BRENTMOOR RETIREMENT COMMUNITY.

PRINTED: 01/28/2025 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 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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) BRENTMOOR RETIREMENT COMMUNITY A4506 19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements General Requirements, {A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: | 6. At a minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in an emergency specific to the individual: Il This regulation is not met as evidenced by: Based on interview and record review, the facility failed to provide the responsibilities of specific staff members in an emergency on the Individual Evacuation Plan (lEP), for one of one resident who required an IEP (Resident #2), The census was 15. Review of Resident #2's medical record, showed the facility admitted the resident on 5/3/23, with diagnoses which included cervical spondylosis (a degenerative disease that causes wear and tear on the bones and cartilage in your neck), lumbar spinal stenosis (a narrowing of the spinal canal in the lower back that occurs over time) and high blood pressure. Review of the resident's IEP dated 11/11/24, showed the resident required staff assistance of one person with opening the fire door and propelling his/her wheelchair. The IEP indicated medication technician or floor staff would need to assist, but did not indicate the specific staff position responsible for the resident in the event of total evacuation. Missourl Department of Health and Senior Services LABORATORY DIRECTOR'S OR-PRET Se as fer TATIVE’S SIGNATURE TITLE {X6) DATE ¢ , Di = ae — p p > I L STATE FORM B99 LJKK14 If continvationisheet 1 of 13 PRINTED: 01/28/2025 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: COMPLETED A. BUILDING: Cc 1996BC B. WING J _____ 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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 GOMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} BRENTMOOR RETIREMENT COMMUNITY A4506 Continued From page 1 During an interview on 1/16/25 at 2:48 P.M., the Memory Care Director said she was responsible for creating the resident's IEPs. She said she thought it would be important to designate a specific person to provide the evacuation of the resident so there is no confusion on who is responsible. She was not aware the IEP did nat specify a specific person with as much detail was needed. During an interview on 1/16/25 at 3:15 P.M., the Executive Director said the nurse is responsible for creating the IEPs. She said she thought the | IEP document specified which person would be responsible and did not know their form was not specific. She said it would be important to identify which specific staff would be responsible. 19 CSR 30-86.047(28)(F}(1)(A) Community Based Assessment-Time Period, 5 day The facility may admit or retain an individual for residency in an assisted living facility only if the individual does nat require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: A. Within five (5) calendar days of admission; II | This regulation is not met as evidenced by: | Based on interview and record review, the facility failed to complete a community based assessment (CBA) for each resident within five calendar days of admission, for two of two Missourl Department of Health and Senior Services STATE FORM aege LJKK14 {f continuation shset 2 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN QF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: Cc 49968C B. WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4} 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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) BRENTMOOR RETIREMENT COMMUNITY 44749 Continued From page 2 sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 9/19/22; -Diagnoses included congestive heart failure, diabetes, and chronic kidney disease; -No documented CBA within five days of admission. 2. Review of Resident #2's medical record, showed the following: -Admit date 5/3/23; -Diagnoses included cervical spondylosis (age-related wear and tear of the spinal disks), lumbar spinal stenosis (narrowing of the open spaces in the lower spine), and high bload pressure. Review of the resident's CBA dated 5/3/23, showed the following: -The "prescription meds, dosage and Physician/pharmacy" section was blank; -The "home health agency, condition, frequency and procedure” section was blank. 3. During an interview on 1/16/25 at 2:48 P.M., the Memory Care Director said the nurse is responsible for completing the CBAs. She said she expected them to be filled out completely and was not aware some were not complete and | some did not have all the information required. 4. During an interview on 1/16/25 at 3:17 P.M., _ the Administrator said the nurse is responsible for filling out the CBAs, and she expected them to be filled out completely. She was not aware some of the CBAs were not completed and missing information. Missouri Department of Health and Senior Services STATE FORM 66a LUKK11 (continuation sheat 3 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 19968C ——<$<———————————— 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4)1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6) 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) BRENTMOOR RETIREMENT COMMUNITY A4750 19 CSR 30-86.047(28)(F)(1}(B) Community Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B, At least semiannually; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to complete community based assessments (CBA) semi-annually for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date facility 9/19/22; -Diagnoses included congestive heart failure, diabetes, and chronic kidney disease; -One CBA dated 10/13/23; -No documented semi-annual CBA review dated 4/2024 or 10/2024. 2. Review of Resident #2's medical record, showed the following: -Admit date 5/3/23: -Diagnoses included cervical spondylosis (age-related wear and tear of the spinal disks), lumbar spinal stenosis (narrowing of the open spaces in the lower spine), and high blood pressure; Missouri Department of Health and Senior Services STATE FORM see LJKK14 \f continuation sheet 4 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (%2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 19968C 8. WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (x4) 1D 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) BRENTMOOR RETIREMENT COMMUNITY 44750 Continued From page 4 -Initial CBA dated 5/23/23; -No documented semi-annual CBA review dated 11/2023, 5/2024, or 11/2024. 3. During an interview on 1/16/25 at 2:48 P.M., the Memory Care Director said the nurse is responsible for completing the CBAs and she was not aware the CBAs were to be completed semi-annually or at change of condition. She said she knew they needed to be completed in the first five days of admission. 4. During an interview on 1/16/25 at 3:17 P.M., the Executive Director said that the nurse is responsible for completing the CBAs. She said she was aware they were to be completed semi-annually and at change of condition but she was nat aware they were not being completed. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident “gs needs and preferences, services to be | provided, and goals expected by the resident or the resident's legal representative in partnership with the facility; Ii This regulation is not met as evidenced by: Based on interview and record review, the facility failed to develop individualized service plans which included resident needs, services to be Missouri Department of Health and Senior Services STATE FORM ae LJKK11 lf continuation sheet 5 of 13 PRINTED: 01/29/2025 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 (DENTIFICATION NUMBER; COMPLETED A. BUILOING: GC 19968C —————————— 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST 8€ PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY A4754 Continued From page 5 provided by staff and goals expected by the resident or the resident's legal representative for ane of two sampled residents (Residents #2). The census was 15, Review of Resident #2's medical record, shawed the facility admitted the resident on 5/3/23, with diagnoses which included cervical spondylosis (age-related wear and tear of the spinal disks), lumbar spinal stenosis (narrowing of the open spaces in the lower spine), and high blood pressure. Review of the resident's progress notes showed the following: -On 10/22/24 at 6:51 A.M., the resident is having more difficulty in transferring fram both bed to chair and chair to toilet. The resident didn't have strength and wanted the staff to do it for him/her and would get frustrated when encouraged to try to do it on his/her own; -On 10/28/24 at 6:39 A.M., the resident was having a difficult time transferring him/herself, was not able to keep his/her head up as if he/she were freezing where he/she couldn't move his/her lower extremities. The resident was assisted by two staff and a sliding board; ~On 11/15/24 at 10:57 A.M., the resident was losing muscle mass and strength to assist with transfers; -On 11/16/24 at 2:10 P.M., the resident needed extra help and was unable to lift his/her left arm or move his/her legs. Staff used a slide board for transfer but it was difficult; -On 11/21/24 at 2:04 P.M., it was getting harder for the resident to transfer and two staff had to be utilized, They used a slide board to get him/her from the toilet to the chair; -On 12/5/24 at 10:44 A.M., the resident required two staff during transfers and his/her muscle Missouri Department of Health and Senior Services STATE FORM 6899 LUKK11 \f continuation sheet 6 of 13 PRINTED: 01/28/2025 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 te 19968C Se 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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) GROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY A4754 Continued From page 6 mass was progressively deteriorating. The resident could not hold the weight of his/her head and the strength in his/her arms was becoming weaker; -On 12/22/24 at 9:43 A.M., staff had a difficult time transferring the resident and he/she said he/she was feeling weaker; -On 12/23/24 9:46 A.M., the resident was unable to slide him/herself on the slide board and two person staff assistance was required; -On 12/26/24 at 10:48 A.M., the resident needed two staff person assistance on the sliding board and was unable to help with the transfer; -On 1/3/25 at 2:05 A.M., the resident was difficult to transfer and needed two person assist; -On 1/7/25, at 8:06 P.M. the resident met with the nurse and conversed about his/her physical strength and transfers while performing side board transfer to toilet. The resident said he/she needed more help in the mornings and at night. Review of the resident's ISP dated 10/16/24, showed the following: -Need: Toileting Assistance. The resident required moderate assistance times one with slide board for all transfers; -Need: Mobility. The resident had limited use of his/her lower extremities, and required staff assistance for use of sliding board for all transfers; -The ISP did not indicate preferences and goals; ~The ISP did not identify two person staff assistance was required; -The {SP did not give specific instructions on how to assist the resident to use the slide board. During an interview on 1/16/25 at 3:15 P.M., Medication Technician A said the staff needed to | use a gait belt and a slide board and it required , two people, to transfer the resident. He/she said Missouri Department of Health and Senior Services STATE FORM Bene LUKK41 (FeontInuation sheet 7 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING: COMPLETED Cc 19968C =O 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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 LSG IDENTIFYING INFORMATION) CGROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY A4754 Continued From page 7 the resident required the additional assistance for about six months. He/she said he/she did not have additional instructions on how to assist the resident. During an interview on 1/16/25 at 2:48 P.M., the Memory Care Director said notes had been made about his/her care needing to increase but the ISP had not been updated with those details. She said she could understand why the details would be important instructions for the staff and should have been included for them in the ISP. During an interview on 1/16/25 at 3:17 P.M., the Executive Director said she expected all details of a resident's care to be included in the JSP. She was not aware the ISP had not been updated with | the details of additional support needed for the resident during transfers and the information should have been included in the plan, | 19 CSR 30-86.047(58)(A) Resident Recard | A4836 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 ' sS 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 iegally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director; III Missouri Department of Health and Senior Services STATE FORM 5886 kerd If continvation sheet 8 of 13 PRINTED: 01/28/2025 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 1O3 19968C B. WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) 1D | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFIGIENCY MUST BE PRECEDED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE } DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY 44836 Continued From page 8 This regulation is not met as evidenced by: Based on interview and record review, the facility failed to maintain a record for each resident that included contact informatian of the resident's preferred dentist and funeral director, for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 9/19/22: -Diagnoses included congestive heart failure, diabetes, and chronic kidney disease; -No documentation of preferred dentist or funeral home. 2. Review of Resident #2's medical record, showed the following: -Admit date 5/3/23; -Diagnoses included cervical spondylosis (age-related wear and tear of the spinal disks), lumbar spinal stenosis (narrowing of the open spaces in the lower spine}, and high blood pressure; -No documentation of preferred dentist or funeral home. 3. During an interview on 1/16/25 at 2:28 P.M., the Memory Care Director said she was aware the dentist and funeral homes were not listed in some of the resident's charts. She said she did not know it was required to be a part of the resident record. 4. During an interview on 1/16/25 at 3:17 P.M., the Executive Director said she was aware the dentist and funeral home were required to be in the resident's record. She said she was not aware those items were not in the record. Missouri Department of Health and Senior Services STATE FORM 6698 LuKK11 If cantinuatlon sheet 9 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 19968C B. WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (x4) to SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x) 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) BRENTMOOR RETIREMENT COMMUNITY A8004 Continued From page 9 AB004 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/Ill This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to review resident rights with residents or their representative annually, for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 9/19/22; -Diagnoses included congestive heart failure, diabetes, and chronic kidney disease; -A documented review of resident rights dated 9/23/23; -No documented annual review of resident rights for 9/2024. 2. Review of Resident #2's medical record, showed the following: -Admit date 5/3/23; -Diagnoses included cervical spondylosis {age-related wear and tear of the spinal disks), lumbar spinal stenosis (narrowing of the open spaces in the lower spine), and high blood pressure; Missouri Department of Health and Senior Services STATE FORM Bane LuKK14 If continuation sheet 10 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 19968C ——————— 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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 LSG IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY A8004 | Continued From page 10 -A documented review of resident rights dated 9/27/23; -No documented annual review of resident rights for 9/2024. 3. During an interview on 1/16/25 at 2:28 P.M., the Memory Care Director said she knew the resident rights had to be reviewed with them upon move in. She said she was not aware they needed to be completed annually. 4. During an interview on 1/16/25 at 3:17 P.M., the Administrator said she was aware resident rights needed to be reviewed upon admission and annually, She said she was not aware they were not being completed. 19 CSR 30-88.010(10) Advance Directive Requirements Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of emergency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents’ next of kin, legally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decisian making as well as the facility's policies regarding the provision of emergency or life-sustaining | medical care or treatment. If a resident has a written advance health-care directive, a copy shall be placed in the resident's medical record Missouri Department of Health and Senior Services STATE FORM ea) LUKK11 lf continuation sheet 11 of 13 PRINTED: 01/28/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES 01) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3}) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED G 19968C B. WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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) BRENTMOOR RETIREMENT COMMUNITY A8010| Continued From page 11 and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents’ next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. WAI This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to review advanced directives with residents or their representative annually, for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 9/19/22: -Diagnoses included congestive heart failure, diabetes, and chronic kidney disease; -A documented review of resident rights dated 9/23/23: -No documented annual review of advanced directives for 9/2024. 2. Review of Resident #2's medical record, showed the following: -Admit date 5/3/23; -Diagnoses included cervical spondylosis {age-related wear and tear of the spinal disks), lumbar spinal stenosis (narrowing of the open spaces in the lower spine), and high blood pressure; -A documented review of resident rights dated 9/27/23; -No documented annual review of advanced Missouri Department of Health and Senior Services STATE FORM eich LUKK11 IF continuation sheet 12 of 13 PRINTED: 01/28/2025 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 G 19968C B. WING 01/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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) BRENTMOOR RETIREMENT COMMUNITY A8010 Continued From page 12 directives for 9/2024, 3. During an interview on 1/16/25 at 2:28 P.M., the Memory Care Director said she knew the advanced directives had to be reviewed with the residents and/or their responsible party upon move in. She said she was not aware they needed to be completed annually. 4. During an interview on 1/16/25 at 3:17 P.M., the Administrator said she was aware advanced directives needed to be reviewed upon admission and annually. She said she was not aware they were not being completed. Missouri Department of Health and Senior Services STATE FORM éag9 LJKK11 (fcontinuation sheet 13 of 13 PLAN OF CORRECTION Provider Name: Brentmoor Retirement Community Street Address, City, Zip: Provider number: | 19968C PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE This serves as the allegation of compliance for Brentmoor Retirement Community. Brentmoor asserts that all corrections described in this plan of correction have been implemented. In regard to the specific deficiencies, we have outlined our corrective action and continued interventions to assure compliance with regulations and our plan of actions. The staff of Brentmoor is committed to delivering high quality health care to its residents to obtain their highest level of physical, mental, and psychosocial functioning. We respectfully submit that Brentmoor is in substantial compliance as set forth below, and we are confident that we will be found in substantial compliance with regulations upon re- survey. The statements made on the plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. Brentmoor has completed the following interventions as a result of the findings from survey exiting on January 16, 2025. 8600 Delmar, St Louis, MO 63124 Corrections for the example cited during the survey will include: e Failed to provide responsibilities of specific staff on Resident #2 IEP- Updated Resident #2 IEP providing specific staff responsibilities. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e All residents that require a IEP are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur are as follows: e Education provided to ALF Manager on IEP requirements and regulation. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Executive Director and/or designee will audit all IEP’s quarterly for 2 quarters or until compliance is met. Any and all errors will be corrected immediately. 2/20/2025 admissions within 5 days of admission date for 4 weeks or until compliance is met. Any and all errors will be corrected immediately. Corrections for the example cited during the survey will include: e Failed to complete semi-annually community based Corrections for the example cited during the survey will include: e Failed to complete based assessment (CBA) for resident #1 and #2 within 5 days of admission and input all information leaving no blanks. Resident #1 & 2 information has been updated. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e Allresidents are considered to be at risk for deficient practice. The measures that will be put into place or systematic 2/20/2025 changes to ensure that the deficient practice will not recur are as follows: e Education provided to the Memory Care Director & Nurse CBA regulations and requirements. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Memory Care Director and/or designee will audit all new assessment (CBA) for resident #1 and #2. Resident #1 & 2 information has been updated. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e All residents are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur are as follows: 2/20/2025 e Education provided to the Memory Care Director & Nurse CBA regulations and requirements. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Memory Care Director and/or designee will audit all patients to get CBA’s up to date. Any and all errors will be corrected immediately. The Executive Director and/or designee will audit any residents due for the month(semi-annual date) for 12 months and ensure those are completed and any errors be provided to the Memory Care Director. Corrections for the example cited during the survey will include: e Failed to develop ISP which includes residents needs and services to be provided by staff and goals expected by the resident and/or legal representative. Resident #2 ISP has been updated to reflect the needs, services and goals required and expected by resident and legal representative. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e Allresidents are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur 2/20/2025 are as follows: e Education provided to the Memory Care Director on ISP regulations and requirements. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Memory Care Director and/or designee will audit all patients ISP’s. Any and all errors will be corrected immediately. The Executive Director and/or designee will audit 2 randomly selected residents to ensure the ISP is meeting the regulation and requirements. All errors will be corrected immediately and notification/education will pd | Corrections for the example cited during the survey will include: e Failed to obtain record for each resident to include all required information. Resident #1 & 2 records have been updated. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e Allresidents are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur are as follows: e Education provided to the Memory Care Director on ISP regulations and requirements. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Memory Care Director and/or designee will audit all patients demographics. Any and all errors will be corrected immediately. The Executive Director and/or designee will audit 2 randomly selected residents to ensure the demographics are meeting regulations. All errors will be corrected immediately and notification/education will be provided to the Memory Care Director. 2/20/2025 met. All errors will be corrected immediately and notification/education will be provided to the Memory Corrections for the example cited during the survey will include: e Failed to review resident rights annually. Resident #1 & 2 have been corrected. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e Allresidents are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur are as follows: e Education provided to the Memory Care Director on ISP 2/20/2025 regulations and requirements. Resident Rights will be reviewed during the semi-annualy ISP meetings. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Memory Care Director and/or designee will update all residents and legal authorized representatives of resident rights. The Executive Director and/or designee will audit 2 randomly selected residents to ensure the compliance is Corrections for the example cited during the survey will include: e Failed to review Advance Directive annually. Resident #1 & 2 have been corrected. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e Allresidents are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur are as follows: e Education provided to the Memory Care Director on ISP 2/20/2025 regulations and requirements. Advance Directives will be reviewed during the semi-annualy ISP meetings. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Memory Care Director and/or designee will review all residents and legal authorized representatives of Advance Directives. The Executive Director and/or designee will audit 2 randomly selected residents to ensure the compliance is met. All errors will be corrected immediately and notification/education will be provided to the Memory 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: 09/06/2024 FORM APPROVED Missour’ Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: (X3) DATE SURVEY COMPLETED Cc 08/22/2024 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (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 TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY 19 CSR 30-86.047(5) Administrator - Licensed AATO3 The operator shall designate an individual for administrator who is currently licensed as an administrator by the Missouri Board of Nursing Home Administrators, in accordance with Chapter 344, RSMo. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to employ a licensed Administrator at all times. The census was 15. Review of an email dated 8/22/24 at 3:43 P.M., from the Assistant Board Administrator for the Board of Nursing Home Administrators, showed the former facility Administrator was terminated on 7/23/24 and the Executive Director has been the acting Administrator since that time without a license from the board. The Executive Director said a Corporate Staff Member would be stepping in as Administrator on 8/24/24, possibly but the Corporate Staff Member is not a current licensed Adminisirator either. During an interview on 8/22/24 at 4:00 P.M., the Executive Director said she was the Business Office Manager but when the former Administrator quit effective 7/23/24, she was promoted to Executive Director. She sent an application in to the Board of Nursing Home Administrators, for an emergency license but she sent it in too late. Therefore the facility does not currently have a licensed Administrator and has not since 7/23/24, | During an interview on 8/22/24 at 4:25 P.M., the Corporate Staff Member said she let her Administrator's license lapse because she did not get the required continuing education units and she would not be stepping in as the Administrator = pping go PZ Missouri Department of Health and Senipe Benued Za LABORATORY DIRECTOR'S OR PROVIDERJ@UPPLIER REpS Si fE'S SIGNATURE TITLE (X€) DATE Be im al WMishmector STATE FORM to 6398 JWMD11 ff continuation sheet 1 of 2 PRINTED: 03/06/2024 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 19968C 8. WING _____H4H4H 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR ESC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 1 | on 8/24/24. M000240971 Missouri Department of Health and Senior Services STATE FORM sea JWNMD11 ff continuation sheet 2 of 2 PLAN OF CORRECTION Provider Name: Brentmoor Retirement Community Street Address, x “ 8600 Delmar, St Louis, MO 63124 City, Zip: Date of Survey: 8/22/24 Provider number: | 19968C PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE This serves as the allegation of compliance for Brentmoor Retirement Community. Brentmoor asserts that all corrections described in this plan of correction have been implemented. In regard to the specific deficiencies, we have outlined our corrective action and continued interventions to assure compliance with regulations and our plan of actions. The staff of Brentmoor is committed to delivering high quality health care to its residents to obtain their highest level of physical, mental, and psychosocial functioning. We respectfully submit that Brentmoor is in substantial compliance as set forth below, and we are confident that we will be found in substantial compliance with regulations upon re- survey. The statements made on the plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. Brentmoor has completed the following interventions as a result of the findings from survey exiting on August 22, 2024. Corrections for the example cited during the survey will include: e Failed to employ LNHA within 10 days of previous LNHA exiting. The facility will identify other situations having the potential to be affected by the same deficient practices as follows: e Allresidents and staff are considered to be at risk for deficient practice. The measures that will be put into place or systematic changes to ensure that the deficient practice will not recur are as follows: e Hired and retain LNHA full-time. 8/28/2024 e Corporate office understands that a full-time LNHA must be employed at all times per regulation. The facility will monitor the corrective actions to ensure that the deficient practice will not recur as follows: e Report any concerns or issues identified through the monitoring process or additional education needed to the governing board for follow up and corrections. e Corporate office will monitor and ensure that compliance is being met. The plan of correction will be accomplished by:August 28th, 2024 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: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING; (X3) DATE SURVEY COMPLETED B. WING 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY (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) A4505| 19 CSR 30-86.045(3)(A)(5) Individual Evacuation A4505 ' Plan - In Resident ISP ’ General Requirements. | (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: . 5. Include an individualized evacuation plan in the resident ' s individual service plan; II _ This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents who required more than minimal assistance to safely evacuate the facility had an individual evacuation plan (IEP, the planning documented prepared by an assisted living facility which outlines the plan to safely evacuate the resident out of the facility in the event of an emergency) in the residents’ individualized service plan (ISP, the planning documented prepared by an assisted living facility | which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) for two of two sampled residents with an IEP (Residents #1 and #2). The census was 17. | 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -Diagnoses included dementia without behaviors, high blood pressure, Alzheimer's disease, depression and anxiety. Review of the resident's IEP dated 5/25/23, showed the following: -The resident required assistance with opening | Missouri Department of Health and Senior Services LABORATORY, CTOR'S OR PROVIDER/S! IER REPRESENTATIVE'S SIGNATURE TITLE STATE FORM If continuation sheet 1 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: 19968C NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD BRENTMOOR RETIREMENT COMMUNITY SAINT LOUIS, MO 63124 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 1 the fire door and propelling his/her wheelchair; -The resident required more than minimal assistance to move to the area of refuge (AoR); -The resident was required to go to the North AoR. Review of the resident's ISP dated 5/26/23, showed the ISP did not address the resident required an IEP. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22; -Diagnoses included chronic pain, depression, hemiparesis (weakness or the inability to move on one side of the body), high blood pressure, insomnia, muscle weakness, seizure disorder and anxiety disorder. Review of the resident's IEP dated 5/23/23, showed the following: -The resident required assistance with opening the fire door and propelling his/her wheelchair; -The resident required more than minimal assistance to move to the area of refuge (AoR); -The resident required support from one floor staff. Review of the resident's ISP dated 7/19/23, showed the ISP did not address the resident required an IEP. 3. During an interview on 9/25/23 at 3:52 P.M., the Executive Director said she was aware the IEP needed to be in the ISP but was not aware they were not in the ISP's. 19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements Missouri Department of Health and Senior Services STATE FORM 6899 JXOE11 DEFICIENCY) If continuation sheet 2 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 2 General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in an emergency specific to the individual; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to provide the responsibilities of specific staff members, in an emergency, on the Individual Evacuation Plan (IEP, the planning documented prepared by an assisted living facility which outlines the plan to safely evacuate the resident out of the facility in the event of an emergency) for one of two sampled residents (Resident #1). The census was 17. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -Diagnoses included dementia without behaviors, high blood pressure, Alzheimer's disease, depression and anxiety. Review of the resident's IEP dated 5/25/23, showed the following: -The resident required assistance with opening the fire door and propelling his/her wheelchair; -The resident required more than minimal assistance to move to the area of refuge (AoR); -The resident was required to go to the North AoR; -Either the Medication Technician or the Floor Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 3 staff were responsible for evacuation of the resident; -The resident's IEP did not specify which staff member was assigned to the resident. During an interview on 9/25/23 at 4:02 P.M., the Executive Director (ED) said she was aware of the requirements of a resident's IEP and one of the requirements was to indicate which staff member was responsible for the resident in the event of a fire. The ED said she was not aware the resident's IEP did not indicate which staff member was assigned to the resident. 19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan - Evaluate General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. At a minimum the evacuation plan shall include the following components: C. The plan shall evaluate the resident for his or her location within the facility and the proximity to exits and areas of refuge. The plan shall evaluate the resident, as applicable, for his or her risk of resistance, mobility, the need for additional staff support, consciousness, response to instructions, response to alarms, and fire drills; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents who required more than minimal assistance to safely evacuate the facility had an individual evacuation plan (IEP, the Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 4 planning documented prepared by an assisted living facility which outlines the plan to safely evacuate the resident out of the facility in the event of an emergency) with the resident's location within the facility and the proximity to exits and areas of refuge (AoR), for two of two sampled residents with an IEP (Residents #1 and #2). The census was 17. 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -Diagnoses included dementia without behaviors, high blood pressure, Alzheimer's disease, depression and anxiety. Review of the resident's IEP dated 5/25/23, showed the IEP did not include the distance or proximity from the resident's room to the exit or to the AoR. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22; -Diagnoses included chronic pain, depression, hemiparesis (weakness or the inability to move on one side of the body), high blood pressure, insomnia, muscle weakness, seizure disorder and anxiety disorder. Review of the resident's IEP dated 5/25/23, showed the IEP did not include the distance or proximity from the resident's room to the exit or to the AoR. 3. During an interview on 9/25/23 at 3:54 P.M., the Executive Director said she was aware the feet and proximity should be on the IEP, but said she was not aware the feet and proximity were not put on the IEP. Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY 19 CSR 30-86.022(7)(D)(1 - 8) Area of Refuge Requirements Exits, Stairways, and Fire Escapes. (D) An " area of refuge " shall have- 1. An area separated by one- (1-) hour rated smoke walls, from the remainder of the building. This area must have direct access to the exit stairway or access the stair through a section of the corridor that is separated by smoke walls from the remainder of the building. This area may include no more than two (2) resident rooms; 2. A two- (2-) way communication or intercom system with both visible and audible signals between the area of refuge and the bottom landing of the exit stairway, attendants ' work area, or other primary location as designated in the written plan for fire drills and evacuation; 3. Instructions on the use of the area during emergency conditions that are located in the area of refuge and conspicuously posted adjoining the communication or intercom system; 4. Asign at the entrance to the room that states AREA OF REFUGE IN CASE OF FIRE" and displays the international symbol of accessibility; 5. An entry or exit door that is at least a one and three-fourths inch (1 3/4") solid core wood door or has a fire protection rating of not less than twenty (20) minutes with smoke seals and positive latching hardware. These doors shall not be lockable; 6. Asign conspicuously posted at the bottom of the exit stairway with a diagram showing each location of the areas of refuge; 7. Emergency lighting for the area of refuge; and 8. The total area of the areas of refuge on a floor shall equal at least twenty (20) square feet for each resident who is blind or requires the use of a wheelchair or walker housed on the floor. II Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 6 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 6 This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure a two-way communication device was installed at the bottom landing of the exit stairway and failed to ensure instructions on how to utilize the area was conspicuously posted adjoining the communication device. The facility also failed to ensure a sign was placed at the entrance to the area of refuge that stated "AREA OF REFUGE IN CASE OF FIRE" and displayed the international symbol of accessibility. The facility also failed to post a sign at the bottom of each exit stairway with a diagram showing each location of the area of refuge for two of two areas of refuge (AoR). The census was 17. 1. Observation on 9/25/23 between 8:00 A.M. and 3:30 P.M., of the north AoR, on the second floor, showed the following: -No AoR signage posted outside the area which indicated the area was an AoR; -No instructions posted on how to operate the two-way communication system located in the AoR; -No AoR signage with diagram, posted at the bottom of the exit stairway, which showed the location of the AoR; -No two-way communication device or instructions posted on how to operate the two-way communication device at the bottom of the exit stairway. 2. Observation on 9/25/23 between 9:00 A.M. and 3:30 P.M., of the south AoR, on the second floor, showed the following: -No AoR signage posted outside the area which indicated the area was an AoR; -No instructions posted on how to operate the two-way communication system located in the Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 7 AoR; -No AoR signage with diagram, posted at the bottom of the exit stairway, which showed the location of the AoR; -No two-way communication device or instructions posted on how to operate the two-way communication device at the bottom of the exit stairway. 3. During an interview on 9/25/23 at 4:15 P.M., the Executive Director (ED) said she was not aware a two-way communication device was required to be installed at the bottom of the exit stairway for each north and south AoR. The ED said she was not aware after installing a two-way communication device, instructions on how to use the two-way communication device was required to be conspicuously posted. The ED said she was not aware AoR signage had to be posted outside of the AoR which indicated the area was an AoR that there was not any signage posted. 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the annual screenings were completed for two of two sampled residents (Residents #1 and #2) and failed to ensure the one-step was read 24 to 48 hours after administered for one of two sampled residents (Resident #1). The facility also failed to ensure the required initial two-step Tuberculosis (TB) test upon hire and annual one-step TB test was Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 8 completed for two of two sampled employees. The census was 17. Review of the general requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents and staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -lf the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease; -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test; -All employees and volunteers are required to obtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is Zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 9 annual test within the past two years; -If the initial test is negative, the second test should be given as soon as possible within one to three weeks after employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record. 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -An initial one-step TB/PPD test administered on 2/3/20 and read on 2/6/20 with results of O mm; -A documented one-step TB/PPD test administered on 2/13/20 and read on 2/13/20 with results of 0 mm. The one step TB/PPD was read the same day it was administered and not one to three days later; -No documented annual screenings for 2/2021, 2/2022 or 2/2023. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22; -An initial one-step TB/PPD test administered on 11/10/21 and read on 11/12/21 with results of 0 mm; -A documented one-step TB/PPD test administered on 11/17/21 and read on 11/19/21 with results of 0 mm; -No documented annual screening for 11/2022. 3. Review of Employee T's personnel file, showed the following: -Hire date 12/9/21; -No documented initial two-step TB/PPD test administered in 2021; Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 10 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 10 -No documented annual one-step TB/PPD test administered for 12/2022: -A documented one-step TB/PPD test administered on 3/15/23 and read on 3/17/23 with results of 0 mm. 4. Review of Employee U's personnel file, showed the following: -Hire date 4/10/23; -No documented initial two-step TB/PPD test administered in 2022: -No documented annual one step TB/PPD test administered for 2023. 5. During an interview on 9/25/23 at 3:55 P.M., the Executive Director (ED) said she had a TB/PPD binder which contained the resident's and staff's TB/PPD information, in the facility but she never was able to find the binder. The ED said she thought the previous nurse may have picked it up by mistake when he/she departed the facility. The ED said she was aware of the TB/PPD requirements for both residents and staff. The ED said she trusted the previous nurse(s) (there were three nurses who would have been responsible for the TB/PPD during this timeframe) to administer the tests and the screenings, and document everything. The ED said she did not think to audit the nurses because she trusted they would do what was expected of them. 19 CSR 30-86.047(20)(1) Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (I) Written statement signed by a licensed Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 11 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 11 physician or physician ' s designee indicating the person can work in a long-term care facility and indicating any limitations; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure employees had a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility and indicated any limitations, for two of two sampled employees. The census was 17. 1. Review of Employee T's personnel file, showed the following: -Hire date 12/9/21; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 2. Review of Employee U's personnel file, showed the following: -Hire date 4/10/23; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 3. During an interview on 9/25/23 at 4:02 P.M., the Executive Director (ED) said she thought they did not have to do physicals anymore but she was told by her contact with corporate that they still needed to be done. The ED said that she was not aware that the physician statement was not in the physicals in the employee's files. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 12 The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to develop individualized service plans (ISP, the planning document prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) which included resident needs, preferences, services to be provided by staff and goals expected by the resident or the resident's legal representative for two of two sampled residents (Residents #1 and #2) when the facility did not document the residents’ falls and interventions for each fall on the resident's ISP. The census was 17. 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -Diagnoses included dementia without behaviors, high blood pressure, Alzheimer's disease, depression and anxiety. Review of the resident's ISP dated 5/26/23, showed the following: -Need: Fall Risk: The resident was at a low fall Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 13 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 13 risk. The goal of the resident was to remain safe from falls. The staff's intervention was to help the resident throughout his/her day to avoid falling. A note which said the resident had a fall on 5/25/21, with no injuries. The resident had an unsteady gait due to chronic back pain and osteoarthritis (when the cartilage that cushions the ends of bones in your joints gradually deteriorates). The resident had therapy and the staff were to monitor for increased weakness, complaints of increased pain, increased visual changes and to make sure the resident's apartment was free from clutter. The staff were to make sure the bathroom floor was dry after showers and there was proper lighting. The staff were also required to make sure the resident had on shoes and socks or something skid resistant on his/her feet. The last intervention was to monitor for adverse reactions to new medications. Review of the resident's progress notes, showed the following: -On 8/1/23 at 3:50 A.M., the resident had a fall in his/her room. The resident got up from his/her wheelchair without locking the wheels and fell. No injuries noted or bruises and no complaint of pain; -On 9/14/23 at 10:47 P.M., Medication Aide G found the resident on the floor in front of his/her bathroom with the resident's wheelchair nearby. The resident said he/she did not hurt anything and just wanted off the floor; -On 9/19/23 at 8:55 A.M., the Community Administrator found the resident on the floor next to his/her bed; -On 9/19/23 at 10:54 A.M., the resident had an alarm placed at his/her bedside table to alert staff when the resident got out of bed. Review of the resident's ISP dated 5/26/23, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 14 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 14 -The ISP did not show the resident had a movement sensor located by his/her bed to alert staff the resident was moving from his/her bed; -The ISP did not address the falls and interventions used in 2023. During an interview on 9/25/23 at 3:45 P.M., the Resident Care Director (RCD) said Resident #1's fall potential should have been updated to show “high risk" on the resident's ISP because the resident has had several falls lately. The RCD said the resident had a sensor next to his/her bed which alerted the care staff when the resident moved around a lot in his/her bed. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22; -Diagnoses included chronic pain, depression, hemiparesis (weakness or the inability to move on one side of the body), high blood pressure, insomnia, muscle weakness, seizure disorder and anxiety disorder. Review of the resident's progress notes, showed the following: -On 5/19/23 at 1:00 P.M., the resident had a fall in his/her room. The resident said he/she reached for a bag and his/her chair slid from under him/her. No injuries noted or bruises and no complaint of pain; -On 6/14/23 at 7:22 A.M., staff found the resident on floor by the bed. No injuries or bruises noted and no complaints of pain. Review of the resident's ISP dated 7/18/23, showed the following: -Need: Fall risk: The resident was a moderate fall risk. The goal of the resident was to remain safe from falls. The staff's intervention was to help the Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER 19968C PRINTED: 10/10/2023 FORM APPROVED (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: 8600 DELMAR BOULEVARD BRENTMOOR RETIREMENT COMMUNITY (x4) ID PREFIX TAG SAINT LOUIS, MO 63124 SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) Continued From page 15 resident throughout the day to avoid falls; -Need: Safety checks at night time. The goal of the resident was to remain safe from falls at the facility. The staff's intervention was to check on the resident every two hours during the night; -Need: Safety checks during the day. The goal of the resident was to remain safe from falls at the facility. The staff's intervention was to check on the resident every two hours during the day; -The ISP did not address the falls and interventions used in 2023. Review of the resident's progress notes dated 9/23/23 at 2:02 A.M., showed the resident fell out of his/her chair. No injuries or bruises noted and no complaints of pain. 3. During an interview on 9/25/23 at 3:47 P.M., the Executive Director (ED) said it would be important to list the potential of fall risk on each resident's ISPs and all of the interventions the facility utilized should be listed on the ISPs as well. The ED said Resident #1 should be listed as a "high fall risk" on his/her ISP because he/she had several falls lately. The ED said she had interventions in place for the residents and their high fall risks, but the interventions were not documented on the resident's ISPs as they should be. 19 CSR 30-86.047(47)(B) Physicians Orders Requirements Medication Orders. (B) Physician 's written and signed orders shall include: name of medication, dosage, frequency and route of administration and the orders shall be renewed at least every three (3) months. Computer generated signatures may be used if Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED A. BUILDING: 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENT FY NG INFORMATION) Continued From page 16 safeguards are in place to prevent their misuse. Computer identification codes shall be accessible to and used by only the individuals whose signatures they represent. Orders that include optional doses or include pro re nata (PRN) administration frequencies shall specify a maximum frequency and the reason for administration. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, facility staff failed to ensure physician's orders were signed by a physician every three months for two of two sampled residents (Residents #1 and #2). The census was 17. 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -Diagnoses included dementia without behaviors, high blood pressure, Alzheimer's disease, depression and anxiety. -A signed physician's order sheet (POS) dated 5/2023; -No signed POS for 8/2023. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22; -Diagnoses included chronic pain, depression, hemiparesis (weakness or the inability to move on one side of the body), high blood pressure, insomnia, muscle weakness, seizure disorder and anxiety disorder. -No signed POS in 2023. During an interview on 9/25/23, at 3:28 P.M., the Resident Care Director (RCD) said she called the Missouri Department of Health and Senior Services STATE FORM 6899 D PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 17 of 24 JX0E11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 17 resident's physician who told her the last signed POS was from February of 2023. 3. During an interview on 9/25/23 at 4:10 P.M., the Executive Director (ED) said the nurse was required to complete this but it was not happening and she was not aware it was not happening. The ED said she was aware the POS required a physician's signature every three months. 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 complete the required monthly medication review process (recapitulation) for two Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 18 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER 19968C PRINTED: 10/10/2023 FORM APPROVED (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: 8600 DELMAR BOULEVARD BRENTMOOR RETIREMENT COMMUNITY (x4) ID PREFIX TAG SAINT LOUIS, MO 63124 SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) Continued From page 18 of two sampled residents (Residents #1 and #2). The census was 17. 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -Diagnoses included dementia without behaviors, high blood pressure, Alzheimer's disease, depression and anxiety. Review of the resident's physician order sheets (POS) dated 7/2023, 8/2023 and 9/2023, showed no documentation of a completed recapitulation. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22; -Diagnoses included chronic pain, depression, hemiparesis (weakness or the inability to move on one side of the body), high blood pressure, insomnia, muscle weakness, seizure disorder and anxiety disorder. Review of the resident's POS dated 7/2023, 8/2023 and 9/2023, showed no documentation of a completed recapitulation. 3. During an interview on 9/25/23 at 4:00 P.M., the Executive Director (ED) said the previous nurse would have been responsible for completing the monthly recapitulation. The ED said the previous nurse should have sent the resident's POS over to the physician via fax and have the physician complete the recapitulation. The ED said she had seen the faxes to and from the facility regarding this but could not find the faxes. The ED said this information should have been uploaded in the resident's individual chart and she did not know it was not uploaded there. Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 19 19 CSR 30-87.020(28) Backflow Requirements The potable water system shall be installed to preclude the possibility of backflow. Devices shall be installed to protect against backflow and back siphonage at all fixtures and equipment where an air gap at least twice the diameter of the water supply inlet is not provided between the water supply inlet and the fixture 's flood level rim. A hose shall not be attached to a faucet unless a backflow prevention device is installed. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure there was an air gap between the drain pipe of the ice machine and the floor drain for two of two ice machines. The census was 17. 1. Observation on 9/25/23 between 7:50 A.M. and 12:20 P.M., of the ice machine located in the main kitchen, showed a plastic tube extended from the back of the ice machine, down to the floor. There was a hole in the floor and the tubing went directly down into the drain. 2. Observation on 9/25/23 between 6:52 A.M. and 12:26 P.M., of the ice machine located in the kitchenette on the second floor, showed a plastic tube extended from the back of the ice machine, down to the drain. There was a hole in the floor and the tubing went directly down into the floor. 3. During an interview on 9/25/23 at 2:18 P.M., the Executive Director (ED) said she was not aware the ice machines required an air gap and the ED did not know what an air gap was. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 20 of 24 PRINTED: 10/10/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA (X2) MULT PLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 19968C — 09/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES D PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENT FY NG INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) BRENTMOOR RETIREMENT COMMUNITY Continued From page 20 The outer clothing of all employees shall be clean and employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure the proper use of hairnets and beard restraints for one of one day of observation. The census was 17. 1. Observation on 9/25/23, of Cook D, showed the following: -Between 7:55 A.M. and 8:45 A.M., he/she prepared breakfast of French toast, sausage links and oatmeal with a hairnet on but his/her bangs which were approximately 4 inches long, stuck out of the front of the hairnet and several pieces of hair which were approximately 3 inches long, stuck out of both sides of the hairnet; -Between 11:59 A.M. and 12:15 P.M., he/she came into the kitchen without a hairnet on and wrapped containers of food while several cookies were sitting out on cookie sheets and while another cook prepared lunch room trays. Cook D's ponytail was approximately 6 inches long and his/her bangs were approximately 4 inches long. 2. Observation on 9/25/23 between 12:00 P.M. and 12:17 P.M., of Cook E, showed he/she prepared lunch room trays without a beard restraint on. Cook E's beard was approximately 3 inches long. 3. During an interview on 9/25/23 at 1:54 P.M., the Executive Director (ED) said the cooks should have worn hairnets and beard restraints. The ED said she knew the cooks had access to hair restraints and did not know why the cooks were Missouri Department of Health and Senior Services STATE FORM 6899 JX0E11 If continuation sheet 21 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED A. BUILDING: 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY (X4) ID SUMMARY STATEMENT OF DEFIC ENCIES PREFIX (EACH DEFIC ENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENT FY NG INFORMATION) Continued From page 21 not wearing them. The ED said all hair should be in the hair restraint and bangs should not be sticking out. 19 CSR 30-88.010(10) Advance Directive Requirements Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of emergency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents’ next of kin, legally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decision making as well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment. If a resident has a written advance health-care directive, a copy shall be placed in the resident's medical record and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents’ next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. W/II This regulation is not met as evidenced by: Class II* Missouri Department of Health and Senior Services STATE FORM 6899 D PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 22 of 24 JX0E11 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 22 Based on interview and record review, the facility failed to review advanced directives with residents or their representative, annually for two of two sampled residents (Residents #1 and #2). The census was 17. 1. Review of Resident #1's medical record, showed the following: -Admit date 1/31/20; -A documented initial review of the resident's advanced directives for 2020; -No documented annual review for 1/2021, 1/2022 or 1/2023. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/31/22: -No documented initial review of resident's advanced directives in 2022: -No documented annual review for 1/2023. 3. During an interview on 9/25/23 at 1:51 P.M., the Executive Director (ED) said the previous nurse was supposed to do the resident advanced directives annual reviews. The ED said the nurse clearly was not doing the annual reviews. The ED said she thought she was. 19 CSR 30-88.010(36) Personal Clothing/Possessions Each resident shall be permitted to retain and use personal clothing and possessions as space permits. Personal possessions may include furniture and decorations in accordance with the facility's policies and shall not create a fire hazard. The facility shall maintain a record of any personal items accompanying the resident upon admission to the facility, or which are brought to Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 23 of 24 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROV DER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 19968C NAME OF PROVIDER OR SUPPLIER (X2) MULT PLE CONSTRUCTION A. BUILDING: 8600 DELMAR BOULEVARD SAINT LOUIS, MO 63124 BRENTMOOR RETIREMENT COMMUNITY SUMMARY STATEMENT OF DEFIC ENCIES (EACH DEFIC ENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENT FY NG INFORMATION) (x4) ID PREFIX TAG Continued From page 23 the resident during his or her stay in the facility, which are to be returned to the resident or responsible party upon discharge, transfer, or death. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to ensure personal inventory lists were completed for two of two sampled residents (Residents #1 and #2). The census was 17. 1. Review of Resident #1's medical record, showed an inventory sheet on an undated piece of paper, with the resident's room number and nickname at the top of the paper, listing the resident's belongings. 2. Review of Resident #2's medical record, showed an inventory sheet on an undated notebook paper, with the resident's room number and "inventory" at the top of the paper, listing the resident's belongings. 3. During an interview on 9/25/23 at 10:40 A.M., the Executive Director (ED) said she made the inventory sheets that day, 9/25/23, after the Regulatory Auditors asked for inventory sheets . The ED said she had not been completing inventory sheets upon admission for the residents. The ED said the inventory sheets were a part of the admission process and there was no reason as to why the inventory sheets were not done other than she did not think of it. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 D PREFIX TAG JX0E11 PRINTED: 10/10/2023 FORM APPROVED (X3) DATE SURVEY COMPLETED 09/25/2023 STREET ADDRESS CITY STATE ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 24 of 24 PLAN OF CORRECTION Provider/Supplier Brentmoor Retirement Community Name: Street Address, 8600 Delmar Bivd. City, Zip: St. Louis, MO 63124 Date of Survey: 09/25/2023 ID PREFIX TAG PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE A4505 19CSR 30-86.045(3)(A)(S) Individual Evacuation Plan — In ISP 10/12/2023 A4505 Resident 1: Review of the resident's ISP dated 5/26/23, showed the ISP did not address the resident required and JEP. All Assisted Living Residents’ ISPs were reviewed by the Executive Director and were updated to show that IEPs were required. Additionally, all Face sheets were updated to include IEP Requirement. The Resident Care Manager will review all updated ISPs/IEPs in electronic and paper charts and will provide in-service educating Staff on the cross-reference of ISP/IEP. Monthly Fire Drill will alert Resident Care Manager of any changes required to IEP, and will update accordingly The Resident Care Manager will update the ISP/IEP every 6 months or with change of condition. The Executive Director will review all ISP/IEP after the monthly Fire Drill. 10/12/2023 A4505 Resident 2: Review of the resident's ISP dated 5/26/23, showed the ISP did not address the resident required and IEP. All Assisted Living Residents’ ISPs were reviewed by the Executive Director and were updated to show that JEPs were required. Additionally, all Face sheets were updated to include IEP Requirement. The Resident Care Manager will review all updated ISPs/IEPs in electronic and paper charts and will provide in-service educating staff on the cross-reference of ISP/EP. Monthly Fire Drill will alert Resident Care Manager of any changes required to IEP, and will update accordingly The Resident Care Manager will update the ISP/IEP every 6 10/12/2023 months or with change of condition. The Executive Director will review all ISP/AEP after the monthly Fire Drill. The Executive Director will review all ISP/AEP after monthly Fire Drill. A4506 19 CSR 30-86.045(3)(A)(6a) individual Evacuation Plan-Staff Requirements. 10/12/2023 A4506 This regulation is not met as evidenced by: the facility failed to provide the responsibilities of specific staff members on the IEP. Resident 1: The resident's IEP did not specify which staff member was assigned to the resident. All Residents’ IEPs were reviewed and updated by the Executive Director and were updated to reflect the assigned staff member responsible to assist during evacuation. The form in our electronic chart did not provide the option to select which area of refuge or which staff was assigned to each resident. We have modified our on-line IEP to reflect these necessary options. Each resident apartment is assigned to evacuate to a specific area of refuge, either north or south as indicated on the IEP and the Fire Evacuation Plan posted in various locations in the Assisted Living unit. The Medication Tech is assigned to the South Area of Refuge, and the Care Aide is assigned to the North Area of Refuge. The Resident Care Manager will verify the proper procedure is followed during the monthly Fire Drill. The Resident Care Manager will provide In-Service to all Assisted Living Staff regarding IEP Assignments. Executive Director will monitor to ensure compliance. 10/16/2023 A4508 19 CSR 30-86.045(3)(A)(6)(C) Individual Evacuation Plan — Evaluate: The plan shall evaluate the resident for his or her location within the facility and the proximity to exits and areas of refuge. 10/16/2023 A4508 Resident 1: IEP did not include the distance or proximity from the resident's roam to the exit or to the Area of Refuge. All IEPs were updated In electronic chart with the number of feet from the Resident’s apartment to the assigned area of refuge. Staff was In-Serviced on the updated IEP forms in electronic chart. Resident #2: EP did not include the distance or proximity from the resident's room to the exit or to the Area of Refuge. All IEPs were updated In electronic chart with the number of feet from the Resident's apartment to the assigned area of refuge. 10/16/2023 Staff was In-Serviced on the updated /EP forms in electronic chart. Area of Refuge and staff are assigned to apartment, so no confusion about this. Executive Director will monitor compliance. A2228 19 CSR 30-86.022(7)(D}(1-*) Area of Refuge Requirements 10/16/2023 A2228 Regulation not met as follows: Review of NORTH AREA of REFUGE on 2"4 Floor showed the following: -No AoR signage posted outside the area which indicated the area was an AoR; -No instructions posted on how to operate the two-way communication system located in the AoR; -No AoR signage with diagram, posted at the bottom of the exit stairway, which showed the location of the AoR; -No two-way communication device or instructions posted on how to operate the two-way communication device at the bottom of the exit stairway. New signs are posted outside both doors leading into the North Area of Refuge. New signs posted with arrows towards the North Area of Refuge throughout the 2" floor, at bottoms of emergency stairwells. Updated Fire Evacuation Plan sign is located throughout the 24 floor, in the emergency stairwell, and at the front desk. Operation instructions for the two-way communication device are next to the device on the table where the two-way communication device is located in the North Area of Refuge. There is a two-way communication device located on the window ledge behind the front desk in the first-floor lobby. There are operating instructions next to the two-way communication device. (There is no phone service or electrical access in stair wells.) Regulation not met as follows: Review of SOUTH AREA of REFUGE on 2"¢ Floor showed the following: -No AoR signage posted outside the area which indicated the area was an AoR; -No instructions posted on how to operate the two-way communication system located in the AoR; -No AoR signage with diagram, posted at the bottom of the exit stairway, which showed the location of the AoR; -No two-way communication device or instructions posted on how to operate the two-way communication device at the bottom of the exit stairway. New signs are posted outside both doors leading into the SOUTH Area of Refuge. 10/16/2023 New signs posted with arrows towards the South Area of Refuge throughout the 2" floor, at bottoms of emergency stairwells. Updated Fire Evacuation Plan sign is located throughout the 24 floor, in the emergency stairwell, and at the front desk. Operation instructions for the two-way communication device are next to the device on the table where the two-way communication device is located in the South Area of Refuge. There is a FIRST RESPONDER two-way communication device located on the window ledge behind the front desk in the first- floor lobby. There are operating instructions next to the two-way communication device. (There is no phone service or electrical access in stair wells.) Discussed this with . Executive Director will monitor this with Resident Care Manager and Fire Department. A4724 19 CSR 30-86.047(19) TB Screen Residents & Staff — Regulation not met 10/20/2023 A4724 Resident 1 — No Documented screening for 2/2021, 2/2022, 2/2023 Resident 2 —- No Documented screening for 11/2022 Employee T - No Documented Screening administered in 2021 or 2022. Documented one-step was administered on 3/15/23 Employee U — Hired on 4/10/23. No 2-step in 2022 or 2023. The binder containing the proof of screening was either misplaced or discarded by previous DON. All PPD screenings have been completed at this time. The Resident screenings have been recorded in our electronic chart, and a due date for next screening has been entered into on-line medical records system(ALIS} so we can be sure to have ail residents screened appropriately. All employees with missing screenings have received their initial screening and will be scheduled for the second step. Going forward all new hires will be required to receive their TB screening prior to working their first shift. The Resident Care Manager is responsible for ensuring this requirement has been completed. The Executive Director will review all employee files prior to first day worked. The TB test record will be uploaded into on-line charting (ALIS) and will be assigned an expiration date. System will generate notice of testing required. 10/20/2023 A4733 19 CSR 30-86.047(20)(1) Personnel Record — Physician Statement, employee 10/20/2023 A4733 This regulation is not met. The facility failed to ensure employees had a written statement by a licensed physician or physician's designee which indicated the person could work ina long-term care facility and_ indicated any limitations. 10/20/2023 Employee T: -Hire date 12/9/21; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. Employee U: -Hire date 4/10/23; -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. All personnel files have been reviewed. Employees who were missing statement by physician or physician’s designee have received physicals and their personnel files have been updated. The Resident Care manager is responsible for ensuring that all employees have physician’s statement prior to their first shift. The Executive Director will review all personnel files prior to first shift. A47/54 19CSR30-/6.047(28)(G) Individual Service Plan - Develop 10/20/2023 AA4ATSA4 Facility must develop an individualized service plan (ISP), which outlines a residents needs and preferences, services to be provided, and goals expected by the resident or the resident's legal representative in partnership with the facility. This regulation is not met: the facility failed to develop individualized service plans (Residents #1 and #2) when the facility did not document the residents’ falls and interventions for each fall on the resident's ISP. All residents will require an updated detailed |SP within 30days of new residency and every 6 months after unless needs have changed. Incidents such as falls etc. will be documented with an intervention for each individual Resident. Resident Care Manager has reviewed all ISP of residents, staff also will receive training on our Alis program to maintain proper documentation of residents as well. Resident Care Manager and Executive Director will meet monthly to review ail resident charts, including ISPs and IEPs. 10/20/2023 A4799 19 CSR 30-86.047(47)(B) Physicians Orders Requirements A4799 10/20/2023 Regulation not met . Facility failed to ensure physicians orders were signed by a physician every three months. Resident 1: No signed POS for 8/2023 Resident 2: No signed POS in 2023 All residents’ orders must be reviewed and signed by the resident’s physician every three months. The Resident Care Director is responsible for ensuring that the POS are signed by 10/20/2023 physician every three months. The Resident Care Director has reviewed the Resident Charts and updated with signed POS. Going forward, Resident care Director and Executive Director will review Resident charts every quarter to verify that POS have been reviewed by and signed by physicians. A4837 19 CSR 30-86.047(58)(B) Resident Condition/Medication Review 10/20/2023 A4837 Regulation not met. The facility failed to complete the required monthly medication review process. Resident 1: Review of the resident's (POS) dated 7/2023, 3/2023 and 9/2023, showed no documentation of a completed recapitulation. Resident 2: Review of the resident's POS dated 7/2023, 8/2023 and 9/2023, showed no documentation of a completed recapitulation. All resident charts must be reviewed at least monthly noting the resident's general conditions and needs. Any residents controlling their own medications require a review of med consumption, noting if medications are being used appropriately, administration, regime review, etc. The Resident Care Manager and the LPN are responsible for this review. Effective 10/20/2023, all medications will be controlled, administered and managed by Brentmoor Assisted Living Staff. Review of the residents ability to control their medications resulted in this determination. The LPN will perform monthly review of condition and medication for all Assisted Living Resident and will record the recapitulation in the electronic chart for each resident. The Executive Director will monitor by reviewing chart monthly with Resident Care Director. 10/20/2023 A6028 19 CSR 30-87.020(28) Backflow Requirements 10/20/2023 A6028 Regulation not met. Facility failed to ensure there was an air gap between the drain pipe of the ice machine and the floor drain for two of two ice machines. Ice maker removed from 2"¢ floor on 10/21/2021. Air gaps installed ice machine in main kitchen. Executive Director will monitor status of ice machine in main kitchen. 10/20/2023 A003 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints A7003 Employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. This regulation is not met. The facility failed to ensure the proper use of hairnets and beard restraints for one of one day of observation of Chef and Kitchen staff. 10/20/2023 All employees have been In-Serviced regarding hair net, beard net and glove requirement when in kitchen, while handling food and while serving food to residents. Chef is responsible for her staffs use of hair nets, beard nets and gloves. Resident Care Manager is responsible for her staff's use of hair nets and gloves while serving food to residents. Executive Director will make daily observation of staff involved in preparing, handling and serving food for proper use of hair nets, beard nets and gloves. Executive Director will monitor compliance. A8010 19 CSR 30-88.010(10) Advance Directive Requirements. 10/20/2023 Regulation Not Met: Annual review of Advanced Directives was not in Resident 1 or Resident 2 chart. Resident Care Manager was In-Serviced regarding Annual Review of Advanced Directives. All Residents reviewed their Advanced Directives, and Annual Review form was completed A8010 by resident and placed in chart. 10/20/2023 As stated previously in Plan of Correction, Executive Director and Resident Care Manager will be reviewing charts on regular basis. Executive Director will create a spreadsheet with all required reviews listed and will monitor completion of reviews. A8037 19 CSR 30-88.010(36) Personal Clothing/Possessions 10/20/2023 Resident Inventory: Regulation Not Met, no inventory of property in Resident 1 or Resident 2. Inventory of Resident's property must be established at move in and updated regularly. All Residents’ property has been inventoried and Inventory form has been placed in Resident A8037 Chart. It is the responsibility of the Resident Care Director to 10/20/2023 collect the inventory sheet from resident or resident’s responsible party at the time of move in. Resident Chart will be reviewed by Executive Director and Resident Care Manager on a monthly basis. Updates will be made accordingly.. 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.