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).