HIDDEN LAKE HEALTH CARE CENTER.

f / PRINTED: 12/23/2025 oe ; FORM APPROVED Missouri Department of Health and Senior Services a STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION {X3) DATE SURVEY ANG PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 12/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL i (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i CROSS-REFERENCED TO THE APPROPRIATE DATE : DEFICIENCY) HIDDEN |LAKE HEALTH CARE CENTER A3201: 19 CSR 30-86.032(2) Substantially Constructed & | Maintained The building shall be substantially constructed _ and shall be maintained in good repair and in | accordance with the construction and fire safety i rules in effect at the time of initial licensing. II/III | | ‘ This regulation is not met as evidenced by: ; Class III Based on observation and interview, the facility ' failed to ensure the facility was substantially : constructed and maintained in good repair. Staff : failed to maintain all resident apartments, | including those which were not currently occupied : and the facility walls, in resident rooms and _ resident use areas. This had the potential to : affect all residents. The census was 6. _ 1. Observation on 12/6/25 between 7:43 A.M. and | 3:20 P.M. of resident room #15, showed the ; ceiling of the room was entirely missing, exposing i the buildings wooden trusses and roof. The floor | of the room was entirely covered in at least two inches of pink fiberglass insulation. 2, Observation on 12/8/25 between 8:18 A.M. and 3:20 P.M., of the dining room south wall, showed | a black stencil of “The fondest memories are | made when we gathered around the table". | : Surrounding the stencil were over 100 scattered \ i | staples which were placed into the wall. That area | was covered with holes from previously used | . staples. 3. During an interview on 12/8/25 at 2:15 P.M., the Maintenance Director (MD) said he was ‘ aware room 15 was missing its ceiling and the insulation was on the floor. The MD said the room : has been in that condition since before he was Missouri Department of Health and Senior Services LABORATORY. DIRE@TOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE ee EPAO11 If continuation sheet 1 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A3201 Continued From page 1 working at the facility over a year ago. The MD said he has not been given permission to repair the room. 4. During an interview on 12/8/25 at 2:50 P.M., the Administrator said the facility is currently being surveyed by construction teams to determine the full extent of the repairs needed to the facility. The Administrator said he has not gone into room 15 himself but he was aware several rooms were in various stages of refurbishing. 19 CSR 30-86.032(33) Call Systems Requirements All assisted living facilities and all residential care facilities whose plans are approved or which are initially licensed for more than twelve (12) residents after December 31, 1987 shall be equipped with a call system consisting of an electrical intercommunication system, a wireless pager system, buzzer system or hand bells. An acceptable mechanism for calling attendants shall be located in each toilet room and resident bedroom. Call systems for facilities whose plans are approved or which are initially licensed after December 31, 1987 shall be audible in the attendant’ s work area. II/ll} This regulation is not met as evidenced by: Class Il* Based on observation and interview, the facility failed to ensure their call system was maintained and functioning with an audible alert in the nurse's office. This had the potential to affect all residents. The census was 6. Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 2 of 14 PRINTED: 12/23/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 12/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) HIDDEN LAKE HEALTH CARE CENTER A3234 Continued From page 2 1. Observation on 12/8/25 between 7:34 A.M. and 3:20 P.M. of the nursing station, showed the call light computer was turned off and its display was black. 2. Observation on 12/8/25 between 8:16 A.M. and 8:54 A.M., of resident room 1, in the bathroom, on the wall, showed a call light device. This Regulatory Auditor (RA) pulled the lever down and a small red light started to blink. This RA waited approximately 15 minutes to see if a staff member would arrive. No staff member attended to the activated call light. The light was checked then again at 8:54 A.M. and the light was still active. 3. Observation on 12/8/25 at 11:55 A.M., showed a RA pulled the wall cail light alert system of the front entrance women's bathroom, in the small stall. The wall call light alert system lit up red when the string was pulled down. At 12:10 P.M., the Director of Nursing walked past the bathroom and approached the RA who sat near the bathroom, but did not go into the bathroom to check the call light alert. At 12:22 P.M., a staff member went into the Nurse's station where the computer alerting the staff of active call light alerts was. The staff member did not check the bathroom stall. At 1:49 P.M., the call light alert system was still unanswered. 4. During an interview on 12/8/25 at 3:15 P.M, the Maintenance Director said the computer with the call light system was tured off during the day. He did not know who turned it off or why it was turned off. He said the staff had turned it off in the past but did not know if this was the case this time. He said he normally checks the call light system weekly, on Mondays. He said he kept Missouri Department of Health and Senior Services STATE FORM 6838 EPAG11 {f continuation sheet 3 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A3234 Continued From page 3 track of these checks but failed to produce any documentation showing the checks had been completed. He said he did not know the system was turned off on 12/8/25 and did not do his normal Monday check because of "State being in the building.” He said it would have been important to check this “especially because State is in the building.” 5. During an interview on 12/8/25 at 3:17 P.M., the Administrator said since State was present in the building, a lot of planned checks and meetings were not completed. He said someone still should have checked the call light system and ensured if was working. He said he did not know he staff had been turning the call light systern off, leaving the residents with no way to call for help. He said the call light system should never be turned off. *The higher 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. I This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure the required annual tuberculosis screening was completed, for three of three sampled residents (Residents #2, #3 and #1). The census was 6. General requirements for TB testing for residents in Long Term Care Facilities, 19 CSR 20-20.100, Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 4 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 reads as follows: -Long-term care facilities shall screen their residents 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; -Ail 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. 1. Review of Resident #2's medical record, showed the following: -Admit date 10/28/20; -No initial two-step completed. 2. Review of Resident #3's medical record, showed the following: -Admit date 2/7/22- -Annual screening conducted 6/3/24; -No annual screening conducted 6/2025. 3. Review of Resident #1's medical record, showed the following: -Admit date 3/27/25; -No initial fwo step TB test was conducted. Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet § of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4724 Continued From page 5 4. During an interview on 12/8/25 at 2:51 P.M., the Director of Nursing said she knew the residents required an annual TB screening. She said in the past; the facility had an infection contro! Nurse who was responsible for ensure all residents had this in their file. However, that Nurse resigned. She said she was still working on who would be responsible for the TB tests and screenings going forward. 5. During an interview on 12/8/25 at 2:53 P.M., the Administrator said he knew all residents required an annual TB screening. He did not know this information was missing. 19 CSR 30-86.047(20)(} 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: () 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; Ill This regulation is not met as evidenced by: Based on interview and record review, the facility failect to ensure all employees had a physician's statement in their personnel file which indicated the employee could work in long-term care for four of four sampled employees. The census was 6. 1. Review of Level One Medication Aide E's personnel file, showed the following: -Hire date 9/20/10; Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 6 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4733 Continued From page 6 -No physician statement indicating the employee can work in long-term care. 2. Review of Dining Associate G's personnel file, showed the following: -Hire date 12/23/13; -No physician statement indicating the employee can work in long-term care. 3. Review of Dining Manager B's personnel file, showed the following: -Hire date 8/27/16; -No physician statement indicating the employee can work in long-term care. 4. Review of Maintenance Director F’s personnel file, showed the following: -Hire date 3/26/24; -No physician statement indicating the employee can work in long-term care. 5. During an interview on 12/8/25 at 2:35 P.M., the Director of Nursing said Hurnan Resources was responsible for ensuring the employees had a Physician statement indicating the employee could work in long-term care. She said this was a problem previously but she thought the problem was corrected and they had statements for each employee. She said all employees required a Physician statement. 6. During an interview on 12/8/25 at 2:37 P.M_, the Administrator said he knew all employees required a Physician staternent indicating the employee could work in long-term care. He said he did not know employees did not have this statement in their personnel file. Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 (X2) MULTIPLE CONSTRUCTION PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 7 of 14 PRINTED: 12/23/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 12/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) HIDDEN LAKE HEALTH CARE CENTER A4750 Continued From page 7 A4750 19 CSR 30-86.047(28)(F(1}(B) Community Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; I This regulation is not met as evidenced by: Based on interview and record review, the facility failed to complete a community-based assessment (CBA) semi-annually, for three of three sampled residents (Residents #2, #3, and #1). The census was 6. 1. Review of Resident #2's medical record, showed the facility admitted the resident on 10/28/20, with diagnoses which included dementia, high cholesterol, and high bload pressure. Review of the resident's medical record showed the following: -Semi-annual CBA completed 2/28/23; -No semi-annual CBA for 3/2023, 2/2024, 8/2024, or 2/2025. 2. Review of Resident #3's medical record, showed the facility admitted the resident on 2/7/22, with diagnoses which included dementia, high blood pressure, and osteoarthritis (wearing down of protective cartilage that cushions the Missouri Department of Health and Senior Services STATE FORM 6838 EPAG11 {f continuation sheet § of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4750 Continued From page 8 ends of the bones). Review of the resident's medical record showed the following: -No semi-annual CBA completed 2/2024, 8/2024, or 2/2025. 3. Review of Resident #1's medical record, showed the facility admitted the resident on 3/27/25, with diagnoses which included history of falling, dementia, joint pain and high cholesterol. Review of the resident's medical record, showed no semi-annual CBA was completed for 9/2025. 4. During an interview on 12/8/25 at 2:41 P.M., the Director of Nursing said she was aware the CBAs for residents needed to be done still but she was behind and did not get them finished 5. During an interview on 12/8/25 at 2:50 P.M., the Administrator said he was aware a CBA needed to be done semi-annually but was not aware it was not done for several residents. 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 Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) {f continuation sheet 9 of 14 PRINTED: 12/23/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 12/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) HIDDEN LAKE HEALTH CARE CENTER A4754 Continued From page 9 with the facility; This regulation is not met as evidenced by: Based on interview and record review, the facility failed to develop individualized service plans (SP), which included resident needs, goals and services to be provided by staff, for one of three sampled residents (Resident #1). The census was 6. Review of Resident #1’s medical record, showed the facility admitted the resident on 3/27/25, with diagnoses which included history of falling, dementia, joint pain and high cholesterol. Review of the resident's ISP dated 10/22/25, showed the following: -Need: Fall history. The resident had a history of fails. The resident had a witnessed fall on 10/22/25 and 10/31/25. The resident had an unwitnessed fall on 11/28/25. The ISP failed to include any interventions which would help prevent future falls; -The ISP included no other information for the care of the resident. Review of the residents nursing notes dated 11/7/25, showed the resident was to wear an electrocardiogram (ECG) monitor for 14 days. Review of the Medication Review Report (MRR) dated 12/8/25, showed the resident needed assistance with putting on Ted hose (compression hose) each morning and have them removed in the evening and washing them by hand each night then placed up to dry. The MRR further included the resident was to receive assistance with showers in the evening every Tuesday and Friday. Dental care for the resident was also included for the resident and monitoring Missouri Department of Health and Senior Services STATE FORM 6838 EPAG11 If continuation sheet 10 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4754 Continued From page 10 for pain on every shift. During an interview on 12/8/25 at 2:41 P.M., the Director of Nursing (DON) said she had started building the ISP for the resident, but she did not complete it yet. The DON said she was working on other duties and had not checked on the status of ail the ALF residents ISPs to make sure they were all up to date. The DON said the interventions for each of the falls along with the ECG monitor, showering tasks, dental tasks, and TED hose should have been put into the ISP. During an interview on 12/8/25 at 2:50 P.M., the Administrator said he was not aware the resident ISPs were not up to date for all the residents and said all the resident's needs, goals and staff tasks needed te be put into the ISP. 19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer ' s disease or related dementia shail provide orientation training regarding mentally confused residents such as those with Alzheimer ‘s disease and related dementias as follows: (A) For employees providing direct care to such persons, the orientation training shail include at least three (3) hours of training including ata minimum an overview of mentally confused residents such as those having Alzheimer 's disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) if continuation sheet 11 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4856 Continued From page 11 provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and AAI This regulation is not met as evidenced by: Class I* Based on interview and record review, the facility failed to ensure all employees providing direct care to residents had at least three hours of Alzheimer's disease and/or dementia training recorded in the employee's file, for two of two sampled employees who provided direct care to residents. The census was 6. 1. Review of Level One Medication Aide (LIMA) E's personnel file, showed the following: -Hire date 9/20/10; -No decumentation of a three hour training course covering Alzheimer’s and dementia. 2. Review of LIMAA's personnel file, showed the following: -Hire date 8/18/25; -No documentation of a three hour training course covering Alzheimer's and dementia. 3. During an interview on 12/8/25 at 3:05 P.M, the Director of Nursing said the employees who provide direct care to the residents should have at least three hours of training. She did not know why this was not in the employee's file and said it should have been. 4. During an interview on 12/3/25 at 3:05 P.M, the Administrator said the employees who provide direct care to the residents should have at least three hours of training. He did not know this training was missing from the employee's file. Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 12 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4856 Continued From page 12 *The higher the classification merited due to the extent of the violation. 19 CSR 30-86.047(63)(B) Dementia Training-Non-Direct Care Staff, 1 hr In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer ‘s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer ’s disease and related dementias as follows: (B) For other employees who do not provide direct care for, but may have daily contact with, such persons, the orientation training shall include at least one (1) hour of training including at a minimum an overview of mentally confused residents such as those having dementias as well as communicating with persons with dementia: and II/fl This regulation is not met as evidenced by: Class fl? Based on interview and record review, the facility failed to ensure all employees providing in-direct care to the residents, had the required one hour Alzheimer's or dementia training documented in the employee's personnel file, for four of four in-direct care sampled employees. The census was 6. 1. Review of Dining Associate G's personnel file, showed the following: -Hire date 12/23/13; -No documentation of a one hour training course covering Alzheimer's and dementia. Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 13 of 14 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X41} PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 HIDDEN LAKE HEALTH CARE CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A4857 Continued From page 13 2. Review of Dining Manager B's personnel file, showed the following: -Hire date 8/27/16: -No documentation of a three hour training course covering Alzheimer’s and dementia. 3. Review of Maintenance Director F's personnel file, showed the following: -Hire date 3/26/24; -No documentation of a three hour training course covering Alzheimer’s and dementia. 4. Review of Dining Associate B's personnel file, showed the following: -Hire date 7/11/24; -No documentation of a one hour training course covering Alzheimer’s and dementia. 5. During an interview on 12/8/25 at 3:05 P.M., the Director of Nursing said the employees who provide in-direct care to the residents should have at least one hour of fraining. She did not know why this was not in the employee's file and said it should have been. 6. During an interview on 12/8/25 at 3:05 P.M, the Administrator said the employees who provide in-direct care to the residents should have at least one hour of training. He did not know this training was missing from the employee's file. *The higher the classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 899 EPAG11 PRINTED: 12/23/2025 FORM APPROVED {X3} BATE SURVEY COMPLETED Cc 12/08/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) If continuation sheet 14 of 14 PLAN OF CORRECTION Provider Name: | - Hidden Lake Healthcare Center Assisted Living I] Street Address, City, Zip: 11728 Hidden Lake Drive St. Louis, MO 63138 Date of Survey: 12/28/2025 Provider number: | 18442N ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE This plan of correction is prepared and executed because it is required by provisions of the state regulations, and not because Hidden Lake Assisted Living Facility II (Provider # 18442N) agrees with the allegations and citations listed on the statement of deficiencies. Hidden Lake Assisted Living Facility Il maintains that the alleged deficiencies do not, individually, and collectively jeopardize the health and safety of residents, nor are they such character as to limit our capacity to render adequate care as prescribed by the regulations. This plan of correction shall operate as Hidden Lake Assisted Living Facility II’s written credible allegation of compliance. — By submitting this plan of correction, Hidden Lake Assisted Living Facility II does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Hidden Lake Assisted Living Facility I reserves al] rights to raise all possible contentions and defenses in any civil or criminal claim, action, or proceeding. A3201 19 CSR 30-86.032 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Room 15 has been swept and cleaned. The ceiling has been repaired and new drywall has been put up by Maintenance Director. All staples on the dining room wall has been potential to be affected by the same deficient practice; affected by this deficiency. make sure that solutions are sustained. The facili 01/09/2026 must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness; An in-service was conducted by maintenance, DON, and designees that all unoccupied rooms must be locked at all times. There is a sign off sheet completed by nursing every shift showing these rooms are checked and locked. This will be audited weekly for 4 weeks and then quarterly. Random rounds will be conducted weekly by Administrator/DON or designee once a week to ensure compliance with locking all empty rooms. All training reports and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any concerns will be addressed - immediately. : A3234 19CSR 30-86.032 (33) Call System Requirements 01/09/2026 | What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; on after realizing it was off on the day of the survey. notential to be affected by the same deficient practice; After a review of this requirement, all residents could be affected by this deficienc How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness All staff has been in-serviced by the DON, Administrator, and designees that the call light system needs to be turned . on and functioning at all times. A sign off sheet has to be completed by nursing on each shift, This will be audited weekly for 4 weeks and then quarterly. Random checks will be conducted by the Administrator/DON or designee once a week on an ongoing basis to ensure the call system is on and functioning as well as staff responding appropriately to call lights. All cali light training reports and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any . concerns will be addressed immediately. A4724 19CSR 30-86.047 (19) TB screening of residents & staff | 01/09/2026 a What corrective action(s) will be accomplished for | those residents found to have been affected by the deficient practice; Lo Resident #1 has now received a 1‘ and 2™ step TB skin | test.. P| Resident #2 has now received a 1 and 2™ step TB skin fo test. | | Resident #3 has now had an annual TB screening updated. | f | How you will identify other residents having the potential to be affected by the same deficient practice; An audit was conducted of all residents for TB screening and testing. All residents have received 1‘ and 2™4 step TB skin tests or updated annual screening for signs and symptoms of TB. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness The facility is attempting to hire another nurse to assist DON with infection control. TB skin tests will be audited weekly for 4 weeks and then monthly by the DON or designee. All TB screen training reports and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any concerns will be What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Level I Med Aide (E), Dining Associate (G) Dining Manager (B) and Maintenance Director (F) now has appropriate MD statement in their file signed by the current DON.of the facility. How you will identify other residents having the potential to be affected by the same deficient practice; How the facility plans to monitor its performance to | make sure that solutions are sustained. The facility . must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness This will be audited weekly for 4 weeks and then monthly. All Physician statements, training reports and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and the Administrator, Any concerns will be addressed immediately. A physician letter was obtained acknowledging his delegation of the DON by name to provide statement for employees that they can work in AL. All AL employees have a physician statement that they are able to work in long term care signed by the DON. HR will ensure that all new hires will have the physician statement. 19 CSR 30-86.047 (28) (F) (1) (B) Community Based Assessments Semi-annually. | | What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; P| Resident #1 had a Community Based Assessment (CBA) a7 completed on 12/12/2025 by DON | | sResident #2 had a CBA completed on 12/12/2025 by DON | sid | =| Resident #3 had a CBA completed on 12/12/2025 by DON | sid Ly How you will identify other residents having the a potential to be affected by the same deficient practice; An audit was conducted of all AL residents for Community Based Assessments. All residents of AL now have a community-based assessment completed How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness DON/designee will ensure that all new residents will have a community-based assessment. This will be audited weekly for 4 weeks and then once a month on new residents and then quarterly. All community-based assessment training reports and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any concerns will be addressed immediately. A4754 19 CSR 30-86.047(28) (G) Individual Service Plan (ISP | | What corrective action(s) will be accomplished for those residents found to have been affected by the / deficient practice; | si Resident #1’s ISP has been updated and completed. | How you will identify other residents having the potential to be affected by the same deficient practice; How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness The DON/designee will ensure that all new resident to AL have an ISP. This will be audited weekly for 4 weeks and then monthly x 6 months and then quarterly. All ISP training reports and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any concerns will be addressed immediately. 19 CSR 30-86.047 (63)(A) Aizheimer’s/Dementia Training 01/09/2026 Direct Care Staff (3 hrs What corrective action(s) will be accomplished for Pn those residents found to have been affected by the a deficient practice; The DON/designee has completed the required training for a direct care staff Level 1 Medication Aide (A) and Level 1 Medication Aide (E). How you will identify other residents having the a potential to be affected by the same deficient practice All residents have the potential to be affected by a deficient na practice in this area. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections a achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness Training was conducted by the DON and designees regarding the required dementia training for all direct care staff in AL. The DON/designee and HR will ensure that all AL direct care staff including new hires will receive the training to meet the requirements. This will be audited weekly for 4 weeks and then quarterly. All Dementia training for direct care staff AL training and audits will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any concerns will be addressed immediately. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; The required one hour training was completed for non- direct care staff dining manager (G), dining manager (E) and maintenance director (F) _. How you will identify other residents having the potential to be affected by the same deficient How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that corrections achieved are sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness The one hour dementia training was conducted by the DON and designees for all non-direct care staff in AL . The DON/designee and HR will ensure that all AL non-direct care staff including new hires will receive the required dementia training. This will be audited weekly for 4 weeks and then quarterly. All dementia training audits for non-direct care staff will be brought to the facility QAPI quarterly and reviewed by the IDT team and Administrator. Any

PRINTED: 09/22/2024 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 18442N B. WING 12/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ESTATES OF HIDDEN LAKE, THE 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 December 07, 2023, the facility failed to ensure the complete fire alarm system was tested and maintained in accordance with National Fire Protection Association (NFPA) 72, 1999 edition. The facility census on December 07, 2023 was 5. This deficiency potentially affects 5 of 5 residents. Record review on December 07, 2023, at 2:37 P.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. Documentation shows the most recent annual fire alarm system inspection was completed on February 28, 2023. During an interview on December 07, 2023, at 3:27 P.M. the facility Director of Plant Operations said no semi-annual fire alarm system inspection had been completed. He/She contacted the fire alarm company and scheduled a semi-annual inspection during the interview. Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 51XH11 If continuation sheet 1 of 1 NO PLAN OF CORRECTION (POC) IS INCLUDED WITH THIS STATEMENT OF DEFICIENCY (2567 FORM).

PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING: Cc 04/25/2024 18442N B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x5) COMPLETE DATE (X4) ID PREFIX TAG A1227| 19 CSR 30-86.012(27)(A) Home-like A1227 Construction Req. Home-Like Requirements with Respect to Construction Standards. (A) Any assisted living facility formerly licensed as a residential care facility shall be more home-like than institutional with respect to construction and physical pliant standards. II This regulation is not met as evidenced by: Based on observation and interview, the facility failed to keep the facility home-like, in good repair and in good condition for one of one day of observation. This had the potential to affect all residents. The census was 15. 1. Observation on 4/18/24 between 10:30 A.M. and 4:30 P.M., of the courtyard, showed the following: -The green wooden windowpane on the glass door going to the outside of the courtyard, had peeled paint, broken pieces and was detached in several areas. The outside of the door, near the bottom of the door frame, covered with peeled paint and a whole at the bottom left corner; -A wooden gazebo, covered with multiple pieces of torn tarp and Christmas lights; -Multiple air conditioning units missing vent covers which exposed weeds growing in the unit; -The grass and weeds were approximately 1 to 1 1/2 ft tall; -A ladder laid in the grass; -Two wooden raised planters approximately 4 ft by 3 ft, covered with rotted wood and broken wood pieces in several areas; 2. Observation on 4/18/24 between 7:00 A.M. and 4:30 P.M., of the front yard, showed grass approximately 1 foot (ft) high. Missouri Depayi LABORATORY (X6} DATE @RESENTATIVE'S SIGNAFORE TITLE STATE-FORK 8699 6Y3F 71 If continuation shest 1 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 3. Observation on 4/18/24 between 11:53 A.M. and 4:30 P.M., of the front yard, over a resident's window, showed an awning approximately 5 ft wide, covered with rust stains and a metal piece underneath was bent out of shape. 4. Observation on 4/18/24 between 1:09 P.M. and 4:30 P.M., near the door to the courtyard, showed a water fountain that was out of order. 5. During an interview on 4/24/24 at 11:34 A.M., the Administrator said he/she aware all furniture needs to be in working condition and was not aware items was in disrepair. She said she was not aware of disrepaired air conditioning units, gazebos and the door to the courtyard. She was aware it had to be in working condition. Maintenance staff was responsible for keeping the grass cut. It's part of the maintenance task to get it trimmed and keep it trimmed. She said the Maintenance Director was not as effective as he could have been and was let go. She was not aware there were areas of grass that were knee high and the water fountain not working. 19 CSR 30-86.032(34) Hot Water 105-120 Degrees F Plumbing fixtures which are accessible to residents and which supply hot water shall be thermostatically controlled so that the water temperature at the fixture does not exceed one hundred twenty degrees Fahrenheit (120°F) (49°C) and the water shall be at a temperature range between one hundred five degrees Fahrenheit (105°F) (41°C) and one hundred twenty degrees Fahrenheit (120°F) (49°C). I/II This regulation is not met as evidenced by: Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 Class II Based on observation, interview and record review, the facility failed to ensure water temperatures were maintained between 105 degrees Fahrenheit (F) and 120 degrees F for two of two days of observation. This had a potential to affect all residents. The census was 15. 1. Review of the facility's water temperature log, dated February 2024, provided by the facility on 4/2/24, showed water temperatures in the following resident rooms: -On 2/5/24: -In resident room 1, 83 degrees F; -In resident room 3, 89 degrees F; -In resident room 5, 92 degrees F; -In resident room 7, 96 degrees F; -In resident room 8, 92 degrees F; -In resident room 2, 91 degrees F; -On 2/7/24: -In resident room 2, 91 degrees F; -In resident room 4, 83 degrees F; -In resident room 6, 89 degrees F; -In resident room 8, 82 degrees F; -In resident room 10, 82 degrees F; -On 2/13/24: -In resident room 1, 83 degrees F; -In resident room 2, 83 degrees F; -In resident room 3, 82 degrees F; -In resident room 4, 81 degrees F; -In resident room 5, 83 degrees F; -On 2/15/24: -In resident room 1, 81 degrees F; -In resident room 2, 81 degrees F; -In resident room 3, 83 degrees F; -In resident room 4, 86 degrees F; -In resident room 5, 87 degrees F; -On 2/19/24: Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 3 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 -In resident room 1, 83 degrees F; -In resident room 4, 83 degrees F; -In resident room 9, 86 degrees F; -In resident room 7, 87 degrees F; -On 2/23/24: -In resident room 1, 89 degrees F; -In resident room 4, 91 degrees F; -In resident room 9, 91 degrees F; -In resident room 7, 91 degrees F. 2. Observation on 4/2/24 at 11:00 A.M., showed the Director of Plant Operations measured the hot water temperatures at the sink in resident rooms and obtained the following temperatures: -In resident room 1, 74.2 degrees F, water felt cold to the touch; -In resident room 6, 78.9 degrees F; -In resident room 14, 80.8 degrees F. 3. Observation on 4/2/24 at 3:13 P.M., showed hot water temperatures at the sinks in the following rooms when measured with a dial-type thermometer: -In resident room 1, 80 degrees F; -In resident room 2, 76 degrees F; -In resident room 9,76 degrees F; -In resident room 4, 80 degrees F; -In resident room 13, 80 degrees F; -In resident room 14, 80 degrees F. 4. Observation on 4/18/24 at 9:05 A.M., of room 5, of the bathroom, showed the water temperature measured at 78.8. During an interview on 4/29/24 at 9:06 A.M., Resident #1 said since he/she does not have hot water, he/she used baby wipes to freshen up under his/her arms, breasts and between legs. He/she said he/she has been without hot water in his/her apartment for approximately a year. The Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 4 resident said the last time he/she has taken a shower was when he/she last had water. 5. Observation on 4/18/24 at 11:37 A.M., of room 7, of the bathroom, showed the water temperature measured at 79.8 degrees F. 6. Observation on 4/18/24 at 9:21 A.M., of room 5, of the bathroom, showed the water temperature measured at 78.4 degrees F. 7. Observation on 4/18/24 at 11:37 A.M., of room 7, of the bathroom, showed the water temperature measured at 79.2 degrees F. 8. During an interview on 4/2/24 at 3:15 P.M., Resident #9 said he/she has never had hot water in his/her room, and he/she uses a plastic tub to warm up water and use to wash up. 9. During an interview on 4/2/24 at 3:17 P.M., Resident #10 said the water has never been hot since he/she lived here. He/She just took cold showers. 10. During interviews on 4/2/24 at 10:35 A.M. and 11:00 A.M., the Director of Plant Operations said they have two new hot water heaters, installed in October 2023. About a month ago, he received notice that there was a problem with the hot water temperatures on one hall, and that was when he started monitoring the water temperatures. They had a company come to the facility to assess the situation, and they said the cold water is bleeding into the hot water, and the company might need to dig under the ground, underneath the hallway, to fix the problem. Every room on this hall (rooms 1-15) are affected by the problem with the lack of hot water. The residents took showers on the other hall where the hot water temperatures Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 5 of 38 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 11728 HIDDEN LAKE DRIVE ESTATES OF HIDDEN LAKE, THE SAINT LOUIS, MO 63138 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 (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 Continued From page 5 were fine. 11. During an interview on 4/25/24 at 11:34 A.M., the Administrator said maybe two to three weeks she's been aware of the water temperatures and there has been no hot water. Prior to that the Maintenance Director (MD) said the temps were low and not really getting warm. They thought it may have been a valve not working. She said a family member told her the water was not getting warm. The previous director was in the process of getting someone to come out to repair it. Once she became aware she asked what was the plan and what were they doing to get it fixed. They had created a shower room, but she said there was no plan for washing faces and hands. She purchased a towel warmer to warm up towels and face cloths. She had informed the families they will move their loved ones to other areas of the building. The plan was to move them to another location because when the company called to do the repairs did come out they said it would require extensive work to determine the cause of why the water temperature was not getting warm because the water heaters were brand new She said they told her they would need to go underground to determine what's causing the issue. M0O00231912 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: Missouri Department of Health and Senior Services STATE FORM oeee 6Y3F11 DEFICIENCY) If continuation sheet 6 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 6 Based on interview and record review, the facility failed to ensure the required two step tuberculosis (TB) test was completed prior to admission for two of two sampled residents (Residents #1 and #2). The census was 15. 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; -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 Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 7 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 7 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 Resident #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -A documented one-step TB/PPD test administered 3/23/22, three months late with a read date 10/24/22, seven months later and 0 (millimeters) mm in duration; -A documented second-step TB/PPD test administered 10/24/22 with the read date 10/26/22 and 0 mm in duration; -No documented annual review of TB/PPD for 2023. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -Diagnoses included Alzheimer's disease, vitamin D deficiency, anxiety disorder, restless legs syndrome and high blood pressure; -A first-step TB/PPD test administered on 1/10/23, with an unknown read date which showed a reading of 0 mm in induration; -A second-step TB/PPD test administered on Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 8 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 8 2/24/23, with an unknown read date which showed a reading of 0 mm in induration. 3. During an interview on 4/18/24 at 2:45 P.M, the Administrator said she was aware a two-step TB/PPD test had to be administered to residents upon admission. She was unaware the residents TB/PPD tests were incomplete. 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 maintain a written statement signed by a licensed physician or physician's designee indicating the person can work in a long-term care facility for two of two sampled employees. The census was 15. 1. Review of the Administrator's personnel file, showed the following: -Hire date 3/11/24: -A documented physical with out a statement by a physician or a licensee designee which indicated the employee can work in long-term care with or without limitations. 2. Review of Dietary Aide A's personnel file, showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 9 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 9 -Start date 4/14/24: -No written statement by a licensed physician or physician's designee which indicated the person could work in a long-term care facility. 3. During an interview on 4/25/24 at 12:30 P.M., the Administrator said she was not aware a physician statement was required to be documented in every employee's file. 19 CSR 30-86.047(28)(D) Complete a Premove-in Screening 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: (D) Completes a premove-in screening conducted as required by section 198.073.4 (4), RSMo (CCS HCS SCS SB 616, 93rd General Assembly, Second Regular Session (2006)). II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to complete a pre-move in screening prior to admitting residents, for one of two sampled residents (Resident #2). The census was 15. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -Diagnoses included Alzheimer's disease, vitamin D deficiency, anxiety disorder, restless legs syndrome and high blood pressure; -No documented pre-screening. During an interview on 4/25/24 at 11:40 A.M., the Administrator said she was aware a Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 10 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 10 pre-screening was required prior to admitting a resident. The Administrator said she was not aware a resident was missing the prescreening. She said the person doing the pre-screenings was certified as an assessor, so she assumed they were being done. 19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: A. Within five (5) calendar days of admission; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure all sections of the community based assessment (CBA) were completed, for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma. Review of the resident's CBA dated 1-22-23, showed the prescription medications, dosage and Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 11 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 11 physician/pharmacy section was not competed and a note that read "SEE MAR" (medication administration record). 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -Diagnoses included Alzheimer's disease, vitamin D deficiency, anxiety disorder, restless legs syndrome and high blood pressure. Review of the resident's CBA dated 1/9/23, showed the following: -The health problems section was not completed; -The medication section was not completed; -The home health agency section was not completed. 3. During an interview on 4/25/24 at 1:00 P.M., the Administrator said she was aware each resident required a completed CBA documented in their chart. The Administrator was not aware some residents' CBAs were not completed. 19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually The facility may admit or retain an individual for residency in an assisted living facility only if the individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (F) Completes a community based assessment conducted by an appropriately trained and qualified individual as defined in section (4) of this rule: 1. Time frame requirements for assessment shall be: B. At least semiannually; II Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 12 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 12 This regulation is not met as evidenced by: Based on interview and record review, the facility failed to ensure a semi-annual community based assessment (CBA) was completed, for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -A documented CBA dated for 1/22/23; -No documented semi-annual CBA dated for 6/2023 and 12/2023. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -Diagnoses included Alzheimer's disease, vitamin D deficiency, anxiety disorder, restless legs syndrome and high blood pressure; -A CBA dated 1/9/23; -No documented semi-annual CBA completed for 7/2023 or 1/2024. 3. During an interview on 4/25/24 at 1:00 P.M., the Administrator said she was aware each resident required a completed CBA documented in their chart. The Administrator was not aware some residents' CBAs were not completed. 19 CSR 30-86.047(28)(G) Individual Service Plan - Develop The facility may admit or retain an individual for residency in an assisted living facility only if the Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 13 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 individual does not require hospitalization or skilled nursing placement as defined in this rule, and only if the facility: (G) Develops an individualized service plan (ISP), which means the planning document prepared by an assisted living facility which outlines a resident "s needs and preferences, services to be provided, and goals expected by the resident or the resident ' s legal representative in partnership with the facility; II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to develop individualized service plans (ISP, the planning document prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) which included resident needs, preferences, services to be provided by staff and goals expected by the resident or the resident's legal representative for two of six sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the facility admitted the resident on 12/18/21 with diagnoses which included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma. Review of the resident's nurse's notes, showed the following, -On 2/8/24 at 2:26 P.M., staff found the resident on the floor in his/her apartment. Staff checked the resident over, vital signs and performed range of motion. There were no injuries noted. Staff helped the resident off the floor. The resident's physician and family were notified. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 14 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 14 Review of the resident's ISP dated 1/8/22, showed the following: -Need: The resident was a moderate risk for falls due to related decreased mobility; -Services to be provided: Staff to encourage the resident to call for assistance; -The ISP did not indicate what services to be provided due to the resident's fall on 2/8/24. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -Diagnoses included Alzheimer's disease, vitamin D deficiency, anxiety disorder, restless legs syndrome and high blood pressure. Review of the resident's ISP dated 1/11/23, showed the following: -Focus: The resident had an activities of daily (ADLs) living self-care performance deficit related to decreased mobility. The goal indicated the resident had an ADL self-care deficit related to decreased mobility. The interventions were the following: -Bathing/showering: Assist as needed with showers by staff on Wednesday and Saturday evenings; -Bathing: Staff will set out towels and clean clothing, preparing bathmat on floor, prepare water temperature. The staff were required to assist with bathing as needed, offer/encourage resident to apply lotion on the resident; -The ISP did not specify what kind of assistance the resident required with his/her bathing/showering. 3. During an interview on 4/18/24 at 2:15 P.M., the Administrator said she was aware all of the residents needs, goals, preferences and services Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 15 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 15 to be provided were to documented on the resident's ISP. She was unaware some were not completed. 19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements 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: (H) Reviews the ISP with the resident, or legal representative of the resident, at least annually or when there is a significant change in the resident "s condition which may require a change in services; Il This regulation is not met as evidenced by: Based on interview and record review, the facility failed to review resident individualized service plans (ISP, the planning documented prepared by an assisted living facility which outlines a resident's needs and preferences, services to be provided, and the goals expected by the resident or the resident's legal representative in partnership with the facility) annually for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -A documented ISP dated 1/8/22: -No documented ISP dated for 1/2023 and 1/2024. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 16 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 16 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -Diagnoses included Alzheimer's disease, vitamin D deficiency, anxiety disorder, restless legs syndrome and high blood pressure; -An ISP dated 1/11/23; -No documented ISP dated for 1/2024. 3. During an interview on 4/25/24 at 12:35 P.M., the Administrator said all residents should have an annual review regarding their ISP, when needed and if there's a change of condition. 19 CSR 30-86.047(38) Assist to be Clean & Odor A4779 Free The facility shall encourage and assist each resident based on his or her individual preferences and needs to be clean and free of body and mouth odor. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to provide baths for one of one sampled resident (Resident #1). This had the potential to affect all residents. The census was 15. Review of Resident #1's medical record, showed the facility admitted the resident 12/18/21 with diagnoses which included Parkinson's disease, glaucoma, tremors, and high blood pressure. Review of the resident's shower log for April 2024, showed the resident was to be showered every Tuesday and Friday. On days 4/2, 4/5 and 4/16 it was documented electronically by Caregiver E. 4/9 and 4/12 was documented Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 17 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 17 electronically by two unknown staff members. During an interview on 4/18/24 at 9:05 A.M., Resident #1 said he/she has not had hot water in a year. He/She said he/she has not had a shower since he/she has not had hot water. He/She uses baby wipes to clean under his/her arms, breasts and between his/her legs. He/She said he/she did not like the fact he/she has had no shower but he/she manages. During an interview on 4/24/24 at 1:13 P.M., Caregiver E said he/she has not given the resident a shower since sometime in February. He/She was unsure of why his/her initials were electronically documented as being done but he/she has not. During an interview on 4/25/24 at 11:34 A.M., the Administrator said she never found out what happened with the resident's showers. She said the resident had received two showers but didn't want to go to the shower room because it has a lift he/she did not want to use. The resident did not have his/her showers documented. The Administrator could not say how long it has been since the resident had a shower. 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 shall 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. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 18 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 18 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. W/III This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to ensure a pharmacist, physician or a Registered Nurse completed a review of residents' medications every other month for two of two sampled residents (Residents #1 and #2) and failed to document a self-administering assessment for one resident. The census was 15. 1. Review of #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -No documentation of a medication review performed by a pharmacist, physician or Registered Nurse for the years 2022, 2023 and 1/2024 or 3/2024. -No documented self-administration assessment performed by a facility staff member. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -No documented medication regimen review for 3/2023, 5/2023, 7/2023, 9/2023, 11/2023, 1/2024 Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 19 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 19 and 3/2024. 3. During an interview on 4/25/24 at 12:45 P.M., the Administrator said she was aware the pharmacy reviews needed to be completed every other month. The Administrator said she was not aware the reviews had not been completed as scheduled. 19 CSR 30-86.047(58)(B) Resident Condition/Medication Review The facility shall maintain a record in the facility for each resident, which shall include the following: (B) Areview monthly or more frequently, if indicated, of the resident 's general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries involving the resident; III This regulation is not met as evidenced by: Based on interview and record review, the facility failed to perform a monthly review of medication consumption of a resident (Resident #1) who controlled his/her own medication for one of one Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 20 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 20 sampled residents. The census was 15. Review of #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -No documentation of a self-administration assessment. During an interview on 4/18/24 at 9:05 A.M., the resident said no one from the facility ever asked him/her what are his/her medications were for and what was the dosage. During an interview on 4/24/24 at 11:34 A.M., the Administrator said she was unable to locate a self-administration policy. She was aware residents who self-administered needed a self administration assessment performed in the facility. She was not aware the resident did not have one. 19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety Staffing Requirements. (A) The facility shall have an adequate number and type of personnel for the proper care of residents, the residents ' social well being, protective oversight of residents and upkeep of the facility. At a minimum, the staffing pattern for fire safety and care of residents shall be one (1) staff person for every fifteen (15) residents or major fraction of fifteen (15) during the day shift, one (1) person for every twenty (20) residents or major fraction of twenty (20) during the evening shift and one (1) person for every twenty-five (25) Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 21 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 21 residents or major fraction of twenty-five (25) during the night shift. 1/II Time Personnel Residents 7 a.m. to 3 p.m. (Day)* 1 3-15 3 p.m. to 9 p.m. (Evening)* 1 3-20 9 p.m. to 7 a.m. (Night)* 1 3-25 *If the shift hours vary from those indicated, the hours of the shifts shall show on the work schedules of the facility and shall not be less than six (6) hours. Ill This regulation is not met as evidenced by: Class Il Based on interview and record review, the facility failed to develop a system to ensure staff trained in cardiopulmonary resuscitation (CPR) were available on each shift, to meet the needs of full code residents, for six of 15 residents who were full code residents. The census was 15. Review of a list of full code residents provided by the facility, showed six residents who were full code. Review of the facility's schedule for March of 2024, showed the following: -On 3/2/24, there was no CPR trained person on shift from 7:00 A.M., to 3:00 P.M.; -On 3/2/24, there was no CPR trained person on shift from 7:00 A.M., to 3:00 P.M.; -On 3/3/24, there was no CPR trained person on shift from 7:00 A.M., to 3:00 P.M.; -On 3/4/24, there was no CPR trained person on shift from 3:00 P.M., to 11:00 P.M.; Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 22 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 22 -On 3/8/24, there was no CPR trained person on shift from 7:00 A.M., to 3:00 P.M.; -On 3/9/24, there was no CPR trained person on shift from 3:00 P.M., to 3/10/24 at 7:00 A.M.; -On 3/10/24, there was no CPR trained person on shift from 3:00 P.M., to 11:00 P.M.; -On 3/16/24, there was no CPR trained person on shift from 7:00 A.M. to 3:00 P.M.; -On 3/24/24, there was no CPR trained person on shift from 3:00 P.M. to 3/25/24 at 7:00 A.M.; -On 3/25/24, there was no CPR trained person on shift from 3:00 P.M., to 11:00 P.M.; -On 3/26/24, there was no CPR trained person on shift from 3:00 P.M., to 11:00 P.M.; -On 3/28/24, there was no CPR trained person on shift from 3:00 P.M. to 11:00 P.M. During an interview on 4/25/24 at 11:34 A.M., the Administrator said she had been the Administrator of the facility since 3/11/24. The Administrator said she was aware there were residents who were full code residing in the facility. The Administrator said she was not aware the facility's schedule did not include CPR trained or certified staff on all shifts. The Administrator said the facility's staff schedule was made by the previous Director of Nursing and the facility staff. The Administrator said she assumed the schedule included CPR trained or certified staff. 19 CSR 30-86.047(63)(A) Alz/Dementia Training-Direct Care Staff, 3 hr In addition to the orientation training required in section (62) of this rule any facility that provides care to any resident having Alzheimer ' s disease or related dementia shall provide orientation training regarding mentally confused residents such as those with Alzheimer 's disease and Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 23 of 38 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 11728 HIDDEN LAKE DRIVE ESTATES OF HIDDEN LAKE, THE SAINT LOUIS, MO 63138 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 23 related dementias as follows: (A) For employees providing direct care to such persons, the orientation training shall include at least three (3) hours of training including at a minimum an overview of mentally confused residents such as those having Alzheimer 's disease and related dementias, communicating with persons with dementia, behavior management, promoting independence in activities of daily living, techniques for creating a safe, secure and socially oriented environment, provision of structure, stability and a sense of routine for residents based on their needs, and understanding and dealing with family issues; and I/II This regulation is not met as evidenced by: Class Ill Based on interview and record review, the facility failed to ensure all indirect employees completed the required one hour training of Alzheimer's disease or dementia for one of one sampled dietary employee. The census was 15. 1. Review of employee A's personnel file, showed the following: -Hire date 4/14/24; -No documentation of Alzheimer's disease or dementia training. 2. During an interview on 4/18/24 at 1:15 P.M., the Dietary Director said no dietary staff member had the required one hour Alzheimer's disease or dementia training. She said she was not aware this training was required. 3. During an interview on 4/18/24 at 2:15 P.M., the Human Resources Manager (HRM) said she was aware some staff members did not have the Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 24 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 24 required Alzheimer's disease or dementia training because there was not enough "paid seats" in the training system the facility utilized. She said all of the dietary staff members missed the training because they do not have access to the training. The HRM said the Dietary Director was responsible to make sure the training was completed. The HRM said everyone should have access to the training but she was not aware indirect employees required on hour of Alzheimer's disease or dementia training. The HRM said the facility had access to the training sine 2020 or 2021. 4. During an interview on 4/25/24 at 11:47 A.M., the Administrator said she was not aware dietary staff had not completed the required one hour Alzheimer's disease or dementia training. She said she was aware it was a required training. 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: Based on observation and interview, the facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents when chemicals were found in Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 25 of 38 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 11728 HIDDEN LAKE DRIVE ESTATES OF HIDDEN LAKE, THE SAINT LOUIS, MO 63138 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 (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 Continued From page 25 unlocked areas accessible to residents, in/on unlocked and unsupervised cleaning carts, for one of one day of observation. This had the potential to affect all residents. The census was 15. Observation on 4/18/24 at 10:10 A.M., of room 21, showed a 19-ounce (0z) spray can of Lysol and a 32 oz of Comet spray disinfecting cleaner on a kitchenette table. The Lysol's precautionary statement read "Hazardous to humans and domestic animals. Causes mild eye irritation. Do not spray in eyes, on skin, or on clothing. Wash hands thoroughly after use and before eating. Keep out of reach of children." The Comet's precautionary statement read, "CAUTION: May cause eye irritation. In case of contact with eyes, flush thoroughly with water. If irritation persists, see a physician. If swallowed, drink a glassful of water. May be irritating to skin. For sensitive skin or prolonged use, wear gloves." During an interview on 4/25/24 at 11:39 A.M., the Administrator said all chemicals should be locked and secured. She was not aware there was an unlocked room with chemicals and she would have expected it to be locked or not present in that room at all. 19 CSR 30-87.020(13) Carpeting Carpeting, if used as a floor covering, shall be of closely woven construction, properly installed, easily cleanable and maintained in good repair. Carpeting is prohibited in food-preparation, equipment-washing and utensil-washing areas where it would be exposed to large amounts of grease and water, in food-storage areas and toilet room areas where urinals or toilet fixtures Missouri Department of Health and Senior Services STATE FORM oeee 6Y3F11 DEFICIENCY) If continuation sheet 26 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 26 are located. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to maintain clean carpet in the common area and in a resident's room for one of one day of observation. This had the potential to affect all residents. The census was 15. 1. Observation on 4/18/24 between 7:05 A.M. and 5:00 P.M., of the common area, showed the entire floor, covered with various large stains. 2. Observation on 4/18/24 between 9:45 A.M. and 5:00 P.M., of room 21, showed multiple dark stains on a beige carpet near the entrance to the apartment. During an interview on 4/25/24 at 11:34 A.M., the Administrator said the carpet needs to be cleaned or replaced. She was aware the carpets looked like that and was in the process of getting it addressed. A new Maintenance Director starts 5/2. There's an ongoing working plan to address the carpet. The spots are everywhere and being able to hit every area is taking some time. She's put a work order process in place to schedule them but it's too many areas to do quickly. 19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean Walls and ceilings, including doors, windows and skylights, shall be clean and maintained in good repair. Ill This regulation is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain the walls and Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 27 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 27 ceiling of the hot water/mechanical room, located directly adjacent to the main dining room during two of two days of observation. The census was 45: Observation on 4/2/24 at 10:30 A.M. and on 4/18/24 between 12:45 P.M. and 5:00 P.M., showed a mechanical room directly adjacent to the main dining room, which contained hot water heaters and heating, ventilation and air conditioning (HVAC) equipment. The right side of the room contained an air-handling unit. The wall to the side and behind, and the ceiling above the air handler had a green-black substance which covered the entirety of the two walls up to the ceiling above. When touched, the substance rubbed off and appeared green on the inspector's hand. During an interview on 4/2/24 at 10:30 A.M., the Director of Plant Operations said he thought the cause of the wall discoloration occurred when there was a water leak in the room before he worked at the facility (at least seven months prior). 19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed Nonfood-contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. III This regulation is not met as evidenced by: Based on observation and interview, the facility failed to ensure all non-food contact surfaces were wiped clean for one of one day of observation. The census was 15. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 28 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 28 Review of the facility's undated kitchen cleaning schedule, showed the following: -On Sunday: Check coffee and tea refill, wipe down units/ drain trays. Drain and clean steam table, refill with clean water. Clean refrigerator and freezer inside. Remove all items from shelves wipe entire inner surfaces/make sure all food and beverage items are wrapped, dated, and labeled. Check dates of leftovers (3 day shelf life). Check dates of all dairy. Polish both units with stainless steel cleaner and dry towel; -Monday: Check coffee and tea refill, wipe down units/ drain trays. Drain and de-lime steam table, refill with clean water and de-lime dish machine. Clean all low shelving. Polish low shelving units with stainless steel cleaner and dry towel: -Tuesday: Check coffee and tea refill, wipe down units and drain trays. Drain and clean steam table, refill with clean water. Clean trash cans including dish room cans and bus carts; -Wednesday: Check coffee and tea refill, wipe down units and drain trays. Drain and clean steam table, refill and clean water. Clean refrigerator and freezer inside. Remove all items from shelves wipe entire inner surfaces and make sure all food and beverage items are wrapped, dated, and labeled. Check dates of leftovers (3 day shelf life). Check dates of all dairy. Polish both units with stainless steel cleaner and dry towel; -Thursday: Check coffee and tea refill, wipe down units and drain trays. Drain and de-lime steam table, refill with clean water and de-lime dish machine. Wipe down all walls/doors in pantry; -Friday: Check coffee and tea refill, wipe down units and drain trays. Drain and clean steam table, refill with clean water. Clean trash cans including dish room cans and bus carts; -Saturday: Check coffee and tea refill, wipe down Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 29 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 29 units and drain trays. Drain and clean steam table, refill with clean water. Detail food transportation cart, inside and out including wheels. 1. Observation on 4/18/24 between 7:25 A.M. and 8:45 A.M., of the kitchenette, showed the following: -The water inside the warmers had chunks of food floating around and the color of the water was murky; -Two, three shelf, rolling carts, one black and one grey, covered with food crumbs and sticky liquid spots; -A plastic four compartment utensil holder, covered with food grime; -The beige towel which laid on the bottom shelf of the warmers, covered with food crumbs and food stains; -The outside of the toaster, covered with food crumbs and food grime. The thick layer of food crumbs covered the table under the toaster; -The outside and the inside of the microwave, covered with food grime and crumbs; -Multiple tray coverings, stacked in on the warmer, covered with food grime; -The outside of the refrigerator and the handles, covered with food grime. 2. During an interview on 4/18/24 at 12:39 A.M., the Director of Dietary said she expected staff to wipe non-food surfaces down daily and especially between lunch and dinner. 3. During an interview on 4:25/24 at 11:39 A.M., the Administrator said it is expected the kitchenette area be cleaned routinely, especially at night. She said she was not aware it has not been done and not aware it was not being done properly. She said the rolling carts should be a Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 30 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 30 part of the cleaning schedule and the steamer should get drained after the meal service. She was not aware that was not being done and was not aware the deep cleaning schedule was not being followed. 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 III Based on interview and record review, the facility failed to review resident rights with residents or their representative upon admission and annually for two of two sampled residents. (Residents #1 and #2) The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -No documentation of an initial review of resident rights for 12/2021; -No documentation of an annual review of resident rights for 2022, 2023 and 2024. 2. Review of Resident #2's medical record, Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 31 of 38 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 11728 HIDDEN LAKE DRIVE ESTATES OF HIDDEN LAKE, THE SAINT LOUIS, MO 63138 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 31 showed the following: -Admit date 1/9/23; -No initial review of the resident's rights for 2023; -No annual review of the resident's rights for 2024. 3. During an interview on 4/25/24 at 12:30 P.M., the Administrator said she was aware the facility should have an initial review and annual reviews of each resident, but she was not aware the reviews were not done. 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 Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 (X2) MULTIPLE CONSTRUCTION PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE If continuation sheet 32 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 32 contacted annually to assure their accessibility and understanding of the facility policies regarding emergency and life-sustaining care. I/II This regulation is not met as evidenced by: Class III Based on interview and record review, the facility failed to review advanced directives with residents or their representative annually for two of two sampled residents (Residents #1 and #2). The census was 15. 1. Review of Resident #1's medical record, showed the following: -Admit date 12/18/21; -Diagnoses included tremors, Parkinson's disease, osteoarthritis, high blood pressure and glaucoma; -A documented review of advanced directives dated for 12/20/21; -No documentation of an annual review of advanced directives dated for 12/2022 and 12/2023. 2. Review of Resident #2's medical record, showed the following: -Admit date 1/9/23; -An initial review of the resident's advanced directives dated 1/6/23; -No annual review for 2024 advanced directives. 3. During an interview on 4/25/24 at 12:30 P.M., the Administrator said she was aware the facility should have an initial review and annual reviews of each resident, but she was not aware the reviews were not done. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 33 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 33 19 CSR 30-88.010(15) 30 Day Notice-Transfer/Discharge No resident shall be transferred or discharged except in the case of an emergency discharge unless the resident, and the next of kin, or a legally authorized representative or designee, and the resident's attending physician and the responsible agency, if any, are notified at least thirty (30) days in advance of the transfer or discharge, and casework services or other means are utilized to assure that adequate arrangements exist for meeting the resident's needs. In the event that there is no next of kin, legally authorized representative or designee known to the facility, the facility shall notify the appropriate regional coordinator of the Missouri State Ombudsman's office. II This regulation is not met as evidenced by: Based on interview and record review, the facility failed to issue an appropriate emergency discharge to residents (Residents #3, #4, #5, #6, and #8) when the facility discharged the residents without issuing a 30 day discharge notice beforehand to the residents or the residents’ responsible party. The census was 15. 1. Review of a list of discharged residents provided by the facility, showed the following: -Resident #3 was discharged from the assisted living facility to a skilled nursing facility; -Resident #4 was discharged from the assisted living facility to a skilled nursing facility; -Resident #5 was discharged from the assisted living facility to a skilled nursing facility; -Resident #6 was discharged from the assisted living facility to a skilled nursing facility; -Resident #8 was discharged from the assisted living facility to another assisted living facility. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 34 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 34 2. Review of Resident #8's medical record, showed the following: -Admit date 10/27/21; -Diagnoses included high blood pressure, anemia, psychotic disturbance, mood disturbance, anxiety and urinary tract symptoms. Review of the resident's progress notes, showed on 3/28/24 at 10:34 P.M., the resident was discharged from the facility today and the resident's family moved him/her to a different location. Review of the resident's medical record, showed no documented discharge notice given to the resident or the resident's responsible party. 3. Review of Resident #6's medical record, showed the following: -Admit date 3/18/24; -Diagnoses included Alzheimer's disease, anxiety disorder, disorientation, dementia and anemia. Review of the resident's progress notes, showed the following: -On 3/18/24 at 3:43 P.M., the resident arrived to the skilled facility at 2:55 P.M., with his/her family members. The resident was escorted to his/her room. The resident was introduced to the staff. The resident tolerated a full body skin assessment with no open areas noted. The resident's feet were very dry and he/she needed to be seen by the podiatrist. The resident received and tolerated a shower and was assisted into a pull up brief. No other issues were noted at this time; -On 3/18/24 at 3:52 P.M., the resident's primary care physician called the facility and was given the resident's report regarding his/her admission. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 35 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 35 The primary care physician verified all orders with request to fax them to his/her office. The resident was constantly redirected away from the exit doors with some hesitation at times. Review of the resident's medical record, showed no documented discharge notice given to the resident or the resident's responsible party. 4. Review of Resident #5's medical record, showed the following: -Admit date 3/19/24; -Diagnoses included dementia, mood disturbance, anxiety and insomnia. Review of the resident's progress notes, showed the following: -On 3/19/24 at 4:21 P.M., the resident was admitted from Assisted Living memory care. The resident did not have mobility device with him/her but may use furniture, redirection and guidance. The resident wandered but did not exit seek. The resident had impaired cognition, was a poor historian, pleasantly confused and required meal set up and cues. The resident had a mechanical soft diet. The resident's family was aware of "transfer" and transition to skilled, nursing care center; -On 3/19/24 at 7:37 P.M., the resident's primary care physician was notified of the resident's admission into the Care Center and verified all orders. The resident received and tolerated a bed bath. The resident was assisted into his/her bed clothes after dinner. The resident went to bed and fell fast asleep with no noted distress. The resident received and tolerated assist of one person with his/her dinner with cues and physical assist. Review of the resident's medical record, showed Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 36 of 38 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: 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 ESTATES OF HIDDEN LAKE, THE (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 36 no documented discharge notice given to the resident or the resident's responsible party. 5. Review of Resident #3's medical record, showed the following: -Admit date 3/20/24; -Diagnoses included high blood pressure, diabetes, Alzheimer's disease and hyperlipidemia. Review of the resident's progress notes, showed on 3/20/24 at 12:30 P.M., the resident was admitted from the assisted living facility with no distress noted. The resident was escorted into the facility in a wheelchair by a family member. The resident ambulated with his/her walker and was able to make his/her needs known. The resident spoke few words. The resident did not have any complaints of pain. The resident spoke with the resident's primary care physician's office regarding the resident's admission. Review of the resident's medical record, showed no documented discharge notice given to the resident or the resident's responsible party. 6. Review of Resident #4's medical record, showed the following: -Admit date 3/21/24; -Diagnoses included vascular dementia, psychotic disturbance, mood disturbance and anxiety. Review of the resident's progress notes, showed on 3/21/24 at 2:50 P.M., the resident was admitted to skilled from assisted living facility. The resident was pleasantly confused. The resident required stand by assist of one person for all activities of daily living. The resident wandered but did not exit seek. The resident did Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 PRINTED: 05/15/2024 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 04/25/2024 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 37 of 38 PRINTED: 05/15/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 04/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 11728 HIDDEN LAKE DRIVE SAINT LOUIS, MO 63138 (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) ESTATES OF HIDDEN LAKE, THE Continued From page 37 not have any distress noted. At the time of the "transfer," the resident's primary care physician and family were made aware. The resident's primary care physician verified the resident's orders. Review of the resident's medical record, showed no documented discharge notice given to the resident or the resident's responsible party. 7. During an interview on 4/25/24 at 11:34 A.M., the Administrator said she was aware residents required a 30 day discharge notice and an opportunity to appeal the discharge. The Administrator said some of the residents were "transferred" from the assisted living facility side to the skilled nursing care facility side. The Administrator said she was not aware that a notice was needed for an "internal transfer." The Administrator said she could not locate the discharge policy. *The higher classification merited due to the extent of the violation. Missouri Department of Health and Senior Services STATE FORM 6899 6Y3F11 If continuation sheet 38 of 38 PLAN OF CORRECTION ame: Street Address, City, Zip: 11728 HIDDEN LAKE DR SAINT LOUIS MO 63138 Date of Survey: 04/25/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 18442N PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION ID PREFIX TAG SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE anne 1ON ‘ DEFICIENCY) This plan of correction is submitted as the facility’s credible allegation of compliance for all citations. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. As of 05/02/24 facility has a new maintenance director to oversee the preventative maintenance program. As of 4/272024 facility has obtained an outside vendor to provide ongoing lawn care service. Wooden door has been replaced, awning and water fountain will be repaired or replaced by 06/24/24. A1227 Homelike Maintenance Personnel education has been initiated and will 06/24/2024 be completed by 06/24/24 related to the preventative maintenance audits to identify and address working conditions and disrepair items. As of 06/24/24 the maintenance department will perform routine audits according preventative maintenance program schedules. All audits will be reviewed monthly by administrator and brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. A3235 Water Temps MO00231912 MO00231983 MO00234921 By 06/24/24 facility will collaborate with families for each resident within the affected rooms to make a plan to move them to a location where the water temps are able to be maintained in accordance with regulation. 06/24/2024 As of 05/30/24 staff will follow abnormal water temp policy and protocols to ensure no resident is exposed to abnormal temps until each resident is moved. Maintenance Personnel education has been initiated and will be completed by 06/24/24 related to water temp monitoring. Water temp audits will continue to be checked and logged in the assisted living facility weekly per preventative maintenance program. All audits will be reviewed monthly by the administrator and brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Resident #1 and Resident #2 TB testing are current and All resident's TB test and/or screens will be audited and/or completed according to regulation by 06/24/24. A4724 06/24/2024 TB screen New ALF DON and Clinical personnel education has been initiated and will be completed by 06/24/24 related to the TB testing and screening regulations. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents and staff are affected by this deficient practice and will ensure compliance. Human Resource and Administrator education has been initiated and will be completed by 06/24/24. As of 05/28/24 administrator and dietary aide A have been assessed by physician designee. By 06/24/24 all ALF staff file’s will be audited and/or assessed by physician or physician A4733 designee a written statement will be obtained to indicate if Physician person can work with or without limitations. New hires wiil 06/24/2024 statement have physician statement. Human Resources and/or designee will complete monihly audit of new hire files to ensure statement has been completed. All audits will be reviewed by administrator monthly and brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this AA747 deficient practice and will ensure compliance. Premove-in screening There is a New Facility Certified Assessor who has been in 06/24/2024 serviced on the prescreening regulations and the expectations to be compliant. Resident #2 s no longer a resident. As of 05/20/24 all new referrals for assisted living will have a premove-in screening completed and the Administrator will review and sign off on all premove-in screenings. New ALF DON and/or designee will complete monthly audit of new move-in files to ensure premove-in screening has been completed. All audits will be reviewed by administrator monthly for (6) months and brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. a The facility recognizes that residents are affected by this deficient practice and will ensure compliance. There is a New Facility Certified Assessor who has been in serviced on the community-based assessment (CBA) regulations and the expectations to be compliant. Resident #1 will have a new CBA completed by 06/24/24. Resident #2 no longer a resident. By 06/24/24 All CBA’s will be audited for each resident to AATAS ensure complete. 06/24/2024 CBA 5-day Any new admissions after 06/26/24 will have the CBA completed within 5 days of admission. Beginning 06/24/24 CBA audit will be conducted weekly for (6) weeks, then monthly, and when necessary, by the Administrator and/or designee. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. There is a New Facility Certified Assessor who has been in serviced on the community-based assessment (CBA) regulations and the expectations to be compliant. A4750 Resident #1 will have a new CBA completed by 06/24/24. CBA semi- Resident #2 no longer a resident. 06/24/2024 annuaily By 06/24/24 Ail CBA’s will be audited for each resident and a new one completed and automatically scheduled within the facility's electronic medical records system to be completed semi-annually and when needed. Any new admissions after 06/26/24 will have the CBA completed semi-annually from admission. Beginning 06/24/24 CBA audit will be conducted weekly and when necessary, by the Administrator and/or designee. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. There is a New Facility Certified Assessor who has been in serviced on the Individual Service Plan (ISP) development regulations and the expectations to be compliant. Resident #1 will have a new ISP completed by 06/24/24. Resident #2 no longer a resident. A4754 ISP develop 06/24/2024 By 06/24/24 All ISP’s will be audited for each resident and a new one developed if needed. Beginning 06/24/24 ISP’s audit will be conducted weekly and when necessary for (6) weeks and then monthly, by the Administrator and/or designee. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. There is a New Facility Certified Assessor who has been in serviced on the Individual Service Pian (ISP) regulations and the expectations to be compliant. Resident #1 will have a new ISP completed by 06/24/24. Resident #2 no longer a resident. A4755 ISP requirements 06/24/2024 06/24/2024 By 06/24/24 All ISP’s will be audited for each resident and a new one automatically reviewed and/or updated when the CBA is completed or a change in condition noted. , Beginning 06/24/24 ISP’s audit will be conducted weekly and when necessary for (6) weeks and then monthly, by the Administrator and/or designee. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. A4779 Assist Resident #1 has received assistance from staff to keep him/her clean and odor free. Resident preferences for showers has been followed. New ALF DON and Clinical Personne! education has been initiated and will be completed by 06/24/24 related to assisting residents to be clean and odor free including providing showers. Beginning 06/03/24 New ALF DON and/or designee will audit all shower records weekly and when necessary. All audits will be reviewed by administrator monthly for (6) months and when necessary, then brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. As of 05/28/24 Resident #1 drug regimen has been reviewed by a pharmacist. Resident will have a self-administration assessment completed by 06/24/24. Family is managing medications until self-administration assessment is completed. Resident #2 no longer a resident. ne ar egimen New ALF DON and Clinical Personnel education has been Review 9 initiated and will be completed by 06/24/24 related drug regimen review regulations and expectations for compliance. By 06/24/24 All resident will have a drug regiment review completed by a pharmacist or Registered nurse and every other month thereafter. New ALF DON and/or designee audit drug regimens every other month started 06/24/24. Drug review schedule and completed reviews will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Resident #1 and each resident in assisted living will have a self-administration assessment completed by 06/24/24. New ALF DON and Clinical Personnel education has been A4837 initiated and will be completed by 06/24/24 completing seif- Resident administration assessment upon admission, semi-annually and condition when needed. Administrator will audit all self-administration assessments by 06/24/24 and semi-annually thereafter. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. 06/24/2024 06/24/2024 A4841 Staff Ration, Safety A4856 Alz/dementia training A6005 Toxic Materials The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Human Resource Personnel education has been initiated and will be completed by 06/24/24 and the regulation related to CPR certified staff and the expectations for compliance. By 06/24/2024 there will be adequate number of CPR trained staff on each shift. 06/24/2024 Administrator and/or designee will review and audit the staffing schedule monthly to ensure adequate CPR trained is scheduled for each shift. All audits will be brought to the facility Quality Assurance | Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. New ALF DON and Human Resource Personnel education has been initiated and will be completed by 06/24/24 regarding required training for staff and required training completed. By 06/24/24 Human Resources (HR) Personnel will audit employee files and/or ensure training has been provided including to employee A. 06/24/2024 All new hires assigned to work within the assisted living facility will receive the required ALZ/Dementia training according to regulations and maintained by HR personnel. All training reports and audits will be brought to the facility Quality Assurance Meetings and reviewed monthly by administrator and/or designee for 6 months and by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. As of 05/20/24 Lysol Spray and Comet in room 21 has been stored with family. ALF staff and Housekeeping Personnel education has been initiated and will be completed by 06/24/24 related to toxic chemicals regulation and expectations for compliance. 06/24/2024 By 06/24/24 all ALF units will be audited for proper storage of toxic materials This will be done routinely with unit cleaning schedule. New ALF DON and/or designee will review audits and cleaning schedules monthly and when necessary. All audits will be reviewed by administrator monthly for (6) months and when necessary and brought to the facility Quali Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Common area has been cleaned and improvement noted and will have significant signs of improvement noted by 06/24/24. Room 21 has been cleaned with improvement noted and ongoing cleaning is occurring and the entire carpeting will be cleaned by 06/24/24. Maintenance and Housekeeping Personnel education has been initiated and will be completed by 06/24/24 related to carpet cleaning and/or repair regulation and expectation of compliance. As of 05/29/24 facility has hired a floor tech to specifically work cleaning and/or repairing of carpeting and all floors in collaboration with maintenance. A6013 Carpeting 06/24/2024 By 06/24/24 carpets wiil be initially cleaned by new floor tech and an outside vendor will be used to assist. The areas will be cleaned and maintained on a preventative cleaning schedule per week and when necessary. Starting 06/24/24 the administrator and/or designee will review audits weekly, cleaning schedules, weekly, and complete walking rounds weekly to validate carpeting cleaning for (6) weeks then monthly for (6) months and when necessary All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the [DT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Maintenance and Housekeeping Personnel education has been initiated and will be completed by 06/24/24 related cleaning/repair regulation and expectation of compliance. By 06/24/24 all walls and ceilings will be audited for the need to clean and/or repair. A6015 Wails/Doors Clean 06/24/2024 These repairs will be prioritized and completed according to cleaning and maintenance preventative schedules per week. The administrator and/or designee will review audits and complete weekly walking rounds to validate completion All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. A067 06/24/2024 Noncontact Food surface A8004 Resident Rights annual A8010 Advance Directives Food Service Personnel education initiated and will be completed by 06/24/24 related to non-contact food surface cleaning. As of 05/28/24 kitchenette, rolling carts, and steamer have been cleaned and cleaning schedule is being followed including draining the water from the steamers. By 06/24/24 Documentation of the cleaning will be completed. Administrator and/or designee will audit cleaning schedule documentation and complete visual inspection of surface cleaning. This will be done weekly for (6) weeks then monthly for (6) months and when necessary. All audits will be brought to the facility Quality Assurance Meetings to be reviewed by the IDT and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Resident #1 will have resident rights reviewed by 06/24/24. Resident #2 no longer a resident. New ALF DON and Clinical Personnel education has been initiated and will be completed by 06/24/24 related to regulation for resident rights review. 06/24/2024 New ALF DON and/or designee will review resident rights with all residents by 06/24/24 and ensure annual completion. As of 06/24/24 any new admissions will have resident rights reviewed upon admissions, annually, and when needed. All resident rights will be reviewed quarterly by the IDT in clinical meeting and any concerns addressed immediately. The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Resident #1 will have resident rights reviewed by 06/24/24. Resident #2 no longer a resident. New ALF DON and Clinical Personnel education has been initiated and will be completed by 06/24/24 related to regulation for advanced directives. 06/24/2024 New ALF DON and/or designee will review advance directives with all residents by 06/24/24 and ensure annual completion. As of 06/24/24 any new admissions will have advance directives reviewed upon admissions, annually, and when needed. ane | clinical meeting and any concerns addressed immediatel The facility recognizes that residents are affected by this deficient practice and will ensure compliance. Residents #3,#4,#5,#6 and #8 are no longer residents. Each resident's next of kin or legally authorized representative were notified prior to transfer to healthcare facility. By 06/24/24 Administrator will review regulation regarding 30- day notice with IDT to ensure understanding and ongoing compliance. A8015 30-day notice 06/24/2024 By 06/24/24 any resident requiring 30-day notice for transfer or discharge will receive written notice according to regulation and notice place in their medical records. These resident’s notice will be reviewed by the IDT prior to providing and any concerns addressed immediately. 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. mine tortor dy [>4