CEDARHURST OF ST. CHARLES ASSISTED LIVING & MEMORY CARE.

PRINTED: 02/25/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (%5) PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TaG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) CEDARHURST OF ST CHARLES ASSISTED LIVING & A2253' 19 CSR 30-86.022(9)(G) Fire Alarm * System-Correct Faults Complete Fire Alarm Systems. (G) Upon discovery of a fault with the complete fire alarm system, the facility shall correct the fault. I/Il This regulation is not met as evidenced by: Class Il Based on observation and interview, the facility failed to correct a fault with the complete fire alarm system. The facility census was 104. This deficiency affects 104 of 104 residents. Observation showed the fire alarm with a trouble signal on the panel. The panel showed CO , Detectors were at 0% life left. . During an interview on 2-20-2025 at 1:30 pm the maintenance director said they had the fire alarm company in the fix it and change out all the detectors. The alarm panel wont acknowledge the new detectors, and have scheduled a programmer to come out and resolve the programming issue. The fire alarm is functioning and has been tested and is working. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards, (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Hr Services LABORATORY DIREC, JRISUPPLIER REPRESENTATIVE'S SIGNATURE (X8) DATE yond da che p Jer b,0 +: STATE FORM /' = 4DWX11 \Foontinuation sheet 1 of 2 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 CEDARHURST OF ST CHARLES ASSISTED LIVING & (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 02/25/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 02/20/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(9)(G) Fire Alarm System-Correct Faults Complete Fire Alarm Systems. (G) Upon discovery of a fault with the complete fire alarm system, the facility shall correct the fault. I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility failed to correct a fault with the complete fire alarm system. The facility census was 104. This deficiency affects 104 of 104 residents. Observation showed the fire alarm with a trouble signal on the panel. The panel showed CO Detectors were at 0% life left. During an interview on 2-20-2025 at 1:30 pm the maintenance director said they had the fire alarm company in the fix it and change out all the detectors. The alarm panel wont acknowledge the new detectors, and have scheduled a programmer to come out and resolve the programming issue. The fire alarm is functioning and has been tested and is working. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Based on observation and interview, the facility Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 4DWX11 If continuation sheet 1 of 2 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 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 CEDARHURST OF ST CHARLES ASSISTED LIVING & SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG Continued From page 1 failed to ensure protection from hazards by storing unnecessary combustible materials in any part of the building. The facility census was 104. This affected 104 of 104 residents. Observation showed the resident storage room with supplies, furniture, boxes, and miscellaneous items piled in the floor in an excessive amount. This greatly increased the fuel load of this room. During an interview on 2-20-2025, at 1:30 P.M. the Maintenance Director said he/she would organize the items in the storage room and get rid of what wasn't needed. 19 CSR 30-86.032(2) Substantially Constructed & Maintained 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 Ill Based on observations and an interview this facility had failed to maintain the building in good repair. The facility census was 104. This potentially affected 104 of 104 residents. Observation showed several ceiling tiles missing in the laundry room. During an interview on 2-20-2025 at 1:36 P.M. with the maintenance director said they had a water leak and had to remove the damaged tiles. Missouri Department of Health and Senior Services STATE FORM 6899 4DWX11 (X2) MULTIPLE CONSTRUCTION PRINTED: 02/25/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/20/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE If continuation sheet 2 of 2 PLAN OF CORRECTION Provider/Supplier Cedarhurst of St. Charles Name: Street Address, . . 1800 First Capitol Drive St. Charles, MO 63301 City, Zip: Date of Survey: 2/20/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE Faulty CO2 detector fixed on 2/22/25 by Barcom. ESD or A2253 Designated person will do monthly check on system and sign off 2/22/2025 in TELS system when completed. Resident storage cleaned and organized on 3/6/25. Resident A2257 storage will be checked monthly by ESD or designated person. 3/6/2025 ESD or designee will sign off in TELS system when completed. | | INC All ceiling tiles were replaced on 2/21/25. ESD or designated A3201 person will do monthly checks for damaged ceiling tiles and sign 2/21/2025 off in TELS when completed. [I | WII The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 05/28/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: {X3) DATE SURVEY COMPLETED Cc 05/17/2024 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING 30676 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 CEDARHURST OF ST CHARLES ASSISTED LI (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A6041 19 CSR 30-87.020(41) Toilet Room Requirements Toilet rooms shall be conveniently located and easily accessible to residents and employees. Toilet rooms shall be completely enclosed. Toilet fixtures shall be kept clean and in good repair. A | supply of toilet tissue shall be provided at each toilet at all times. Easily cleanable receptacles shall be provided for waste materials. Toilet rooms used by women employees shall have at : least one (1) covered waste receptacle. III This regulation is not met as evidenced by: Class Ill Based on observation, interview, and record review, the facility failed to ensure resident | bathooms were cleaned daily and maintained in a neat, orderly manner for six resident (Resident | #2, #3, #4, #5, #6 and #7) of eight sampled residents. The facility census was 104. The facility did not provide a policy for the cleaning and maintenance of the resident's _ bathrooms. 1. Review of Resident #2's face sheet showed the resident was admitted to the facility on 12/9/22 with the diagnoses of Dementia, anxiety and Alzheimer's disease. Review of the care plan for use of the bathroom dated 11/1/23 showed resident needs assistance and reminders to use the bathroom, changing ‘ briefs and peri care. Observation on 5/17/24 at 10:00 A.M. of the resident's bathroom showed feces smeared on the toilet seat and hand rail in the bathroom. Missoufi Department of Hgalth and Senior Services LABQRATJORY DIRECTO! aS OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATOR E TITLE (X6) DATE ZAIN LKR. ALLUT UE ) tsk &ls/a4f STATE FORM / 6899 QKZL11 If continuation sheat 1 of 4 PRINTED: 05/28/2024 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 C 30676 B. WING 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 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) CEDARHURST OF ST CHARLES ASSISTED LI\ Continued From page 1 2. Review of Resident #3's face sheet showed the resident was admitted to the facility on 11/5/21 with the diagnosis of Alzheimer's disease. Review of the care plan for use of the bathroom dated 5/7/24 showed resident needs reminders to use the bathroom and assistance with peri care. Observation on 5/17/24 at 10:05 A.M. of the resident's bathroom showed feces smeared on the toilet seat. 3. Review of Resident #4's face sheet showed the resident was admitted to the facility on 1/2/20 with the diagnoses of Alzheimer's disease and dementia. Review of the care plan for use of the bathroom dated 9/21/23 showed resident needs assistance with all aspects of using the bathroom and peri care. Observation on 5/17/24 at 10:15 A.M. of the resident's bathroom showed: -Feces smeared on the toilet seat; -A brown substance smeared on the light switch. 4. Review of Resident #5's face sheet showed the resident was admitted to the facility on 12/20/23 with the diagnosis of cognitive impairment. Review of the care plan for use of the bathroom dated 2/27/24 showed resident needs reminders and prompts to change briefs and to use the bathroom. Housekeeping services weekly. Observation on 5/17/24 at 9:55 A.M. of the resident's bathroom showed: Missouri Department of Health and Senior Services STATE FORM Sa99 QKZL11 If continuation sheet 2 of 4 PRINTED: 05/28/2024 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 C 30676 B. WING 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 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) CEDARHURST OF ST CHARLES ASSISTED LI\ Continued From page 2 -There was a strong odor of feces in the bathroom; -There were feces on the rug on the floor in front of the toilet; -Feces were smeared on the toilet seat. 5. Review of Resident #6's face sheet showed the resident was admitted to the facility on 2/8/24 with the diagnosis of dementia. Review of the care plan for use of the bathroom dated 2/27/24 showed the resident needs assistance to use the bathroom and needs help with peri care. Observation on 5/17/24 at 12:10 A.M. of the resident's bathroom showed feces smeared on the toilet seat. 5. Review of Resident #7's face sheet showed the resident was admitted to the facility on 1/16/23 with the diagnosis of dementia. Review of the care plan for use of the bathroom dated 9/12/23 showed needs reminders to use the bathroom and change soiled briefs. Observation on 5/17/24 at 10:20 A.M. of the resident's bathroom showed atoilet riser covered the toilet seat, there was a black substance on the toilet riser and the toilet seat. During an interview on 5/17/24 at10:00 A.M., Level One Medication Aide (L1MA) A said the following: -A housekeeper will come to the memory care unit several days a week and clean the resident rooms and bathrooms; -If a resident has an accident, the memory care staff should clean up the feces or urine then notify Missouri Department of Health and Senior Services STATE FORM Sa99 QKZL11 If continuation sheet 3 of 4 PRINTED: 05/28/2024 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 C 30676 B. WING 05/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 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) CEDARHURST OF ST CHARLES ASSISTED LI\ Continued From page 3 the housekeeper to sanitize the room. During an interview on 5/1724 at 10:15 A.M. Housekeeper C said the following: -He/She cleans the memory care unit three days a week; -There were several rooms on the memory care unit that he/she will check every day that he/she works, due to the resident's incontinence; -There are supplies kept on the memory care unit for staff to clean if a resident is incontinent, then they will let a housekeeper know to sanitize the room. During an interview on 5/17/24 at 11:15 A.M. the Director of Nursing said the following: -Housekeeping will clean the resident rooms and bathrooms on the memory care unit several times a week; -The memory care staff should clean the rooms or bathrooms if a resident is incontinent then notify housekeeping to sanitize the room. There are supplies in a closet for the staff to sue. During an interview on 5/17/24 at 12:20 P.M. the Administrator said the following: -It was her expectation for the staff to ensure that resident rooms, bathrooms and common areas are clean; -She would expect staff to clean up an incontinent episodes then notify housekeeping to sanitize the rooms. MO234858 Missouri Department of Health and Senior Services STATE FORM Sa99 QKZL11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Cedarhurst St. Charles Name: Street Address, . _ 1800 First Capitol Dr. St. Charles, MO 63301 City, Zip: Date of Survey: 5/17/24 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE ED/AED/DON/ESD provided in-service to housekeeping and Director or designee will check Memory Care apartment A6041 cleanliness and cleaning procedure. care staff on the restroom cleaning procedures. Memory Care restrooms twice daily x60 days. Memory Care Director will keep a log at the Memory Care nurses station. All new employees will be in-serviced during orientation and quarterly on restroom 5-21-24 ED/AED/DON/ESD provided an in-service to care staff and housekeeping staff on the availability and location of housekeeping supplies in MC. All new care staff and housekeeping staff will be in serviced during orientation and quarterly. 5-21-24 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 01/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED EFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 30676 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 CEDARHURST OF ST CHARLES ASSISTED LIVING & (x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4776 19 CSR 30-86.047(35) Protective Oversight Protective oversight shall be provided twenty-four (24) hours a day. For residents departing the premises on voluntary leave, the facility shall have, at a minimum, a procedure to inquire of the resident or resident ' s guardian of the resident's departure, of the resident ' s estimated length of absence from the facility, and of the resident's whereabouts while on voluntary leave. I/II This regulation is not met as evidenced by: Class |* Based on observation, interview, and record review, the facility failed to provide protective oversight to prevent injury for one resident (Resident #1) with diagnoses of dementia, anxiety disorder, and macular degeneration (a disease that affects a person's central vision). On 1/14/24, the resident exited the facility at approximately 2:00 A.M. in below freezing temperatures without staff knowledge to an outdoor sitting/smoking area that required a key card for reentry. The resident was outside for approximately 46 minutes, unable to get back inside on his/her own. The outside temperature on 1/24/24 at 2:51 A.M. was -1 degree Fahrenheit (F) with wind chills up to -25 degrees F. The facility identified two residents (Resident #1 and #2) who smoked and were assessed as safe to smoke independently and could regain access to the facility on their own. Resident #2 said he/she | was not aware of how he/she would get back into the facility from outside. The facility census was 98, Review of the undated facility policy, Smoking, showed the following: -Residents and visitors may smoke in the outside designated areas only, if available; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVID) UPPLIER REPRESENTATIVE'S SIGNATURE TLE (x6) DATE STATE FORM 6899 133511 If continuation sheet 1 of 11 PRINTED: 01/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 30676 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 NAME OF PROVIDER OR SUPPLIER CEDARHURST OF ST CHARLES ASSISTED LIVING & PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 -All residents who wish to smoke will be evaluated for safety and their ability to handle smoking equipment safely. Evaluations for | smoking safely will occur in conjunction with the | Individualized Service Plan (ISP) reviews or on a change in condition; -All residents who are active smokers will have their smoking status addressed in the ISP; -The designated smoking areas in this Community are outside. 1. Review of Resident #1's face sheet showed the following: -Admission date of 10/31/23; -Diagnoses included dementia, anxiety, macular degeneration, rheumatoid arthritis, and adult failure to thrive. Review of the resident's ISP, completed on 10/31/23, showed the following: -The resident was alert and oriented and was able to make his/her own choices and was able to make needs known; -The resident smoked cigarettes outside the facility in the designated smoking area; -The resident had access to a key card to make it in the building as often as needed; -The resident walked his/her dog while outside smoking; -The resident dressed appropriately for the weather while outside; -The resident would be safe while outside smoking and would dress appropriately and take the key access card while outside; -Please supervise the resident while outside getting fresh air so the resident did not leave the property unsupervised; -Monitor the resident for changes in mood or behavior and notify the nurse and physician; -Observe the resident's location in the community Missouri Department of Health and Senior Services STATE FORM ouee 4133511 If continuation sheet 2 of 11 PRINTED: 01/26/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: c 01/14/2024 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 NAME OF PROVIDER OR SUPPLIER CEDARHURST OF ST CHARLES ASSISTED LIVING & (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 2 to be sure of his/her safety and the safety of others; -Provide or arrange one on one or frequent checks to monitor the resident until no longer | trying to leave the community unsupervised; -The resident had periods of confusion and impaired judgement and needed help finding his/her way around the community. Review of the resident's smoking evaluation, dated 10/31/23, showed the following: | -The resident was able to hold a cigarette in a safe manner without assistance and dispose of ashes and cigarette in a safe manner; | | -The resident understood the community's smoking policy and procedure and was capable of following the policy; -Staff determined the resident was able to be an independent smoker. The resident's smoking evaluation, dated 10/31/23, did not address the resident's ability to regain entry into the facility. Review of the resident's general information note, dated 1/14/24 at 2:50 A.M., showed staff found the resident outside. Memory care staff heard the resident yelling out for help. The resident stated he/she locked himself/herself out of the community. Staff notified the supervisor. Observation of the facility's camera footage (video only, no audio) for 1/14/24, reviewed with the environmental services director (ESD) on 1/14/24 at 7:45 P.M. showed the following: -At 1:48 A.M. the resident opened the door to the outside smoking area on the first floor, felt outside with his/her hand, came back inside and closed the door; -At 1:58 A.M. the resident wore a winter coat with Missouri Department of Health and Senior Services STATE FORM ee 133511 If continuation sheet 3 of 11 PRINTED; 01/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 NAME OF PROVIDER OR SUPPLIER CEDARHURST OF ST CHARLES ASSISTED LIVING & (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 3 a hood, pants and shoes and went out the door to the smoking area with his/her dog. The resident was not wearing a hat or gloves; -At 2:02 A.M. the resident looked in through and knocked on the window and attempted to get back in through the door which he/she could not open; -At 2:16 A.M. the resident sat in a chair by the smoking area door with the coat hood pulled over his/her head; -At 2:22 A.M. and 2:30 A.M. the resident pulled on the door, and attempted to get back inside; -At 2:41 A.M. the resident sat in a chair by the smoking area door; -At 2:44 A.M. three staff members brought the resident inside; -The resident was outside for 46 minutes. During an interview on 1/14/24 at 5:01 P.M. Certified Nurse Assistant (CNA) B said when he/she completed rounds on 1/13/24 around 7:00 P.M. the resident was confused. CNAB heard a thump when he/she passed by the resident's _ room. CNA B checked on the resident who said he/she had bumped his/her head. The resident was unsteady and was looking for his/her dog that was laying on the resident's bed. The resident said that was not his/her dog and started pulling on the dog's legs. The resident said the apartment he/she was in was not his/her apartment. CNA B notified Certified Medication Technician (CMT) A of the resident's confusion. CNAB checked on the resident again around 1:00 A.M. and the resident was in his/her room talking to his/her dog. Resident #1 was an independent smoker and could smoke on his/her own. There was an exit door on the first floor to the smoking area. Staff members receive an alert on their pagers that notify them when an exit door is opened. On 1/14/24 CNAB did not receive Missouri Department of Health and Senior Services STATE FORM = 133511 If continuation sheet 4 of 11 PRINTED: 01/26/2024 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 c B. WING —__ 01/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE CEDARHURST OF ST CHARLES ASSISTED LIVING & SAINT CHARLES, MO 63301 (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) A4776 Continued From page 4 ' notification when the resident opened the smoking area exit door. Staff heard the resident from outside the building. When the resident | came back inside, his/her knuckles were very red and cold. The resident said he/she was going to a graduation and wanted some hot tea. The _ resident had a coat with a hood on but no hat or gloves. Staff contacted emergency medical services (EMS) who transported the resident to the hospital. During an interview on 1/14/24 at 7:54 P.M. CMT Asaid CNAB told him/her the resident had been confused earlier in the shift on 1/14/24, saying the apartment was not his/hers and not recognizing his/her dog, and that the resident said he/she had bumped his/her head. CMT A said he/she did not observe this and CMT A's interaction with the resident when administering his/her medications around midnight did not show anything unusual. Staff found the resident outside around 3:00 A.M. CMT A did not receive any alert on his/her pager that any exit door had been opened. When staff brought the resident and his/her dog back inside, his/her hands and nose were red and cold. CMT _ Aattempted to obtain the resident's vital signs, but it was difficult because the resident was so cold and shaking. The resident was very anxious and worried about his/her dog. CMT Acalled EMS and notified the Director of Nursing (DON). The resident said he/she forgot his/her key. CMT A | had never seen the resident take his/her dog | outside at night before and the resident going outside at night was unusual. During an interview on 1/14/24 at 4:36 P.M. resident assistant (RA) C said he/she was working on the memory care unit on the third floor on 1/14/24 around 3:00 A.M. when he/she heard Resident #1 screaming “Help me, help me!" from Missouri Department of Health and Senior Services STATE FORM eee 133511 If continuation sheet 5 of 11 PRINTED: 01/26/2024 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 Cc 30676 8. WING J _______ 01/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 (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) CEDARHURST OF ST CHARLES ASSISTED LIVING & Continued From page 5 | the outside smoking area on the first floor. RAC | thought it was a homeless person at first before he/she realized it was a resident. RA C went downstairs and found the resident sitting on a bench in the outside smoking area hunched over with his/her dog and let the resident back into the facility. The resident was confused and kept saying “Help me, help me!". RAC was not aware the resident ever went outside or that the resident ever took his/her dog outside. RA C was not aware Resident #1 was a smoker. | During an interview on 1/14/24 at 3:34 P.M. the Life Enrichment Director said Resident #1 was admitted to the facility a few months ago. The resident was a smoker and utilized the outside smoking area, which was near his/her hallway. The resident was usually alert and oriented but he/she could not see very well. Staff sent the resident to the hospital around 3:00 A.M. that morning after finding him/her wandering outside with his/her dog. The staff who found the resident said the resident was very confused at that time. Review of Wunderground.com showed the | temperature on 1/14/24 at 2:51 A.M. was -1 Fahrenheit (F)with wind chills as low as -25 F Observation of the outdoor smoking area, located on the back side of the facility, on 1/14/24 at 8:13 P.M. showed an approximately 8 foot wide by 15 foot long concrete surface with a sidewalk located on either side of a double-door entrance. The concrete surface connected directly to an adjacent parking lot. There was a small overhang, located above the double-door entrance, that extended out from the building (the overhang did not extend down to the ground). The area had standard outside lighting and there were bushes on either side of the entrance with Missouri Department of Health and Senior Services STATE FORM = 133511 If continuation sheet 6 of 11 PRINTED: 01/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 30676 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 NAME OF PROVIDER OR SUPPLIER CEDARHURST OF ST CHARLES ASSISTED LIVING & (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 6 no constructed shelter or windbreak present. A proximity door card reader and door bell were | located to the right of the doors (as viewed from the outside facing the building) and a metal chair and a metal cigarette receptacle were located to _ the left of the doors. During an interview on 1/14/24 at 10:31 A.M. hospital staff D said the resident was admitted to the hospital on 1/14/24 with diagnoses of frost bite to both hands and altered mental status. During a telephone interview on 1/25/24 at 10:27 A.M. the Emergency Department (ED) charge nurse said the resident was seen in the ED on 1/14/24. He/She reviewed the resident's physician's notes which showed the resident was admitted to the hospital on 1/14/24 for skin changes consistent with first and second degree frost bite to both hands. The resident was in significant pain which required intravenous (IV) pain medication to be administered in the ED to alleviate pain before the resident could be admitted to the hospital. Wound care was consulted for topical treatment to the resident's hands. 2. Review of Resident #2's undated face sheet showed the following: -Admission date of 12/21/22; -Diagnoses included dementia, nicotine dependence, insomnia, disorientation, syncope (a loss of consciousness for a short period of time) and collapse, and stroke. Review of the resident's smoking evaluation, dated 12/21/23, showed the following: -The resident was able to hold a cigarette in a safe manner without assistance and dispose of ashes and cigarettes in a safe manner; Missouri Department of Health and Senior Services STATE FORM td 133511 If continuation sheet 7 of 11 PRINTED: 01/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERI/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 30676 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) NAME OF PROVIDER OR SUPPLIER CEDARHURST OF ST CHARLES ASSISTED LIVING & Continued From page 7 -The resident understood the community's smoking policy and procedure and was capable of following the policy; -Staff determined the resident was able to be an independent smoker. The resident's smoking evaluation dated 12/21/23, did not address the resident's ability to regain entry into the facility. | Review of the resident's ISP, completed 12/29/23, showed the following: -The resident required reminders and redirection on an “as needed" basis. Offer reminders when the resident was forgetful; -The resident required frequent safety checks when outside; -The resident liked to go outside on the patio. If it was too hot outside, remind the resident to wear appropriate clothing and offer fluids; -The resident would continue to go outside to smoke cigarettes and remain safe. Staff would perform checks on the resident while he/she was outside if the weather was too hot or too cold. During an interview on 1/14/24 at 6:07 P.M. the resident said he/she went outside to smoke after supper. The resident was not sure if he/she was supposed to use a key or enter a code at the door to get back into the facility. The resident showed the surveyor a bracelet with a door key and a white key card but seemed confused and said he/she did not know how he/she gets back into the facility, saying he/she just opened the door. The resident continued to appear confused and asked the inspector what their name was several times and said he/she could not remember what he/she had eaten for dinner. The resident was unable to recall the name of the facility and again said he/she was not sure how to get back into the Missouri Department of Health and Senior Services STATE FORM 6899 133511 if continuation sheet 8 of 11 PRINTED: 01/26/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 30676 B. WING STREET ADORESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 NAME OF PROVIDER OR SUPPLIER CEDARHURST OF ST CHARLES ASSISTED LIVING & (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) Continued From page 8 facility from the outside smoking area. During an interview on 1/14/24 at 8:25 P.M. the life enrichment director said when the weather was nice, a lot of residents went outside. If staff noticed it was a specific resident, they may keep an eye on them. Residents only had to sign out if they were leaving facility grounds. Resident #2 typically went outside to smoke in the mornings about 8:45 A.M. and in the evening after supper. Resident #2 had told him, at least once, that he/she wasn't sure how to use the key card to get back inside. The life enhancement director had to remind Resident #2 how to use the key card. | 3. During an interview on 1/14/24 at 5:18 P.M. the life enrichment director said residents had key cards they used to swipe to unlock the doors to | get into the facility. Staff members' pagers received a notification any time someone opened an exit door. There was only one designated smoking area, which was outside on the first floor. There were two residents who smoked, Resident #1 and #2. Observation on 1/14/24 showed the following: -At 8:13 P.M. CMT A opened the exit door to the smoking area on the first floor. CMT Adid not receive any notification on his/her pager that an | exit door had been opened; -At 8:15 P.M. CMT A opened the exit door by the activity room on the first floor. CMT A did not receive any notification on his/her pager that an exit door had been opened. During an interview on 1/14/24 at 8:30 P.M. and 10:02 P.M. the environmental services director said he completed monthly checks of the exit doors to ensure they were working and checked the batteries in the doors weekly. He did not Missouri Department of Health and Senior Services STATE FORM - 133511 If continuation sheet 9 of 11 PRINTED: 01/26/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING; (x3) DATE SURVEY COMPLETED Cc 01/14/2024 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 CEDARHURST OF ST CHARLES ASSISTED LIVING & (x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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) AA776 | Continued From page 9 complete any checks to ensure the exit doors were sending alerts to staff members pagers. The battery sensors on the doors may not be working properly due to the cold temperatures. The environmental services director discovered on 1/14/24 that one exit door on the first floor had a battery that failed. The other exit door on the first floor had a magnet that had snapped off. This was why those exit doors were not sending signals to the staff members’ pagers. During an interview on 1/14/24 at 6:50 P.M., 7:31 P.M., 9:08 P.M. and 9:52 P.M. the executive _ director said Resident #1 went outside a couple _ of times a day to walk his/her dog and was not sure how often Resident #1 went outside to smoke. The facility did not have a policy and procedure regarding how often to complete residents' smoking assessments, but she would expect staff to complete them every six months and more frequently if there was a significant change with a resident. The life enhancement director found Resident #1’s key card in his/her dresser drawer in the resident's apartment. Resident #1 normally carried the key card in | his/her coat pocket. The life enhancement director had just spoken to the resident at the hospital. The resident said he/she went outside with the dog and forgot his/her key card and panicked. The main front door of the facility was never locked. All other doors were locked but had doorbells. Resident #1 did not use the doorbell, call pendant, or walk to the unlocked front door. Any time an exit door was opened, a notification was sent to staff members pagers. Staff should pay attention and be aware of residents coming and going. She was not aware the two exit doors ° on the first floor were not alerting to staff members' pagers. The environmental services director went with CMT A to the exit doors and Missouri Department of Health and Senior Services STATE FORM 6890 133511 If continuation sheet 10 of 11 PRINTED: 01/26/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 01/14/2024 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1800 FIRST CAPITOL DRIVE SAINT CHARLES, MO 63301 CEDARHURST OF ST CHARLES ASSISTED LIVING & (xa)ID | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) | Continued From page 10 | also observed the two exit doors on the first floor were not sending alerts to staff members’ pagers. The executive director was not aware Resident #1 had been confused about not knowing his/her apartment and dog. She would expect staff to _ inform the Director of Nursing and monitor the | resident more frequently since that was completely out of the ordinary for Resident #1. Resident #2 had confusion at times. Some days he/she was better than others. She had never observed Resident #2 go outside at night. Staff should be doing more frequent checks on the residents when it was hot or cold outside. She expected staff to conduct frequent checks of | residents when they went outside, especially during inclement weather. “The higher classification merited due to the extent of the violation and the violation's effect on the residents. NOTE: At the time of the complaint investigation, the violation was determined to be at an imminent danger Class | level. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address the imminent danger. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. | At the time of exit, the severity of the deficiency was lowered to the class || level. } | MO230242 | Missouri Department of Health and Senior Services STATE FORM -_ 133511 If continuation sheet 11 of 11 PLAN OF CORRECTION Provider/Supplier Name: Cedarhurst St. Charles ae 1800 First Capital Drive St. Charles, MO 63379 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER mm ID PREFIXTAG | PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION | COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE ee Pe DON or Designee will do quarterly assessments on residents to determine their ability to gain access to the community should they exit doors leading to the outside. Assessments will be completed quarterly or with a significant change in health. Initial assessments were completed 1/15/24 and will be due in April, July, October. ISP’s will be updated after each assessment. DON/ED has created a binder to be kept at the nurse's station and concierge’s desk of the residents that need assistance to regain access to the community so staff are able to assist the residents that would like to sit outside on the porch. Staff will monitor residents at risk every 10-15 minutes in extreme temps (Below 32 degrees and above 85 degrees). Staff have been in- served on 1/17/24 regarding how to use and where to locate this binder. 1/15/24 1/17/24 ESD or Designee will perform daily checks on doors leading to the outside that alarm the staff pagers when someone exits the doors. These doors were repaired on 1/14/24 and continue to be checked daily. Doors will be checked daily for 90 days then continue to be checked weekly. ESD will check doors daily during times of extreme temps (below 32 degrees/above 85 degrees). Ring doorbells were installed on the front door and 4 back exits to assist residents and families with access to the community. Ring alarm is programed on the nurse phone, ED, AED, DON, MCD, and ESD's phones. ESD to keep log. Residents in-serviced on how to use the ring doorbells. Signage on doors for residents/guests to please ring doorbell and assistance will arrive shortly and vestibule in the front of the 1/14/24 Residents will be in-serviced to sign out at front desk before leaving the community property. A quarterly letter will be distributed to residents and families reminding them to sign out at the front desk if they are leaving the premises. This letter will remind residents on the lower level to sign out at the front desk 1/15/24 only if they are leaving the premises. A sign is hung on the rear doors reminding residents/families the vestibule door is open and they may sit in that area until the door is answered. New residents will be in-serviced at their lease signing and upon arrival to the community. Staff in-serviced to respond immediately to an open-door page received on their pager. If no resident is located outside when a door alarm goes off in extreme temps (below 32 degrees and above 85 degrees) residents will be checked to assure everyone is accounted for. If no resident is located outside during normal temps, staff will do resident check in the immediate area of the building. New staff will be in-serviced at new hire orientation 1/15/24 Staff in-service to notify DON or LPN immediately when noticing a significant change with a resident. After DON is notified, 30- minute checks will be implemented until mental status change begins to resolve or other interventions are put in place. In- service will continue with new employees at new hire orientation. A4776 1/15/24 Resident #1 in-serviced on Ring doorbell as well as pushing pendant when needing to exit the building to take dog out. Resident will receive safety checks every hour within the facility during extreme temperatures of (below 32 degrees and above 85 degrees). Resident will be monitored every 15 minutes if outside during extreme temperatures. Resident care plan A4776 1/19/24 Resident #2 will receive safety checks every hour within the facility during extreme temperatures (below 32 degrees and above 85 degrees). Resident will be monitored every 15 minutes if outside during extreme temperatures. Residents care plan updated. Resident #2 will be transitioning to MC on 2-10- 24. Resident will receive three scheduled/supervised smoking breaks per day, care plan updated. A4776 1/15/24 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.