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.