TRUSTWELL LIVING AT RICHMOND HEIGHTS.

PRINTED: 12/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A BUILDING: COMPLETED 8. WING ________ 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORNATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ALLEGRO A2224] 19 CSR 30-86.022(7)(A)(2) Exits/Stairways After 12/31/87 Exits, Stairways, and Fire Escapes. {A} Each floor of a facility shall have at least two {2) unobstructed exits remote from each other. lil 2. For a facility whose plans were approved after December 31, 1987, for more than twenty (20) beds, the required exits shall be doors leading directly outside, one- (1-) hour enclosed stairs or outside stairs or a two- (2-) hour rated horizontal exit as defined by paragraph 3.3.61 of 2000 edition NFPA 101. The one- (1-} hour enclosed = stairs shall exit directly outside at grade. Access S AS A la eel to these shall not be through a resident bedroom or a hazardous area. I/Il O YG, ©. This regulation is not met as evidenced by: Class Il Based on observation and interview, the facility failed to maintain unobstructed exits remote from each other. The facility census was seventy-one, This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025 at 2:05 PM, revealed the exterior exit door at the base of stairwell two is sticking, and excessive force is required to open the door. During the exit interview on December 10, 2025 at 4:05 PM, the maintenance person stated that he would have the door repaired. 19 CSR 30-86,022(10)(A} Hazardous Area Requirements Protection from Hazards. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE TITLE (X8) DATE tx ECV te Ditecrect l | I l2. Zo KEFT11 If continuation sheet 1 of 6 PRINTED: 12/19/2025 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 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO 19 CSR 30-86.022(7)(A)(2) Exits/Stairways After 12/31/87 Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. Il 2. For a facility whose plans were approved after December 31, 1987, for more than twenty (20) beds, the required exits shall be doors leading directly outside, one- (1-) hour enclosed stairs or outside stairs or a two- (2-) hour rated horizontal exit as defined by paragraph 3.3.61 of 2000 edition NFPA 101. The one- (1-) hour enclosed stairs shall exit directly outside at grade. Access to these shall not be through a resident bedroom or a hazardous area. I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to maintain unobstructed exits remote from each other. The facility census was seventy-one. This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025 at 2:05 PM, revealed the exterior exit door at the base of stairwell two is sticking, and excessive force is required to open the door. During the exit interview on December 10, 2025 at 4:05 PM, the maintenance person stated that he would have the door repaired. 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 KEFT11 If continuation sheet 1 of 6 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to maintain self closing smoke partition doors that separate the laundry rooms from the residential spaces. The facility census was seventy-one. This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025 at 1:24 PM revealed both smoke partition doors of the second floor laundry had magnetic door stops that held the doors open, but were not attached to the fire alarm system. Observation on December 10, 2025 at 12:23 PM revealed both smoke partition doors of the third Missouri Department of Health and Senior Services STATE FORM 6899 KEFT11 PRINTED: 12/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/10/2025 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 6 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 floor laundry had magnetic door stops that held door open, but were not attached to the fire alarm system. Observation on December 10, 2025 at 3:30 PM revealed the smoke partition door of the first floor laundry had magnetic a door stop that held door open, but was not attached to the fire alarm system. During the exit interview on December 10, 2025 at 4:10 PM, the maintenance person stated that they would remove the magnetic holds. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated wastebaskets shall be used for trash. II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to ensure only metal or UL- or FM-fire-resistant rated wastebaskets were being used for trash. The facility census was seventy-one. This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025, between 12:00 PM and 4:00 PM, revealed over 50 non metal or UL-FM fire-resistant rated wastebaskets in use throughout the facility and occupied rooms. Although maintenance removed all the unapproved wastebaskets at the time of discovery, the sheer number of deficiencies requires a plan of correction to address this Missouri Department of Health and Senior Services STATE FORM 6899 KEFT11 PRINTED: 12/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/10/2025 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 3 of 6 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 situation going forward with staff, family, and residents. During the exit interview on December 10, 2025 at 4:15 PM, the maintenance person advised he understood which trash cans are acceptable. 19 CSR 30-86.022(17) Oxygen Storage Requirements Oxygen storage shall be in accordance with NFPA 99, 1999 Edition. II/III This regulation is not met as evidenced by: Class Ill Based on observation and interview the facility failed to store portable compressed gas cylinders in accordance with NFPA 99, 1999 Edition. The facility census was seventy-one. This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025 at 2:28 PM, revealed 4 compressed gas cylinders of CO2 standing upright and not stored in an approved rack, or secured by chain or band in the store room of the kitchen During the exit interview on December 10, 2025 at 4:20 PM, the maintenance man stated he would make the chain longer to secure all the compressed gas cylinders properly. 19 CSR 30-86.032(2) Substantially Constructed & Maintained Missouri Department of Health and Senior Services STATE FORM 6899 KEFT11 PRINTED: 12/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/10/2025 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 4 of 6 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 The building shall be substantially constructed and shall be maintained in good repair and in accordance with the construction and fire safety rules in effect at the time of initial licensing. II/III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to maintain the building in good repair. The facility census was seventy-one. This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025 at 1:25 PM revealed a large wall penetration in the second floor laundry room, behind a washing machine. Observation on December 10, 2025 at 1:27 PM revealed ceiling tiles missing in the electrical room across from room 235. During the exit interview on December 10, 2025 at 4:25 PM, the maintenance person stated that they would repair the drywall. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are subject to physical damage. II/Ill Missouri Department of Health and Senior Services STATE FORM 6899 KEFT11 PRINTED: 12/19/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/10/2025 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 5 of 6 PRINTED: 12/19/2025 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 12/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 5 This regulation is not met as evidenced by: Class Ill Based on observation and interview, the facility failed to ensure only one appliance shall be connected to one extension cord and only two electrical appliances may be served by one duplex receptacle. The facility census was seventy-one. This deficiency affected seventy-one of seventy-one residents. Observation on December 10, 2025, between 12:00 PM and 4:00 PM, revealed over 40 unapproved extension cords, multiplugs, and daisy chained surge protectors in use throughout the facility and occupied rooms. Maintenance removed/repaired all the extension cords, multiplugs, and daisy chained surge protectors at the time of discovery. However, the number of deficiencies requires a plan of correction to address this situation going forward with staff, family, and residents. During the exit interview on December 10, 2025 at 4:30 PM, the maintenance person advised that he will watch out for further instances of residents using unauthorized extension cords and multiplugs. Missouri Department of Health and Senior Services STATE FORM 6899 KEFT11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier Name: Allegro Richmond Heights Street Address, City, Zip: 1055 Bellevue Ave., Richmond Heights, 63117 Date of Survey: 12/10/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER COMPLETION ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION DATE SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Exits/Stairways after 12/31/1987: A2224 The noted stairwell two exit door has been inspected by the Director of Maintenance and greased to prevent the need for A2256 A2286 resistant rating requirements. Letters to be provided to new families/residents moving forward to further educate. Oxygen Storage Requirements: A2298 , The noted chain was replaced with a longer chain to properly 42/31/2025 excessive force. secure the compressed gas cylinders A3201 12/31/2025 removed from the doors and walls preventing the doors from 2a0es being held open. Wastebaskets, Metal/UL/FM-Requirements Offending waste baskets were removed the day of the inspection. Informational letters and flyers were provided to residents, families, and visitors explaining the UL or FM fire 12/31/2025 The noted magnetic holds to the laundry room doors have been The missing ceiling tiles noted in the 24 floor electrical room have been replaced. The noted large wall penetration behind the washing machine has been covered with new drywall. The patch has been surrounded by joint compound to fill the gap between the new and old wall. Extension Cords/ Duplex receptacles The offending cords were removed the day of the inspection. Informational letters and flyers were provided to residents, families, and visitors explaining the UL rating requirements. Letters to be provided to new families/residents moving forward to further educate. 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. 12/31/2025 Hazardous Area Requirements: Substantially constructed & Maintained A3219 12/31/2025

PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED B.WING 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ALLEGRO A2202) 19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard General Requirements. (D) The department shall have the right of inspection of any portion of a building in which a licensed facility is located unless the unlicensed portion is separated by two- (2-) hour fire-resistant construction. No section of the building shall present a fire hazard. |/II This regulation is not met as evidenced by: Class Il Based on observation and interview, the facility failed to ensure no part of the building presented a fire hazard when the facility improperly stored carbon dioxide cylinders (CO2 tanks) in the kitchen, for one of one observed day. The census was 82, Observation on 10/30/24 between 7:25 A.M. and 4:15 P.M., of the kitchen, showed one CO2 tank on the floor unsecured, to the left of the soda machine dispenser, and one full tank on the floor unsecured, in the dry storage area of the kitchen. During an interview on 10/30/24 at 4:15 P.M., the Administrator said she was aware there were CO2 tanks stored in the kitchen. The Administrator said she was aware the CO2 tanks were required to be stored in a rack or secured/chained to the wall, but not aware the CO2 tanks were not securely stored in the kitchen. | 19 CSR 30-86.032(34) Hot Water 105-120 Degrees F | Plumbing fixtures which are accessible to Missouri Department of Health and Senior Services LABORATORY, DIREGTOR'S OR PROVIDER/SUPB! REPRESENTATIVE'S SIGNATURE (X6) DATE If continuation sheet $G9511 2.5 \2004 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 residents and which supply hot water shall be thermostatically controlled so that the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120°F) (49°C) and the water shall be at a temperature range between one hundred five degrees Fahrenheit (105°F) (41°C) and one hundred twenty degrees Fahrenheit (120°F) (49°C). I/II This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to ensure water temperatures were maintained between 105 degrees Fahrenheit (F) and 120 F, for one of one day of observation. The census was 82. 1. Review of the facility's "Water Temps" maintenance work documents, showed the following: -On 6/3/24, the water temperature on the first floor, in resident room 139, measured 117 degrees F. The water temperature in the main kitchen, measured 141 degrees F. The water temperature on the second floor, in resident room 212, measured 119 degrees F. The water temperature on the second floor, in the bistro, measured 120 degrees F. The water temperature on the third floor, in resident room 310, measured 117 degrees F. The water temperature on the third floor, in the community room measured 120 degrees F. The water temperature on the fourth floor, in resident room 421, measured 118 degrees F. The water temperature on the fourth floor, in the resident accessible kitchenette, measured 120 degrees F; -On 7/11/24, the water temperature on the first floor, in resident room 116, measured 119 degrees F. The water temperature in the main Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 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 15 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 kitchen, measured 140 degrees F. The water temperature on the second floor, in resident room 239, measured 117 degrees F. The water temperature on the second floor, in the bistro, measured 120 degrees F. The water temperature on the third floor, in resident room 330, measured 118 degrees F. The water temperature on the third floor, in the community room, measured 119 degrees F. The water temperature on the fourth floor, in resident room 401, measured 118 degrees F. The water temperature on the fourth floor, in the resident accessible kitchenette, measured 120 degrees F; -On 8/23/24, the water temperature on the first floor, in resident room 110, measured 117 degrees F. The water temperature in the main kitchen measured 140 degrees F. The water temperature on the second floor, in resident room 216, measured 117 degrees F. The water temperature on the second floor, in the bistro, measured 119 degrees F. The water temperature on the third floor, in resident room 301, measured 119 degrees F. The water temperature on the third floor, in the community room, measured 120 degrees F. The water temperature on the fourth floor, in resident room 421, measured 118 degrees F. The water temperature on the fourth floor, in the resident accessible kitchenette, measured 119 degrees F; -On 9/16/24, the water temperature on the first floor, in resident room 101, measured 117 degrees F. The water temperature in the main kitchen, measured 141 degrees F. The water temperature on the second floor, in resident room 232, measured 118 degrees F. The water temperature on the second floor, in the bistro, measured 120 degrees F. The water temperature on the third floor, in resident room 306, measured 116 degrees F. The water temperature on the third floor, in the community room, measured 119 Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 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 3 of 15 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 degrees F. The water temperature on the fourth floor, in resident room 407, measured 119 degrees F. The water temperature on the fourth floor, in the resident accessible kitchenette, measured 119 degrees F. 2. Observation on 10/30/24 at 2:27 P.M. in resident room 216, at the kitchen sink, showed the water temperature measured 133.3 degrees F, when recorded for two minutes with a calibrated digital thermometer. During an interview on 10/30/24 at 2:30 P.M., Resident #6 said sometimes the water temperature is too hot when he/she took showers. 3. Observation on 10/30/24 between 2:35 P.M. and 2:42 P.M., in resident room 210, showed the following: -At the kitchen sink, the water temperature measured 127.4 degrees F, when recorded for two minutes with a calibrated digital thermometer; -In the back shower, the water temperature measured 130.1 degrees F, when recorded for two minutes with a calibrated digital thermometer; -In the front shower, the water temperature measured 127.4 degrees F, when recorded for two minutes with a calibrated digital thermometer. 4. Observation on 10/30/24 between 2:50 P.M. and 2:58 P.M., in resident room 314, showed the following: -At the kitchen sink, the water temperature measured 129.2 degrees F, when recorded for two minutes with a calibrated digital thermometer; -At the bathroom sink, the water temperature measured 130.6 degrees F, when recorded for two minutes with a calibrated digital thermometer; -In the shower, the water temperature measured Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 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 4 of 15 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 128.6 degrees F, when recorded for two minutes with a calibrated digital thermometer. During an interview on 10/30/24 at 2:53 P.M., Resident #9 said the water temperature was hot but maintainable. 5. Observation on 10/30/24 at 2:45 P.M., on the third floor, in the community room, showed the sink water temperature measured 134.2 degrees F, when recorded for two minutes with a calibrated digital thermometer. Steam was visible from the faucet and the water was hot to the touch. 6. Observation on 10/30/24 at 2:53 P.M., on the fourth floor, in resident room 412, showed the water in the bathroom sink measured 132.2 degrees F when recorded for two minutes with a calibrated digital thermometer. 7. During an interview and observation on 10/30/24 between 3:00 P.M. and 3:25 P.M., showed the water heater smart touch screen was stuck on "standby 0%." The Maintenance Director (MD) said sometimes the screen did this but when he would touch it a few times, it would come back on. The MD said he was mainly responsible for taking the water temperatures and he knew the water temperatures had to be ina certain limit. The MD said he logged the water temperatures monthly on a form and he took the temperature on each floor in main areas and in different resident rooms. The plumbing company came and restarted the machine, the MD said he did not know he could do that to get the screen running again. The MD did not know he should calibrate his thermometer and he did not know how to do so. The MD went to resident room 202 and took the temperature of the kitchen sink. The Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 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 5 of 15 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 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 5 MD held the thermometer vertically, with the probe more than half way in the running water and about 1 to 2 inches from the spout. The MD said no one had shown him how to take water temperatures. The MD said a couple months ago, the local Health Department came out and told him to lower the water temperature. He said at that time, the smart touch screen read 115 degrees F and he lowered it to 110 degrees F. 8. During an interview on 10/30/24 at 4:22 P.M., the Administrator said she was not aware the water temperatures were that high. The Administrator said she was not aware the MD did not know how to take the water temperature correctly or calibrate his thermometer. The Administrator said she knew the water temperatures should be in the range of 105 degrees F and 120 degrees F. The Administrator said the MD should be logging the temperatures and be taking the temperature from the sinks and showers. 19 CSR 30-86.047(58)(A) Resident Record Admission Info The facility shall maintain a record in the facility for each resident, which shall include the following: (A) Admission information including the resident ' s name; admission date; confidentiality number; previous address; birth date; sex; marital status; Social Security number; Medicare and Medicaid numbers (if applicable); name, address and telephone number of the resident's physician and alternate; diagnosis, name, address and telephone number of the resident ' s legally authorized representative or designee to be notified in case of emergency; and preferred Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 (X2) MULTIPLE CONSTRUCTION CROSS-REFERENCED TO THE APPROPRIATE PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 6 of 15 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 dentist, pharmacist and funeral director; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed ensure all resident medical records were updated to include the resident's preferred dentist, pharmacist and funeral director for six of eight sampled residents (Residents #4, #5, #1, #8, #6, and #7). The census was 82. 1. Review of Resident #4's medical record, showed the following: -Admit date 11/4/20; -No documented preferred funeral home, pharmacy, or dentist. 2. Review of Resident #1's medical record, showed the following: -Admit date 3/30/24; -No documented preferred funeral home or dentist. 3. Review of Resident #5's medical record, showed the following: -Admit date 12/21/23; -No documented preferred funeral home. 4. Review of Resident #8's medical record, showed the following: -Admit date 6/4/24: -No documented preferred funeral home. 5. Review of Resident #6's medical record, showed the following: -Admit date 8/8/24: -No documented preferred dentist. 6. Review of Resident #7's medical record, showed the following: -Admit date 10/3/24; Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 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 7 of 15 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: 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 ALLEGRO (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 -No documented preferred dentist. 7. During an interview on 10/30/24 at 4:15 P.M., the Administrator said she was aware the pharmacy and funeral home needed to be included in the record but was unaware that a dentist was required. She said she was not aware the information was not included in the resident files. 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) Areview 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 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 Missouri Department of Health and Senior Services STATE FORM 6899 $G9511 PRINTED: 11/14/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 10/30/2024 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 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 8 resident was completed for six of eight sampled residents (Residents #2, #4, #1, #6, #8 and #5). The census was 82. 1. Review of Resident #2's medical record, showed the following: -Admit date 1/31/19; -No documented monthly summary for 7/2024, 8/2024 and 9/2024. 2. Review of Resident #4's medical record, showed the following: -Admit date 11/4/20; -No documented monthly summary for 6/2024, 7/2024, 8/2024 and 9/2024. 3. Review of Resident #1's medical record, showed the following: -Admit date 3/30/24; -No documented monthly summary for 8/2024 and 9/2024. 4. Review of Resident #6's medical record, showed the following: -Admit date 8/8/24: -No documented monthly summary for 8/2024 and 9/2024. 5. Review of Resident #8's medical record, showed the following: -Admit date 6/4/24: -No documented monthly summary for 6/2024, 7/2024, 8/2024 and 9/2024. 6. Review of Resident #5's medical record, showed the following: -Admit date 12/21/23; -No documented monthly summary for 7/2024, 8/2024 and 9/2024. Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 9 of 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 9 7. During an interview on 10/30/24 at 2:21 P.M., the Director of Nursing said she had not been completing the monthly summaries for the past three months because she was the only nurse in the building during that time. She said she was aware they were required but was unable to complete them. 8. During an interview on 10/30/24 at 4:15 P.M., the Administrator said she was aware monthly summaries were not being completed on the residents. She said they only had one nurse in the community and she was trying to assist where she could to keep up with the documentation but they had not been able to do so. 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. 1/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 Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 10 of 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 10 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 in cardiopulmonary resuscitation (CPR) were available on each shift, to meet the needs of full code residents, for 30 of 82 residents who resided in the facility. The census was 82. Review of the facility's list of resident code status’, showed 30 residents with a full code status resided in the facility. Review of the facility's schedule for the month of October 2024, showed the following: -On 10/1/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/2/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/3/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/4/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/5/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/6/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/7/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/8/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 11 of 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 11 -On 10/9/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/10/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/11/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/12/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/13/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/14/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/15/24 from 5:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/16/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/17/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/19/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/20/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/22/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/23/24 from 7:30 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/24/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/26/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift; -On 10/27/24 from 11:00 P.M. to 7:00 A.M., no CPR trained person on shift. During an interview on 10/30/24 at 4:15 P.M., the Administrator said a former nurse had been responsible for scheduling but now she is being trained for CPR certification and will be taking over the scheduling. She said she was aware there were employees without the training but she was not aware they had shifts that were not Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 12 of 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 12 covered with at least one person who is CPR trained. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/III This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to ensure staff washed their hands and/or changed gloves between tasks while preparing and serving resident meals for one of one observed meal preparation and service. This had the potential to affect all residents. The census was 82. Observation on 10/30/24 between 7:25 A.M. and 8:03 A.M., showed the following: -At 7:28 A.M., Cook A donned a pair of gloves and used his/her right hand and poured liquid eggs onto the stove top griddle. He/she walked to the upright refrigerator and opened the door with his/her right hand. He/she grabbed a container of spinach and mushrooms and carried it over to the counter. He/she grabbed a handful of spinach with her right gloved hand and placed it on the eggs on the stove top. He/she grabbed a handful of sliced mushrooms and put them in the eggs on the stove top. He/she grabbled a spatula with his/her right hand and flipped the Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 13 of 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 13 eggs on the stove top and walked back over to the counter. He/she grabbed a handful of cheese with his/her right hand and placed it on the eggs on the stove top. After plating the eggs he/she removed his/her gloves and washed his/her hands; -At 7:39 A.M., Cook A donned a new set of gloves and passed the spatula from his/her left hand to his/her right hand. He/she flipped pancakes on the stove top and used both hands to get a warming tray. With right hand he/she used a spatula to move the pancakes into the top warming tray with his/her left hand on top of the pancake. With his/her right hand he/she lifted the lid off the warming tray for the bacon, on the steam table. He/she grabbed a handful of bacon from the steam table with his/her right hand and placed it on a plate. With both hands, he/she grabbed another tray and placed it on the counter. With his/her right hand he/she grabbed the spatula and scooped more pancakes off the stove top and into the warming tray with his/her left hand on top of the pancakes. He/she removed his/her gloves and washed his/her hands; -At 7:46 A.M., Cook A donned a new set of gloves and grabbed the spatula with his/her right hand and rested his/her left hand on the counter top. He/she put down the spatula and with both hands grabbed a loaf of bread. With both hands, he/she opened the bag of bread and with his/her right hand and grabbed approximately five slices of bread from the bag and placed them on the counter top next to the stove top. With his/her right hand, he/she picked up the spatula and moved the pancakes on the stove top to the warming tray with his/her left hand on top of the pancakes. He/she picked up a spray can of oil with his/her left hand and passed it to his/her right hand and sprayed the stove top. With his/her Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 14 of 15 PRINTED: 11/14/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1055 BELLEVUE AVENUE RICHMOND HEIGHTS, MO 63117 (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) ALLEGRO Continued From page 14 right hand, she grabbed the lid to the warming tray and placed it over the pancakes. With both hands, he/she picked up a bow! of french toast mixture. He/she held the bow! in his/her left hand and with his/her right hand, dunked a slice of bread into the mixture and placed it on the stove top. He/she repeated these steps until all slices of bread were on the stove top. He/she removed his/her gloves and washed his/her hands; -At 8:03 A.M., Cook A donned a new set of gloves and passed a cleaning cloth from his/her left hand to his/her right hand and wiped off the counter top. With his/her right hand, he/she grabbed the spatula to move the french toast on the stove top. With his/her right hand, he/she picked up french toast slices and placed them into a Styrofoam container. He/she walked to the steam table and with his/her left hand, grabbed bacon slices and placed them into the same container. He/she removed his/her gloves and washed his/her hands. During an interview on 10/30/24 at 4:15 P.M., the Administrator said Cook A should have changed gloves when transitioning from task to task. She said she would have expected him/her to change gloves between touching surfaces and touching food and that once a surface has been touched the gloves are contaminated. She was not aware the cook was not changing gloves or washing hands between tasks. Missouri Department of Health and Senior Services STATE FORM 6899 SG9511 If continuation sheet 15 of 15 PLAN OF CORRECTION Provider/Suppli er Name: Allegro Richmond Heights Street Address, City, Zip: 1055 Bellevue Avenue Date of Survey: 10/30/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE COMPLETION TAG ACTION SHOULD BE CROSS-REFERENCED TO THE DATE APPROPRIATE DEFICIENC 19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard A2202 (D) The department shall have the right inspection on any portion of a building in which licensed facility is located unless the unlicensed portion is separated by two-(2) hour fire-resistance construction. No section of the building shall present a fire hazard. I/II The Dining Services Director will ensure that the CO2 tanks in 11/14/2024 the kitchen are properly secured for the soda machine dispenser using the chains that are provided. The Dining Services Director will ensure that it always remains secure, Ongoing especially when changing out the CO2 tanks. The Dining Services Director will ensure that the extra CO2 11/14/2024 tanks in the dry storage area of the kitchen are properly stored. It will be monitored by the Maintenance Director & Executive ; Director for compliance. Ongoing A3235 19 CSR 30-86.032(34) Hot Water 105-120 Degrees F Plumbing fixtures which are accessible to residents, and which supply hot water shall be thermostatically controlled so that the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120*F)(49*C) and the water shall be at temperature range between one hundred five degrees Fahrenheit (105*F)(41*C) and one hundred twenty degrees Fahrenheit (120*)(49*C). I/II The Maintenance Director has purchased a digital thermometer 11/5/2024 to use when testing water temperatures that was suggested by surveyors. The Maintenance Director will keep logs and test the water Ongoing temperatures using the recommended digital thermometer in resident apartments, community spaces & community A4836 bathrooms to ensure compliance. The Maintenance Director will monitor the water heater to ensure it is in working order with proper temperatures. It will be monitored for compliance by the Executive Director 19CSR 30-86.047(58)(A)} Resident Record Admission Information 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 & Medicaid numbers (if applicable); name; address and telephone number of resident's physician and alternate; diagnosis, name address and telephone of the resident's legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director; Hi Resident #4 Resident Record Admission or Face Sheet has been updated to reflect their preferred funeral home, pharmacy and dentist. Resident #1 Resident Record Admission or Face Sheet has been updated to reflect their preferred funeral home and dentist. Resident #5 Resident Record Admission or Face Sheet has been updated to reflect their preferred funeral home. Resident #8 Resident Record Admission or Face Sheet has been updated to reflect their preferred funeral home. Resident #6 Resident Record Admission or Face Sheet has been updated to reflect their preferred dentist. Resident #7 Resident Record Admission or Face Sheet has been updated to reflect their preferred dentist. The Move-In Coordinator will ensure families & residents complete the move-in-paperwork in its entirety ensuring that we have preferred funeral home, pharmacy and dentist upon admission. The Resident Services Director & the Assistant Resident Services Director will monitor them for compliance when receiving al] the paperwork for new move ins. Ongoing 11/20/2024 11/20/2024 11/20/2024 11/20/2024 11/20/2024 11/20/2024 Ongoing Ongoing — A4837 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) Areview monthly or more frequently, if indicated, of residents 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 logging of the medication regimen review process; a monthly weight; a record of each referral of resident for services from an outside service; and a record of any resident incidents including behaviors that presenta reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III Resident Condition & Medication Reviews/Monthly Summaries for residents #1, #2, #4, #5, #6 & #8 have 12/05/2024 been completed to reflect the requirements of this regulation. The Resident Services Director & The Assistant Resident Services Director will ensure that monthly Ongoing summaries are completed on all residents to reflect the requirements of this regulation moving forward. The Executive Director will monitor for compliance, Ongoing ongoing. A4841 . , , 19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have adequate number and type of personnel for the proper care of residents, the residents’ social well-being, protective oversight of residents and upkeep of facility. At minimum, the staffing pattern for safety and care of residents shall be one (1) staff person for every (15) residents or a major fraction of fifteen (15) during the day shift, one (1) person for every 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. The Resident Services Director & Assistant Resident Ongoing Services Director will ensure appropriate staff are | receiving training regarding CPR. Furthermore, they will monitor the schedule to ensure 12/05/2024 that appropriately trained staff are available on each shift to meet the needs of full-code residents. The Executive Director will monitor for compliance. Ongoing 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/HI 11/30/2024 All Cooks and Servers have been in-service on proper handwashing by the Dining Services Director. All Cooks and Servers have been in-service on proper La donning of gloves, infection control measures & how to | avoid cross contamination by the Dining Services Director. . Ongoing It will be monitored for compliance by the Executive Director, ongoing. 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.