Autumn View Gardens at Schuetz Road.

PRINTED: 09/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3} DATE SURVEY COMPLETED {X2} MULTIPLE CONSTRUCTION A, BUILDING: c 09/04/2025 22909 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11210 SCHUETZ ROAD SAINT LOUIS, MO 63146 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES Ip 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-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY} AUTUMN VIEW GARDENS AT SCHUETZ ROAD AAT9T 49 CSR 30-86.047(46) Safe & Effective Medication System The administrator shall develop and implement a safe and effective system of medication control and use, which assures thal all residents ' medications are administered by personne! at ieast eighteen (18) years of age, in accordance with physicians " instructions using acceptable aches nursing techniques. The facitity shall employ a Ce. a licensed nurse sight (8) hours per week for every thirty (30) residents to monitor each resident's ‘ condition and medication. Administration of Pl EF Correct er) Medication shall mean defivering to a resident his | on 0 or her prescription medication either in the original pharmacy container, or for internal medication, removing an individual) dose from the pharmacy comlainer and placing it in a small cup container or liquid medium for the resident to rernove from the container and seif-administer, External prescription medication may be applied by facility personnal if the resident is unable to do sce and the resident's physician so authorizes. All | individuals who administer medication shall be trained in medication administration and, if nota physician or a licensed nurse, shall be a certified medication technician or fevel | medication aide. Wil This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to provide a safe and effective medication | system when a staff member who was not qualified to pass medications administered | Medication to one sampled resident (Resident | #2}. Additionally, the facility failed to have a system in piace to ensure staff maintained an appropriate certification to administer medications Missouri Department of Health and Sanior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE Evecvtive Director OVW (X6) DATE STATE FORM uation sheet 1 of 4 PRINTED: 09/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 22909C — 09/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11210 SCHUETZ ROAD SAINT LOUIS, MO 63146 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) AUTUMN VIEW GARDENS AT SCHUETZ ROAD Continued Fram page 1 to residents. The census was 94. 1. Review of Resident #2’s medical record, showed the facility admitted the resident on 7/23/22, with diagnoses which included dementia, high bloed pressure, chronic kidney disease, and diabetes,. Review of the resident's physician's order sheet (POS) dated 8/2025, showed the following: -An order for Atorvastatin (helps prevent serious cardiovascular events like heart attack and stroke) 20 milligram (mg) tablet, give one tablet by mouth at bedtime; -An order for Creon (used to treat people who cannot digest food normally because their pancreas does not make enough enzymes) 36,000 unit capsule, give two capsules by mouth three times daily with meals; -An order for Donepezil (used to treat dementia) 5 mg tablet, give one tablet by mouth one time daily; -An order for Memantine (used to treat moderate to severe Alzheimer's disease) 5 mg tablet, give one tablet by mouth two times daily; -An order for Terbinafine (used to treat fungal skin infections) 1% creme, apply topically to nails two times daily. Review of the resident's medication administration record (MAR) dated 8/2025, showed the following: -On 8/1, 8/4, 8/5, 8/10, 8/12, 8/24, 8/26, 8/27, 8/28, and 8/29/25, Level One Medication Aide (LIMA) D administered Atorvastatin at bedtime, to the resident; -On 8/1, 8/4, 8/5, 8/10, 8/12, 8/24, 8/26, 8/27, 8/28, and 2/29/25, LIMA D administered Creon during the evening timeframe, to the resident; -On 8/1, 8/4, 8/5, 8/10, 8/12, 8/24, 8/26, 8/27, Missouri Department of Health and Senior Services STATE FORM 6838 OVWX14 If continuation sheet 2 of 4 PRINTED: 09/19/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 22909C — 09/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11210 SCHUETZ ROAD SAINT LOUIS, MO 63146 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) AUTUMN VIEW GARDENS AT SCHUETZ ROAD Continued From page 2 8/28, and 8/29/25, L1MAD administered Donepezil during the evening timeframe, to the resident: -On 8/1, 8/4, 8/5, 8/10, 8/12, 8/24, 8/26, 8/27, 8/28, and 8/29/25, L1MA D administered Memantine during the evening timeframe, to the resident; -On 8/1, 8/4, 8/5, 8/10, 8/12, 8/24, 8/26, 3/27, 8/28, and 8/29/25, LIMA D administered Terbinafine during the evening timeframe, fo the resident. 2. Review of LIMA D’s employee file, showed the following: -Date of hire 10/1/24: -L1MA certificate expired on 10/28/24; -No documentation that a renewed state licensed certification of L1MA was obtained. 3. During an interview on 9/4/25 at 1:44 P.M_, the Business Office Manager (BOM) said the Health Services Director (HSD) was responsible for the recertifications of the LIMAs and she was not aware that L1MA D's certification had expired. She said she was aware certification was required to pass medications. 4. During an interview on 9/4/25 at 1:35 P.M_, the HSD said LIMA D had been working as a LIMA and passing medications. She said the BOM was responsible for checking the certifications. She was not aware L1MA D had a certification which had expired. She said she was aware certification was required to pass medications. 5. During an interview on 9/5/25 at 1:32 P.M., the Administrator both the BOM and the HSD are responsible for checking the recertifications' of the L1MAs. She said she was not aware LIMA D's certification had expired and she was aware a Missouri Department of Health and Senior Services STATE FORM 6838 OVWX14 If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 22909C NAME OF PROVIDER OR SUPPLIER 11210 SCHUETZ ROAD AUTUMN VIEW GARDENS AT SCHUETZ ROAD SAINT LOUIS, MO 63146 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 certification was needed to pass medications. Missouri Department of Health and Senior Services STATE FORM 899 OVWX1i (X2) MULTIPLE CONSTRUCTION PRINTED: 09/19/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 09/04/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) lf continuation sheet 4 of 4 PLAN OF CORRECTION t— Provider/ Supplier Name: Auturnn View Gardens Assisted Living Creve Coeur ——i__ Street Address, | 44910 Schuetz Road Creve Coeur, MO 63146 City, Zip: [— Date of Survey: September 4, 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 [ [ [ | Please accept this Plan of Correction as our Credible Allegation | of Compliance. 4 | This Pian of Correction is submitted to meet requirements | éstablished by the state and federal law. L T AAS? | 19 CST 30-86.047 (46) Safe & Effective Medication System | ——} Lith, tit The administrator shail develop and implement a safe and effective system of medication contro! and use, which assures that all residents’ medications are administered. All individuals who administer medication shall be trained in medication administration; a licensed nurse, certified mecication technician, or level 1 medication aide. —— t é ‘| All current staff have been verified that they are certified and scanned in the electronic medical recard system to enable checking each month. _ 1 ED/ HSD/ Designee will ensure all are certified by auditing reports in electronic médical record system each month for expiration dates. As upcomming recertifications are needed, two options will be advised. 1. HSD is certified to do update classes for L1MA (or) [. { 2. ‘Utilize Guardian Pharmacy L1MA classes | 7 Prior to employment, all new hires will be audited for current certification and added on electronic medical record system for monthly audits. = a | |