ST LOUIS ALTENHEIM.

PRINTED: 08/07/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (x3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING: Cc 07/22/2025 B. WING 07585N NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5408 SOUTH BROADWAY ST LOUIS ALTENHEIM SAINT LOUIS, MO 63111 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.032(20) Cooling System, 85 Degrees Air conditioning, fans or a ventilating system shall be available and used when the room temperature exceeds eighty-five degrees Fahrenheit (85°F) and the reasonable comfort needs of individual residents shall be met. I/II This regulation is not met as evidenced by: Class Il Based on observation, interview and record review, the facility failed to ensure temperatures in residents’ rooms/resident areas on the secured, memory care unit met the reasonable comfort needs of residents, resulting in temperatures ranging from 81 degrees Fahrenheit (F) to 86 degrees F. This had the potential to affect all the residents. The census was 18. Review of the facility's Extreme Weather policy (undated), showed the following: -It is the policy of the facility to protect residents, staff and others who may be in the facility from harm during emergency events. The priority of the facility is to minimize the stress residents could experience from extreme temperatures related to weather events. To mitigate the risk, we rigorously maintain our systems of heating, ventilation and air conditioning (AC) and generator. In the event of a disruption to these systems during extreme weather we will initiate the following actions; -Administrator: -Monitor and obtain updates on weather conditions, and facility conditions. Assign staff to regularly check internal temperatures in resident areas; -Contact vendors for needed equipment Missouri Department of Health and Senior Services DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S S\G TITLE (x6) DATE 2QJE11 If continuation sheet 1 of 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 07585N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 5408 SOUTH BROADWAY ST LOUIS ALTENHEIM SAINT LOUIS, MO 63111 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 such as heaters or coolers; -Monitor the situation in coordination with local response authorities. If indicated by conditions, initiate the Evacuation P&P, either partial to ensure safety of impacted residents, or full if situation is severe and anticipated to be prolonged; -Communicate with local emergency management and state survey agency regarding facility situation status, critical issues, and resource requests; -Inform staff, residents, and families/representatives of the situation and provide updates as needed; -If indicated, assign staff to secure the facility and implement a limited visitation policy; -Director of Nursing (DON): -Assess residents frequently for comfort and any change of condition; -ldentify residents whose fragile condition may require transfer; -Ensure continuation of resident care and essential services; -Distribute appropriate comfort equipment throughout the facility (e.g., portable fans), as needed; -Provide increased hydration and implement cooling measures as indicated; -If unable to maintain safe temperatures in all resident areas, gather residents into the alternate areas where temperatures can be maintained within an acceptable range. Review of the facility's temperature logs, showed a single temperature was recorded once a day, from 6/24 through 6/27/25, 6/29/25, 6/30/25 and 7/2 through 7/8/25. Times were not consistetly recorded, seven of the dates with single temperatures were recorded in the morning and there was no documentation of where the Missouri Department of Health and Senior Services STATE FORM 6899 2QJE11 PRINTED: 08/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/22/2025 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 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 07585N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 5408 SOUTH BROADWAY ST LOUIS ALTENHEIM SAINT LOUIS, MO 63111 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 2 temperature was taken on each floor. Room humidity was recorded on some of the logs, with no calculations of the temperatures and humidity docmented. Review of the weather forecast report, dated 7/22/25, showed a heat advisory was in effect. The weather conditions were sunny, with a high temperature of 94 degrees F and heat index temperature of 100-105 degrees F. Observation on 7/22/25 between 11:17 A.M. and 1:39 P.M., showed the following: -The air temperature in the hallway outside There was a high velocity fan on the floor in the middle of the hallway; -The air temperature in resident room 402 measured 81 degrees F. There were no fans or air conditioning in the room; -The air temperature in resident room 403 measured 81 degrees F. There was no fan or air conditioning in the room; -The temperature in the hallway outside resident rooms 409-412 measured 85 degrees F. There were no fans or portable AC units in the hallway; -The air temperature in resident room 409 measured 83 degrees F. There were no fans or air conditioning in the room; -The temperature in the hallway outside resident rooms 413-420 measured 86 degrees F. There was a portable AC unit in the hallway. The temperature was set to 71 degrees F and the air temperature on the AC unit read 84 degrees F; -The air temperature in resident room 419 measured 80 degrees F. There were no fans or air conditioning in the room; -The temperature in the hallway outside resident rooms 421-424 measured 86 degrees F. There were no fans or portable AC units in the hallway; Missouri Department of Health and Senior Services STATE FORM resident rooms 401-403 measured 85 degrees F. 6899 2QJE11 PRINTED: 08/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/22/2025 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 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 07585N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 5408 SOUTH BROADWAY ST LOUIS ALTENHEIM SAINT LOUIS, MO 63111 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 -The air temperature in resident room 422 measured 81 degrees F. There were no fans or air conditioning in the room; -The air temperature in resident room 424 measured 83 degrees F. There were no fans or air conditioning in the room; -The air temperature in the activity room measured 83 degrees F. There were no fans or air conditioning in the room; -The air temperature in the resident's tv room measured 81 degrees F. There were approximately ten residents in the room. There was a portable AC unit in the hallway across from the tv room. The temperature on the AC unit was set to 65 degrees F and the room temperature on the AC unit read 83 degrees F. Observation and interview on 7/22/25 at 1:50 P.M., showed Resident #4 lay in his/her bed, wearing only a brief. He/She said he/she told staff he/she was hot today, and they brought him/her a fan. The air temperature in his/her room measured 81 degrees F. There was a high velocity fan on the floor in the middle of his/her room. During an interview on 7/22/25 at 1:49 P.M., Nurse Aide B said he/she did not know how long the air conditioning had been out. Resident #4 complained of being hot and he/she put a fan in his/her room. Resident #4 was the only resident who complained. He/She did activities with the residents and did not know much about the air conditioning situation. During an interview on 7/22/25 at 1:55 P.M., Licensed Practical Nurse A said the air had been out for a few weeks. The residents have not complained of being hot. There are only one or two residents with the cognitive ability to know it is Missouri Department of Health and Senior Services STATE FORM 6899 2QJE11 PRINTED: 08/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/22/2025 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 6 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 07585N NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION A. BUILDING: 5408 SOUTH BROADWAY ST LOUIS ALTENHEIM SAINT LOUIS, MO 63111 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 4 hot. Staff complete hydration rounds every hour or so. Staff go in the residents’ rooms to see if "it is too hot for the staff". If staff think the resident's room is too hot, they bring the resident into the tv room. If the resident refuses to leave the room, a fan is placed in the room. The Maintenance Director takes the temperature in the resident rooms in the morning. Nursing staff do not take temperatures in the resident rooms. During an interview on 7/22/25 at 9:33 A.M., the Maintenance Director said there have been issues with the cooling system for a few months. He thinks the chillers and handlers need to be replaced. There are small thermostats on each floor. He/She selects three random rooms on each floor and measures the air temperature, three times per week. A company comes to the facility every week to show him how to regulate the temperatures. During an interview on 7/22/25 at 9:07 A.M., the Administrator said the building is warm. There have been issues with the cooling unit for about 60 days. The system is old, and it provides heating and cooling via water. It operates with chillers (an air conditioning system which uses a method of producing chilled water and sending water to the chilled water coil of the air conditioner) and handlers. The humidity is causing the system to not function properly. The system will be replaced, but it is going to take some time. They are expecting a bid from a company this week. They check the temperatures daily and offer the residents fans and portable air conditioning units. On 7/29/25 at 1:23 P.M., the Administrator said she reviewed the temperature logs daily and was aware the temperatures were checked once daily. The nurses are responsible to ensure additional hydration to the residents. Missouri Department of Health and Senior Services STATE FORM 6899 2QJE11 PRINTED: 08/07/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 07/22/2025 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 5 of 6 PRINTED: 08/07/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED Cc 07585N — 07/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5408 SOUTH BROADWAY SAINT LOUIS, MO 63111 (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) ST LOUIS ALTENHEIM A3221 | Continued From page 5 M000257459 Missouri Department of Health and Senior Services STATE FORM oe 2QJE11 If continuation sheet 6 of 6 PLAN OF CORRECTION Provider/Supplier | c+ | quis Altenheim Name: Street Address, | 54g S, Broadway, St. Louis, MO 63111 City, Zip: Date of Survey: 7/22/2025 07585N PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE This Plan of Correction (POC) is being submitted as required under state and federal law. The submission of this POC does not constitute an admission of the part of St. Louis Altenheim. St. Louis Altenheim’s submission of this POC does not constitute an admission that the surveyor’s findings were accurate, nor that the deficiencies cited were correct and/or the scope and severity was merited. This POC is solely intended to ensure compliance within state and federal regulatory guidelines. Compliance will be achieved no later than 9/1/2025 en 49 CSR 30-86.032(20) Cooling System, 85 degrees (20) Air conditioning, fans or a ventilating system shall be available and used when the room temperature exceeds eighty-five degrees | Fahrenheit (85°F) and the reasonable comfort needs of individual residents shall be met. The facility will ensure temperatures in residents’ rooms/resident areas on the secured memory care unit meet the reasonable comfort needs of residents. 9/1/2025 What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: e Resident #4 room temperature is 78 degrees F. Individual air conditioning unit was placed in the room for comfort to the resident's preference. e Temperature in the hallway outside resident rooms 401-403 is 79 degrees F. e Temperature in resident room 402 is 75 degrees F. e Temperature in resident room 403 is 76 degrees Fs e Temperature in the hallway outside resident rooms 409-412 is 79 degrees F. ° Temperature in in resident room 409 is 77 degrees F, e Temperature in the hallway outside resident rooms 413-420 is 78 degrees F. e Temperature in resident room 419 is 78 degrees Fis e Temperature in the hallway outside resident rooms 421-424 is 78 degrees F. e Temperature in resident room 422 is 78 degrees EF. e Temperature in resident room 424 is 75 degrees F. 7/27/2025 between 2p-5p e Temperature in the activity room is 78 degrees F. e Temperature in the resident's TV room is 78 degrees F. How you will identify other residents having the potential to be affected by the same deficient practice. The administrator conducted a temperature audit of all areas of the Assisted Living Facility (ALF) unit to identify any other areas of 7/28/2025 temperature concern. All areas have been corrected. a compliance will be met after completion of the audit. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur. e The Maintenance Director will receive training from the Administrator, or their designee, covering the importance of air temperature checks at varying times in resident rooms as well as residents’ areas. 8/30/2025 e Nursing staff on the ALF unit will receive training from the Director of Nursing, or designee, regarding recognizing heat-related stress for cognitive impaired residents. | How the facility plans to monitor its performance to make sure that solutions are sustained. During an Extreme Heat Warning (St. Louis City area): The Administrator or their designee will conduct and document temperature checks in all resident rooms on the ALF unit at a minimum of 2 times a day at different times of the day. One of the times will be at peak heat time. Routine Monitoring (when no extreme heat warning is in effect 9/1/2025 for the St. Louis City area): To ensure sustained compliance, the Administrator or their designee will monitor and document temperatures in five random resident rooms twice per day. This monitoring will continue on a weekly basis until substantial compliance is achieved and maintained. A3221 will be added to the QAPI agenda to include findings until substantial compliance is met.

PRINTED: 05/24/2024 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 07585N B. WING __- 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5408 SOUTH BROADWAY SAINT LOUIS, MO 63111 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x6) 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) ST LOUIS ALTENHEIM 149 CSR 30-86.047(47)(G) Medication Administration, Documented Medication Orders. (G) The administration of medication shall be recorded on a medication sheet or directly in the resident's record and, if recorded on a medication sheet, shall be made part of the resident's record. The administration shall be recorded by the same individual who prepares the medication and administers it. II/IIl This regulation is not met as evidenced by: Class II* Based on observation, interview and record review, the facility failed to record medication given to residents directly into the resident's record for two of two sampled residents (Residents #2 and #1). The census was 16. 4. Review of Resident #2's medical record, showed the facility admitted the resident on 8/27/22, with diagnoses that included dementia, hyperlipidemia (high levels of lipids in the blood), glaucoma, high blood pressure, chronic fatigue, and a history of falling. Review of the resident's physician's orders dated March 2024, showed daily at 8:00 P.M., the resident was to be given losartan potassium (used to treat high blood pressure) oral tablet 25 milligrams (mg), melatonin (used as a sleep aide) tablet 3 mg, rosuvastatin calcium (used to treat high cholesterol) oral tablet 40 mg, and at 8 A.M., sarna (used to treat itching) lotion 0.5-0.5%. Review of the resident's Medication Administration Record (MAR) for the month of March 2024, showed the resident did not receive the losartan potassium on 3/9 or 3/28, the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PRQVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE [31 /a0ay ae 2HHH11 If continuation sheet 1 of 4 STATE FGRM PRINTED: 05/24/2024 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 07585N — 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5408 SOUTH BROADWAY SAINT LOUIS, MO 63111 (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) ST LOUIS ALTENHEIM Continued From page 1 melatonin on 3/28, and the rosuvastatin on 3/1, 3/9 and 3/28/24. Review of the resident's MAR for the month of April 2024, showed the resident did not receive any of his/her prescribed medications on 4/5 and 4/19/24. Review of the resident's MAR for the month of May 2024, showed the resident did not receive his/her losartan potassium on 5/4, 5/9, 5/10, 5/11, and 5/12, melatonin on 5/4 and 5/11, and rosuvastatin on 5/4, 5/9, 5/10, 5/11 and 5/12/24. 2. Review of Resident #1's medical record, showed the facility admitted the resident on 12/19/22, with diagnoses that included hypothyroidism (disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormones), diabetes, Alzheimer's disease, restlessness and agitation. Review of the resident's physician's orders dated March 2024, showed daily at 8:00 P.M., the resident was to be given atorvastatin calcium (for cholesterol) tablet 40 mg, daily at 11:00 P.M.; donepezil HCI (used to treat Alzheimer's disease) oral tablet 10 mg, two times daily; accucheck (for blood sugars) at 7:30 A.M. and 4:00 P.M., and two times daily novolog flex (used to treat diabetes) pen at 7:30 A.M. and 4:00 P.M., two times daily; divalproex sodium (for mood stabilizer) oral tablet 250 mg at 9:00 A.M. and 6:00 P.M., two times daily; metformin (used to treat diabetes) 1000 mg at 9:00 A.M. and 6:00 P.M., two times daily; and olanzapine (used to treat Alzheimer's disease) 2.5 mg at 8:00 A.M. and 10:00 P.M. Review of the resident's MAR for March of 2024, Missouri Department of Health and Senior Services STATE FORM 6899 2HHH11 If continuation sheet 2 of 4 PRINTED: 05/24/2024 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 07585N — 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5408 SOUTH BROADWAY SAINT LOUIS, MO 63111 (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) ST LOUIS ALTENHEIM Continued From page 2 showed the resident did not receive atorvastatin on 3/28/24; Donepezil on 3/1, 3/9, and 3/10/24; Accucheck for P.M. on 3/5/24, A.M. or P.M. on 3/9 and 3/10/24, or P.M. on 3/22, 3/24, 3/25 and 3/26/24; Novolog flex pen for P.M. on 3/5/24, A.M. or P.M. on 3/9 and 3/10/24, for P.M. on 3/22, 3/24, 3/25, and 3/26/24, and for A.M. on 3/29/24. Review of the resident's MAR for April of 2024, showed the resident did not receive atorvastatin on 4/5, 4/6, or 4/28/24; Donepezil on 4/5, 4/6, 4/19, and 4/26/24; Accucheck for A.M. on 4/2/24, for A.M. or P.M. on 4/4, 4/6, 4/7, 4/20, and 4/21/24, for P.M. on 4/26/24, and for A.M. and P.M. on 4/27 and 4/28/24; Divalproex for P.M. on 4/6/24; Metformin for P.M. on 4/6/24; Novolog flex pen for A.M. 4/2/24, for A.M. and P.M. on 4/4, 4/6, 4/7, 4/20, and 4/21/24, for P.M. on 4/26/24, for A.M. and P.M. on 4/27 and 4/28/24, and P.M. on 4/30/24 and Olanzapine for P.M. on 4/5, 4/6, and 4/26/24. Review of the resident's MAR for May of 2024, showed the resident did not receive atorvastatin on 5/4, 5/5 and 5/11/24; Donepezil on 5/4, 5/5, 5/9, 5/10, 5/11, and 5/13/24; Accucheck for P.M. on 5/2, 5/4, 5/5, and 5/15/24; Divalproex for P.M. on 5/4/24; Metformin for P.M. on 5/4/24; Novolog for P.M. for 5/2, 5/4, 5/5, and 5/15/24 and Olanzapine for P.M. on 5/4, 5/5, and 5/15/24. During an interview on 5/16/24 at 11:30 A.M., the Director of Nursing (DON) said the residents should be getting their medications as ordered and if a medication is missed, she should be notified along with the resident's physician. She was not aware the residents had missed their medications and she said it should be documented if there was a concern with the Missouri Department of Health and Senior Services STATE FORM 6899 2HHH11 If continuation sheet 3 of 4 PRINTED: 05/24/2024 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 07585N — 05/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 5408 SOUTH BROADWAY SAINT LOUIS, MO 63111 (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) ST LOUIS ALTENHEIM Continued From page 3 resident receiving their medications as ordered. During an interview on 5/16/24 at 11:30 A.M., the Administrator said the residents should be getting their medications as ordered and she was not aware the residents had missed these doses of medication. *The higher classification merited due to the extent of the violation. M000230390 Missouri Department of Health and Senior Services STATE FORM 6899 2HHH11 If continuation sheet 4 of 4 PLAN OF CORRECTION Provider/Supplier St. Louis Altenheim Name: Street Address, City, Zip: PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER 07585N PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD | COMPLETION BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 5408 S. Broadway, St. Louis, MO 63111 ID PREFIX TAG This Plan of Correction (POC) is being submitted as required under state and federal law. The submission of this POC does not constitute an admission of the part of St. Louis Altenheim. St. Louis Altenheim’s submission of this POC does not constitute an admission that the surveyor’s findings were accurate, nor that the deficiencies cited were correct and/or the scope and severity was merited. This POC is solely intended to ensure compliance within state and federal regulatory guidelines. Compliance will be achieved no later than June 15, 2024 “— 49 CSR-30-86.047(47)(G) Medication, Administration, | A4809 Documented The facility will record medication given to residents directly 6/15/2024 into the resident’s record. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: e Resident #2 o Medication Administration Record (MAR) discrepancies in March 2024, April 2024, and May 2024 reported to physician and Resident's Responsible Party. o All medication administering staff were educated on: “Medication Administration Rights including Right Documentation” and facility policy “Documentation of Medication Administration”. o All medication administering staff completed the competency: “prepare, administer, report, and record medications” e Resident #1 o Medication Administration Record (MAR) discrepancies in March 2024, April 2024, and May 2024 reported to physician and Resident's Responsible Party. o All medication administering staff were educated on: “Medication Administration Rights including Right Documentation” and facility policy “Documentation of Medication Administration”. o All medication administering staff completed the competency: “prepare, administer, report, and record medications” 5/30/2024 How you will identify other residents having the potential to be affected by the same deficient practice. 5/30/2024 An audit of each ALF resident's Medication Administration Record MAR) was completed by the Director of Nursing on 5/30/2024. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur. The DON or designee will educate all medication administering staff 6/15/2024 on: “Medication Administration Rights including Right Documentation” and facility policy “Documentation of Medication Administration”. All medication administering staff will completed the competency: “prepare, administer, report, and record medications” How the facility plans to monitor its performance to make sure that solutions are sustained. The DON completed an audit of each ALF resident's Medication Administration Record (MAR) for documentation discrepancies on 5/30/2024. The DON or designee will audit 5 random Resident MARs x 4 weeks and then 5 random Resident MARs monthly until substantial compliance is met. 6/15/2024 The DON or designee will report audit findings to the QAPI committee until substantial compliance is met. A4809 was added to the QAPI agenda to include audit findings until substantial compliance is met.