DOUGHERTY FERRY ASSISTED LIVING & MEMORY CARE.

PRINTED: 05/16/2025 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 04/30/2025 B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 NAME OF PROVIDER OR SUPPLIER DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2217 19 CSR 30-86.022(5)(D) Fire Drill Requirements, | Evacuation Fire Drills and Emergency Preparedness. (D) Aminimum 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/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to conduct and/or document fire drills. The census was 71. | During an interview on 4/30/25 at 10:15 A.M., the Administrator said staff have been unable to locate the log book for the fire drills. The Administrator said she was aware the facility should be conducting monthly fire drills and a record of the drills should be kept by the facility but she is not sure where the log has been placed. *The higher the classification merited due to the extent of the violation. 19 CSR 30-86.047(19) TB Screen Residents & Staff The facility shall screen residents and staff for tuberculosis as required for long-term care facilities by 19 CSR 20-20.100. Il This regulation is not met as evidenced by: Based on interview and record review, the facility Health gnd Senior Services RS ORFR O81 21, ENTATIVE'S SIGNATURE TITLE (X6) DATE C > ~ ent of Missouri Depa CS A AZ S=7- | Zs STAFE-FORM 6899 XR3011 If continuation sheet 1 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 failed to ensure the required two step tuberculosis (TB) test was completed prior to hire and a one step test was completed annually for four of four sampled staff. The facility also failed to ensure the required two step TB test was completed prior to admission two of seven sampled residents (Residents #1 and #7). The facility also failed to do the annual screening for three of seven sampled residents (Residents #6, #1, and #7) The census was 71. General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents and staff for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -lf the resident's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease; -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test; Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 -All employees and volunteers are required to obtain Mantoux PPD (purified protein derivative) two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the initial test is negative, the second test should be given as soon as possible within one to three weeks after employment begins. The CDC states TB tests should be read 48 to 72 hours after administration; -Employees with an initial zero to nine millimeters TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record. 1. Review of Employee B's personnel file, showed the following: -Hire date 9/24/24; -No documented two-step TB/PPD test upon hire. 2. Review of Employee H's personnel file, showed the following: -Hire date 11/8/24- -Documented one-step TB/PPD test administrated on 11/8/24; -No documented read date of the first step; -No documented second step. 3. Review of Employee A's personnel file, showed the following: -Hire date 4/24/17; -A TB/PPD blood test dated 12/20/23; -No documented annual screening for 1/2024. 4. Review of Employee C's personnel file, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 20 PRINTED: 05/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C Continued From page 3 -Hire date 1/17/23; -A TB/PPD blood test dated 1/7/23; -No documented annual screening for 1/2024 and 1/2025. 5. Review of Resident #7's medical record, showed the following: -Admit date 1/31/24; -Diagnoses included dementia and Alzheimer's disease; -An annual TB/PPD screening dated 1/1/25; -No documented initial two-step upon admission. 6. Review of Resident #6's medical record, showed the following: -Admit date 1/27/22; -Diagnoses included diabetes and high blood pressure; -An annual TB/PPD screening dated 2/17/25; -No documented annual screenings for 1/2023 and 1/2024. 7. Review of Resident #1's medical record, showed the following: -Admit date 7/20/22; -Diagnoses included high blood pressure, agitation, falls, abnormal weight loss; -An annual TB/PPD screening dated 1/3/25. 8. During an interview on 4/30/25 at 3:47 P.M., the Administrator said she knew the residents and staff required an initial two-step TB/PPD test upon admission and hire. She also knew the staff required an annual one-step TB/PPD test and the residents required an annual screening. She did not know why the residents did not have initial two-step TB/PPD tests and she did not know why the staff did not have initial two-step TB/PPD test. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 If continuation sheet 4 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 19 CSR 30-86.047(20)(I) Personnel Record-physician statement, employ The administrator shall maintain on the premises an individual personnel record on each facility employee, which shall include the following: (I) Written statement signed by a licensed physician or physician ' s designee indicating the person can work in a long-term care facility and indicating any limitations; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure employees had a written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility and indicating any limitations, for two of four sampled employees. The census was 71. 1. Review of Cook A's personnel file, showed the following: -Hire date 4/24/17; -No documented physician statement. 2. Review of Medication Technician B's personnel file, showed the following: -Hire date 9/24/24; -No documented physician statement. 3. During an interview on 4/30/25 at 1:55 P.M., the Business Office Manager said she was not aware the employees needed a Physician's statement indicating they can work in long-term care. 4. During an interview on 4/30/25 at 3:41 P.M., the Administrator said she was aware the employees needed a Physician's statement Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD DOUGHERTY FERRY ASSISTED LIVING & MEMORY C SAINT LOUIS, MO 63122 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 5 indicating they can work in long-term care. She said she did not know the statements were not there for the employees. 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) which included resident needs and services to be provided by staff, for four of seven sampled residents (Residents #6, #7, #1 and #4). The census was 71. 1. Review of Resident #6's medical record, showed the facility admitted the resident on 1/27/22, with diagnoses which included diabetes and high blood pressure. Review of the resident's ISP dated 2/19/25, showed the following: -Need: Mobility/Ambulation. Goal: The resident will maintain and/or maximize current level of functioning with mobility/ambulation. The resident was independent with walking with his/her walker. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 6 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 6 The resident required cues and prompts to use his/her walker but did not require physical assistance. Interventions: The staff were required to provide cues and prompts for safety; -Need: Morning and night care. Goal: The resident will maintain and/or maximize current level of functioning with morning and night care. The resident required verbal reminders for walking and getting out of bed but was able to get out of bed independently. Interventions: The staff were required to provide a verbal reminder for walking and getting out of bed. "Add wake and bed times"; -Need: Bathing. The resident required physical assistance with participation by the resident to complete the tasks; -Need: Grooming. The resident performed grooming/personal hygiene but required physical assistance to complete the task; -Need: Dressing. The resident required physical assistance with dressing. The caregiver dresses/undresses and selects clothing, but the resident was able to assist in task; -Need: Toileting. The resident wore briefs. The resident required physical assistance with parts of toileting tasks; -Need: Wellness checks. The resident required wellness checks daily. During an interview on 4/30/25 at 2:00 P.M., the Resident Care Director (RCD) said the resident was on hospice and the hospice team does everything for him/her. She said the hospice team provided complete and total assistance with bathing, dressing, grooming and toileting. She said the resident was unable to assist in any of his/her activities of daily living. She said if the hospice team did not show up, the facility staff would step in. She said the resident did not eat well and required several cues and prompts when Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 7 of 20 PRINTED: 05/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C Continued From page 7 eating to finish a meal. She said the resident had lost weight but had started meal shakes to help with this. She said she would think all of this information would already be on the resident's ISP. She said the ISP should tell the staff how often to check on the resident. She said it would be very important to include the hospice information and the rest of the information to help new staff. During an interview on 4/30/25 at 2:05 P.M., Medication Technician (MT) D said since he/she was new, this information should be on the resident's ISP to help him/her care for the resident. Review of the resident's ISP dated 2/19/25, showed the following: -The ISP did not address what kind of assistance the resident required for dressing, grooming, toileting, eating and bathing; -The ISP did not address how to cue and prompt the resident when completing tasks; -The ISP did not address how often to check on the resident; -The ISP did not address the resident required hospice services; -The ISP did not address what kind of services hospice provided the resident. 2. Review of Resident #7's medical record, showed the facility admitted the resident on 1/31/24, with diagnoses which included dementia and Alzheimer's disease. Review of the resident's ISP dated 1/28/25, showed the following: -Need: Psychosocial. The resident had chronic anxiety issues; -Need: Morning and night care. The resident Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 If continuation sheet 8 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 required physical assistance with waking and getting out of bed "add wake and bed time"; -Need: Bathing. The resident performed grooming/personal hygiene but required physical assistance to complete the task; -Need: Toileting. The resident required physical assistance with parts of toileting tasks. The resident was on hospice; -Need: Wellness checks. The resident required wellness checks daily. During an interview on 4/30/25 at 2:15 P.M., the RCD said the resident had a stroke and had left side weakness and could not assist in any of his/her activities of daily living. She said if the resident was tired, he/she could not stand either. The staff were required to help the resident with all of his/her activities of daily living. The staff were also required to cut up the resident's food because the resident could not do this him/herself. The resident was not on hospice anymore. She said the resident refused his/her medication quite a bit and was anxious sometimes when new people were around. She said sometimes the resident would yell out. Review of the resident's ISP dated 1/28/25, showed the following: -The ISP did not address any interventions on how to help the resident with his/her anxiety; -The ISP indicated the resident was on hospice when he/she was not; -The ISP did not address the resident's behavior of refusing medication; -The ISP did not address the resident's behavior of yelling out; -The ISP did not address staff must cut up the resident's food and the resident could not stand if he/she was tired. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 20 PRINTED: 05/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C Continued From page 9 3. Review of Resident #1's medical record, showed the facility admitted the resident on 7/20/25, with diagnoses which included high blood pressure, agitation, history of falls, and abnormal weight loss. Review of the resident's ISP dated 2/5/25, showed the need for a fall prevention plan. The resident will be monitored for safety in their environment. The resident is a potential fall risk. The community team will check for appropriate lighting, clutter, spills in the apartment, encourage proper footwear/nonskid footwear, and educate resident to push pendant as needed for assistance with mobility. On 10/13/24, the resident had a fall walking around the building. The resident got him/herself up and did not report the fall. The resident called his/her family and told him/her of the fall. On 3/15/25, the resident slid off the bed when trying to get up to go to the bathroom. Staff reminded the resident to use pendant to call for assistance, educated on proper footwear, and lighting in the room. Review of the resident's progress notes, showed the following: -On 3/11/25 at 11:59 A.M., Nurse E noted the resident reported to staff he/she was going to his/her room using his/her walker and said he/she took the corner too fast, lost his/her balance and fell, causing his/her back to hurt. Staff assisted the resident off of the floor and helped him/her to his/her recliner. Staff assessed the resident and took his/her vital signs; -On 3/13/25 at 10:19 P.M., staff was notified by another resident there was banging on the other side of the wall. Upon arrival, noticed resident was on the floor next to bed. Resident could not say what he/she was doing prior to the fall. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 If continuation sheet 10 of 20 PRINTED: 05/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C Continued From page 10 Review of the resident's ISP dated 2/5/25, showed the the ISP did not address any interventions for the falls that occurred on 3/11/25 and 3/13/25. 4. Review of Resident #4's medical record, showed the facility admitted the resident on 2/2/24, with diagnoses which included heart failure and anxiety disorder. Review of the resident's nurse's note dated 9/19/24, showed the resident tripped over his/her walker and lowered him/herself to the floor. The resident denied pain and required assistance getting up off of the floor. Review of the resident's ISP dated 3/20/25, showed the ISP did not identify the fall or address any interventions for the incident that occurred on 9/19/25. 5. During an interview on 4/30/25 at 3:45 P.M., the Administrator said the ISP's should contain all the specific information about the resident that is needed to care for a resident. The ISP's should also include any falls or other incidents and the interventions the facility has put into place to prevent further occurrences. 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 Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 If continuation sheet 11 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 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: 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 and funeral director for seven of seven sampled residents (Residents #6, #1, #7, #4, #3, #5 and #2). The census was 71. 1. Review of Resident #6's medical record, showed the following: -Admit date 1/27/22; -No documented preferred dentist; -No documented preferred funeral home. 2. Review of Resident #1's medical record, showed the following: -Admit date 7/20/22; -No documented preferred dentist; -No documented preferred funeral home. 3. Review of Resident #7's medical record, showed the following: -Admit date 1/31/24; -No documented preferred dentist; -No documented preferred funeral home. 4. Review of Resident #4's medical record, showed the following: -Admit date 2/2/24: -No documented preferred dentist; -No documented preferred funeral home. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 5. Review of Resident #3's medical record, showed the following: -Admit date 6/14/24; -No documented preferred dentist; -No documented preferred funeral home. 6. Review of Resident #5's medical record, showed the following: -Admit date 6/25/24: -No documented preferred dentist; -No documented preferred funeral home. 7. Review of Resident #2's medical record, showed the following: -Admit date 7/18/24: -No documented preferred dentist; -No documented preferred funeral home. 8. During an interview on 4/30/25 at 3:45 P.M., the Administrator said the Wellness Nurse would typically gather the information for the funeral home and dentist during the initial resident assessment. She said she was aware they were required to be a part of the record and was not aware the information was not being collected or included. 19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails Employees shall thoroughly wash their hands and the exposed portions of their arms with soap and warm water before starting work, during work as often as is necessary to keep them clean and after smoking, eating, drinking or using the toilet. Employees shall keep their fingernails clean and trimmed. II/III This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 13 of 20 PRINTED: 05/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C Continued From page 13 Class II* Based on observation and interview, the facility failed to ensure all staff washed their hands and/or wore gloves when plating and serving food in the kitchen. The census was 771. Observation on 4/30/25 between 8:12 A.M. and 8:43 A.M., of the breakfast plating and service, showed the following: -At 8:12 A.M., Cook A donned a pair of gloves, with his/her right hand, he/she grabbed plates and placed them onto the servery line. With his/her right hand, he/she lifted the warming lid off the steam table and placed it to the side. With same gloved hand, he/she picked up four waffles and placed one on each plate. With same gloved hand, he/she picked up a warming container with bacon and used gloved hand to place bacon onto each plate. With same gloved hand, he/she picked up a bottle of syrup and poured syrup into individual cups on the plates and placed the plates into the window; -At 8:30 A.M., Cook A donned a new pair of gloves and with his/her right hand, picked up a spatula. With his/her left hand, he/she grabbed a container of liquid eggs and poured eggs onto the stove top. With his/her right hand, he/she used the spatula to flip the eggs and place them onto two plates. With left gloved hand, he/she grabbed strips of bacon and placed them onto the plates, removed gloves and washed hands; -At 8:37 A.M., Cook A donned a new pair of gloves and with his/her right hand, opened an egg carton, walked to the refrigerator and opened the door of the refrigerator, grabbed sausage links from a bag and dropped them into the fryer. With his/her left gloved hand, he/she grabbed a plate and placed it on the servery. With the same gloved hand, he/she grabbed the warming lid on Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 If continuation sheet 14 of 20 PRINTED: 05/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C Continued From page 14 the steam well and used his/her hand to grab bacon and placed it on the plate. With his/her left hand, he/she grabbed a cooking spray bottle and sprayed the stove top surface. With the same gloved hand, he/she grabbed a carton of liquid eggs and poured the eggs onto the stove top. With his/her right hand, he/she grabbed a spatula and flipped the eggs, moved the eggs to the plate, and with the same gloved hand, grabbed bacon and placed the bacon onto the plate, removed gloves and washed hands. During an interview on 4/30/25 at 3:35 P.M., the Administrator said the staff should be washing their hands all the time. They should be changing their gloves if they touch their body, if they cough, if they sneeze or in-between transitions of surfaces. She said she expected them to use tongs for plating and not use their hands that have touched other surfaces. *The higher the classification merited due to the extent of the violation. 19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review Each resident admitted to the facility, or his or her next of kin, legally authorized representative or designee, shall be fully informed of the individual's rights and responsibilities as a resident. These rights shall be reviewed annually with each resident, and/or his or her next of kin, legally authorized representative or designee, either in a group session or individually. II/III This regulation is not met as evidenced by: Class II* Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 If continuation sheet 15 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 Based on interview and record review, the facility failed to review resident rights with residents or their representative annually for four of seven The census was 71. 1. Review of Resident #6's medical record, showed the following: -Admit date 1/27/22: -Diagnoses included high blood pressure and diabetes; -No documented annual review of resident rights for 1/2024 and 1/2025. 2. Review of Resident #1's medical record, showed the following: -Admit date 7/20/22; -Diagnoses included high blood pressure, agitation, falls, and abnormal weight loss; -No documented annual review of resident rights for 7/23, 7/24 and 7/25. 3. Review of Resident #7's medical record, showed the following: -Admit date 1/31/24; -Diagnoses included dementia and Alzheimer's disease; -No documented initial review of resident rights; -No documented annual review of resident rights for 1/2025. 4. Review of Resident #4's medical record, showed the following: -Admit date 2/2/24: -Diagnoses included heart failure and anxiety disorder; -No documented annual review of resident rights for 2/2025. 5. During an interview on 4/30/25 at 3:48 P.M., Missouri Department of Health and Senior Services STATE FORM sampled residents (Residents #6, #1, #7 and #4). 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 16 the Administrator said she was aware the residents required an annual review of their rights but did not know the residents did not have this annual review completed. *The higher the classification merited due to the extent of the violation. 19 CSR 30-88.010(10) Advance Directive Requirements Prior to or upon admission and at least annually after that, each resident or his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding provision of emergency and life-sustaining care, of an individual's right to make treatment decisions for himself or herself and of state laws related to advance directives for health-care decision making. The annual discussion may be handled either on a group or on an individual basis. Residents’ next of kin, legally authorized representatives or designees shall be informed, upon request, regarding state laws related to advance directives for health-care decision making as well as the facility's policies regarding the provision of emergency or life-sustaining medical care or treatment. If a resident has a written advance health-care directive, a copy shall be placed in the resident's medical record and reviewed annually with the resident unless, in the interval, he or she has been determined incapacitated, in accordance with section 475.075 or 404.825, RSMo. Residents’ next of kin, legally authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. I/II Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 17 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to review advanced directives with residents or their representative annually for four of seven sampled residents (Residents #6, #1, #7 and #4). The census was 71. 1. Review of Resident #7's medical record, showed the following: -Admit date 1/31/24: -Diagnoses included dementia and Alzheimer's disease; -No documented advanced directives upon admission; -No documented annual review of advanced directives for 1/2025. 2. Review of Resident #6's medical record, showed the following: -Admit date 1/27/22: -Diagnoses included high blood pressure and diabetes; -No documented annual review of advanced directives for 1/2024 and 1/2025. 3. Review of Resident #1's medical record, showed the following: -Admit date 7/20/22; -Diagnoses included high blood pressure, agitation, falls, and abnormal weight loss; -A documented review of advanced directives dated 1/11/23; -No documented annual review of advanced directives for 1/2024, or 1/2025. 4. Review of Resident #4's medical record, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 18 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 -Admit date 2/2/24: -Diagnoses included heart failure and anxiety disorder; -No documented annual review of advanced directives for 2/2025. 5. During an interview on 4/30/25 at 3:49 P.M., the Administrator said she was aware residents required an annual review of their advanced directives but was not aware the residents did not have this. *The higher the classification merited due to the extent of the violation. 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/Ill 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 for five of seven sampled residents (Residents #6, #7, #4, #3 and #5). The census was 71. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 20 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION PRINTED: 05/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/30/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD DOUGHERTY FERRY ASSISTED LIVING & MEMORY C SAINT LOUIS, MO 63122 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 19 1. Review of Resident #6's medical record, showed the following: -Admit date 1/27/22; -No documented inventory sheet. 2. Review of Resident #7's medical record, showed the following: -Admit date 1/31/24: -No documented inventory sheet. 3. Review of Resident #4's medical record, showed the following: -Admit date 2/2/24: -No documented inventory sheet. 4. Review of Resident #3's medical record, showed the following: -Admit date 6/14/24; -No documented inventory sheet. 5. Review of Resident #5's medical record, showed the following: -Admit date 6/25/24; -No documented inventory sheet. 6. During an interview on 4/30/25 at 3:48 P.M., the Administrator said she was aware an inventory sheet needed to be included in the resident record but was not aware some of the residents were missing the inventory sheet. Missouri Department of Health and Senior Services STATE FORM 6899 XR3011 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 20 of 20 PLAN OF CORRECTION Provider/Supplier Name: Doughtery Ferry Assisted Living and Memory Care Street Address, City, Zip: 2929 Doughtery Ferry Rd, St Louis, MO 63122 Date of Survey: 04/30/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE A2217 immediate Action: e Fire Drill was conducted. 4/30/2025 Long- Term Quality Measure (to ensure no recurrence of citation/violation): e The Maintenance Manager/designee will be responsible for conducting twelve (12) fire drills annually with at least | 04/30/2025 one every three months on each shift. Ongoing Who is Responsible for Long-Term Quality Measures Outcomes: « The Executive Director (ED) will audit monthly the fire drill binder to ensure 12 fire drills are conducted annually with at least one every three months on each shift. State of Review in QAPI Monthly Meeting: e Fire Drill will be reviewed during QAPI/ the Quality Management meeting. immediate Action: e Residents #1 and #7 have received the required two step TB test e Residents #6, #1, and #7 have received the annual screening for TB. « Employees B, H, A, and C have received the required 2 A4724 step TB/PPD test. 6/27/2025 e Audit of all resident TB screenings completed any inconsistencies will be addressed immediately. e Ongoing all new admissions will have completed 2 Step PPD or T-Spot prior to moving into the community. e Ongoing new employees will complete the 2 step TB/PPD test within one month of start date. Long- Term Quality Measure (to ensure no recurrence of citation/violation): e The Executive Director, Director of Nursing or designee will ensure all new admission charts have a complete TB 2 step or t-spot prior to move in. The Executive Director will audit 100% of new admission charts each month to ensure TB screenings are complete. Audit log will be kept and reviewed at the monthly QAPI/ Quality Manage management meeting. Who is Responsible for Long-Term Quality Measures Outcomes: e Director of Nursing and Director of Resident Care for resident charts. e Business Office Manager for employee files. State of Review in QAPI Monthly Meeting: e All new admissions will be reviewed during QAPI/ Quality Manage management meeting. Immediate Action: e Cook A’s, and Medication Technician B’s written statement by a physician has been completed. e All team members will have a written statement from a A4733 physician. e All new team members will have a written statement from a physician stating the individual is able to work for a long-term care facility. Long- Term Quality Measure (to ensure no recurrence of citation/violation): « The Business office Manager/designee will be 06/27/2025 responsible for conducting audits of new employee files upon hire and one month after hire. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly the new team member files to All new team members will have a written statement from a physician stating the individual is able to work for a long-term care facility State of Review in QAPI Monthly Meeting: e Employee file audit will be reviewed during QAPI/ the Quality Management meeting. Immediate Action: e Residents #6's, #7’s, #1’s, and #4’s Individualized A4754 Service plan have been developed and updated. e An audit of all residents Individualized Service plans completed, and inconsistencies will be addressed immediately. e All new residents will have developed Individual Service Plans. Long- Term Quality Measure (to ensure no recurrence of citation/violation): e The Director of Nursing/designee will be responsible for reviewing resident ISP upon admission or after an moe as 06/25/2025 incident or change of condition to ensure proper development of the ISP. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly a sample of residents to verify ISP’s are updated. State of Review in QAPI Monthly Meeting: e ISP audit log will be reviewed during QAPI/ the Quality Management meeting. immediate Action: e Residents #6's, #1’s, #7’s, #4, #3, #5, and #2’s records have been reviewed and updated to include preferred dentist and funeral home. A4836 e An audit of all resident record completed to ensure record has preferred dentist and funeral home any inconsistencies will be addressed immediately. e =6All new residents will have developed updated records to include a preferred dentist and funeral home. Long- Term Quality Measure (to ensure no recurrence of citation/violation): e The Director of Nursing/designee will be responsible for reviewing resident records upon admission and at care 06/25/2025 plans ensure preferred dentist and funeral home are documented. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly a sample of residents to verify records are updated. State of Review in QAPI Monthly Meeting: e Record audit log will be reviewed during QAPI/ the Quality Management meeting. Immediate Action: A7002 e Kitchen staff was reeducated on hand washing and glove protocol. Long- Term Quality Measure (to ensure no recurrence of citation/violation) 06/25/2025 e The Director of Food and Beverage will be responsible for auditing proper hand washing and glove use in the kitchen through observation and demonstration. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly a sample of kitchen team members hand hygiene and glove use. State of Review in QAPI Monthly Meeting: e Hand hygiene and glove use protocol audit log will be reviewed during QAPI/ the Quality Management meeting. Immediate Action: e Residents #6's, #1's, #7 and #4’s Resident Rights have been reviewed with the resident or resident representative. A8004 e §6©Audit of resident records for annual resident rights 06/25/2025 review completed; any inconsistencies will be addressed immediately. e All new residents will have resident rights review completed upon admission and annually. e Long- Term Quaility Measure (to ensure no recurrence of ciation/violation): e The Director of Nursing/designee will be responsible for Resident Right review during care plans at least annually. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly a sample of residents fo verify records are updated. State of Review in QAPI Monthly Meeting: ISP audit log will be reviewed during QAPI/ the Quality Management meeting. Immediate Action: e Residents #6's, #1's, #7 and #4’s Advance Directives have been reviewed with the resident or resident A8010 representative and updated. e Audit of resident records for annual Advance Directives 06/25/2025 review completed: any inconsistencies will be addressed immediately. e All new residents will have Advance Directives review completed upon admission and annually. Lonqg- Term Quaility Measure (to ensure no recurrence of ciation/violation): e The Director of Nursing/designee will be responsible for Advance Directives review during care plans at least annually. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly a sample of residents to verify records are updated. State of Review in PI Monthly Meeting: e Advance Directives audit log will be reviewed during QAPI/ the Quality Management meeting. Immediate Action: e Residents #6’s, #7’s, #4’s, #3’s and #5’s personal inventory lists have been completed. A8037 ¢ Audit of resident records for personal inventory lists completed; any inconsistencies will be addressed immediately. e ~All new residents will have personal inventory lists completed upon admission. Long- Term Quaility Measure (to ensure no recurrence of ciation/violation): e The Director of Nursing/designee will be responsible for 06/25/2025 personal inventory lists completion during admission process. Who is Responsible for Long-Term Quality Measures Outcomes: e The Executive Director (ED) will audit monthly a sample of residents to verify records are updated. State of Review in QAPi Monthly Meeting: « Personal inventory lists audit log will be reviewed during QAPI/ the Quality Management meeting. 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.

THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM) Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER PRINTED: 02/27/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 02/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD DOUGHERTY FERRY ASSISTED LIVING & MEMORY C SAINT LOUIS, MO 63122 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 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 III Based on record review and interview on February 25, 2025, the facility failed to conduct fire drills with at least one (1) fire drill every three (3) months on each shift. The facility census on was 72. This deficiency affects 72 out of 72 residents. Record review at 11:30 A.M. showed no drills had been conducted on any shift for the previous 12 months. Further review showed no full evacuation had been done in the previous 12 months. During an interview on February 20, 2025, at the time of discovery., the Maintenance Director stated he/she had been doing the drills, but could not find the folder 19 CSR 30-86.022(6)(A)(1 - 3) Fire Safety Training Requirements-employees Fire Safety Training Requirements. (A) The facility shall ensure that fire safety training is provided to all employees: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TITLE (X6) DATE If continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 1. During employee orientation; 2. At least every six (6) months; and 3. When training needs are identified as a result of fire drill evaluations. II/III This regulation is not met as evidenced by: Class III Based on record review and interview on February 25, 2025, the facility failed to insure all employees had fire safety training as required by regulation. The census was 72. This deficiency affects 82 put of 82 residents. Record review at 11:33 A.M. showed the facility could not produce any documentation showing fire safety training for all employees upon hiring and semi-annually. During an interview on February 25, 2025 at the time of discovery, the Maintenance Director stated he/she would start documenting the training. 19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain Complete Fire Alarm Systems. (C) All facilities shall test and maintain the complete fire alarm system in accordance with NFPA 72, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on February 25, 2025, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Missouri Department of Health and Senior Services STATE FORM 6899 MH3711 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Protection Association (NFPA) 72, 1999 edition. The facility census was 72. This deficiency affects 72 out of 72 residents. Record review at 10:45 A.M., showed no semi-annual fire alarm system inspection had been completed of the fire alarm system as required by (NFPA) 72, 1999 edition. Table 7-3.1. Further review showed the moat recent annual inspection was completed on April 12, 2024. During an interview on February 25, 2025, at the time of discovery., the Maintenance Director said he/she would make sure the semi-annual inspection was done when required. 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. 1/II This regulation is not met as evidenced by: Class II Based on record review and interview on February 25, 2025, the facility failed to insure the complete fire alarm system was tested monthly. The facility census was 72. This deficiency affects 72 out of 72 residents. Record review at 11:50 A.M., showed the facility failed to activate and test the complete fire alarm at least once a month. During an interview on February 25, 2025, at the time of discovery, the Maintenance Director stated that the alarm was tested each month, but Missouri Department of Health and Senior Services STATE FORM 6899 MH3711 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 could not find the records. 19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13 Sprinkler Systems. (A) Facilities licensed on or after August 28, 2007, or any section of a facility in which a major renovation has been completed on or after August 28, 2007, shall install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition. I/II This regulation is not met as evidenced by: Class II Based on record review and interview on February 25, 2025, the facility failed perform a monthly check on the complete sprinkler system as per National Fire Protection Association (NFPA) 13, 1999 ed. The facility census was 72. This deficiency affects 72 out of 72 residents. Record review at 12:15 P.M.. showed no documentation of a monthly check of the sprinkler system. During an interview on February 25, 2025 at the time of discovery, the Maintenance Director stated he/she did not know a monthly check was needed. State Statute This regulation is not met as evidenced by: Class II 9998-State Statue Missouri Department of Health and Senior Services STATE FORM 6899 MH3711 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/25/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 DOUGHERTY FERRY ASSISTED LIVING & MEMORY C (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 Based on record review and interview on February 25, 2025, the facility failed to have a current boiler inspection certification under 11 CSR40-2.022. The facility census 72. This deficiency affects 72 out of 72 residents. 11 CSR 40-2.022 Section (4) states: " Frequency of inspection of heating boilers, water heaters, pool heaters, and fired jacketed steam kettles. (A) Steam heating boilers shall be inspected every two (2) years. The certificate inspection shall be an internal inspection where construction permits; otherwise the inspection shall be as complete as possible while the boiler is in operation. (B) Hot water heating boilers and fired jacketed steam kettles shall be inspected every two (2) years. 1. Hot water heating and hot water supply boilers over thirty (30) years old shall be internally inspected every two (2) years where construction permits, otherwise the inspection shall be as complete as possible while the boiler is in operation. 2. Hot water heating and hot water supply boilers that are not over thirty (30) years old shall be externally inspected every two (2) years. The inspector may mandate an internal inspection if the inspector feels it is necessary. 3. Water heaters, pool heaters, and fired jacketed steam kettles shall be externally inspected every two (2) years." Record review at 1:10 P.M. showed the current State Certificate expired on November 2, 2024. During an interview on February 25, 2025 at the time of discovery, the Maintenance Director stated he/she did not the certificate was expired. Missouri Department of Health and Senior Services STATE FORM 6899 MH3711 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 5 of 5

Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD DOUGHERTY FERRY ASSISTED LIVING & MEMORY C SAINT LOUIS, MO 63122 PRINTED: 03/20/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 03/12/2024 (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 A3214 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/IIl This regulation is not met as evidenced by: Class III Based on document review and interview on March 12, 2024, the facility failed to insure the facility's electric wiring was inspected every two (2) years by a qualified electrician. The facility census 67. This deficiency affects 67 out of 67 residents. Document review showed the facility failed to have the electric wiring inspected every 2 years. Futher review showed the most recent certificate expired in August Of 2023. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE STATE FORM 6399 123011 DEFICIENCY) (X6) DATE If continuation sheet 1 of 2 PRINTED: 03/20/2024 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 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 2929 DOUGHERTY FERRY ROAD SAINT LOUIS, MO 63122 (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) DOUGHERTY FERRY ASSISTED LIVING & MEMORY C A3214 | Continued From page 1 During an interview on March 12, 2024 at 12:05 P.M., the Administrator stated he/she would contact the electrical vendor. Missouri Department of Health and Senior Services STATE FORM 6899 1Z3Q11 If continuation sheet 2 of 2 AN ADMINISTRATOR SIGNATURE COULD NOT BE OBTAINED. THE FACILITY DID NOT RETURN A PLAN OF CORRECTION THEREFORE, NO POC IS INCLUDED WITH THE STATEMENT OF DEFICIENCIES (2567 FORM)