DOLAN MEMORY CARE AT CALAIS.

Dec 05 2023 2:32pm — Lyon 3149911302 2 12/04/2023 12:23:20 PM -O0600 FAXCOM PAGE 4 OF 4 PRINTED: 11/14/2023 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDERISUPPLIERICLIA (K2) MULTIPLE CONSTRUCTION &3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 27755 B. WING 40/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1225 TENNANT ROAD SAINT LOUIS, MO 63146 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY ORLSC IDENTIFYING INFORMATICN) CRCSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DOLAN MEMORY CARE AT CALAIS A4506) 19 CSR 30-86.045(3)(A)(6)(A) Individual Evacuation Plan-Staff Requirements General Requirements. (A) If the facility admits or retains any individual needing more than minimal assistance due to having a physical, cognitive or other impairment that prevents the individual from safely evacuating the facility, the facility shall: 6. Ata minimum the evacuation plan shall include the following companents: A. The responsibilities of specific staff positions in an emergency specific to the indivicual: |! This regulation is net 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 three sampled residents (Residents #3, #2 and #1). The census was 34. 1. Review of Resident #3's medical record, showed the following: -Admit date 10/3/18: -Diagnoses included Alzheimer’s disease, chronic kidney disease, glaucoma, macular degeneration, major depressive disorder and anxiety. Review of the resident's IEP dated 10/30/2023, showed the following: -The resident's room is 10 feet from the exit -The resident is able to follow directions; Misscuri Department of Health and Senior Services PI6211 if continuation sheet 4 af4 State of Missouri 3143403414 12/05/2023 08:33AM Pg 02/02 PRINTED: 11/14/2023 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 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1225 TENNANT ROAD SAINT LOUIS, MO 63146 (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) DOLAN MEMORY CARE AT CALAIS Continued From page 1 -The resident is able to ambulate but uses a wheelchair and will require assistance with pushing the resident's wheelchair; -Level of resistance: None; -The resident's IEP did not specify which staff position was assigned to the resident. 2. Review of Resident #2's medical record, showed the following: -Admit date 2/9/22: -Diagnoses included Alzheimer's disease, anxiety, diabetes and insomnia. Review of the resident's IEP dated 8/16/23, showed the following: -The resident has no safety awareness; -The resident required assistance with pushing the resident's wheelchair; -The resident room is five feet from the exit; -The resident's IEP did not specify which staff position was assigned to the resident. 3. Review of Resident #1's medical record, showed the following: -Admit date 3/22/23; -Diagnoses included Alzheimer's disease, general anxiety disorder, high blood pressure and rheumatoid arthritis. Review of the resident's IEP dated 8/1/23, showed the following: -The resident room is five feet from the exit; -The resident will not appropriately respond; -The resident is non-ambulatory and will require 100% physical assistance; -The resident's IEP did not specify which staff position was assigned to the resident. 4. During an interview on 10/30/23 at 1:45 P.M., the House Manager said she did not know the Missouri Department of Health and Senior Services STATE FORM 6899 P16211 If continuation sheet 2 of 4 PRINTED: 11/14/2023 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 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1225 TENNANT ROAD SAINT LOUIS, MO 63146 (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) DOLAN MEMORY CARE AT CALAIS Continued From page 2 IEP required specific staff positions to be assigned to each resident. 5. During an interview on 10/30/23 at 2:45 P.M., the Administrator said she was not aware the IEP required specific staff positions to be assigned to each resident. 19 CSR 30-87.020(28) Backflow Requirements The potable water system shall be installed to preclude the possibility of backflow. Devices shall be installed to protect against backflow and back siphonage at all fixtures and equipment where an air gap at least twice the diameter of the water supply inlet is not provided between the water supply inlet and the fixture ' s flood level rim. A hose shall not be attached to a faucet unless a backflow prevention device is installed. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure there was an air gap between the drain pipe of the ice machine and the floor drain for four of four ice machines. The census was 34. 1. Observation on 10/30/23 between 8:13 A.M. and 2:31 P.M., of the ice machine located in the dry food storage room in the Lyon house kitchen, showed a plastic tube extended from the back of the ice machine, down to the floor. There was a drain in the floor and the tubing went directly down into the drain. 2. Observation on 10/30/23 between 8:26 A.M. and 2:31 P.M., of the Calais house dry food storage, showed a plastic tube extended from the back of the ice machine, down to the floor and extended to the drain. The tube entered the drain Missouri Department of Health and Senior Services STATE FORM 6899 P16211 If continuation sheet 3 of 4 PRINTED: 11/14/2023 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 10/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1225 TENNANT ROAD SAINT LOUIS, MO 63146 (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) DOLAN MEMORY CARE AT CALAIS Continued From page 3 pipe and extended for at least two inches into the floor drain before making direct physical contact with the pipe. 3. Observation on 10/30/23 between 9:16 A.M. and 2:31 P.M., of the Clermont house dry food storage, showed a plastic tube extended from the back of the ice machine, down to the floor and extended to the drain. The tube entered the drain pipe and extended for at least two inches into the floor drain before making direct physical contact with the pipe. 4. Observation on 10/30/23 between 9:22 A.M. and 2:31 P.M., of the Lourdes house dry food storage, showed a plastic tube extended from the back of the ice machine, down to the floor and extended to the drain. The tube entered the drain pipe and extended for at least two inches into the floor drain before making direct physical contact with the pipe. 5. During an interview on 10/30/23 at 2:45 P.M., the Administrator said she did not know what an air gap was and was not aware the ice machines required an air gap to be present. Missouri Department of Health and Senior Services STATE FORM 6899 P16211 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier Dolan Memory Care Calais Name: Street Address, City, Zip: 1225 Tennant Rd. St. Louis MO 63146 Date of Survey: 10/30/2023 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE e The corrective action to be taken will be to add the room A4506 exit direction of left or right and what staff assignment 10/30/2023 will direct them to safety to the IEP e Other resident charts will be reviewed for deficient - 12/20/2023 practices e Upon developing IEP the nurse manger will make sure the exit direction and staff assignment is present on the Ongoing initial ISP meeting with the family e Resident care coordination will review all IEP’s ona quarterly audits. Ongoing e All four ice machines now has an air gap placed AG028 between the drain and the pipe. 10/30/2023 e Ensuring that the air gap between the drain and pipe on Onaoin the ice machine are maintained. going e House manager will check drain position weekly and Ongoing notify maintenance if air gap has been breached e Routine maintenance check every 3 months with calcigen tabs put down the drain to insure that backflow Ongoing is not possible. 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.