MATTIS POINTE ASSISTED LIVING.

PRINTED: 06/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 4962 MATTIS ROAD SAINT LOUIS, MO 63128 (X4)1D | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION | (6) PREFIX | (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) | MATTIS POINTE-ASSISTED LIVING BY AMERICARE A8023) 19 CSR 30-88.010(23) Develop/Implement A/N Policies | The facility shall develop and implement written i policies and procedures that prohibit ; mistreatment, neglect, and abuse of any resident ' and misappropriation of resident property and : funds, and develop and implement policies that : require a report to be made to the department for “any resident or to both the department and the Department of Mental Health for any vulnerable » person whom the administrator or employee has reasonable cause to believe has been abused or - neglected. I/II ; This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to follow their abuse and neglect policy when an alleged incident of abuse occurred and employees were allowed to continue to have contact with residents, for one of one sampled resident. (Resident #1) The census was 28. Review of the facility's undated “Reporting Abuse to Facility Management" policy, showed the : following: : -Guideline: it is the responsibility of our ' employees; and facility consultants, to promptly : report any incident or suspected incident of _ resident neglect; or abuse, including injuries of _ unknown source/origin, and theft or misappropriation of resident property to facility management. -Procedural Steps: 1. Our facility does not condone or tolerate abuse of residents. 2. Employees, facility consultants and/or i attending physicians are to report any suspected | abuse or incidents of abuse to facility Missouri Department of Health and Senior Services PIRECFOR'S OR PR@VIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE a, ‘TITLE . 6) DATE Z Pe —— 8898 5G2H11 If continuation sheet 1 of 7 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 MATTIS POINTE-ASSISTED LIVING BY AMERICARE {X4) ID PREFIX TAG Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING SAINT LOUIS, MO 63128 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION} Continued From page 1 | Management. 3. The administrator and director of nursing services are to be notified of suspected abuse or incidents of abuse as soon as possible. If such incidents occur or are discovered after hours, facility management should be called at home or : paged and informed of such incident. _ 4. When an actual case of mistreatment, neglect, | injuries of an unknown source, or abuse is reported, the following persons or agencies should be notified: All alleged or suspected cases should be reported to the respective State agency. a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The resident's representative (sponsor) of record; c. The resident's attending physician; 5. Notices to the above agencies/individuals may be submitted via US mail, special carrier, fax, email, or by telephone. Such notices include: : a. The name of the resident; - b. The type of abuse that was committed (i.e., . verbal, physical, sexual, neglect, etc); c. The date and time the alleged incident occurred; _d. The name(s) of all persons involved in the i alleged incident; and e. What immediate action was taken by the facility. 6. All personnel, resident's family members, visitors, etc are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or it's staff. 7. To assist in recognizing incidents of abuse, the following definitions of abuse are provided: a. Abuse if defined as the willful infliction of injury; unreasonable confinement; intimidation; punishments with resulting physical harm, pain or 899 5G2H14 PRINTED: 06/20/2024 STREET ADDRESS, CITY, STATE, ZIP CODE 4962 MATTIS ROAD PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 06/10/2024 (XS) COMPLETE DATE If continuation sheet 2 of 7 PRINTED: 06/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4962 MATTIS ROAD SAINT LOUIS, MO 63128 (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) MATTIS POINTE-ASSISTED LIVING BY AMERICARE Continued From page 2 | mental anguish: or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well being. b. Verbal abuse is defined as any use or oral, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents regardless of their age, ability to comprehend, or disability. f. Mental abuse is defined as, but is not limited to humiliation, harassment, threats of punishment, or withholding of treatment or services. 8. Any individual observing an incident of resident abuse or suspecting resident abuse should promptly report such incident to a member of the nursing staff or to management. _ Review of Resident #1's face sheet, showed the : following: : -The facility admitted the resident on 9/20/22; -Diagnoses included diabetes, dementia, and : major depressive disorder. Review of the resident's nurses notes, showed the following: -Behavior note on 5/17/24 at 2:23 P.M., the resident had no issues today just couldn't find his/her purse for a minute but it was in his/ner closet; ~Behavior note on 5/18/24 at 1:59 P.M., Certified Medication Aide (CMA) went in resident's room that morning and the resident had his/her clothes everywhere. His/her microwave was hanging off the counter. He/she had his/her vacuum plugged in and water was on the carpet like he/she had fet the sink run over. All types of things were in his/her sink. Clothes were all on the floor, bathroom had stuff everywhere. He/she said someone kept coming in his/her room messing Missouri Department of Health and Senior Services STATE FORM oN 6899 5G2H11 if continuation sheet 3 of 7 ‘7 PRINTED: 06/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B.WING 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE 4962 MATTIS ROAD SAINT LOUIS, MO 63128 x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8) 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) ; MATTIS POINTE-ASSISTED LIVING BY AMERICARE A8023: Continued From page 3 "up his/her room as he/she wouldn't do those : things. Everything in his/her medicine drawer was soaking wet. He/she pulled his/her clothes : out of the closet and said his/her family did it _ when he/she wasn't there. His/her family called | him/her that morning and he/she told the family | he/she fell out of the bed the night before. The _ CMA asked the resident about the fall but he/she | said he/she didn't remember telling his/her family that; -Behavior note on 5/18/24 at 9:15 P.M., the resident told both CMA's on shift that a black woman with "natural hair” was on the couch in the resident's room. Resident also said upon waking up, the woman ran out of the room. Resident was very forgetful throughout the shift; ~Behavior note on 5/27/24 at 10:16 P.M., the resident said staff told him/her it was time for him/her to move out so he/she started to pack his/her room; -Behavior note on 5/30/24 at 2:33 P.M., the resident was concerned items are being moved around his/her room; -Behavior note on 5/31/24 at 7:19 P.M., today resident had a great morning. Resident had ' lunch and dinner in the dining room and went to bingo after dinner around 6:30 P.M. CMAB went to check on resident and to give the resident his/her medications. The resident was in his/her | chair upset. CMA B asked the resident what was wrong and resident said he/she was sick of this place and being told what to do. CMAB was giving the resident his/her medications when he/she hit the medication cup out of CMA B's hand. As CMAB was picking up the medications, : he/she asked the resident was he/she refusing to , take his/her medications. The resident said he/she was not going to take them. CMAB contacied the resident's power of attorney (POA) ; to inform him/her of the issue he/she was having Missouri Department lealth and Senior Services STATE FORM P [ $699 §G2H11 If continuation sheet 4 of 7 PRINTED: 06/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION (DENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4962 MATTIS ROAD SAINT LOUIS, MO 63128 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID : PROVIDER'S PLAN OF CORRECTION (X5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) : TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) MATTIS POINTE-ASSISTED LIVING BY AMERICARE | Continued From page 4 : with the resident. CMA B and POA agreed they would give the resident time to get him/herself together. When CMA B returned to ask resident if ! he/she was going to take his/her medications, the : resident became very aggressive with CMAB and : tried to leave out the front door of the community. ' CMAB asked for help from CMA A at that time, : and the resident then threatened CMA B and : grabbed CMA B by the arm and told him/her to ; Shut up. CMAA tried to talk to the resident to get him/her to return to his/her room because the resident was trying to leave out the front door but the resident was refusing. POA and staff were made aware of the resident's behavior; -Behavior note on 6/2/24 at 12:51 A.M., the resident was upset about incident from previous day, said his/her feelings were hurt. Other than that, no unusual behaviors to report. Review of the resident care plan (individualized service plan) dated 6/2/24, showed the following: -Special Considerations: | have a history of anxiety, depression and agitation. | tend to get very upset easily, and tend to lash out at staff and my family. | am being followed by a psychiatrist for these behaviors. | have had a decline in cognition and memory impairment. | have been overflowing my sink in my room, as | am | forgetting my faucet is running. | do not have any recollection of these events occurring. I have paranoid and obsessive compulsive disorder behaviors as well. | tend to think people are stealing items from my room, my money and other items. | tend to horde things in my room as _ well. Per my family's request, the sink has been : turned off in the kitchenette area. : Review of the facility's self report dated 6/2/24, : showed the Administrator received a text | message on Friday, 5/31/24, from an employee Missouri Department of ith and Senior Services STATE-F OR! See8 5G2H11 If continuation sheet 5 of 7 PRINTED: 06/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED Cc 06/10/2024 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4962 MATTIS ROAD SAINT LOUIS, MO 63128 MATTIS POINTE-ASSISTED LIVING BY AMERICARE (x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX | (BACH DEFICIENCY MUST BE PRECEDED BY FULL ! pREEIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x8) COMPLETE DATE | Continued From page 5 (CMAA), which informed the Administrator and : the Director of Nursing (DON), there was an _ altercation between a resident and a staff _ member (CMA B) regarding the resident refusing i to take his/her medications. The Administrator and DON reviewed the cameras and could see i the resident and employee "having words with | one another." it was observed that the resident grabbed a hold of CMA B's right forearm, and CMA B pulled his/her own arm backwards and | was free from the residents’ hands. At no time, was there physical contact from CMA B towards the resident. The Administrator was able to talk to the resident on the phone and was able to calm the resident down. The resident told the Administrator that CMA B was "being rude" to him/her but did not indicate any kind of verbal or physical abuse. On 6/2/24, CMA B cailed the Administrator and said the resident's family had been told by CMAA that CMA B had cussed and "laid hands” on the resident. The Administrator spoke fo the resident's family who said an employee had informed him/her of the altercation on Friday evening and he/she did not want CMA B to take care of the resident. The Administrator and DON went to the community around 9:45 A.M., interviewed CMA B and placed him/her on leave pending an investigation. Review of the facility's investigation summary dated 6/5/24, showed CMA B engaged in a verbal altercation which included using obscene language with the resident. Based on resident, family member, and staff interviews, it was determined CMA B had used inappropriate language with the resident. CMAB was terminated on 6/5/24, and a performance counseling was given to CMAA regarding not sharing concerns of abuse and neglect to j management. All staff were inserviced on 6/5/24, Missouri Department of-Nealth and Senior Services UR } e899 5G2H11 If continuation sheet 6 of 7 PRINTED: 06/20/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION iDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc B. WING ee 06/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4962 MATTIS ROAD SAINT LOUIS, MO 63128 MATTIS POINTE-ASSISTED LIVING BY AMERICARE 4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL : (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ; A8023: Continued From page 6 ; On abuse and neglect and when to report. i During an interview on 6/10/24 at 12:33 P.M., the : Administrator said CMA A contacted her during the altercation but did not elaborate on the extent : of the situation or give indication of potential i abuse. She said she spoke to the resident to : assist with calming him/her down and the resident "informed her that CMA B was being rude to | him/her. She said she did not ask additional _ questions about what specifically CMA B did or _ Said to understand how he/she was being rude. She said there could always be more questions to _ ask but she had not asked any additional questions to fully understand the extent of the . treatment of CMA B to the resident. She said had ; More questions been asked during the altercation, she could have placed CMAB on leave sooner. As a result, CMA B worked an additional shift on 6/1/24, placing other residents - in a situation for potential harm. *The higher classification merited due to the - extent of the violation. . MO00237014 Missouri Department of Health and Senior Services STA 8899 5G2H11 If continuation sheet 7 of 7 PLAN OF CORRECTION | Provider/Supplier Mattis Pointe- Assisted Living by Americare Name: Street Address, 4962 Mattis Road, St. Louis, MO 63128 City, Zip: | Date of Survey: 06/10/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 19 CSR 30-88.010 (23) Develop/Implement A/N Policies The facility shail develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of any resident and misappropriation of resident property and funds, A8023 and develop and implement policies that require a report to be 7/15/2024 made to the department for any resident or to both the department and the Department of Mental Health for any vulnerable person whom the administrator or employee has reasonable cause to believe has been abused or neglected. II/I!I The facility will ensure to follow the abuse and neglect policy when an alleged incident of abuse occurs. Employees that are alleged/suspected of abuse and neglect will be suspended pending further investigation and not continue to have contact with residents until investigation can be completed. All residents who reside at the facility are considered at risk for this deficient practice. |CMABwasterminatedon 6/5/24 | CMA A received a performance counseling and reeducated on reporting concerns of alleged abuse and neglect to management on 6/5/24 Administrator and or designee in-serviced all staff on abuse and neglect policy and how to report suspected abuse and neglect on 6/5/24. Regional Nurse consultant and/or designee to in-service Administrator and Director of Nursing by 7/12/2024 on facility abuse and neglect policy and employees that are alleged/suspected of abuse and neglect will be suspended pending further investigation and not continue to have contact with residents until investigation can be completed. Administrator and/or designee will monitor for continued compliance ensuring that all staff members receive abuse and neglect training and reporting requirements prior to or on first day of working in the facility and annually. Administrator will report continued compliance to Regional Director of Operations monthly on Administrator monthly report. The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being sub ed on this form. WY (ste, Lonu/ Gl a'/p4/