GABLES AT BRADY CIRCLE, LLC THE.

Missouri Department of Health and Senior Services PREFIX TAG A4748 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER A2222 19 CSR 30-86.022(7\(A) Exits-2 per O41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: GABLES AT BRADY CIRCLE, LLC, THE SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Floor-Remote/Unobstructed Exits, Stairways, and Fire Escapes. (A) Each floor of a facility shall have at least two (2) unobstructed exits remote from each other. ull This regulation is not met as evidenced by: Class II : Based on observation and interview, the facility failed to ensure the door leading to the exit, in the northeast haliway was unobstructed for one of one day of observation. The census was 22. Observation on 12/16/25 between 7:37 A.M. and 4:50 P.M., of the building five exit for the northeast hallway, showed the green lit exit sign above the northeast door. Directly in front of the door was a two-person wooden bench which extended across the entire doorway causing the exit to be obstructed During an interview on 12/16/25 at 1:53 P.M., the Administrator said he was unaware the doorway was blocked, and the bench was originally set up as a resting area in the hallway, away from the . door. The Administrator said the doorway should not be obstructed by anything and staff should ensure the exit is clear for the safety of the residents. 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, 3 ad-onty, if the facility: A. BUILDING: STREET ADDRESS, CITY. STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 PREFIX TAG | AATAQ i ga20 {X2) MULTIPLE CONSTRUCTION PRINTED: Cc PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} This plan of correction is submitted as required under State law and policies. ‘The submission of this plan does not constitute an admission on the part of The Gables at Brady Circle (Facility) as ,to the accuracy of the surveyors ifindings nor the conclusions drawn |therefrom. This plan of correction does not constitute an admission on | the part of the Facility that the findings icited are accurate, that the findings i constitute a deficiency or the scope and severity regarding any of |the i; deficiencies cited are correctly ' applied. This Plan of Correction is intended to constitute the Facility’s credible letter alleging compliance. ; Compliance has been and will! be iachieved no later than 2/7/26. Compliance will be maintained: as | provided in the Plan of Correction. A2222 Wooden bench moved from house 5 exit door by maintenance staff 'on | 12/17/25. 4 se: WOQT?11 (X3} DATE SURVEY COMPLETED 42/16/2025 01/02/2026 FORM APPROVED {X5) COMPLETE DATE sfeefew (X68) DATE | (fal tinuatidn sheet 1 of S Missouri Depariment of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER GABLES AT BRADY CIRCLE, LLC, THE (X4) ID PREbIX TAG A4749 Continued From page 1 (X1} PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A. BUILDING: B. WING (X2) MULTIPLE CONSTRUCTION PRINTED: 01/02/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 (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 shal} be: A. Within five (5) calendar days of admission; | This regulation is not met as evidenced by: Based on interview and record review, the facility faiied to complete a community based assessment (CBA) within five days of admission, for one of two sampied residents (Resident #1). The census was 22. Review of Resident #1's medical record, showed the following: -The facility admitted the resident on 7/31/25; -Diagnoses included dementia, high blood pressure and acute pain; -No documented CBA completed by 3/5/25. During an interview on 12/16/25 at 11:57 A.M., the Care Manager (CM) said the CBA was not done because the resident has not been at the facility for 6 months. The CM said it was under his/her impression the CBA needed to be done every 6 months or on change in condition. The CM said he/she was not aware the CBA needed to be done within 5 days of admission. During an interview on 12/16/25 at 1:44 P.M. the ‘ Administrator said he was not aware the CBA was not completed for the resident. The PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} | Direct care staff and maintenance staff (educated by administrator on ‘inspection for obstructions of exits/entrances during their regular tour of duty by 1/22/26. Record of ; said education to be maintained in administrator’s office. , Maintenance staff to report any obstructions of exits to administrator. | Corrective actions to be taken as deemed necessary by administrator. | A4749 Director of Nursing and Care Manager | | ‘ educated by Administrator to requirements for completion of | resident community based | assessments (CBA) within 5 days of admission on 1/22/26. Record of said education to be maintained in the Administrator’s office. 12/16/2025 (x5) COMPLETE DATE ileal ee Administrator said he uses persanal observations of the resident, input from staff and family to complete the resident individualized service plan; |All resident CBA’s reviewed by Care he did not know he was supposed to use the CBA. The Administrator said he did not know the CBA was to be done within 5 days of admission. Manager and updated, if necessary, by 1/22/26. Missouri Department of Health and Senior Services STATE FORM 6859 WOT711 if continuation sheet 2 of 5 PRINTED: 01/02/2026 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 30048 {X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING C STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE GABLES AT BRADY CIRCLE, LLC, THE x4) ID PREFIX | TAG A4827 SAINT LOUIS, MO 63114 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} 19 CSR 30-86.047(54) Drug Regimen Review ‘ A physician, pharmacist or registered nurse shall - review the medication regimen of each resident. This shall be done at least every other month. The review shall be performed in the facility and shail include, but shall not be limited to, indication ' for use, dose, possible medication interactions _ and medication/food interactions, ' contraindications, adverse reactions and a review - of the medication system utilized by the facility. Irregularities and concerns shall be reported in writing to the resident’ s physician and to the administrator/manager. If after thirty (30) days, ’ there is no action taken by a resident's physician ‘ and significant concerns continue regarding a resident's or residents’ medication order(s), the administrator shall contact or recontact the ' physician to determine if he or she received the _ information and if there are any new instructions, HAL : This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM Class II* . Based on interview and record review, the facility ' failed to ensure a Pharmacist, Physician ora _ Registered Nurse completed a review of , fesident's medications every other month, for one of two sampled residents (Resident #3). The census Was 22. _ Review of Resident #3's medical record, showed the following: _ Admit date 10/14/24; _ -Diagnoses included high blood pressure, high ' cholesterol and depressian; -No documentation of a medication review for 6/2025, 7/2025 and 9/2025, and 11/2025. sag3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED.TO THE APPROPRIATE DEFICIENCY) Administrator wil! review all | ewly | admitted resident CBA’s | for completion within 5 days of admission for 2 months to ensure compliance. | Resident #1 Resident CBA updated by Director of | Nursing by 1/7/26. | A4827 | Director of Nursing and Care Manager educated by Administrator to review residents’ medications every ather j|month by 1/22/26. Record of |said jeducation to be maintained in| the |Administrator’s office. |All Residents’ medications reviewed by Pharmacist or Director of Nursing by 2/7/26. ‘Care Manager to audit 3 medication reviews monthly for 3 months, to ensure compliance. WOT?11 1 = DATE SURVEY COMPLETED 12/16/2025 (x8) COMPLETE DATE continuation sheet 3 of S NAME OF PROVIDER OR SUPPLIER GABLES AT BRADY CIRCLE, LLC, THE (<4) ID PREFIX TAG A4827 A8010 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X41) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING; B. WING PRINTED: 01/02/2026 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULI. REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 During an interview on 12/16/25 at 1:43 P.M., the Administrator said the Pharmacist comes to review each house with each chart. He said he thought they wrote a report but he was not aware it needed to be in each resident's chart. *The higher classification is 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 ar his or her next of kin, legally authorized representatives or designees shall be informed of facility policies regarding pravision 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, !egaliy authorized representatives or designees shail 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, legaily authorized representatives or designees shall be contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. Missouri Department of Health and Senior Services STATE FORM fe) PREFIX TAG A4827 | A8010 E39 PROVIDER'S PLAN OF CORRECTION (EACH CGRRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) A8010 Office Manager educated by Administrator to annual review of jadvanced directives requirements by 1/22/26. Record of said in-service to be maintained in the Administrator’s office. |Administrator to review 3 resident business files for annual review of advance directive monthly for 2 | months and provide further education as necessary to maintain compliance. ‘Resident 3 Resident discharged on 12/19/25. WOT? t1 12/16/2025 (45) COMPLETE DATE if continuation sheet 4 of 5 PRINTED: 01/02/2028 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES 01) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: GOMPLETED c EWING 12/16/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 (M4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 1X5) 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) GABLES AT BRADY CIRCLE, LLC, THE 48018 Continued From page 4 TAL . This regulation is not met as evidenced by: , Class Ml Based on interview and record review, the facility failed to review advanced directives with residents or their representative annually, for one of two sampled residents (Resident #3). The census was 22. ' Review of Resident #3's medical record, showed the following: -Admit date 10/14/24: ' -Diagnoses included high blood pressure, high ‘ cholesterol, and depression; -A documented review of resident rights dated 10/14/24. -No documented annual review of advanced ' directives for 10/2025. During an interview on 12/16/25 at 1:43 P.M., the Administrator said was aware advanced ' directives needed to be reviewed annually with _ the residents. He was not aware they were not completed. Missouri Department of Health and Senior Services STATE FORM eoag WOT?T11 if corftinuation sheet 5 of &

PRINTED: 06/12/2024 7 j FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 30048 = 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE 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) A4718, 19 CSR 30-86.047(14)(A) Controlled Substance This plan of correction is submitted as | Offense-Apply for Waiver required under State law and policies. The submission of this plan does not A facility shall not employ, as an agent or a paris P employee who has access to controlled constitute an admission on the part of | substances, any person who has been found The Gables at Brady Circle (Facility) as contendere in a criminal prosecution under the _— : laws of any state or of the United States for any findings nor the conclusions drawn offense related to controlled substances. || therefrom. This plan of correction (A) A facility may apply in writing to the does not constitute an admission on department for a waiver of this section of this rule the part of the Facility that the findings for a specific employee. || . eel cited are accurate, that the findings | | |constitute a deficiency or the scope This regulation is not met as evidenced by: and severity regarding any of the Based on interview and record review, the facility - . . : | failed to ensure no employee who had been deficiencies cited are correctly applied. found guilty of any offense related to controlled This Plan of Correction is intended to substances, had access to facility controlled constitute the Facility’s credible letter | Substances, for one of three sampled employees. alleging compliance. Compliance has The census was 16. . : been and will be achieved no later than Observation on 5/29/24 between 8:00 A.M. and | 7/26/24. Compliance will be 1:56 P.M., of the medication pass, showed the j maintained as provided in the Plan of following: : -At 8:00 A.M., Level One Medication Aide (LIMA) Correction. A administered three resident's medications. A | locked narcotics box was in the second drawer of the medication cart; -At 12:53 P.M., LIMAA administered Resident sails | #5's medication; | olze he ‘ -At 1:56 P.M., LIMAA administered Resident #4's Office manager in-serviced by medication. Administrator to update all good cause | Review of LIMA A's personnel file, showed the SEES before hire for New employees following: in addition to the Family Safety Registry “Hire date 2/28/24; check on 6/28/24. Record of said -A Family Care Safety Registry check dated . ‘ . . | al n 2/28/24 which showed a felony conviction with an education to be maintained i the arrest date of 9/11/95: | Administrator’s office. Missouri Departmentof He ad Senior Soy ices LABORATOR Grecrox Ps ROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE . TITLE (XG) DATE eZ ‘ ; FZ ee bfalzn Se . = Pcie STATE FORM ("= aa99 Q8J711 lf continuation sheet 1 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 30048 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREE| ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE 0X4) 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) A4718| Continued From page 1 -A good cause waiver dated 2/7/19 for a different Administrator will review all new | facility; ‘employee files for record of | -No documentation of a good cause waiver for completion of updated good cause ti ility. ; | aang waiver and Family Safety Registry _ During an interview on 5/29/24 at 1:58 P.M., LIMA check before hire for one month and | A said he/she passed medications at the facility Ongoing as necessary to maintain | since he/she was hired at the facility in 2/2024. LIMA A said the only resident who had a narcotic penipllantce. was Resident #5. LIMA A said he/she had the keys to the medication cart and the key for the Good cause waiver for Level One narcotics box at all times. Medication Aide (LIMA) A updated on | | During an interview on 5/29/24 at 4:03 P.M., the | 5/30/24, Administrator said he knew LIMAA required a good cause waiver to be able to have access to | contralled substances, but he was not aware the | good cause waiver was required to have the facility's name on it. 19 CSR 30-86.047(19) TB Screen Residents & A4724 «| AAT24 aieoley Staff { Office manager in-serviced by The facility shall screen residents and staff for _ tuberculosis as required for long-term care Administrator to maintain record of | _ facilities by 19 CSR 20-20.100. I the required two step tuberculosis (TB) in the This regulation is not met as evidenced by: nner ‘Sar Chae, R H of | Based on interview and record review, the facility employee file on 6/ , “mek 6) failed to ensure the required two-step said in-service to be maintained in the tuberculosis (TB) screening test was completed Administrator’s office. _ Prior to hire for three of three sampled employees and a two-step TB screen test was completed within one month or prior to admission for three of three sampled residents (Residents #1, #2 and #3). The census was 16. General requirements for TB testing for staff and residents in Long Term Care Facilities, 19 CSR Missouri Department of Health and Senior Services STATE FORM eee Q8J711 If continuation sheet 2 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X38) DATE SURVEY COMPLETED B. WING 30048 IE ewe ee 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STAT E, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) (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) GABLES AT BRADY CIRCLE, LLC, THE A4724 Continued From page 2 Director of Nursing in-serviced by 20-20.100, reads as follows: Administrator to complete the. | -Long-term care facilities shall screen their required two-step tuberculosis (TB) | residents and staff for tuberculosis. Each facility screening prior to hire for employees | shall be responsible for ensuring that all test = ne P “ i y results are completed, and that documentation is and within one month or prior to | maintained: admission for residents by 6/28/24. | ag raed ay to wa —— after ‘Record of said education to be. aamission, all residents new to long-term care ., . i P are required to have the initial test of a two-step maintained In the Administrator's TB test; Office. | -If the resident's initial test is negative, the second _ test should be given one to three weeks later. . ‘ : ; |Director of Nursing to review all The CDC (Centers for Disease Control) states TB Hl 8 ; 4 6 ; oe | tests should be read 48 to 72 hours after employee files and resident charts for | administration; completion of TB screening and | | -All long-term care facility residents shall have a administer TB screening if warranted | documented annual evaluation to rule out signs and symptoms of TB disease: by 7/26/24. -All positive findings shall require a chest X-ray to rule out active pulmonary disease: Administrator will review employee TB | _-Individuals with a positive finding need not have screening upon hire and resident TB repeat annual chest X-rays. They shall have a ; . documented annual evaluation to rule out signs screening upon admission, monthly for | and symptoms of tuberculosis disease: three months, and ongoing as -Within one month prior to starting employment, all new to long-term care employees are required to have the initial test of a two-step TB test: | -All employees and volunteers are required to Director of Nursing will review resident obtain Mantoux PPD (purified protein derivative) TB screening annually and administer two-step TB test within one month prior to starting employment in the facility. If the initial test is zero necessary to maintain compliance. screening as needed to maintain _ to nine millimeters (mm), the second test should compliance. be given three weeks after employment begins, unless documentation is provided indicating a Resident 1 PPD test in the past and at least one subsequent : Seat annual test within the past two years: TB screening administered by 7/26/24. -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 Missouri Department of Health and Senior Services STATE FORM 8899 Q8J711 If continuation sheet 3 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 30048 a 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) 44724) Continued From page 3 Resident 2 TB screening administered by 7/26/24. after administration; -Employees with an initial zero to nine mm TB two step test shall have one step tuberculin testing | annually and the results recorded in a permanent Resident : 7 record. TB screening administered by 7/26/24. | 1. Review of Resident #1's medical record, Employee B showed the following: — | -Admit date 8/10/23; TB screening administered by 7/26/24. -No documentation of a two-step TB/PPD test prior to or within one month of admission. 2. Review of Resident #2's medical record, Employee A showed the following: TB screening administered by 7/26/24. | -Admit date 11/1/23; -No documentation of a two-step TB/PPD test prior to or within one month of admission. 3. Review of Resident #3's medical record, showed the following: -Admit date 5/6/24; -No documentation of a two-step TB/PPD test prior to or within one month of admission. | 4. Review of Employee B's personnel file, showed | the following: -Hire date 9/5/21: -No documentation of a two-step TB/PPD test prior to employment. 5. Review of Employee A's personnel file, showed | the following: -Hire date 2/28/24; '-No documentation of a two-step TB/PPD test | prior to employment. 6. During an interview on 5/29/24 at 4:21 P.M., the Administrator said he was aware the residents required a two-step TB/PPD test prior to or within | one month of admission. The Administrator was Missouri Department of Health and Senior Services STATE FORM 5298 Q8J711 lf continuation sheet 4 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED Se 30048 B. WING 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (X65) 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) A4724 | Continued From page 4 | also aware the employees required a two-step | TB/PPD test prior to employment. The | Administrator said he did not have the TB/PPD tests located within the facility. The Administrator | said he thought the Nurse had the tests, but the | Nurse thought he had the tests. 19 CSR 30-86.047(20)(I) Personnel A4733 «= | A4733 Record-physician statement, employ Nurse Consultant in-serviced by Fletlax The administrator shall maintain on the premises an individual personnel record on each facility Administrator to requirements for employee, which shall include the following: completion of statement, by a | (I) Written statement signed by a licensed physician or designee, indicating an | physician or physician s designee indicating the individual can work in a long-term care | person can work in a long-term care facility and indicating any limitations; |I| facility and indicating any limitations by | 6/28/24. Records of said education to | be maintained in the Administrator’s _ This regulation is not met as evidenced by: Based on interview and record review, the facility Office. | failed to ensure employees had a written statement by a licensed physician or physician's Employee B | designee indicating the person can work in a . ‘ : long-term care facility and indicating any Whitten physical ; ron ulgtied by limitations, for two of three sampled employees. physician or physician’s designee by | | The census was 16. 7/26/24. 1. Review of Employee B's personnel file, showed the following: Employee A . | -Hire date 9/5/21: Written physical form signed by | -No written statement by a licensed physician or physicia n or physician’s designee bn physician's designee indicating the person can work in a long-term care facility. 7/26/24. 2. Review of Employee A's personnel file, showed the following: -Hire date 2/28/24: -No written statement by a licensed physician or Missouri Department of Health and Senior Services STATE FORM asco Q8J711 If continuation sheet 5 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 30048 ee 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4733 | Continued From page 5 Office Manager to review new physician's designee indicating the person can employee files for completed physical | Work in a long-term care facility. form upon hire and communicate any | 3. During an interview on 5/29/24 at 3:50 P.M., aesences te Administrator tor-tuyyrer | the Administrator said he was aware each | education and to maintain compliance. | employee required a physician's statement which indicated the person could work in long-term care and in the past, the facility was receiving the : | Physician's statements. However, he had forgotten it was a requirement which was why the | two employees did not have a physician's | statement. | | A4735 19 CSR 30-86.047(20)(K) Personnel Record - aa735 =| A4735 | Orientation training 7f 2 24 | The administrator shall maintain on th ; Administrator in-serviced Staffing € administrator shall maintain on the premises : _ an individual personnel record on each facility Manager to papel completion 4 oY employee, which shall include the following: ‘employee arientation documentation | (K) Documentation of what the employee was by 6/28/24. Documentation of said | instructed on during orientation training; |II education to be maintained in the Administrator’s Office. This regulation is not met as evidenced by: Based on interview and record review, the facility Staffing Manager to review all failed to maintain an individual personnel record 5 ti wa ion of | which included documentation of the employee's employee files for comple orientation training, for two of three sampled orientation documentation and _ employees. The census was 16. complete said documentation — if warranted by 7/26/24. 1. Review of Office Secretary B's personnel file, showed the following: -Hire date 9/5/21; -No documentation of the employee's orientation training. _ 2. Review of Level One Medication Aide A's personnel file, showed the following: -Hire date 2/28/24. Missouri Department of Health and Senior Services STATE FORM 8296 Q8J711 If continuation sheet 6 of 19 PRINTED: 06/12/2024 ; ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED a ies B. WING 30048 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) A4735 | Continued From page 6 Office Manager to review new -No documentation of the employee's orientation employee files for documentation of - training. completed orientation upon hire and | | communicate any absences to 3. During an interview on 5/29/24 at 3:48 P.M., we | the Administrator said he completed the Administrator for further education | | employee's orientation with the employee, and to maintain compliance. verbally. He was not aware documentation of the employee's orientation they received upon hire was required to be documented in the employee's } Secretary B personnel file. Employee Orientation form completed by 6/28/24. A4749 19 CSR 30-86.047(28)(F)(1)(A) Community A4749 Based Assessment-Time Period, 5 day LIMA A The facility may admit or retain an individual for Employee Orientation form completed | residency in an assisted living facility only if the by 6/28/24. 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 A4749 | _ conducted by an appropriately trained and fr zy qualified individual as defined in section (4) of this Admissions coordinator in-serviced by. rule: 3 | 1. Time frame requirements for assessment shall Nurse Consultant to requirements for be: completion of resident community | _ A. Within five (5) calendar days of admission; {I based assessments (CBA) by 6/28/24. . — , ; Record of said education to be. This regulation is not met as evidenced by: Pala . _ : Based on interview and record review, the facility maintained in the Administrator’s | failed to ensure all sections of the community office. based assessment (CBA) were completed and the CBAs were signed and dated, for three of , P . three sampled residents (Residents #1, #2, #2). All resident CBA’s reviewed and | The census was 16. updated, if necessary, by admissions | coordinator by 7/26/24. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 8/10/23, with diagnoses which included schizoaffective disorder, bipolar disorder, and Missouri Department of Health and Senior Services STATE FORM oa) Q8J711 If continuation sheet 7 of 19 (X4) ID PREFIX TAG A4749 STATE FORM Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER GABLES AT BRADY CIRCLE, LLC, THE , completed. (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30048 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 vascular dementia. Review of the resident's CBA dated 8/1 0/23, showed the following: -The health problems section not completed; -The medication section not completed: -The physician/clinics section not completed; -The home health agency section not completed; -The other health care provider section was not completed. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 11/1/23, with diagnoses which included dementia and incontinence. Review of the resident's CBA dated 11/6/23, showed the following: -The health problems section not completed; -The medication section not completed; -The physician/clinics section not completed; -The home health agency section not completed; -The other health care provider section not 3. Review of Resident #3's medical record, showed the facility admitted the resident on 5/6/24, with diagnoses which included Alzheimer's disease, ischemic heart disease (damage or disease in the heart's major blood vessels), rheumatoid arthritis, high blood pressure, and hypothyroidism (deficiency of thyroid hormones). Review of the resident's CBA dated 5/8/24, | showed the following: -The health problems section not completed; -The medication section not completed: -The physician/clinics section not completed: -The home health agency section not completed: Missouri Department of Health and Senior Services B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 6899 (X2} MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 06/12/2024 FORM APPROVED ——— ————______.. ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE TAG DEFICIENCY) Administrator will review resident. CBA’s for completion within 5 days of admission and semi-annually to maintain compliance. | Resident 1 Resident CBA updated by SCIONS | coordinator by 7/26/24. Resident 2 Resident CBA updated by admissions coordinator by 7/26/24. Resident 3 Resident CBA updated by admissions coordinator by 7/26/24. Q8J711 (X3) DATE SURVEY COMPLETED 05/29/2024 (x8) COMPLETE DATE If continuation sheet 8 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 30048 a 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) A4?49 | Continued From page 8 -The other health care provider section not completed. 4. During an interview on 5/29/24 at 4:14 P.M., _ CMT C said he/she is responsible for completing the CBAs and he/she was not aware they were incomplete. 5. During an interview on 5/29/24 at 4:14 P.M., the Administrator said that he was aware the CBAs were to be completed and he was not aware they were not being completed. uf ay as 19 CSR 30-86.047(46) Safe & Effective A4797 44797 | Medication System The administrator shall develop and implement a All level a medication aides (LIMA) | Safe and effective system of medication control and certified medication technicians | and use, which assures that all residents ' (CMT) in-serviced by Director of | medications are administered by personnel at Nursing to procedures for least eighteen (18) years of age, in accordance _ 2 with physicians ' instructions using acceptable administering eye-drops properly and | _ nursing techniques. The facility shall employ a supervision of residents while | licensed nurse eight (8) hours per week for every administering medication by 7/26/24. thirty (30) residents to monitor each resident s Record of said education to | be | condition and medication. Administration of i ; — medication shall mean delivering to a resident his maintained in the Administrator’s | or her office. prescription medication either in the original pharmacy container, or for internal medication, . removing an individual dose from the pharmacy Staffing Manager to observe container and placing it in a small cup container medication pass of each LIMA and CMT. or liquid medium for the resident to remove from weekly for one month and monthly | the container and self-administer. External prescription medication may be applied by facility thereafter for . three months . to | personnel if the resident is unable to do so and maintain compliance and provide the resident's physician so authorizes. All further education, if deemed individuals who administer medication shall be trained in medication administration and, if nota necessary. | | | Missouri Department of Health and Senior Services STATE FORM saga Q8J711 If continuation sheet 9 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING; (X3) DATE SURVEY COMPLETED 30048 B. WING a 05/29/2024 NAME OF PROVIDER OR SUPPLIER ‘ STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) _ Continued From page 9 | physician or a licensed nurse, shall be a certified medication technician or level | medication aide. Vl This regulation is not met as evidenced by: Class II Based on observation, interview and record review, the facility failed to ensure a safe and effective medication system for two of three residents observed during the medication pass. | The facility staff failed to administer eye-drops properly, watch residents consume their medication, and left medications with residents unsupervised, for one of one medication pass (Residents #5, #6 and #2). The census was 16. Observation on 5/29/24 between 8:01 A.M. and 11:25 A.M., of the morning medication pass, showed the following: -At 8:01 A.M., Level One Medication Aide (LIMA) A prepared Resident #6's medication and then | Carried it over to the resident who sat at the dining | room table eating breakfast. LIMAA gave the | resident his/her medication and before the resident could take his/her medication, the LIMA walked into the kitchen to heat up another resident's breakfast plate. LIMAA had his/her back towards the resident while the LIMA heated | up the other resident's plate. LIMA A then gave the other resident his/her breakfast plate and walked back to the medication cart which was completely out of view of Resident #6. LIMAA prepared another resident's medication and | Resident #6 had still not consumed all of his/her _ Medication yet; -At 8:07 A.M., LIMAA gave Resident #5's medication to him/her and before the resident | could take his/her medication, the LIMA walked away to give another worker his/her keys. LIMAA Missouri Department of Health and Senior Services STATE FORM 5889 Q8J714 If continuation sheet 10 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED — 30048 iil 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) A4797 | Continued From page 10 walked outside of the facility, completely out of | view, to talk with the other employee. Resident #5 had not consumed his/her medication yet and the medication sat on the dining room table in front of the resident with no staff present; -At 8:10 A.M., LIMA A approached Resident #2 | with his/her eye drop medication. LIMAA told the resident he/she had his/her eye drop medication and asked the resident to put his/her head back. The resident put his/her head back and LIMAA dropped one eye drop into each eye, then gave the resident a tissue. The resident wiped the medication from his/her cheeks which had streamed out of his/her eyes. LIMA A did not hold the resident's inner canthus and did not instruct | the resident to do so. After the resident had wiped his/her cheeks, LIMAA placed the resident's glasses back on him/her: -At 8:15 A.M., Resident #5 still had his/her medication on the dining room table, in front of him/her, untouched. LIMA A stayed in the kitchen | doing dishes with his/her back towards the residents; -At 8:25 A.M., Resident #5 still had his/her medication on the dining room table, in front of him/her, untouched; -At 8:29 A.M., LIMAA walked out of the kitchen, | into the living room to check his/her phone. Resident #5 still had his/her medication, untouched. When LIMA A was done checking his/her phone, he/she approached Resident #5 and told him/her to take his/her medication. LIMA Awalked into the kitchen with his/her back toward the resident to get a glass of water for the resident. LIMAA returned to the resident with the glass of water and told the resident to take his/her | medication again. The resident took his/her medication at that time: -At 11:25 A.M., LIMAA approached Resident #2 _with his/her eye drop medication. LIMA A told the Missouri Department of Health and Senior Services STATE FORM aie Q8J711 If continuation sheet 11 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (%3) DATE SURVEY COMPLETED i B. WING 30048 $$ 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION | (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 44797 | Continued From page 11 resident to put his/her head back so he/she could give him/her the eye drop medication. LIMAA administered an eye drop into each eye. The resident had a tissue in his/her hand and wiped his/her eyes with the tissue. LIMA A did not hold the resident's inner canthus and did not instruct "the resident to do so. During an interview on 5/29/24 at 2:06 P.M., LIMA A said he/she was trained to hold the inner canthus after administering eye drops at a | | different facility, but not at this facility. LIMA A said _ he/she knew to hold the inner canthus after administering the eye drops but had forgotten to today. LIMA A said he/she should always watch | the residents take their medications and it was the first time that Resident #5 had not taken _ his/her medication immediately after being given it. During an interview on 5/29/24 at 4:05 P.M., the Administrator said he was aware after administering eye drops, the inner canthus has to | be held. The Administrator said he was not aware _ this was not being done in the medication pass. The Administrator said the staff should watch the residents take their medication and he was not | aware this was not being done. A4799 A4799| 19 CSR 30-86.047(47)(B) Physicians Orders A4799 Requirements Staffing Manager/Shift leader in-| | Medication Orders. serviced to obtain signed physician’s | (B) Physician ' s written and signed orders shall orders every three months by Director include: name of medication, dosage, frequency and route of administration and the orders shall of Nursing by 6/28/24. Record of said be renewed at least every three (3) months. education to be maintained in the | | Computer generated signatures may be used if _Administrator’s office. safeguards are in place to prevent their misuse. Missouri Department of Health and Senior Services STATE FORM Be08 Q8J711 If continuation sheet 12 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30048 NAME OF PROVIDER OR SUPPLIER GABLES AT BRADY CIRCLE, LLC, THE (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) A4799 Continued From page 12 Computer identification cades shall be accessible to and used by only the individuals whose signatures they represent. Orders that include optional doses or include pro re nata (PRN) administration frequencies shall specify a maximum frequency and the reason for administration. II/IlI This regulation is not met as evidenced by: Class II* Based on interview and record review, facility Staff failed to ensure physician's orders were signed by a physician every three months for two of three sampled residents (Residents #1 and #2). The census was 16. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 8/10/23, with diagnoses which included schizoaffective disorder, bipolar disorder, and vascular dementia. Review of the resident's physician's orders sheet (POS) dated 2/2024, 3/2024 and 4/2024, showed no physician's signature. 2. Review of Resident #2's medical record, showed the facility admitted the resident on 11/1/23, with diagnoses which included dementia and incontinence. Review of the resident's POS dated 2/2024, 3/2024 and 4/2024, showed no physician's signature. 3. During an interview on 5/29/24 at 4:08 P.M., _ the Administrator said he was aware a physician signature was required on the resident's POS every 90 days, but he was not aware this was not Missouri Department of Health and Senior Services STATE FORM {X2) MULTIPLE CONSTRUCTION CV———— -——— STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 All resident physician orders reviewed PRINTED: 06/12/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/29/2024 PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) by Director of Nursing or designee for. physician signature and updated, if necessary, by 7/26/24. Director of Nursing or desginee to review signed physician orders monthly to ensure compliance and | provide further education if deemed necessary. Resident 1 Resident physician orders updated by 7/26/24. Resident 2 Resident physician orders updated by | 7/26/24. Q8J711 If continuation sheet 13 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED ———— 30048 nied ee 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A4789 Continued From page 13 happening. The Administrator said the POS | should be signed by a physician every 90 days. A4856 A4856| 19 CSR 30-86.047(63)(A) Alz/Dementia A4856 . . Teed24 Training-Direct Care Staff, 3 hr Office manager in-serviced by | Administrator to maintain record of In addition to the orientation training required in three hours of Alzheimer’s training section (62) of this rule any facility that provides i . . , : care to any resident having Alzheimer ' s disease provided during orientation in the or related dementia shall provide orientation employee file by6/28/24. Record of | training regarding mentally confused residents said in-service to be maintained in the such as those with Alzheimer ' s disease and | related dementias as follows: Administrator's office. (A) For employees providing direct care to such persons, the orientation training shall include at Director of Nursing or designee least three (3) hours of training including at a reviewed all employee files for minimum an overview of mentally confused ; . ; — residents such as those having Alzheimer 's completion of Alzheimer’s training, and. disease and related dementias, communicating provision of said training if necessary, | with persons with dementia, behavior by 7/26/24. management, promoting independence in ' activities of daily living, techniques for creating a Safe, secure and socially oriented environment, Administrator will review all new provision of structure, stability and a sense of employee files for record of | | routine for residents based on their needs, and completion of Alzheimer’s training | understanding and dealing with family issues; and aS . IWAN within 5 days of hire for one month and Ongoing as necessary to maintain compliance. This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility LIMA D failed to ensure all staff who provided direct care Three hours of Alzheimer’s training to residents who had diagnoses of dementia or : Alzheimer's disease, had the required three hour provided by 7/26/24, training to care for residents with diagnoses of Alzheimer's disease or dementia for two of three LIMA A sampled employees. The census was 16. Three hours of Alzheimer’s training provided by 7/26/24. Missouri Department of Health and Senior Services STATE FORM 6889 Q8J711 If continuation sheet 14 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 30048 NAME OF PROVIDER OR SUPPLIER GABLES AT BRADY CIRCLE, LLC, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) A4856 | Continued From page 14 1. Review of Resident Care Survey (a form filled out by the facility during licensure inspections) dated 5/27/24, showed 16 residents with a diagnosis of dementia. 2. Review of LIMA D's personnel file, showed the following: -Hire date 9/1/17; -No documentation of three hours of Alzheimer's | disease and dementia training. 3. Review of LIMAA's personnel file, showed the following: -Hire date 2/28/24: -No documentation of three hours of Alzheimer’s disease and dementia training. | 4. During an interview on 5/29/24 at 3:55 P.M., _ the Administrator said he was not aware all employees who provide direct care to the residents required three hours of Alzheimer's | disease or dementia training documented in their personal file. A6005' 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. II | This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 PREFIX TAG A6005 Seco (X2) MULTIPLE CONSTRUCTION A. BUILDING: — PRINTED: 06/12/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/29/2024 PROVIDER'S PLAN OF CORRECTION | (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A6005 | ulz efe4 Cleaning supplies removed from resident areas by maintenance on. 5/29/24. Maintenance and nursing staff in= | serviced by administrator to monitor for toxic or poisonous materials in resident areas and secure child locks | | on kitchen cabinets during their regular | tour of duty by 6/28/24. Record of said inservice to be maintained in | 'Administrator’s office. Q8J711 If continuation sheet 15 of 19 PRINTED: 06/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED B. WING 30048 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) A6005 Continued From page 15 A6005 | Maintenance staff to report any | Based on observation, interview and record findings to Administrator and ongoing review, the facility failed to ensure poisonous or education/corrective action to be | toxic materials were kept locked up or stored in a completed as deemed necessa ry by | place not accessible to residents when chemicals - were found in unlocked areas accessible to Administrator. | residents for one of one day of observation. This had the potential to affect all residents. The census was 16. 1. Observation on 5/29/24 between 7:13 A.M. and | 3:30 P.M., of house #3, in the unlocked storage cabinet in the hallway across fram the woman's bathroom, showed the following: -One 1/2 full 32 oz spray bottle of Totally Awesome cleaner with bleach. The precautionary statement read, "Caution: Keep out of reach of children. In case of contact with eyes, rinse thoroughly with water. If swallowed, drink a glassful of water. Use with adequate ventilation. Do not mix with other products, especially toilet bowl cleaners, acidic cleaners, or products that | contain ammonia as irritating fumes may result." 2. Observation on 5/29/24 between 7:46 A.M. and 3:30 P.M., of house #1, showed the following: -On an open shelf in the common bathroom next to room 2, one 1/4 full 32 oz spray bottle of Radiance cleaner. The precautionary statement read, "Avoid eye contact and repeated or | prolonged skin contact. Avoid inhalation of vapor, mist or aerosols. Ensure that eyewash stations and safety showers are close to the workstation location. Inhalation: Material may be an irritant to mucous membranes and respiratory tract.": -On an open shelf in the common bathroom across the hall from the laundry room, one 1/2 full 32 oz spray bottle of Totally Awesome cleaner with bleach. The precautionary statement read, "Caution: Keep out of reach of children. In case of contact with eyes, rinse thoroughly with water. If Missouri Department of Health and Senior Services STATE FORM om Q8J711 lf continuation sheet 16 of 19 PRINTED: 06/12/2024 ; FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED ————$_________ B. WING 30048 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 GABLES AT BRADY CIRCLE, LLC, THE (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) A6005 Continued From page 16 swallowed, drink a glassful of water, Use with adequate ventilation. Do not mix with other products, especially toilet bowl cleaners, acidic cleaners, or products that contain ammonia as irritating fumes may result.": -In an unlocked sliding door storage in the _ common hallway off the dining room, two 1/2 full gallon size paint cans of Behr Pro Exterior Flat Paint. Precautionary statement read, "Information on likely routes of exposure, | Inhalation- Prolonged inhalation may be harmful. Skin contact- Prolonged skin contact may cause temporary irritation. Eye contact- Direct contact with eyes may cause temporary irritation. Ingestion- Expected to be a low ingestion hazard." 3. Observation on 5/29/24 between 7:59 A.M. and 3:30 P.M., of house #5, in the unlocked cabinet _ under the kitchen sink, showed one 1/4 full 32 0z _ Spray bottle of Totally Awesome cleaner with bleach. The precautionary statement read, "Caution: Keep out of reach of children. In case of contact with eyes, rinse thoroughly with water. If swallowed, drink a glassful of water. Use with adequate ventilation. Do not mix with other products, especially toilet bow! cleaners, acidic cleaners, or products that contain ammonia as irritating fumes may result." | 4. During an interview on 5/29/24 at 4:13 P.M., the Administrator said all chemicals should be in a locked area, either locked in the housekeeping | closet or locked underneath the kitchen sink. The Administrator said he was not aware there were chemicals in unlocked areas accessible to residents. Missouri Department of Health and Senior Services STATE FORM 6599 Q8J711 lf continuation sheet 17 of 19 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X4) ID PREFIX TAG A8037 A8037 STATE FORM NAME OF PROVIDER OR SUPPLIER GABLES AT BRADY CIRCLE, LLC, THE | 1. Review of Resident #1's medical record, | 2. Review of Resident #2's medical record, | showed the following: | -Admit date 5/6/24; (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 30048 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 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/Iil 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 three of three sampled residents (Residents #1, #2, and #3). The census was 16. showed the following: -Admit date 8/10/23. -No documented inventory sheet. -Admit date 11/1/23; | -No documented inventory sheet. 3. Review of Resident #3's medical record, showed the following: -No documented inventory sheet. 4. During an interview on 5/29/24 at 4:09 P.M., Missouri Department of Health and Senior Services B. WING §a9S (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 06/12/2024 FORM APPROVED STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 'A8037 Office manager and Admissions Coordinator in-serviced Administrator to complete resident personal inventory __ lists education to be maintained in the Administrator’s office. | Administrator will review all resident files within 5 days of admission for completion of personal inventory for three months and ongoing | necessary to maintain compliance. Personal inventory sheets completed | for all residents by 7/26/24. Q8J711 by | upon | admission by 6/28/24. Record of said . (X3) DATE SURVEY COMPLETED 05/29/2024 | | as | | ‘ahewleu (X35) COMPLETE DATE If continuation sheet 18 of 19 PRINTED: 06/12/2024 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 30048 i 05/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11 BRADY CIRCLE SAINT LOUIS, MO 63114 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs) 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) GABLES AT BRADY CIRCLE, LLC, THE Continued From page 18 the Administrator said he was not aware inventory sheets were required on each resident. Missouri Department of Health and Senior Services STATE FORM B99 Q8J711 \f continuation sheet 19 of 19