CEDARHURST OF TESSON HEIGHTS.

AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 08/30/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 08/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. II/IIl This regulation is not met as evidenced by: Class II* Based on record review and interview on August 29, 2024, the facility failed to conduct fire drills with at least one (1) fire drill every three (3) months on each shift. The facility census was 55.This deficiency affects 55 out of 55 residents. Record review at 10:00 A.M. showed no documentation of fire drills being done on any shift in the previous twelve (12) months. Further review showed no complete evacuation had been done on the previous twelve (12) months.. During an interview on August 29, 24, at the time of discovery, the Maintenance Director stated the drills had not been done in the last year, but 2 fire safety trainings had been done. *The higher classification merited due to the extent of the violation. 19 CSR 30-86.022(5)(E) Fire Drill Records Fire Drills and Emergency Preparedness. (E) The facility shall keep a record of all fire drills. The record shall include the time, date, personnel Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 57JE11 If continuation sheet 1 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 participating, length of time to complete the fire drill, and a narrative notation of any special problems. Ill This regulation is not met as evidenced by: Class II* Based on record review and interview on August 29, 2024, the facility failed to keep records of all fire drills to include the time, date, personnel participating, length of time to complete the fire drill, and a narrative notation of any special problems. The facility census was 5). This deficiency affects 55 out of 55 residents. Record review at 10:10 A.M. showed no records of any fire drills on any shift in the previous twelve (12) months. During an interview on August 29, 2024, at the time of discovery, the Maintenance Director said he/she would ensure that fire drills, including the necessary information would be recorded monthly. *The higher classification merited due to the extent of the violation. 19 CSR 30-86.022(9)(E) Fire Alarm System Monthly Test Complete Fire Alarm Systems. (E) Facilities shall test by activating the complete fire alarm system at least once a month. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on August Missouri Department of Health and Senior Services STATE FORM 6899 57JE11 PRINTED: 08/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 29, 2024, the facility failed to insure the complete fire alarm system was tested monthly. The facility census was 55. This deficiency affects 55 out of 55 residents. Record review at 10:15 A.M. showed no documentation the fire alarm system had been tested in the previous twelve (12) months. During an interview on August 29, 2024 at the time of discovery, the Maintenance Director stated the alarm was not tested monthly. 19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing Sprinkler Systems. (B) Facilities that have a sprinkler system installed prior to August 28, 2007, shall inspect, maintain, and test these systems in accordance with the requirements that were in effect for such facilities on August 27, 2007. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on August 29, 2024, the facility failed to ensure the sprinkler system was maintained in accordance with the provisions of National Fire Protection Association (NFPA) 13, 1999 edition; NFPA 13R, 1999 edition and NFPA 25, 1998 edition. The facility census was 55. This deficiency affects 55 out of 55 residents. Record review at 10:30 A.M. showed no documentation of the required monthly inspection of the sprinkler system being performed. Missouri Department of Health and Senior Services STATE FORM 6899 57JE11 PRINTED: 08/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 4 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 During an interview on August 29, 2024 at the time of discovery, the Maintenance Director stated he/she would make sure the monthly inspections were done. 19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant Interior Finish and Furnishings. (D) All curtains and drapes in a licensed facility shall be certified or treated to be flame-resistant as defined in NFPA 101, 2000 edition. II This regulation is not met as evidenced by: Class II Based on observation and interview on August 29, 2024, the facility failed to ensure all curtains and drapes were certified or treated with a flame retardant material. The facility census was 55. This deficiency affects 55 out of 55 residents. Observation between 11:30 A.M. and 12:30 P..M., showed curtains in the following rooms: 257 267 138 146 During an interview on August 29, 2024, at the time of discovery, the Maintenance Director stated that the facility does not supply curtains, but the families bring them in sometimes. He/she furthur stated that the curtains would be treated with a flame retardant Missouri Department of Health and Senior Services STATE FORM 6899 57JE11 PRINTED: 08/30/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 08/29/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 4 THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)

PRINTED: 08/16/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 08/01/2024 B. WING 13663D NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS PROVIDER'S PLAN OF CORRECTION PREFIX {EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (45) COMPLETE DATE ~ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG A4506| 19 CSR 30-86.045(3)(A)(6)(A) Individual A4506 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 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) with responsibilities of specific staff positions, in an emergency, specific to that resident with cognitive or other impairment, that cannot evacuate on their own, for three of five sampled residents (Residents #2, #5 and #3). The census was 46. 1. Review of Resident #2's medical record, showed the facility admitted the resident on 2/21/20, with diagnoses which included Alzheimer's disease, vitamin D deficiency and diabetes. Review of the resident's IEP dated 4/22/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIQER/SUPPLIER REPRESENTATIVE'S SIGNATURE (eltos™ We fed viilE FORM 6889 27Wi11 If continuation sheet 1 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 -The resident required assistance with transferring from bed/chair; -The resident required assistance with navigating the community and finding the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required more than three verbal cues; -The resident required one staff to transfer the resident into his/her wheelchair and escort the resident to the nearest Area of Refuge. In a total evacuation, the resident required staff assistance to the nearest exit which was the front door of the facility; -The IEP did not include the specific staff members assigned to the resident. 2. Review of Resident #5's medical record, showed the facility admitted the resident on 3/20/23, with diagnoses which included diabetes and high blood pressure. Review of the resident's IEP dated 7/28/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; -The resident required assistance with transferring from bed/chair; -The resident could navigate the facility and find the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required no more than three verbal cues; -The resident required one staff to transfer the Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 2 resident into his/her motorized wheelchair. Once in his/her wheelchair, he/she would be able to get to the AoR a total evacuation is necessary to get out of the building; -The IEP did not include the specific staff members assigned to the resident. 3. Review of Resident #3's medical record, showed the facility admitted the resident on 12/22/23, with diagnoses which included high blood pressure, acid reflex and osteoporosis. Review of the resident's IEP dated 6/11/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; -The resident required assistance with transferring from bed/chair; -The resident required assistance with navigating the community and finding the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required more than three verbal cues; -The resident required staff to assist him/her with transferring out of his/her bed into his/her wheelchair and switching to the portable oxygen tank. The resident required staff to assist him/her to the nearest AoR. In a total evacuation, the resident required staff to assist him/her to the nearest exit; -The IEP did not include the specific staff members assigned to the resident. 4. During an interview on 8/1/24 at 4:02 P.M., the Administrator said he was not aware a specific individual would need to be assigned to the Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 3 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 resident in the event of a total evacuation. 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 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 four of five sampled residents with an IEP (Residents #2, #5, #3 and #4). The census was 54. 1. Review of Resident #2's medical record, showed the facility admitted the resident on 2/21/20, with diagnoses which included Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Alzheimer's disease, vitamin D deficiency and diabetes. Review of the resident's IEP dated 4/22/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; -The resident required assistance with transferring from bed/chair; -The resident required assistance with navigating the community and finding the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required more than three verbal cues; -The resident required one staff to transfer the resident into his/her wheelchair and escort the resident to the nearest AoR. In a total evacuation, the resident required staff assistance to the nearest exit which was the front door of the facility; -The IEP did not include the distance from the resident's apartment to the nearest exit. 2. Review of Resident #5's medical record, showed the facility admitted the resident on 3/20/23, with diagnoses which included diabetes and high blood pressure. Review of the resident's IEP dated 7/28/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; -The resident required assistance with transferring from bed/chair; -The resident could navigate the facility and find Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 5 the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required no more than three verbal cues; -The resident required one staff to transfer the resident into his/her motorized wheelchair. Once in his/her wheelchair, he/she would be able to get to the AoR if a total evacuation is necessary to get out of the building; -The IEP did not include the distance from the resident's apartment to the nearest exit. 3. Review of Resident #3's medical record, showed the facility admitted the resident on 12/22/23, with diagnoses which included high blood pressure, acid reflex and osteoporosis. Review of the resident's IEP dated 6/11/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; -The resident required assistance with transferring from bed/chair; -The resident required assistance with navigating the community and finding the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required more than three verbal cues; -The resident required staff to assist him/her with transferring out of his/her bed into his/her wheelchair and switching to the portable oxygen tank. The resident required staff to assist him/her to the nearest AoR. In a total evacuation, the Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 6 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 resident required staff to assist him/her to the nearest exit; -The IEP did not include the distance from the resident's apartment to the nearest AoR. 4. Review of Resident #4's medical record, showed the facility admitted the resident on 5/6/24, with diagnoses which included high blood pressure, congestive heart failure and absence of leg below knee. Review of the resident's IEP dated 4/26/24, showed the following: -The resident required assistance with opening the apartment door; -The resident required assistance with the stairs; -The resident required assistance with transferring from bed/chair; -The resident required assistance with navigating the community and finding the appropriate exits; -The resident could hear the fire alarm without hearing devices; -The resident could visualize fire alarm strobes without visual aids; -The resident required more than three verbal cues; -The resident required staff to assist him/her to his/her wheelchair. The resident could propel him/herself to the AoR. If total evacuation is required, the resident required staff assistance to get down the stairs; -The IEP did not include the distance from the resident's apartment to the nearest AoR. 5. During an interview on 8/1/24 at 4:02 P.M., the Administrator was not aware the distance had to be included in the resident's IEPs. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 19 CSR 30-86.022(5)(D) Fire Drill Requirements, Evacuation Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annually with at least one (1) every three (3) months on each shift. At least four (4) of the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year. IlI/Ill This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to conduct a minimum of 12 fire drills annually with at least one fire drill every three months on each shift. This had the potential to affect all residents. The census was 54. Review of the facility's fire drill documentation on 7/30/24, at 10:30 A.M., showed no records of any fire drills on any shift in the previous twelve (12) months. During an interview on 7/30/24 at 11:30 A.M., the Maintenance Supervisor (MS) said he was aware the fire drills were required but he had not conducted any fire drills in over a year. The MS said he had been focused on other things since starting at the facility and has not gotten to completing fire drills yet. During an interview on 7/30/24 at 11:07 A.M., the Administrator said the facility has not conducted any fire drills for the past year. The Administrator said the facility has done two different trainings on what to do in the event of a fire and how to use Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 fire extinguishers, but no drills have been conducted. The Administrator said he thought they were being done in off hours, but he recently discovered they were not being done at all. *The higher classification merited due to the extent of the violation. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class Il Based on observation and interview, the facility failed to ensure no unnecessary combustibles were store in the facility. This had the potential to affect all residents. The census was 54. Observation on 7/30/24 between 7:58 A.M. and 2:57 P.M., of unoccupied resident room 169, showed the entry door was unlocked and ajar which allowed access. Inside the apartment in the bedroom, two 18" plastic trash can lids turned over and filled with charcoal, placed on the ground near the window. An additional trash can lid which contained charcoal in the bedroom closet. Each trash can lid which contained at least 50 charcoal briquettes, each had a large letter K stamped into the coal. Review of charcoal briquettes cautionary statement, showed "Keep out of reach of children. Harmful or fatal if swallowed. Combustible". Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 9 During an interview on 7/30/24 at 3:19 P.M., the Administrator said he was aware the charcoal was being used in the room. The Administrator said the contractors were using the charcoal to eliminate the urine odor after they failed to remove the smell using other methods. The Administrator said the door to the apartment should have been locked preventing access to the room for the resident's safety. 19 CSR 30-86.047(22) Employee Hours Documented There shall be written documentation maintained in the facility showing actual hours worked by each employee. Ill This regulation is not met as evidenced by: Based on interview and record review, the facility failed to document actual hours worked by each employee, for four of four salaried employees reviewed. The census was 54. Review of the salaried employees’ timesheets, showed the following: -On 7/1/24 through 7/5/24 and 7/8/24 through 7/12/24, the Director of Nursing worked eight hours each day; -On 7/1/24 through 7/5/24 and 7/8/24 through 7/12/24, the Director of Sales worked eight hours each day; -On 7/1/24 through 7/5/24 and 7/8/24 through 7/12/24, the Environmental Services Director worked eight hours each day; -On 7/1/24 through 7/5/24 and 7/8/24 through 7/12/24, the Assistant Executive Director worked eight hours each day; -The timesheets did not document actual hours worked on each day. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 10 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 During an interview on 8/1/24 at 11:20 A.M., the Administrator said salaried staff do not keep track of their hours. The Administrator said he was unaware salaried staff had to keep track of their hours. 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 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: 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 ensure all sections of the community based assessment (CBA) were completed for three of five sampled residents (Residents #5, #1 and #4). The census was 54. 1. Review of Resident #5's medical record, showed the facility admitted the resident on 3/20/23, with diagnoses which included type and high blood pressure. Review of the resident's CBA dated 3/5/23, showed the following: -The health problems section was not completed; -The prescription medication section was not Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 completed; -The dosage and Physician/Pharmacy section was not completed; -A CBA was completed prior to admission. A CBA was not completed within 5 days of admission. 2. Review of Resident #1's medical record, showed the facility admitted the resident on 2/5/24, with diagnoses which included anemia, vitamin D deficiency, hypothyroidism and anxiety. Review of the resident's CBA dated 2/6/24, showed the following: -The prescription medication section was not completed; -The physician/pharmacy section was not completed. 3. Review of Resident #4's medical record, showed the facility admitted the resident on 5/6/24, with diagnoses which included high blood pressure, congestive heart failure and absence of leg below knee. Review of the resident's CBA dated 4/26/24, showed the following: -The prescription medication section was not completed; -The home health agency section was not completed; -The other health care provider section was not completed; -A CBA was completed prior to admission. A CBA was not completed within 5 days of admission. 4. During an interview on 7/30/24 at 12:20 P.M., the Director of Nursing said she was responsible for the CBAs. She said she was aware the CBAs had to be filled out entirely. She was not aware it was required to attach the information to the CBA Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 to complete the document. 5. During an interview on 7/30/24 at 12:25 P.M., the Administrator said he was not aware the CBAs were not completed entirely. 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 ensure all sections of the community based assessment (CBA) were completed for three of five sampled residents (Residents #5, #3 and #2). The census was 54. 1. Review of Resident #5's medical record, showed the facility admitted the resident on 3/20/23, with diagnoses which included type and high blood pressure. Review of the resident's CBA dated 3/19/24, showed the following: -The prescription medication section was not completed; -The dosage and Physician/Pharmacy section Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 13 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 was not completed. 2. Review of Resident #3's medical record, showed the facility admitted the resident on 12/22/23, with diagnoses which included high blood pressure, acid reflex and osteoporosis. Review of the resident's semi-annual CBA dated 6/11/24, showed the following: -The prescription medication section was not completed; -The home health agency section was not completed; -The other health care provider section was not completed. 3. Review of Resident #2's medical record, showed the facility admitted the resident on 2/21/20, with diagnoses which included Alzheimer's disease, vitamin D deficiency and diabetes. Review of the resident's semi-annual CBA dated 3/11/24, showed the following: -The prescription medication section was not completed; -The home health agency section was not completed; -The other health care provider section was not completed. Review of the resident's significant change CBA dated 4/22/24, showed the following: -The prescription medication section was not completed; -The home health agency section was not completed. 4. During an interview on 8/1/24 at 10:20 A.M., the Director of Nursing (DON) said she was Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 14 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 responsible for completing CBAs. The DON said she was aware the CBAs are required to be filled out entirely. She said without looking, she was not aware the CBAs were not filled out entirely. 5. During an interview on 8/1/24 at 8/1/24 at 3:58 P.M., the Administrator said the DON was responsible for CBAs and said the Assistant Administrator also performed the CBAs as well. The Administrator said he was aware the CBAs are required to be filled out entirely and was not aware some CBAs were not filled out entirely. 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 "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) for residents who excessively drank alcohol, had a history of falls, required bathing Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 15 assistance and had hospice needs for one of five sampled residents (Resident #3) and one additional reviewed resident (Resident #6). The census was 54. 1. Review of Resident #6's medical record, showed the following: -Admit date 5/2/23; -Diagnoses included hypokalemia (the amount of potassium in your blood is too low), alcohol use with unspecified alcohol-induced disorder, seizures, high blood pressure and history of a stroke. Review of the resident's progress notes, showed the following: -On 2/9/24 at 5:45 P.M., the resident had a fall in his/her room at 5:30 P.M. The resident did not have any marks or bruising. The staff member notified the resident's Physician and family; -On 2/22/24 at 4:15 P.M., the resident told staff he/she was no longer going down to eat his/her meals because the dining staff were not feeding him/her. The resident said dining staff told the resident he/she makes a mess at meal time and staff do not feed him/her nor do they want him/her there. The Assistant Director of Nursing (ADON) was on the floor assisting a staff member and the staff member told the ADON the resident said the dining staff found out he/she killed some people during his/her time in the Marines and that was why dining staff will not feed the resident. The staff member notified the resident's Physician; -On 2/24/24 at 12:30 P.M., the resident called the Director of Nursing (DON) to his/her apartment and said he/she could not get up. When the DON entered his/her apartment, the resident was lying in his/her bed, saying he/she was sick and could not get out of bed. The resident rolled over and threw up on the side of the bed. The DON asked Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 16 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 16 the did he/she drink alcohol or when was the last time he/she did. The resident then shut down and would not talk and closed his/her eyes. The DON explained to the resident she would have to send him/her to the hospital if he/she would not talk to this Nurse. Again, the resident would not talk. Staff called emergency services and when they arrived, the resident would not talk or answer questions with emergency staff. The resident then began to shake and moan out. The the DON notified the resident's family; -On 2/27/24 at 9:00 A.M., the DON went to visit the resident and do a re-assessment to return from the hospital. The resident would barely open his/her eyes and would not communicate with the DON. The DON spoke to the Nurse at the hospital and the Nurse said the resident was very unsteady, difficulty with standing and transferring him/herself. The resident would yell at staff at the hospital, very shaky, had difficulty eating and food went everywhere. The Nurse said she did not believe the resident would be able to return to the facility and would benefit from skilled rehabilitation (rehab). The Nurse said the resident was walking around, wanting to leave and said the hospital was prison so hospital staff gave the resident an IV of Ativan (used to treat anxiety). The Nurse said the resident was drinking too much and this was why he/she was having seizures. A call was made to a social worker and the social worker said he/she would talk to the resident's family; -On 3/6/24 at 4:00 P.M., the resident was still in the hospital due to being covid positive. The hospital social worker said the resident will be going to rehab when he/she is off of isolation; -On 3/12/24 at 10:30 A.M., the DON called the hospital and the hospital social worker said the resident went to rehab on 3/7/24; -On 3/17/24 at 4:00 P.M., the DON received a call Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 17 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 17 from staff at the front desk of the facility who said the resident returned back from rehab. The DON did not go assess the resident because she was not made aware the resident had returned from rehab. The DON called the rehab facility and was unable to get any answers as to why the resident was returned to the assisted living facility without prior notification. The DON asked for the Administrator or DON of the rehab facility to return her call. Due to the resident returning on a Sunday, the resident did not have any medication but staff ordered them on Monday and ask for the resident's medication list to be sent; -On 3/25/24 at 1:15 P.M., staff said the resident ordered alcohol for the last four days. The resident drank it while taking his/her medication; -On 3/27/24 at 3:45 P.M., staff said the resident drank alcohol with his/her medications; -On 3/28/24 at 9:30 A.M., staff said the resident drank alcohol for the last week while taking his/her medications; -On 3/28/24 at 1:45 P.M., staff said the resident was in his/her room all day drunk. The resident's refused to take a shower and refused lunch. Staff member checked on the resident every hour; -On 3/29/24 at 9:00 A.M., staff said the resident complained of increased tremors and difficulty eating. The resident requested staff assist him/her with feeding him/her. Staff were made aware to help the resident with meals. Therapy services was also made aware and would be working on getting weighted utensils for the resident to use. The staff member notified the resident's Physician; -On 3/31/24 at 3:00 P.M., staff said the resident been in his/her room all day drunk while taking his/her medications; -On 4/2/24 at 2:15 P.M., the DON called the resident's Nurse Practitioner (NP) to make her aware that his/her tremors are becoming much Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 18 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 18 worse and the resident was unable to feed him/herself or give him/herself something to drink. Staff had to feed and give the resident drinks. The DON told the NP that occupational therapy (OT) staff said they do not believe the weighted silverware would help the resident at that time. The resident's NP asked if the resident was still drinking and the DON explained the resident was still drinking and ordering alcohol to be delivered to the facility; -On 4/3/24 at 12:00 P.M., staff said the resident was drinking alcohol while taking his/her medications; -On 4/4/24 at 9:15 A.M., staff said the ADON the resident told therapy staff he/she had fallen overnight. The resident's was asked if he/she reported the fall to anyone and the resident said no and he/she put him/herself back into bed. The resident did not report this to anyone until therapy came to work with him/her this morning. He/she said his/her right knee and right elbow was hurting and the resident had light bruising. The resident had small red bruising to his/her forehead. The resident's refused to transported to the hospital for further evaluation. He/she said he/she did not need to go. The resident's Physician and family was notified; -On 4/4/24 at 4:30 P.M., staff called the ADON to go see the resident's due to a fall. The resident's was in his/her bedroom, laying on his/her right side on the floor. The resident's screamed out in pain and complained of knee and rib pain. The resident said he/she was using the bathroom trying to get back into to bed when he/she fell to the floor. The staff member called emergency services were called and the resident was transported to the hospital. The staff member notified the resident's family and Physician. He/she was admitted for a rib fracture; -On 4/9/24 at 1:45 P.M., the DON called the Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 19 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 19 hospital and staff said the resident was discharged to rehab; -On 4/23/24 at 2:45 P.M., the resident returned to the facility with a family member. The resident had no complaints and was able to transfer and ambulate with no difficulty. The DON reviewed the resident's medication list with the resident's NP and made the resident's Psychiatric NP aware of his/her return. Review of the resident's ISP dated 4/26/24, showed the following: -Need: Dining; -Services to be provided: The resident did not need assistance with dining needs; -Need: Medication management; -Services to be provided: The resident needed someone to assist him/her with all aspects of medication management. Please make sure the resident took his/her medications timely and correctly; -Need: Problematic expressions (complete for resident who exhibit problematic behaviors, i.e. verbal aggression, refusal of care/meals/medications); -Services to be provided: Give the resident choices to help direct care and tell staff what he/she wanted and how it should have been done. Approach the resident in a calm and gentle manner. Encourage the resident to participate in activities and programs that may interest him/her. Encourage "small talk" prior to asking me to do something to help reduce the resident's anxiety and build rapport. Keep the environment peaceful and calm or help the resident go to a more peaceful environment if needed. If the resident was upset, redirect him/her to an activity or a conversation that may interest him/her. Offer choices whenever possible. Listen to the resident and validated his/her reality. Used "therapeutic Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 20 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 fibs" (when you tell a fib or bend the truth to fit the reality of a person who has dementia) if needed to redirect or keep safe. Notify the Nurse if there were changes in the resident's mood or behavior and note the reasons for those changes. If the resident refused care, staff should come back another time or with a different staff member. Give the resident praise and encouragement. Respect his/her privacy during care. Staff to take their time and go at the resident's speed - the resident would get upset when he/she was rushed. Staff talked to the resident about his/her interests and established a trusting relationship with the resident. Staff helped the resident feel independent by breaking down activities into smaller tasks so the resident can do as much for him/herself as possible. Staff kept the resident's daily routine consistent. The resident was prescribed psychotropic medications by his/her Physician. If additional interventions/approaches - specified further; -Need: Fall risk. The resident was assessed and was a fall risk. The resident became unsteady due to his/her disease process at times; -Services to be provided: Encourage the resident to use the bathroom. Remind the resident to wear and use his/her pendant whenever he/she needed assistance. Answer the resident's call light promptly. Monitor the resident for side effects of medications and/or signs of infection and notify the resident's Physician of any changes. Reorient the resident to his/her surroundings whenever he/she appeared turned around. Encourage the resident to drink to prevent dehydration. Keep apartment and the common area of the community free of clutter and cleaned up any spills promptly. Keep the call light with reach inside apartment. Remind the resident to wear his/her glasses and clean them when needed. Remind the resident to wear Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 21 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 21 his/her hearing aid and made sure the batteries were working properly. Remind the resident to use his/her walker, cane or other assistive device. Encourage the resident to wear appropriate, good-fitting, non-skid shoes. Consult with vision or hearing specialists as needed. Consider a conference with rehab services for exercise and gait training. Remind the resident how to properly use his/her assistive equipment if he/she is not using it correctly. Inform family members, friends and frequent visitors to be aware of the resident's falling and prevention strategies. Escort the resident away from any resident that appeared to be aggressive or agitated and from large crowds of people to a calmer environment. Too much commotion and aggressive residents made the resident anxious. Do not rush the resident. Give the resident adequate time to walk to where he/she was going. Encourage the resident to turn on the lights when the resident is in his/her apartment so he/she could see where he/she was going. Refer to the resident's life story to find ways to incorporate a person-directed approach into preventing him/her from falling; -Levels of Care Scoring Results: Supportive. One person provided minimal time to supervise, verbally cue, remind. No hands-on assistance needed; -The ISP did not indicate the resident's need and services to be provided for assistance with dining services; -The ISP did not indicate what services were to be provided for the resident's refusal of medications and taking medications while intoxicated; -The ISP did not indicate what services were to be provided for the resident's alcohol abuse; -The ISP did not indicate what services were to be provided for the resident's falling due to possible alcohol abuse and/or his/her Parkinson's Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 22 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 22 disease. Review of the resident's progress notes, showed the following: -On 4/29/24 at 12:30 P.M., staff said the resident was drinking alcohol while taking his/her medications. The staff notified the manager; -On 5/7/24 at 8:30 P.M., the resident refused his/her medications. Staff believed the resident was drinking; -On 5/13/24 at 3:00 P.M., staff walked into the resident's apartment to give him/her medication and staff noticed the resident was a "little" intoxicated. Staff notified DON; -On 5/15/24 at 12:00 P.M., staff walked into the resident's apartment to give him/her medication and staff noticed the resident was a "little" intoxicated. Staff notified DON; -On 5/18/24 at 12:30 P.M., staff walked into the resident's apartment to give him/her medication and staff noticed the resident was a "little" intoxicated. Staff notified DON; -On 5/18/24 at 8:15 P.M., staff said the resident appeared to be under the influence of alcohol; -On 5/21/24 at 12:30 P.M., a therapy staff member told the DON the resident refused to eat and refused his/her medication. The staff member said the resident said he/she did not want to live and had nothing to live for. The DON, ADON and the therapy staff member talked to the resident. The DON asked the resident why he/she was not eating and at first the resident said because no one would bring him/her food. The therapy staff member told the resident that was not true because he/she brought the resident food twice last week. The DON asked the resident if he/she wanted to live and the resident said that he/she was not going to answer that. The DON then asked the resident if he/she had a plan to kill him/herself and the resident said no. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 23 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 23 The resident said he/she would not be at the facility much longer. He/she said he/she was moving out so staff do not need to worry about him/her. Staff can worry about other people. The DON told the resident everyone was worried about him/her and wanted him/her to be okay. The DON asked the resident if he/she was drinking and he/she said yes. The therapy staff member again asked the resident if he/she would eat and he/she said no. He/she said his/her wheelchair was broke, only one side of the wheelchair was broke but it could still be used but the resident refused to. The DON spoke to a staff member who had worked on the assignment of the resident for the last couple of days and the staff member said the resident did refuse his/her medications and he/she would eat all three of his/her meals. The staff member said he/she made several attempts for the resident to come out of his/her apartment or he/she would bring the food to the resident's and feed him/her but the resident said no. The DON spoke to the Administrator and Assistant Administrator to make them aware; -On 7/1/24 at 6:45 P.M., staff checked on the resident and offered to help him/her clean him/herself up, but the resident refused. The resident also had empty bottles of liquor in his/her room that he/she refused to let staff throw away; -On 7/20/24 at 10:45 A.M., staff called the Assistant Administrator/Nurse to the resident's room after staff noted blood in the resident's bed. Upon entering the room, the resident was in his/her wheelchair facing the window with his/her back to the door. Staff noted dried blood on the resident's posterior scalp. The resident was awake, alert and responded normally. Staff noted dried blood on the resident's sheets and pillowcases. He/she adamantly denied falling, hitting his/her head on something or someone Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 24 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 24 else hitting him/her. When asked what happened, the resident said he/she did not know and he/she woke up like that. Staff noted dried blood was in the shower stall and on the bathroom floor in front of his/her toilet. The Assistant Administrator/Nurse attempted to cleanse the resident's scalp, the resident said "no, leave it alone. I'll be fine." The staff cleaned and sanitized the shower stall and floor in front of toilet. The resident remained at baseline and asked the Assistant Administrator/Nurse to give him/her privacy so he/she could make a phone call; -On 7/21/24 at 6:45 A.M., staff went into the resident's apartment to check on him/her and noticed his/her bed sheets were bloody. Staff asked the resident if he/she wanted assistance and he/she refused. Staff tried to change his/her bed sheets but the resident refused and the staff member immediately called a manager on duty. During an interview on 7/31/24 at 12:15 P.M., former Medication Technician (MT) G said she worked on the floor where the resident lived. MT G said the resident was drunk all of the time. He/she was intoxicated on and off since MT G worked at the facility. MT G said he/she would try to administer the resident's medications but he/she was drunk all of the time. The DON told MT G to sit the cup of medications in the resident's room room and leave when the resident was intoxicated . If he/she decided to take it, it would be up to the resident. He/she would tell the DON about it every time he/she found the resident intoxicated. One day the resident started choking when trying to swallow his/her medications because the resident was intoxicated. The resident eventually started to refuse his/her medications and he/she would say his/her Physician said he/she didn't have to take his/her medications if he/she did not want to. The Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 25 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 25 resident needed assistant with everything, he/she had tremors really bad. MT G said the resident would have "5th's" (large bottles of liquor) in his/her room. He/she would drink a bottle in a day and a half and order another by a food delivery service. MT G said the DON never told him/her how to handle the resident when he/she was under the influence of alcohol. They were too concerned about the money that the resident owed. MT G said the resident told him/her the staff did not feed the resident because he/she had tremors really bad and would drop food all over him/herself. During interviews on 7/31/24 at 1:00 P.M. and on 8/1/24 at 11:22 A.M., the DON said the resident had been drinking since she started working at the facility in December of 2023. The resident's Physician knew of the resident's drinking and he/she allowed the resident to take his/her medications while drinking. The Physician and the resident's family would try to talk to the resident about it and the family limited his/her source of funds but somehow the resident would be able to order the alcohol and have it delivered. The DON said eventually the resident would stop taking his/her medications because he/she was drinking and it would make the resident vomit. The DON should have put the resident's refusal for medications and his/her alcohol usage on his/her ISP but she did not because it was is the resident's home and he/she had the right to refuse his/her medications and drink alcohol. The DON said she knew what he/she would do if another resident was in the facility drinking. She said she would get the resident a breathalyzer to see if they were intoxicated. She was unaware something should have been done to keep the resident from abusing alcohol. The interventions for the resident's fall history was done by the Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 26 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 26 ADON. The ADON is on medical leave. In her absence, the DON should have put the interventions on the resident's ISP. During an interview on 7/31/24 at 1:33 P.M., the Assistant Administrator said a resident's needs and behaviors should be on the ISP. All staff can do is observe and report observations to the resident's Physician. The Assistant Administrator said he would follow directions given from the Physician and not give his personal opinion. The resident being intoxicated is very "opinion based." Staff cannot interject their personal feelings. The Assistant Administrator said he was aware the resident was ordering and consuming alcohol. He was unaware other measures could have been used. During an interview on 8/1/24 at 11:22 A.M., the Administrator said it was the resident's right to drink alcohol. He thought it was okay for a resident to drink alcohol while taking their medications if their Physician was aware. He would not know if a resident was drunk unless a breathalyzer was used. The resident's alcohol use, dining assistance and his/her falls interventions for each fall should have been on his/her ISP. The Administrator said his DON did not put it on the ISP because the resident had been drinking prior to him working there. Everyone was aware of it. He was aware all resident's needs and behaviors should be addressed on their ISP. 2. Review of Resident #3's medical record, showed the facility admitted the resident on 12/22/23, with diagnoses which included high blood pressure, acid reflux, osteoporosis, and atrial fibrillation (an irregular and often very rapid heart rhythm). Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 27 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 27 Review of the resident's progress notes, showed the following: -On 4/2/24, no time noted, the resident was awake and at baseline. The hospice Nurse completed peri-care; -On 4/4/24, no time noted, the resident was awake and at baseline. The hospice Nurse took the resident to lunch. The resident had generalized weakness; -On 4/8/24, no time noted, the resident was awake and at baseline. The hospice Nurse took the resident to lunch. The resident denied pain; -On 4/16/24, no time noted, the resident had weakness but denied pain. The hospice Nurse took the resident to breakfast; -On 4/18/24, no time noted, the resident was awake and at baseline. The resident was short of breath with extrusion. The resident denied pain; -On 5/6/24, no time noted, the resident was weak and had increased anxiety. The hospice Nurse ordered a bedside commode. The resident showed signs of frustration and being scared; -On 5/13/24, no time noted, the resident was asleep but arousable. The hospice Nurse assisted the resident to the bathroom using the resident's wheelchair; -On 5/16/24, no time noted, the resident was awake and at baseline. The resident was very weak, and the resident's appetite decreased; -On 5/28/24, no time noted, the resident was awake and at baseline with therapy; -On 6/3/24, no time noted, the resident was awake and at baseline. The resident denied pain but was no longer able to sit up; -On 6/6/24, no time noted, the resident was awake and at baseline. The resident did not have any immediate needs; -On 6/10/24, no time noted, the resident was awake and at baseline. The hospice Nurse Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 28 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 28 completed a bed bath; -On 6/13/24, no time noted, the resident was awake and at baseline. The hospice Nurse tried to move the resident off his/her butt, but the resident refused. Review of the resident's ISP dated 7/30/24, showed the following: -Need: Bathing: The resident required assistance with a shower once a week, lotion post shower, offer shampoo with showers. Towel dry legs, arms, front and back of body. The weekly shower was required on Wednesdays and Saturdays at 6:30 P.M., as needed. The resident required assistance with all aspects of bathing and assistance with getting in and out of the shower. The resident may need some assistance with bathing, and the staff were required to ask the resident; -Use of bathroom: The resident required assistance with getting in and out of the bathroom. The resident was incontinent and required assistance with cleaning and changing his/her under garments; -The ISP did not indicate if facility staff or if hospice staff were required to bathe the resident; -The ISP did not indicate when the hospice staff were bathing the resident; -The ISP did not indicate preferences of the resident regarding his/her bathing. During an interview on 7/30/24 at 1:30 P.M., the DON said hospice would tell her when the resident had a bath. The DON said hospice would also let the care staff know. The DON said the hospice services should be listed in the resident's ISP, so facility staff know what hospice is doing with the resident. During an interview on 8/1/24 at 3:59 P.M., the Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 29 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 Administrator said he would expect hospice care to be outlined on the ISPs and he thought it was a problem with the way the facility's online database was set up. He said he was not aware the ISP did not indicate the hospice team was bathing the resident as well as the facility staff. MO00234218 19 CSR 30-86.047(36) Proper Care Per Individual Service Plan Residents shall receive proper care as defined in the individualized service plan. |/Il This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to provide proper care for a resident, as defined in their 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), for one of seven sampled residents (Resident #5) who required assistance with transfers and use of the bathroom. The census was 54. Review of Resident #5's medical record, showed the facility admitted the resident on 3/20/23, with diagnoses which included diabetes and high blood pressure. Review of the resident progress notes, showed on 7/23/24 at 9:45 A.M., showed staff found the resident in the bathroom. The resident said Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 30 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 30 he/she had sat there for five hours and was weak and clammy. The resident's family member was there and wanted him/her to go to the hospital. Staff notified the Director of Nursing (DON), the resident's Nurse Practioner and sent the resident out to the hospital. Review of the resident's ISP dated 7/28/24, showed the following: -Need: Use of bathroom; -Services to be provided: The resident required assistance on a daily basis with going to the bathroom. The staff were required to ensure the resident was clean and dry. Observation on 7/31/24 at 3:42 P.M., showed the resident lived in an apartment at the end of a long hall. When inside, the resident was in the bathroom on the toilet. The resident asked (this writer) could | please get someone to help him get up from the toilet. The resident said he/she pressed his/her call pendant 20 minutes ago. This writer went back up the hall toward the concierge desk and saw a dining server. This writer asked the staff member to get help for the resident. The staff member walked to the concierge desk to let someone know the resident needed help. This writer walked down hallway near the resident's apartment and waited approximately 10 minutes. This writer then walked back up the hallway toward the concierge desk and asked the receptionist did the server tell him/her a resident needed help. The receptionist said yes and this writer walked back down the hallway and waited approximately seven minutes. This writer walked back up the hallway toward the concierge desk and saw the Assistant Administrator. This writer told the Assistant Administrator the resident needed assistance as soon as possible. The Assistant Administrator Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 31 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 31 and this writer walked back down the hall the resident's apartment. The Assistant Administrator went into the bathroom to assist the resident. The Assistant Administrator then assisted the resident to his/her bed. The resident rested for approximately five minutes. The resident was breathing hard and was using his/her oxygen. The Assistant Administrator assisted the resident to his/her recliner. During an interview on 7/31/24 at 2:43 P.M., the resident said he/she has waited for staff to come assist him/her with transferring to and from the bathroom, for up to two hours. During an interview on 8/1/24 at 1:23 P.M., the resident's family member said he/she arrived at the resident's apartment on 7/23/24 at approximately 9:00 A.M. and had to unlock the apartment. The resident was in the bathroom sitting on his/her rollator with his/her head down on the sink. The family member said the resident said he/she had been sitting there for hours. He/she said the resident went into the bathroom between 4:00 A.M. and 5:00 A.M., because that was his/her routine. The family member said the resident was really oriented to time and did not think it was suppose to take that long for staff to attend to a resident. The family member said staff told him/her whoever was on duty the night before did not do their job. The family member said he/she felt like the facility was short-staffed. The resident had his/her call light pendant on but when he/she pushes it, staff do not always come. The family member said the resident was very frustrated because he/she called for staff a lot and they don't come. He/she felt bad because if he/she had not came in at 9:00 A.M., he/she would not know how long the resident would have sat in the bathroom which bothered the family Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 32 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 32 member. If staff would have stuck their head in the room they would have heard the resident. Staff told the family member the perform wellness checks on residents every one to two hours. During an interview on 8/1/24 at 11:22 A.M., the DON said the resident recently started requiring assistance in the bathroom. The resident has a call pendant to call staff for assistance. He/she happened to take his/her pendant off one time but he/she wore it all of the time. He/she did not have an intervention for the resident possibly taking his/her call pendant off. The DON expects staff to toilet a resident three to four times a day or as needed. He/she expects staff to follow the ISP. During an interview at 8/1/24 at 11:38 A.M., the Administrator said staff should be assisting the resident according to the ISP. 19 CSR 30-86.047(58)(A) Resident Record Admission Info The facility shall maintain a record in the facility for each resident, which shall include the following: (A) Admission information including the resident ' s name; admission date; confidentiality number; previous address; birth date; sex; marital status; Social Security number; Medicare and Medicaid numbers (if applicable); name, address and telephone number of the resident's physician and alternate; diagnosis, name, address and telephone number of the resident ' s legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director; III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 33 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 33 Based on interview and record review, the facility failed to maintain a record for each resident that included contact information of the resident's preferred dentist, pharmacist and funeral director for four of five sampled residents (Residents #5, #2, #3 and #4). The census was 54. 1. Review of Resident #5's medical record, showed the following: -Admit date 2/5/24- -Diagnoses which included anemia, vitamin D deficiency, hypothyroidism and anxiety; -No documentation of the resident's preferred dentist; -No documentation of the resident's preferred funeral home. 2. Review of Resident #2's medical record, showed the following: -Admit date 2/21/20; -Diagnoses included diabetes, Alzheimer's disease and vitamin D deficiency; -No documentation of the resident's preferred dentist. 3. Review of Resident #3's medical record, showed the following: -Admit date 12/22/23; -Diagnoses included high blood pressure, acid reflex and osteoporosis; -No documentation of the resident's preferred dentist. 4. Review of Resident #4's medical record, showed the following: -Admit date 5/6/24: -Diagnoses included high blood pressure, congestive heart failure and absence of leg below knee; -No documentation of the resident's preferred Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 34 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 34 dentist. 5. During an interview on 8/1/24 at 4:05 P.M., the Administrator said the Sales Team hands over the resident's preferred physician, pharmacy, dentist and funeral home information to the Director of Nursing to update the resident's chart. The Administrator was not aware some residents did not have this information in the medical records. 19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents '' social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. 1/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3-15 3 p.m. to 9 p.m. (Evening)* 1 3-20 9 p.m. to 7 a.m. (Night)* 1 3-25 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 35 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 35 schedules of the facility and shall not be less than six (6) hours. Ill This regulation is not met as evidenced by: Class II Based on interview and record review, the facility failed to develop a system to ensure staff trained in cardiopulmonary resuscitation (CPR) were available on each shift, to meet the needs of full code residents, for 26 of 54 residents who resided in the facility. The census was 54. Review of the facility's schedule for June of 2024, showed the following: -On 6/2/24, on the day shift, no CPR trained person on shift; -On 6/3/24, on the night shift, no CPR trained person on shift; -On 6/5/24, on the morning shift, no CPR trained person on shift; -On 6/6/24, on the morning and night shift, no CPR trained person on shift; -On 6/7/24, on the morning and night shift, no CPR trained person on shift; -On 6/8/24, on the night shift, no CPR trained person on shift; -On 6/10/24, on the morning and night shift, no CPR trained person on shift; -On 6/11/24, on the morning shift, no CPR trained person on shift; -On 6/12/24, on the morning shift, no CPR trained person on shift; -On 6/13/24, on the night shift, no CPR trained person on shift; -On 6/14/24, on the night shift, no CPR trained person on shift; -On 6/15/24, on the morning and night shift, no CPR trained person on shift; -On 6/16/24, on the morning shift, no CPR trained Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 36 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 36 person on shift; -On 6/17/24, on the night shift, no CPR trained person on shift; -On 6/18/24, on the night shift, no CPR trained person on shift; -On 6/19/24, on the morning shift, no CPR trained person on shift; -On 6/20/24, on the morning and night shift, no CPR trained person on shift; -On 6/21/24, on the morning and night shift, no CPR trained person on shift; -On 6/22/24, on the night shift, no CPR trained person on shift; -On 6/23/24, on the night shift, no CPR trained person on shift; -On 6/24/24, on the morning and night shift, no CPR trained person on shift; -On 6/25/24, on the morning shift, no CPR trained person on shift; -On 6/26/24, on the morning shift, no CPR trained person on shift; -On 6/27/24, on the night shift, no CPR trained person on shift; -On 6/28/24, on the night shift, no CPR trained person on shift. During an interview on 8/1/24 at 4:09 P.M., the Administrator said the administration team share the responsibility of the scheduling. The Administrator said he had not received any more documentation from the staff who were CPR certified or trained. The Administrator said he was aware it was a requirement to have CPR certified or trained persons on each shift when the facility had full code residents residing in it. The Administrator said he has staff that were CPR trained but he did not have documentation to show it. The Administrator said he was not aware the schedule did not reflect this requirement but said he knew there were other staff members Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 37 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 37 who were CPR certified or trained but did not have documentation to show it. 19 CSR 30-87.020(5) Toxic Material Storage Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. Il This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents for one of one day of observation. The census was 54. 1. Observation on 7/30/24 between 7:58 A.M. and 2:15 P.M., in resident room 169, showed the following: -The door of the apartment was open; -Three trays of charcoal, two on the floor in the bedroom and one in the closet. The precautionary statement read, "Keep out of reach of children. Harmful or fatal if swallowed."; -In the bedroom of the apartment, two 5 gallon buckets of Sherman Williams ProMar 400 paint. The precautionary statement read, "May irritate eyes. Do not get in eyes, Keep out of reach of children. If swallowed, call a poison control center or doctor immediately. Do not induce vomiting. If in eyes, rinse with water for 15 minutes. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 38 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 38 WARNING: This product contains chemicals known to the State of California to cause elements cancer and birth defects or other reproductive harm. Adequate ventilation required when sanding or abrading the dried film. If Adequate ventilation cannot be provided wear an approved particulate respirator."; -Between 7:58 A.M. and 9:00 A.M., across the hall, an unknown resident sat in his/her apartment with his/her door open talking on the phone. No staff were present. 2. Observation on 7/30/24 between 8:47 A.M. and 3:00 P.M., of the second floor nurse's station, showed the door handle was locked but not all the way closed. A 1/2 full 32 ounce (oz) spray bottle of Array bacterial odor and grease digestant sat underneath the counter. The precautionary statement read, "HAZARD STATEMENTS: CAUSES EYE IRRITATION. Avoid contact with eyes, skin, and clothing. Avoid breathing vapors or mists. Do not spray product into the air. Avoid use and contact of product with immune compromised individuals. Do not apply to food preparation surfaces. Do not reuse this package for storing beverages or liquids. Wash hands and affected areas thoroughly after handling. KEEP OUT OF REACH OF CHILDREN. CHEMICAL HAZARDS: SERIOUS EYE AND MILD SKIN IRRITATION." 3. Observation on 7/30/24 between 8:53 A.M. and 3:02 P.M., of the second floor bistro adjacent to the nurse's station, showed a 1/2 full 32 oz spray bottle of Total Solutions surface sanitizing spray . The precautionary statement read, "Hazards to humans and domestic animals. Caution: Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, dining chew Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 39 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 39 gum or using tobacco. 4. During an interview on 7/30/24 at 4:02 P.M., the Administrator said all chemicals should be locked up and everyone was aware of this requirement. The Administrator said the apartment door for resident room 169 should have been locked and he thought a contractor must have left it open. The Administrator said chemicals should not be kept underneath counters in the nurse's station unless the nurse's station was locked, and chemical should not be kept in unlocked cabinets. 19 CSR 30-87.030(3) Clean Clothing, Hair Restraints 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, interview and record review, the facility failed to ensure all kitchen staff properly wore hairnets during preparation of food for one of one day of observation. The census was 54. Review of the facility's undated "Hair Restraints Procedure and Policy", showed hair restraints shall be worn by all Dining Services Staff. Staff shall wear hair restraints in all food preparation and serving areas. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. 1. Observation on 7/30/24 between 7:40 A.M. and 12:00 P.M., showed Cook C did not wear a Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 40 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 40 hairnet or a beard-net when he/she prepared the breakfast meal which consisted of bacon, sausage, eggs, pancakes and oatmeal. Also, Cook C prepared the breakfast plates through breakfast without a hairnet or a beard-net on. Cook C's hair was approximately 6-8 inches long. Cook C's beard was approximately 1 inch long. 2. Observation on 7/30/24 between 7:48 A.M. and 12:50 P.M., showed Server G wore a hair-net with hair hanging out the sides when he/she served food. Server G's hair was approximately 5-6 inches long on the sides. 3. Observation on 7/30/24 between 11:11 A.M. and 12:00 P.M., showed Server H with a ponytail but without a hair-net on while he/she served food to the residents. 4. Observation on 7/30/24 between 11:14 A.M. and 12:00 P.M., showed Sous Chef J without a beard-net on, while preparing food. Sous Chef J's beard was approximately 1 inch long. 5. During an interview on 7/30/24 at 12:11 P.M., the Dining Services Director said his biggest challenges were having to correct staff who come into the kitchen who are from other departments. They seem to not understand that if they come into the kitchen, then they would need a hairnet on. He was aware all staff had to have hairnets and/or beard-nets on when in the kitchen. 6. During an interview on 8/1/24 at 1:35 P.M., the Administrator said dining staff are constantly reminded to wear hairnets and beard-nets in the all the time. The Administrator said he expected all staff to wear hairnets and/or beard-nets and was not aware the staff did not have on beard-nets. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 41 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER PRINTED: 08/16/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 19 CSR 30-88.010(23) Develop/Implement A/N Policies The facility shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to immediately report and investigate an injury of unknown origin, per the facility's abuse and neglect policy, for one of five sampled residents (Resident #6). This had the potential to affect all residents. The census was 54. Review of the facility's undated abuse and neglect policy, showed the following: -"Abuse" means any act or failure to act performed intentionally or recklessly that causes or likely to cause harm to a resident; -Any physical or mental injury or sexual assault inflicted on a resident, other than by accidental means; -Physical injuries include injuries that a reasonable and prudent person would be able to prevent such as hitting, pinching, or striking, or injury resulting from rough handling; -The abuse and neglect policy did not address investigation injuries of unknown origin. Missouri Department of Health and Senior Services STATE FORM PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A8023 6899 27WI11 If continuation sheet 42 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 42 1. Review of Resident #6's medical record, showed the following: -Admit date 5/2/23; -Diagnoses included hypokalemia (the amount of potassium in your blood is too low), alcohol use with unspecified alcohol-induced disorder, seizures, high blood pressure,chronic pancreatic, history of stroke and a history of a stroke. Review of the resident's progress notes, showed the following: -On 7/20/24 at 10:45 A.M., staff called the Assistant Administrator/Nurse to the resident's room after staff noted blood in the resident's bed. Upon entering the room, the resident was in his/her wheelchair facing the window with his/her back to the door. Staff noted dried blood to the resident's posterior scalp. The resident was awake, alert and responding normally. Staff noted dried blood on the resident's sheets and pillowcases. He/she adamantly denied falling, hitting his/her head on something or someone else hitting him/her. When asked what happened, the resident said he/she did not know and woke up like that. Staff noted dried blood in the shower stall and on the bathroom floor in front of his/her toilet. The Assistant Administrator/Nurse attempted to cleanse the resident's scalp, the resident said "no, leave it alone. I'll be fine." Shower stall and floor in front of toilet cleaned and sanitized. The resident remained at baseline and asked the Assistant Administrator/Nurse to give him/her privacy so he/she could make a phone call; -On 7/21/24 at 6:45 A.M., staff went into the resident's apartment to check on him/her and noticed his/her bed sheets were bloody. Staff asked the resident's if he wanted assistance and he/she refused. Staff tried to change his/her sheet but the resident refused and the staff Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 43 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 43 member immediately called a manager on duty. During an interview on 7/31/24 at 1:33 P.M., the Assistant Administrator said the blood that was found was not definitive. He said he understood injuries of unknown origin but did not know if it was in the facility's policy to report injuries of unknown origin. During an interview on 8/1/24 at 11:22 A.M., the Administrator said the injury of unknown origin should have been reported. *This higher the classification merited due to the extent of the violation. 19 CSR 30-88.010(29) Dignity/Privacy Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the facility personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. II/III This regulation is not met as evidenced by: Class III Based on observation and interview, the facility failed to ensure facility staff treated residents with consideration, respect and full recognition of their dignity and individuality when hospice staff performing peri-care on the resident, did so without informing the resident of what the staff Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 44 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 44 were doing to him/her, for one of five sampled residents (Resident #3). The census was 54. Review of Resident #3's medical record, showed the facility admitted the resident on 12/22/23, with diagnoses which included high blood pressure, acid reflex and osteoporosis. Review of the resident's hospice progress notes, showed the following: -On 4/2/24, the resident was awake and at baseline. The hospice Nurse completed peri-care; -On 6/10/24, the resident was awake and at baseline. The hospice Nurse completed a bed bath. During an interview on 7/30/24 at 2:30 P.M., the resident said he/she did not have any issues with the facility staff, but the hospice staff performed peri-care and bed-baths for the resident. The resident said when the hospice staff care for him/her, they do not communicate what they are going to do with the resident before they do it. The resident said, "I'm human, they can't just come in and change my diaper without telling me what they are doing." The resident said he/she had complained to the Nurse about the hospice staff before. The resident could not recall the last time the hospice staff did this, but said it was "recent." The resident said he/she did not like it when the hospice staff did this, and it upset him/her. The resident said he/she thought it was from the hospice staff not being able to understand the resident when he/she talked. The resident said, "just because they can't understand me, doesn't mean | can't understand them.” During an interview on 8/1/24 at 10:30 A.M., the Director of Nursing (DON) said she was aware Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 45 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 45 the facility was responsible for the hospice team and their actions with each resident. She said she speaks to hospice frequently about the resident. The DON said the hospice team has not mentioned any issues with the resident. The DON said she has not observed the hospice team perform peri-care for the resident. She said she has not specifically asked the resident how hospice is treating him/her, but she has talked to the resident frequently because he/she was not doing the best right now. The DON said she asked the resident if everyone was treating him/her okay and if there were anything that needs to be changed. The DON said the resident did not mention the hospice team did not meet some certain preferences the resident wanted. The DON said she would expect the hospice staff to talk to the resident the whole time while performing peri-care, telling the resident what they are doing and what the next step would be. The DON said the resident had not expressed concerns regarding the hospice team not explaining things to him/her before performing peri-care. The DON said there was an issue in the past for the same thing but with facility staff members, but the facility staff members involved were no longer employed with the facility. The DON said she never asked the resident specifically about the hospice staff treatment. During an interview on 8/1/24 4:06 P.M., the Administrator said he was not aware the facility is responsible for the hospice team. The Administrator said he has not heard any concerns from hospice team, regarding the resident. The Administrator said the resident has had some complaints in the past about the same issue. The Administrator said he would expect all staff to tell the resident what they are doing before they are doing it while performing peri-care. The Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 46 of 48 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 13663D NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 CEDARHURST OF TESSON HEIGHTS (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 46 Administrator said he was not aware the hospice team was not meeting his expectation. 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 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/IlI This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to ensure personal inventory lists were completed and allowed residents to waive this required document, for four of five sampled (Residents #2, #5, #3 and #4). The census was 54. 1. Review of Resident #2's medical record, showed the following: -Admit date 2/21/20; -No documented inventory sheet. 2. Review of Resident #5's medical record, showed the following: -Admit date 3/20/23; -No documented inventory sheet. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 PRINTED: 08/16/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 08/01/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 47 of 48 PRINTED: 08/16/2024 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 13663D — 08/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12335 WEST BEND DRIVE SAINT LOUIS, MO 63128 (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) CEDARHURST OF TESSON HEIGHTS Continued From page 47 3. Review of Resident #3's medical record, showed the following: -Admit date 12/22/23; -No documented inventory sheet. 4. Review of Resident #4's medical record, showed the following: -Admit date 5/6/24: -No documented inventory sheet. 5. During an interview on 8/1/24 at 4:03 P.M., the Administrator said upon admission, the Sales Team gives the inventory sheet to the resident's family members who can complete it. The Administrator said if the family does not complete it, the facility wrote "void" on the inventory sheet. The Administrator was aware all residents were required to have inventory sheets but was not aware writing "void" on the inventory sheets was not acceptable. Missouri Department of Health and Senior Services STATE FORM 6899 27WI11 If continuation sheet 48 of 48 PLAN OF CORRECTION Provider/Supplier Cedarhurst of Tesson Heights Name: Street Address, . . 12335 W Bend Drive Saint Louis, MO 63128 City, Zip: Date of Survey: 08/01/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE The Plan of Correction is submitted as required under State and Federal law. The submission of the Plan of Correction does not constitute an admission on the part of Cedarhurst of Tesson Heights as to the accuracy of the surveyors’ findings or the conclusions drawn therefrom. Submission of the Plan of Correction does not constitute an admission that the findings constitute a deficiency or the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community’s policies and procedures should be considered subsequent remedial measures as the conceptus employed in Rule 407 of the Federal Rules of Evidence and any corresponding State rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this Plan of Correction with the intention that it be inadmissible by any third party in civil or criminal action against the Community or any employee. If the community 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 A4506 evacuating the community, the community shall: six. Ata minimum the evacuation plan shall include the following components: A. The responsibilities of specific staff positions in an emergency specific to the individual. IEPs for each resident will be updated to reflect the responsibilities of specific staff positions in an emergency specific to the individual. 2. Atleast seven different IEPs will be audited by the ED (or their appointee) and reviewed with the DON (or their appointee) each month for the next 90-day period. If the community 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 community, the community shall: six. At a A4508 minimum the evacuation plan shall include the following components: C. The plan shall evaluate the resident for his or her location within the community 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; 1. IEPs for each resident will be updated to include the distance for each resident’s apartment to exits and areas of refuge. As applicable, the IEPs shall include risk of resistance, mobility, any need for additional support, consciousness, response to instructions, response to alarms, and fire drills. 2. Atleast seven different IEPs will be audited by the ED (or their appointee) and reviewed with the DON (or their appointee) each month for the next 90-day period. Fire Drills and Emergency Preparedness. (D) A minimum of twelve (12) fire drills shall be conducted annuaily with at least one (1) every three (3) months on each shift. At least four (4) of A2217 the required fire drills must be unannounced to residents and staff, excluding staff who are assigned to evaluate staff and resident response to the fire drill. The fire drills shall include a resident evacuation at least once a year 1. Fire drills will be conducted in accordance with regulations. The Executive Director (or designee) will audit for completion of fire drills monthly for a 12-month period. A2257 The storage of unnecessary combustible materials in any part of a building in which a licensed community is located is prohibited 1. All unnecessary combustible materials in any part of the community will be removed as soon as possible by the 08/01/2024 Executive Director or designee. 2. All vacant apartments where contractor supplies are being stored will be locked and inaccessible to residents. All staff to be in serviced on keeping vacant apartments locked by the Executive Director or designee no later than 9/14/24. AA738 There shall be written documentation maintained in the community showing actual hours worked by each employee. Each salaried employee will record the time of arrival to the community and their time of exit from the community. Recordings will be documented in the provided calendars. Monthly calendars will be collected 08/05/2024 at the end of each month and filed away for record keeping. Records will be reviewed monthly by the Executive Director or designee. The community may admit or retain an individual for residency in an assisted living community only if the individual does not require hospitalization or skilled nursing placement as defined in A4749 this rule, and only if the community: (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; 1. The Community will complete all community-based assessments conducted within five (5) days calendar days of admission. The Executive Director or designee will complete a monthly audit for new residents for a 6- month period. A4750 The community may admit or retain an individual for residency in an assisted living community only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the community: (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 1. The Community will complete the assessments in their entirety semiannually. They will be inserviced by the Executive Director or designee. The Executive Director or designee will complete an audit for a 6-month period. A4754 The community may admit or retain an individual for residency in an assisted living community only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the community: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living community 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 community 1. The Executive Director or designee will ensure all ISPs match the needs of the residents. The Executive Director (or designee) will review a sample of at least five residents with the DON (or designee) monthly for a 6-month period to ensure ail ISPs match the needs of the residents. A4t tT? Residents shall receive proper care as defined in the individualized service plan. 1. All care staff will be inserviced on timely responses to pendants and the importance of the [SPs prior to 9/14/24 by the Executive Director or designee. A4836 The community shall maintain a record in the community for each resident, which shail include the following: (A) Admission information including the resident's name; admission date; confidentiality number; previous address; birth date; sex; marital status; Social Security number; Medicare and Medicaid numbers (if applicable); name, address and telephone number of the resident's physician and alternate; diagnosis, name, address and telephone number of the resident's legally authorized representative or designee to be notified in case of emergency; and preferred dentist, pharmacist and funeral director 1. The Executive Director or designee will ensure that all resident records include the following: contact information of the preferred dentist, pharmacist, and funeral director. 2. All active resident records will be reviewed to ensure this information is included by the Executive Director or designee. 3. All new resident records will be reviewed to ensure this information is included by the Executive Director or designee. A4841 4. Amonthly audit for new residents will be completed by the Executive Director or designee to for a 90-day period. Staffing Requirements. (A) The community shall have an adequate number and type of personnel for the proper care of residents, the residents’ social well-being, protective oversight of residents and upkeep of the community. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) residents or major fraction of twenty-five (25) during the night shift. Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 13-15 3 p.m. to 9 p.m. (Evening)* 13-20 9 p.m. to 7 a.m. (Night)* 13-25 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the community and shall not be less than six (6) hours 1. The Executive Director or designee will ensure all CPR certifications are collected by those who have active certifications prior to starting employment as of 9/1/24 2. The Executive Director or designee will continue to monitor monthly all CPR certifications’ renewal dates for a 6-month period. 3. The Executive Director or designee will collect evidence of CPR certification past or active for current care staff by 9/14/24. Poisonous or toxic materials consist of the following categories: insecticides and rodenticides; disinfectants, sanitizer and related cleaning or drying agents; and caustics, acids, polishes and other chemicals. Each of these three (3) categories set forth AG6005 shall be stored and physically located separate from each other. All poisonous or toxic materials shall be stored in locked cabinets or in a similar physically separate place used for no other purpose which is not accessible to residents. All poisonous or toxic materials will be removed from resident accessible areas or appropriately stored behind 08/01/24 a lock. 2. All vacant apartments where contractor supplies are being stored will be locked and inaccessible to residents. All staff to be in serviced on keeping vacant apartments locked by the Executive Director or designee no later than 9/14/24. 3. The Executive Director or designee will verify weekly for a 90-day period that such items are stored appropriately and not accessible in resident areas. The outer clothing of all employees shall be clean, and A7003 employees shall use effective hair restraints to prevent the contamination of food or food-contact surfaces. 1. The Community will place hairnets at all entrances to the kitchen including signage as a reminder for wearing 08/05/24 before entering prior to 8/31/24 2. All staff will be inserviced by the Executive Director or designee on appropriately wearing hairnets or beard guards (as applicable) when entering the kitchen prior to 9/14/24. The community shall develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of any resident and misappropriation of resident property and funds, A8023 and develop and implement policies that require a report to be made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. 1. The Executive Director or designee will inservice all care staff on policy and procedure for Abuse and Neglect as well as injuries of unknown origin. This will be completed prior to 9/14/24. Each resident shall be treated with consideration, respect, and full recognition of his or her dignity and individuality, including privacy in treatment and care of his or her personal needs. All persons, other than the attending physician, the community A8030 personnel necessary for any treatment or personal care, or the department or Department of Mental Health staff, as appropriate, shall be excluded from observing the resident during any time of examination, treatment, or care unless consent has been given by the resident. 1. The Executive Director or designee will coordinate with third-party services performing any care to inservice their staff regarding dignity and privacy no jater than 8/31/24. 08/09/2024 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 community's policies and shall not create a A8037 fire hazard. The community shall maintain a record of any personal items accompanying the resident upon admission to the community, or which are brought to the resident during his or her stay in the community, which are to be returned to the resident or responsible party upon discharge, transfer, or death. 1. The Executive Director or designee will audit all inventory sheets monthly for a 3-month period starting 08/24. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.