumpster and/or garbage containers will be covered and kept free of food sources and standing water. Observations on 10/20/25 at 8:30 A.M., 1:00 P.M. and 4:15 P.M., showed the lid to the outside dumpster opened and the dumpster contained food waste and other trash. Observation showed the area unattended by staff. Observations on 10/21/25 at 7:45 A.M. and 10:15 A.M., showed the lid to the outside dumpster opened and the dumpster contained food waste and other trash. Observation showed the area unattended by staff. During an interview on 10/21/25 at 12:00 P.M., the administrator said the lid to the dumpster should be closed when not in use and all staff who put trash in the dumpster are responsible to close the lid when they are done. The administrator said staff had probably not been trained to close the dumpster lid after use because that is not a part of the facility's orientation training. Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 14 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 14 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III This regulation is not met as evidenced by: Class III Based on observation, interview and record review, facility staff failed to ensure staff involved in food preparation and service wore facial hair restraints to prevent the contamination of food and food-contact surfaces. The facility census was 21. 1. Review of the facility's policy titled "Kitchen Services" dated 05/07, showed the policy directed all dietary personnel to wear hair coverings at all times while in the kitchen. Observation on 10/20/25 at 9:10 A.M., showed the cook, who had a long beard, prepared food items in the kitchen without the use of a facial hair restraint. Observation on 10/20/25 at 12:00 P.M., showed the cook prepared and served food items to residents during the lunch meal service without the use of a facial hair restraint. During an interview on 10/20/25 at 12:12 P.M., the cook said staff's hair, including facial hair, should be restrained when in the kitchen and he did not realize that his beard was not restrained. During an interview on 10/21/25 at 12:00 P.M., Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 15 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 15 the administrator said staff should wear hair restraints anytime they are preparing or serving food, which would include facial hair restraints, and all staff are trained on this requirement. 19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS At all times, including while being stored, prepared, displayed, served or transported to or from the facility, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and utensils, unnecessary handling, coughs and sneezes, flooding, drainage and overhead leakage or overhead drippage from condensation. The temperature of potentially hazardous food shall be forty-five degrees Fahrenheit (45°F) or below or one hundred forty degrees Fahrenheit (140°F) or above at all times, except as otherwise provided in this section. In the event of a fire, flood, power outage or similar event that might result in the contamination of food, or that might prevent potentially hazardous food from being held at required temperatures, the person in charge shall immediately contact the Department of Health and Senior Services (the department). Upon receiving notice of this occurrence, the department shall take whatever action that it deems necessary to protect the residents. II/III This regulation is not met as evidenced by: Class III Based on observation, interview and record review, facility staff failed to store food in a manner to protect it from potential contamination and outdated use. The facility census was 21. Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 16 of 19 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 20440D B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE WESTBROOK TERRACE MEMORY CARE II JEFFERSON CITY, MO 65109 DEFICIENCY) Continued From page 16 1. Review of the facility's policy titled, "Kitchen Services" dated 05/07, showed "All food is to be prepared, distributed and served to residents under sanitary conditions. Successful kitchen practices shall include requirements for cleanliness, food storage, food handling, and sanitation." Review showed the policy directed staff to maintain proper storage of food and to store leftovers labeled and dated in proper storage containers. Review of the facility's training record titled, "Labels, Dates, & Storage", undated, showed the training directed staff to: -Cover, label and date perishable leftovers and opened foods; -Label food with the name of the food, the date of preparation or delivery, and the date the food is to be used or discarded; -Date all foods upon delivery, when the food is removed from its original packaging and placed in another container, and when leftover foods are removed from hot or cold holding and placed in a container. Observation on 10/20/25 at 9:10 A.M., showed the reach-in refrigerator contained an undated bowl of tomato salad, an opened and undated 32 ounce (0z.) container of Greek yogurt, and two dozen raw eggs stored over ready-to-eat food items which included two pitchers of orange drink, two protein drinks, bottles of drinking water and salad dressing. Observation on 10/20/25 at 9:15 A.M., showed the reach-in freezer contained: -An opened and undated five pound container of Missouri Department of Health and Senior Services STATE FORM 6899 G0Cca11 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE PRINTED: 11/03/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/21/2025 If continuation sheet 17 of 19 PRINTED: 11/03/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) WESTBROOK TERRACE MEMORY CARE II Continued From page 17 sliced strawberries; -An opened and undated five pound bag of cooked sausage crumbles stored inside an undated plastic resealable bag; -An opened and undated bag of chicken wings stored inside an undated plastic resealable bag; -An opened and undated bag of chocolate chip cookie dough rounds; -An opened and undated bag of breadsticks; -An undated and unlabeled plastic resealable bag which contained an unidentifiable type of ravioli removed from its original package; -An undated case of breaded okra opened to the air. Observation on 10/20/25 at 9:30 A.M., showed an opened and undated bag of vanilla wafers stored in a kitchen cabinet. During an interview on 10/20/25 at 9:30 A.M., the cook said opened and prepared food items should be stored in closed containers and dated with the date it is received and the date it is opened or prepared. The cook said they were currently out of the stickers they use to date the food items. The cook said staff can label the bags with markers, but the marker ink does not stay on the plastic bags. Observation on 10/20/25 at 9:35 A.M., showed an opened and undated 25 pound bag of self-rising flour stored on the floor in the dry goods pantry. During an interview on 10/21/25 at 12:00 P.M., the administrator said opened and prepared food items should be stored in closed containers, labeled with the name of the food, and dated with the date it is received and the date it is opened or Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 18 of 19 PRINTED: 11/03/2025 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 20440D B.WING 10/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 3335 NORTH TEN MILE DRIVE JEFFERSON CITY, MO 65109 (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) WESTBROOK TERRACE MEMORY CARE II Continued From page 18 prepared. The administrator said staff should not store food and raw food should be stored below ready-to-eat food. The administrator said all dietary staff are trained on proper food storage requirements and they are responsible to ensure the food is stored properly. The administrator said he/she did not Know about the issues with the food storage. Missouri Department of Health and Senior Services STATE FORM 6899 GOCQ11 If continuation sheet 19 of 19 P LA N O F C O R RECTION Provider/Supplier Name: | Westbrook Terrace Memory Care II Street Address, City, Zip: | 3335 North Ten Mile Drive Jefferson City, MO 65109 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | 20440D ID PREFIX - = PROVIDER'S PLAN OF CORRECTION: [EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) wae | ‘au The filing of this correction does not constitute any admissions by the facility regarding the alleged violation stated in the summary Statement of Deficiencies dated October 21*', 2025 by the Missouri Department of Health and Senior Services. This plan of correction is filed as evidence of our continuing commitment to provide care in compliance with applicable law. In response to 19 CSR 30-86.047(34)(A) Disease/Infection Control, Report Category | Immediate Action: All staff including those on duty during the time of survey as well as all off duty staff in nursing and dietary who administer medication or for those who assist in meal preparation or meal services, have received infection control education and training as it relates to hand hygiene, hand washing, hair coverings and beard guards. In-servicing will include: e Hand Washing procedure e Gloving Procedure e Use of and sanitizer e Hair & Beard Coverings A4773 11/20/2025 Education/training provided on or before 10/24/2025 by Administrator. Ongoing Compliance: Director of Nursing or designee in absence of will assure on going compliance through monitoring/observing medication administration no less than weekly to assure proper infection control practices are used. Dietary Manager or Cook in absence of to assure ongoing compliance of proper food handling and use of handwashing and gloving with meal preparation through observing meal preparation and serving no less than weekly during different meal times. Any areas of non-compliance concerns found will have additional training and education. ey, lA - AS FF? Completion Date: 11/20/2025 In response to 19CSR 30-86.047(46) Safe & Effective Medication System Immediate Action: Director of Nurses provided in-servicing to all LIMA’s on or before 10/24/2025 as it relates to proper procedures on administering eye drops. In-servicing education was taken from the Level 1 Medication Aide (LIMA) Manal revised November 1993 Unit 4 Lesson 12-Prepare and Administer Medications and then on floor training with return demonstration. Ongoing Compliance: Director of Nursing or designee in absence of will assure ongoing compliance through completion of observation of medication administration with LIMA’s weekly and rotating shift and time of administration. Any identified competency concerns found will have additional training and return demonstration. Completion Date: 11/20/2025 In response to 19 CSR 30-87.020(5) Toxic Material Storage 11/20/2025 Immediate Action: There was a key code lock added to the storage closet bathroom door that is just off the dining room. All staff educated on keeping all chemicals stored behind locked door when not in use. Education completed by the Administrator on or before 10/24/2025. 11/20/2025 Ongoing Compliance: Administrator or designee in absence of, to assure ongoing compliance through completing multiple daily rounds to monitor that no chemicals are left unattended and to assure all chemicals are kept behind locked doors and that all storage closets or chemical areas remain locked when not in use. Completion Date: 11/20/2025 In response to 19 CSR 30-87.020(32) Outside Dumpster Cleanable/Covered Immediate Action: 11/20/2025 A pole was purchased to allow staff to reach the dumpster lid and raise and lower the lid more effectively. All staff educated on keeping the trash dumpster lid closed at all times when not in use. In-servicing completed on 10/24/2025 by Administrator. On-going Compliance: Administrator or designee in absence of will assure ongoing compliance through visual inspections of the trash dumpster several times weekly to assure the lid is closed and that trash is secured. Compliance Date: 11/20/2025 In response to CSR 30-87.030(3) Clean Clothing, Hair Restraints Immediate Action: All staff including those on duty during the time of survey as well as all off duty dietary staff and nursing staff who assist in meal preparation or meal services, have received infection control education and training as it relates hair coverings and beard guards, being worn at all times during meal preparation, meal service or anytime where food contamination could occur. In- A7003 servicing was conducted by the Administrator on or before 10/24/2025. 11/20/2025 Ongoing Compliance: Administrator or designee in absence of will assure ongoing compliance through visual inspections of the kitchen and meal service several times weekly to assure that staff are wearing appropriate hair covering and or beard guards if employee should have a beard. Compliance Date: 11/20/2025 In response to 19 CSR 30-87.030(13) Food Protected, Temp, Need to Contact DHSS Immediate Action: All kitchen food storage areas have been cleaned and open undated foods removed and discarded. Reach in refrigerator cleaned and organized to assure no raw food are stored over ready to eat foods. 11/20/2025 All dietary and other staff who work in the kitchen were provided in-servicing on proper food storage as well as dating and labeling of food. Education completed by Administrator on or before 10/24/2025. Ongoing Compliance: Dietary Manager or designee in absence of will assure ongoing compliance through conducting 3 weekly inspections of all food storage areas to assure foods are stored correctly and o items are labeled and dated. Any non-compliance found will be immediately corrected and additional training conducted. Compliance Date: 11/20/2025 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.